Differential Assessment and Management of Lower Extremity Ulcers

Speaker A: 00:00:10

In the last three classes, we've spent a lot of time talking about lower extremity arterial disease and ischemic ulcers, venous disease and venous ulcers, and neuropathic disease and neuropathic ulcers because those are the three most common types of lower extremity wounds. In later classes, we'll discuss some less common types.

But what we want to talk about right now is the challenge of differential assessment, because patients don't come with a diagnosis in most situations, and some patients are at risk for both arterial disease and venous disease, or both arterial disease and neuropathic disease, or a combination of venous and neuropathic.

So what we want to focus on in this class is how you put all the puzzle pieces together to determine what the underlying etiologic factors are and how you use that data to construct an effective management plan.

So we're going to talk about why a thorough differential assessment is always required before you can establish a management plan for the patient with a leg ulcer. We're going to outline essential parameters to be included in assessment of the patient with the leg ulcer.

We'll include general findings, indicators of vascular status, indicators of sensory, motor and autonomic function, and pain characteristics.

And then at the very end, we're going to have a practice scenario when we're going to utilize assessment findings to determine etiologic factors and appropriate management for a sample patient with a leg ulcer. And here's your usual learning activities. We're going through the video. There is a chapter on differential assessment in the core curriculum.

And when you complete the case studies, you will carry out an exercise in differential assessment.

So, first of all, we've kept saying over and over again, you probably don't want to hear it again, that the first step in effective wound management is identification and correction of etiologic factors. Now, when you think about the common causes of lower extremity wounds, you realize that management varies significantly depending on the etiology.

If you have a venous ulcer, effective management is going to require compression and elevation. But the levels of compression and the utilization of elevation has to be modified, or sometimes even avoided if the patient has arterial disease.

Arterial ulcer management requires measures to improve blood flow, which would not be helpful at all to the patient with venous ulcer management because their problem is the blood gets to the tissues but not back to the heart. And neuropathic ulcer management requires effective offloading, which is irrelevant for venous ulcer management and arterial ulcer management.

So you can see that if you don't get that first question right, if you don't accurately identify the etiologic factors, your management plan will be inappropriate and may make things worse, certainly won't make things better. So it can be overwhelming. Where do you start? We want you to have a pathway. So step number one, don't make up your mind prematurely.

First, get the data, conduct your differential assessment. So I come to you. I have a lower extremity, maybe I have a history that's kind of confusing. I have diabetes.

Yes, I've had a heart attack, blah, blah, blah. That doesn't really help you. But once you gather your data and you start to process it systematically, the answers become much clearer.

So remember that a differential assessment always includes a vascular assessment, sensory motor assessment in most situations, pain assessment and ulcer assessment. So let's look at each one of those vascular assessment you're trying to determine. Do I see indications of ischemic disease?

Do I see evidence of venous disease? So you're going to first just look at the lower extremity, both lower extremities. You're going to look at the color of the leg and foot.

You're going to determine the impact of elevation and dependency. Now, let's say that the legs look the same as the arms and that raising the leg has no impact. Putting the leg down has no impact.

Now take the second patient. Let's say that the legs look pretty kind of pale, and then when you elevate the legs, that pallor becomes much more pronounced.

And when you put the leg down, you've got clear, dependent ruber. Well, that's a clear indication of arterial disease. But what if you saw hemocityrosis?

What if you saw that brown, gray black color over the lower extremity and otherwise the skin looked relatively normal. That could be an indication of venous disease. So it's what, it's checkpoint number one.

Look at the lower extremities, determine the color, see if there's any change with elevation or dependency, see if there are any abnormalities. The second thing you're going to look at is you're going to look at the skin, the hair, the nails.

Is the skin normal thickness or is it very thin and pale and shiny? So if you have thin, shiny skin, absence of hairs, very sparse hair and thin ridged nails, that would push you toward arterial insufficiency.

On the other hand, if the skin looked like normal thickness, but you've got all these scaly crusty areas, normal hair growth, normal nails, you might think, hmm, I'm not going to rule out venous yet. This could be consistent with Venus.

What if you have an area of dermatitis that involves the sock area and it's red and it's pruritic and there's dry, scaly skin that's consistent with venous rheumatitis?

So as you're gathering data about the color of the leg, the impact of elevation and dependency, the status of the skin, hair and nails, you're asking yourself, do I see findings that are consistent with arterial disease? Do I see findings that are consistent with venous disease? Pulses. An absolutely critical parameter.

