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352 PersonalisedCareinlegUlCeration
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Teodorowski, P., Cable, C., Kilburn, S., and Kennedy, C. (2019). Enacting
evidencenal of Community Nursing 24 (8): 370–376. https://doi.org/10.12968/
bjcn.2019.24.8.370.
Tsakos, G., Watt, R., and Guarnizo-
health inequalities: theories, pathways and next steps for research priorities. Community Dentistry and Oral Epidemiology 51 (1): 17–27.
https://doi.org/10.1111/cdoe.12830.
Wise, G. (1986). The social ulcer. Nursing Times 82 (21): 47–49.
World Health Organization (n.d.). Social determinants of health.
https://www.who.int/health- topics/social- determinants- of- health
Wounds UK (2021). Addressing skin tone bias in wound care: assessing signs
and symptoms in people with dark skin tones. https://wounds- uk.
com/best-
careWounds UK (2022). Best practice statement: Active treatment for non-
healing wounds in the community. https://www.wounds- uk.com/
resources/details/activeWynn, M. and Holloway, S. (2019). The impact of psychological stress on
wound healing: a theoretical and clinical perspective. Wounds UK
15 (3): 20–27. https://salford-
the-
and-
based practice: pathways for community nurses. British Jour-
Herreno, C. (2023). Reections on oral
practice- statements/addressing- skin- tone- bias- wound-
assessing- signs- and- symptoms- people- dark- skin- tones
treatment- non- healing- wounds- community.
repository.worktribe.com/output/1350826/
impact- of- psychological- stress- on- wound- healing- a- theoretical-
clinical- perspective.
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CHAPTER
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8
Clinical Management
ofthe Lower Limb
GEORGINA RITCHIE
ective treatment of lower limb ulceration is underpinned by
E
both the art and the science of clinical practice. The National
Institute of Health and Care Excellence (NICE2023) advocates that
all people presenting with a venous leg ulceration should have access
to a healthcare professional with expertise in wound management,
and arguably this advice goes beyond the most common type of
ulceration observed in practice (venous) and should be the case for
all lower limb ulceration. Professional expertise requires a good
understanding of how to apply both art and science within the context of lower limb management and is fundamental to ensure eective clinical practice.
The research tells us that outcomes for patients in terms of faster
healing rates, less frequent infection and less bilateral ulceration are
usually better when lower limbs are managed in specialist settings
such as leg ulcer clinics (Patton2009; Hughesden2021). Also, the
presence of a multidisciplinary approach including medical practitioners, allied health professionals (for example from podiatry) and
nursing professionals improves outcomes for patients (Nuttall and
Rutt-
Howard2020). Arguably in practice this is frequently not the
case, with nurses often being left alone to manage complex
Lower Limb and Leg Ulcer Assessment and Management, First Edition.
Edited by Aby Mitchell, Georgina Ritchie, and Alison Hopkins.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
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353
354 CliniCalManageMentofthelowerliMb
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healthcare needs such as ulceration outside of specialist settings, frequently within patients’ own homes, where care can be delayed if
ulceration assessment and management are not prioritised (Queen’s
Nursing Institute2019).
To apply the science, it is necessary to understand principles
such as Laplace’s law and Pascal’s law; these explain the diering factors that will aect the dose of compression therapy applied and are
explained later in this chapter. Furthermore, it is necessary to understand the components of each of the various compression treatment
systems, to ensure that the person who has lower limb complications
receives the correct type and dose of the therapy. The dierent systems are constructed in dierent ways and so work dierently on the
body. Examples of the various therapies include bandages, hosiery
and wraps and again these are discussed later in the chapter. The art
of practice within the context of lower limb management is to understand techniques for application of compression to the limb and to
ensure the correct dosage of compression and support is applied.
Thus, the art and the science are inextricably linked and once an
understanding of the two is developed, eective clinical treatment
can be achieved in partnership with the patient, leading to faster
Medi healing rates, fewer infections and a better overall experience
for the patient.
