NHS Forth Valley – Lower Limb

Leg Ulcer Chronic Odema ABPI/Doppler Compression Therapy Lymphoedema

Leg Ulcer

A leg ulcer is defined by the National Wound Care Strategy as ‘an ulcer that originates on or above the malleolus but below the knee that takes more than 2 weeks to heal’. There are several reasons why people get leg ulcers, the most common one (approx. 60 – 80%) being due to venous insufficiency arising from faulty valves in the veins and/ or poor calf muscle pump action. A smaller percentage of ulcers (10 – 20%) are caused by poor circulation in the arteries or because of other diseases such as diabetes or rheumatoid arthritis.

It is estimated that approximately 1% of the population in the United Kingdom will suffer from leg ulceration at some point in their lives with the experience often impacting negatively on their quality of life. Without correct treatment, ulcers can remain unhealed for many months or sometimes years, resulting in episodes of infection, pain and immobility.

Chronic Oedema

Chronic oedema is an umbrella term for swelling that does not respond to elevation or diuretics and which has been present for three months or more. It can occur in the limbs and/or the trunk, head and neck or genitalia. There are a few possible causes including.

Dependency’ oedema: associated with immobility
Venous oedema: e.g. resulting from venous disease such

as post-thrombotic syndrome or severe varicose veins

Oedema associated with obesity
Lymphoedema: primary and secondary
Oedema related to advanced cancer
Oedema due to heart failure

Left untreated chronic oedema of the lower limbs can progress and cause skin changes such as discolouration, eczema, dry skin plaques and hardening of the tissues. The risk of developing leg ulcers increases as the tissues become more vulnerable to injury and wounds fail to heal properly. The tissues become prone to infection and can require hospital admission. In the advanced stages the limbs change shape developing skin folds with hard cobblestone skin. They can begin to leak fluid profusely as the skin is unable to contain the fluid.

Chronic oedema can have a significant impact on a person’s quality of life. It is also costly to the health service in terms of time, resources and staffing. The key to managing chronic oedema is early intervention to prevent disease progression. The main interventions include compression therapy, skin care, exercise and elevation. Managing chronic oedema complicated with ulceration, lymphorrhoea (leaky legs) or infection can prove a challenge. However, with appropriate management strategies, these factors can be reduced.

Best Practice Statement. The use of compression therapy for peripheral oedema. considerations in people with heart failure.

ABPI/Doppler

ABPI testing is a non-invasive way of assessing a patient’s vascular status and establishing or excluding the presence of peripheral arterial disease (PAD). Terminology can vary, with terms also used such as ABI (ankle brachial index); ABPI testing may also be referred to as ‘Doppler’ testing, as the Doppler ultrasound is the traditional means used to conduct ABPI testing. A Doppler ultrasound uses high-frequency sound waves to measure the amount of blood flow through the patient’s arteries and veins, usually those that supply blood to the legs, comparing systolic blood pressure at the ankle with that in the arm. Vascular flow studies, also known as blood flow studies, can detect abnormal flow within an artery or vein. The purpose of all ABPI testing is to assess the strength of the arterial blood flow at the ankle.

The role of ABPI assessment in wound management

All patients with a lower limb wound – but particularly a leg ulcer – should undergo ABPI testing, as should patients who are at high risk (e.g. due to diabetes or immobility) or presenting with lower limb-related changes (Wounds UK, 2015). A leg ulcer can be defined as ‘a break on the skin, which fails to heal within 2 weeks’ (NICE, 2016).

Please see below guidance and information on ABPI assessment and interpretation of results:

Compression Therapy

Correctly applied compression therapy is recognised as the mainstay of treatment for both the preventative and therapeutic care of venous disease, with high compression bandaging now established as the treatment of choice for venous leg ulceration. Compression therapy is mainly delivered through the application of bandaging or compression hosiery.

Compression therapy aims to reverse the effects of venous hypertension by:

Decreasing the capacity of and pressure within the superficial veins
Assisting venous return by increasing the blood flow velocity in the deep veins
Reducing oedema and subsequent wound exudate levels
Minimising or reversing skin changes that impact on wound healing.

Reduced compression therapy can be applied in the absence of any red flags for compression (please refer to the Lower Limb Care pathway) as part of immediate and necessary care. High compression therapy should not be applied before the arterial status of the limb has been established (by completing a holistic vascular assessment including ABPI) and should be applied in line with local policy and guidelines.

Please refer to the following for guidance on the selection and application of compression hosiery in NHS Forth Valley:

Links to Application guides and Youtube videos on application of compression bandaging

Bandaging

Coban

Urgo K2 bandaging

Lymphoedema

Lymphoedema is a collection of lymph fluid which cannot drain away. It can be caused by a variety of factors including cancer, cancer treatments, trauma, injury or genetic causes. The result is swelling – often of the limbs but other parts of the body such as the head and neck or the trunk can be affected too.

Initially when people are referred to the Forth Valley Lymphoedema Service, they are assessed by a Lymphoedema Practitioner who will provide the appropriate care and advice. For some people referral to the specialist lymphoedema clinic may be required.

As lymphoedema is a chronic condition, the aims of treatment are individualised to help people manage this as independently as possible. Skin care, gentle exercise and sometimes compression garments and self-massage are all part of the long-term management of lymphoedema.

Treatment at the specialist clinic may additionally involve a short course of specialist bandaging, sometimes in combination with gentle skin massage (manual lymphatic drainage). Following this compression garments are fitted to be worn daily.

Once the swelling has stabilised and people are confident in their self-management regime, then they can be discharged from the Specialist Clinic either for continued monitoring by their Lymphoedema Practitioner or by their GP with the understanding that they can be referred back to the Specialist Clinic at any time if required.

The Lymphoedema Service is an additional service within the TVS and there is a separate referral system in place via SCI Gateway.

Please discuss referral with your GP