If your pulses are easily palpated and normal, then that suggests that you have adequate perfusion and that this probably is not an arterial wound. In contrast, if your pulses are very faint, you have a really hard time palpating them. You had to use a doppler and even with a doppler it's faint.

That definitely suggests significant arterial disease. What about venous refill time? What happens when you elevate the leg? Wait till the veins collapse, put the leg back down.

How long does it take for those veins to refill the. If it's more than 20 seconds, it suggests arterial disease. If it's ten to 15, that's normal.

If it refills extremely promptly, it may indicate venous congestion. Abi, of course, is absolutely critical anytime you suspect an arterial component.

Also very important when doing the workup for venous ulceration, because it's going to dictate what you can do in terms of compression therapy and finally edema. Then you're going to do a sensory motor assessment.

You should do this for any patient with diabetes, any patient with known or suspected b twelve deficiency, any patient with a history of alcoholism and any patient who has a wound and they don't know how they got it. So what are the critical elements of sensory motor assessment? Well, you're going to test with a 5.07 monofilament at ten points.

1st, 3rd, 5th toe pads, 1st, 3rd, 5th metheads, medial portion of the foot, medial and lateral heel, unless obscured by callus and on the dorsal aspect between the first and second toe. And normal findings would be a patient is able to tell you every time you touch their foot with a monofilament.

Failure to respond to the 5.07 monofilament is indicative of sensory neuropathy, loss of protective sensation. If you have access to a tuning fork, you would do vibratory sense testing at the base of the great nail or over the bunion. Bone.

If that's intact, that's a good finding. If it's missing, if it's absent, they no longer have vibratory sense. It tells you they're developing neuropathy. Position.

Since testing, do I know where you're putting my toe? Up, down to the right? To the left? If so, it means that I know where my feet are in space. I'm low risk for falls.

If not, I'm high risk for falls and you have to do intensive education.

You're going to watch me walk, observe my gait, look at the wear pattern in my shoes, inspect my toes for deformities, look at the plantar surface to see if there's callus formation over the plantar surface. All of those are indications of motor neuropathy. So you're looking at sensory neuropathy for evidence of sensory neuropathy.

You're looking for evidence of motor neuropathy. You always check pain pattern. Pain is a major indicator. It tells you so much.

So first of all, you ask the patient on a scale of zero to ten or on a scale of zero to five, how severe is your pain? What things make your pain worse? What things make your pain better? Does position have any impact on your pain?

Does activity have any impact on your pain? So you think, okay, now, if it's Venus, they're probably gonna tell me that their pain is worse.

At the end of the day, when their swelling is worse, they're probably going to tell me that it's improved or relieved partially by elevating their legs and relieving the edema. They're probably going to describe it as kind of aching pain or a feeling of heaviness.

If they have arterial disease and ischemic pain, they're probably going to tell me it gets worse with activity, worse with elevation, better with rest and dependency. They may describe it as aching pain, they may describe it as cramping pain, they may describe it as heaviness and difficulty walking.

If they have neuropathic pain, they're probably going to describe it as pins and needles, electric shock. They're probably going to tell me that it's worse at night and that it can be relieved if they get up and walk.

So pain pattern, very, very helpful in determining what's causing this wound. And then finally, I'm going to look at the ulcer itself. Where is it? Remember how important location is. What does the wound bed look like? Is it pale?

Is it red? Is it wet? Is there anything in the periwound tissue that gives me clues? How much exudate. So first you just gather your data.

Try not to make premature decisions. Just gather your data. Then you're going to determine the probable primary etiology based on three primary things.

What is the location of the wound, what does the wound bed look like and what is the pain pattern? Now remember, this is a process, so we're not done yet. This is just probable primary etiology.

So if it's a venous wound, it would be between the ankle and the knee, but probably around the malleolus. You're going to have a red, wet ulcer bed, and typically they'll have aching pain that is relieved by elevation.

If you look at the surrounding tissue, you're going to see edema and hemocyterosis.

Arterial wounds are going to be located either distally at the area farthest from the heart, toes and distal foot, or in an area of trauma where you have a non healing wound. Abi is usually less than 0.5. That's a contributing assessment factor. So location is going to be distal or an area of trauma that's not healing.