All people who present with ulceration should be considered for
surgical intervention. In the case of venous leg ulceration this may
be for supercial venous surgery such as endovenous ablation
(NICE2023) (discussed in more detail in Chapter9) and in limbs
that have arterial compromise it may include surgery to restore oxygenated blood ow. However, it is important to acknowledge that
surgery may not be an option for all people. This may be for a variety
of reasons such as frailty, which may mean that the person is too
unwell or too vulnerable to undergo surgery, or it may be because
the condition they present with is not one that may be rectied
through surgical intervention, for example in those who present
with postoccurred to the deep veins. In cases such as this, the damage to the
venous system from previous deep vein thrombosis (DVT) is within
the deep veins and not the supercial veins and so surgery would
thrombotic syndrome, where signicant damage has
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Clinical Management ofthe Lower Limb 355
prevention of
prevention of
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not rectify the cause of the ulceration, thus lifelong strong compression is required.
Therefore, in people for whom surgery is not an option, the
underlying cause of the ulceration should be treated as a longterm condition that requires long- term management by the multidisciplinary team (MDT). While the ulcer can be treated and, in
most people, healed, the underlying cause frequently remains. See
Figure 8.1, which depicts lower limb ulceration as a long- term
condition in which the individual can heal and may relapse.
Chapter9 discusses in more detail how to prevent reoccurrence of
ulceration.
To manage the long- term condition the toolbox approach to
compression therapies (discussed later in this chapter) is advocated;
see Table8.1. What the toolbox approach means is that depending on
where in the disease trajectory (from prevention, in the acute phase,
or in the healed stage) the patient is, the patient and practitioner can
select and use the best tool for lower limb management. If we view
the cause of leg ulceration as a long- term condition, the patient and
practitioner together can use and interchange the tools in the toolbox
to manage the lower limb in the long term.
Long-term condition that causes lower limb ulceration
occurrence
FIGURE8.1 Recognition of leg ulceration as a symptom of a long- term
condition.
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acute ulceration
management
Disease trajectory
reoccurrence
TABLE8.1 Tools inthe toolbox.
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Name of tool Also known as
Compression
hosiery kits
Leg ulcer
hosiery kits
Two- layer
compression
hosiery kits
What is this
tool used for?
Small ulceration
that can be
dressed with a
small nonadherent dressing.
Normal-
shaped limbs.
Low levels
of exudate.
Self- management.
When is this tool
not appropriate? Top tips Illustration
Presence of
complexities such
as a distorted
limb shape or
deep skin folds.
Medium to higher
levels of exudate.
Wounds requiring
superabsorbent pads.
Compression hosiery
kits should not be
confused with
compression hosiery
stockings.
FIGURE8.2 Compression
hosiery kit.
Source: Courtesy
of Medi.
Adjustable
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wraps
Compression
wraps
Normal-
shaped limbs.
Low to moderate
levels of exudate.
management.
SelfCan be used if there
is some distortion
due to oedema.
Deep skin folds.
High levels
of exudate.
Wraps can be used in
combination with
other tools, for
example a knee wrap
may be helpful to
manage swelling
around the knee
above the top of the
bandage line.
FIGURE8.3 Compression
hosiery wrap.
Source: Courtesy of L&R.
(Continued)
TABLE8.1 (Continued)
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Name of tool Also known as
Compression
bandages
Multilayer
bandage systems
Inelastic bandage
Elastic bandage
The dierences are
discussed later
in the chapter
What is this
tool used for?
Can be used on all
lower limbs
subject to a
holistic
assessment.
When is this tool
not appropriate? Top tips Illustration
Self- care is unusual. Compression bandages
are eective at
managing the acute
phase of ulceration
and swelling and an
intensive course of
bandaging can be
eective at reshaping
the limb before
transition to other
tools in the toolbox.
FIGURE8.4 Inelastic
bandage.
Source: Courtesy of L&R.
FIGURE8.5 Elastic
bandage.
Source: Courtesy of Urgo.
Name of tool Also known as
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What is this
tool used for?
When is this tool
not appropriate? Top tips Illustration
Compression
hosiery
stockings
Source: Adapted from Wounds UK (2016).
Compression
hosiery
Compression
socks
Compression
tights
Can be used in early
intervention, to
prevent ulceration
or reoccurrence of
ulceration after
healing. See
Chapter9 for a
more in- depth
explanation
of hosiery.
Not to be used as a
single- layer
stocking or sock
for acute
ulceration.
Compression hosiery
stockings or socks
can be layered to
increase dose and
stiness, but this
should only be done
by experienced
practitioners.
FIGURE8.6 Compression
hosiery stockings.
Source: Courtesy of Medi.
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THE CASE FOREARLY INTERVENTION
‘Prevention is better than cure’ is a widely accepted statement within
healthcare practice, and leg ulceration is no exception. Thus, before we
examine the clinical management of leg ulceration, we should rst
explore the need for early intervention to prevent ulceration. The
National Wound Care Strategy Programme (www.nationalwound
carestrategy.net) advocates that mild compression therapy of up to
20 mmHg can be applied to the lower limb in the absence of red ags.
These red ags are acute infection of the leg or foot (e.g. increasing
unilateral redness, swelling, pain, pus, heat), symptoms of sepsis, acute
or chronic limb- threatening ischaemia, suspected acute DVT and suspected skin cancer. These red ags will exclude the person from early
intervention and an immediate referral is needed for treatment.
Application of mild compression is usually achieved through the
application of British Standard Class 1 hosiery stockings. In more
advanced practice it may be achieved through the application of certain bandages, but this is not discussed in this book. The application
of the British Standard Class 1 stocking will usually prevent deterioration of the leg ulcer, but it is unlikely to create healing, and as such
should be used until a full assessment is possible. In cases where the
leg is an usual shape, has deep skin folds or a loss of sensation, or if
there is a large amount of exudate, then again the application of a
British Standard Class 1 hosiery stocking or sock is not advocated.
Chapter9 discusses hosiery in more detail.
CLINICAL MANAGEMENT
Following the holistic assessment discussed in Chapter 5, the lower
limb management plan should follow three key steps, as detailed in
Table8.2. The overarching key to management of each of these areas is
to employ eective compression therapy in partnership with the person.
Step1: ThePerson
A holistic approach to the person’s health and well- being is important. Factors that aect the whole person and therefore indirectly the
leg ulceration and potential healing, such as obesity, pain and
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Clinical Management ofthe Lower Limb 361
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TABLE8.2 Lower limb management plan.
Wound bed
The person The limb
preparation
The person may
require support with
their overall health
and wellmay include
management in
collaboration with
other professionals
such as physicians,
for example if
medication
management is
required (discussed
later in this chapter)
or specialist
dermatology services
for unusual
aetiologies of
ulceration (discussed
in Chapter3).
The wider
determinants of
health, such as social
and economic status,
have a signicant
impact on the person
and a direct eect on
healing of leg
ulceration. See
Chapter7 for a
deeper exploration of
this area.
being. This
The limb overall requires
management. This is
because with lower
limb ulceration the
ulcer itself may be the
most visible symptom,
but ulceration is a
symptom of a leg with
an underlying
pathophysiology, such
as chronic venous
insuciency. This
may include
management in
collaboration with
other healthcare
professionals such as
podiatrists for support
with gait, mobility and
biomechanics
(discussed in
Chapter4).
Limb management will
include managing the
skin, any exudate for
example, and
identifying or
eliminating any other
signicant
pathophysiology, such
as deep vein
thrombosis as part of
the dierential
diagnosis and
safety netting.
This chapter will
examine management
of the limb overall.
The wound itself
will require
management,
through wound
bed preparation
and the selection
of an
appropriate
primary dressing
to manage
local symptoms.
This chapter will
examine wound
management.
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