What is the wound bed going to look like? It's going to be pale and dry. It may be necrotic. What will the pain pattern be? They're going to tell you that it's worse when they get up and walk.

It's worse if they elevate the legs. It's better if they rest with the legs down. Neuropathic, where will it be located?

Either on the plantar surface or an area in contact with the shoes where the feet are getting rubbed against the shoe. The wound bed is usually red and wet.

And if they have neuropathic pain, it will be that shooting kind of pins and needles, electric shock pain that is at least partially relieved by getting up and walking around. Sometimes neuropathic wounds are totally painless and the patient may be totally unaware of the wound and deny any pain at all.

Now, what if it's one of those other wounds? Then the pain will not be affected by activity or position and the ulcer characteristics will not line up with any of these categories.

Okay, so now we have gathered our data. We've used three key points to determine probable primary etiology.

Now we're going to go back to our notes and we're going to look at what is the standard management plan based on what we think is the primary etiology. So if we think it's venous, we're going to be focused on elevation and compression, typically 30 to 40 mercury at the ankle.

If we believe this is an arterial wound, vascular consult is going to be a high priority, as is counseling regarding smoking cessation. The patient's probably going to be placed on medications and eventually we'll be looking at a progressive walking program.

If it's a neuropathic wound, I have to immediately proceed with offloading. So I have to protect the area. If it's the tips or tops of the toes, I have to get footwear that provides a deeper, wider, longer toe box.

If it's plant or surface, I either have to do a total contact cast, a removable cast walker, adhesive belt, offloading. Somehow I have to get the patient off the wound. I have to focus on tight glucose control as well.

If it's some other etiology, it's going to depend on what the etiologic factors are. I've gathered data. I've said based on these primary points, I think my primary etiology is this and my management plan would look like this.

Step four is okay, you're not done yet. You've got to go back.

You've got to check your initial impression, go back, look carefully at your vascular data, look carefully at your sensorimotor data to determine are there any modifications that need to be made in the standard treatment plan? Are there any additional care priorities? Or does your vascular or sensory motor assessment data challenge your initial impression?

So let's say you have a patient with a venous ulcer, and yes, you go back and there's clear evidence of venous insufficiency. You've got edema, you've got the hemocyterosis, you've got a wet wound and you've got that aching pain.

But when you go back and you look carefully at your vascular data, you find that you have moderately severe arterial disease. They have an ABI of 0.7. So you're going to have to modify the level of compression. Or what if you have a patient that's clearly a neuropathic ulcer?

That's primary etiology. It's on the plantar surface. It's over the metatarsal head. It's surrounded by callus.

But when you look at their vascular data, there is coexisting ischemia, Abi of 0.6 that we're going to have to address if we're going to get optimal outcomes. So now I'm going to let you practice. We're going to do it together, actually.

So let's say you have a 67 year old black female who's referred to the wound clinic for a non healing ulcer of the left leg. Here's her relevant medical history. She's had type two diabetes for 20 years. She's currently managed with oral agents in a diet.

Her last a one c was 7.2. She has hypertension, managed with low tension. She has not had an MI. She denies any history of CVA.

She has a questionable DVT following cholecystectomy two years ago. So you just look at her history and you're like, wow, type two diabetes for 20 years.

So that's a risk factor for both arterial disease and neuropathic disease. Hypertension, risk factor for arterial disease. DVT, risk factor for venous disease. So her medical history, she checks all three boxes.

She has risk factors for arterial, venous and neuropathy. Her social history. She lives alone. She's cognitively intact. No tobacco or alcohol use. Okay, let's move ahead to our assessment.

So, on vascular assessment, there's no elevational pallor or dependent ruper. Her pulses are palpable but somewhat diminished. Abi on the right is 0.84. Abi on the left is 0.76. There's two plus edema in the left leg.

Her venous filling time is 14 seconds bilaterally. So she has clear evidence of venous disease in that she has two plus edema in the left leg.

She has evidence of mild to moderate arterial disease because her abis are both below 0.9 but well above 0.5. She does have palpable pulses, though they're somewhat diminished. Her venous filling time is in normal range.

So we're like, okay, so she's got evidence of venous disease, two plus edema. She has evidence of mild to moderate arterial disease. On sensorimotor assessment, no response to 5.07 monofilament bilaterally.

Okay, so she's definitely got sensory neuropathy. She has hammer toes, second through fourth toes bilaterally. She has marked callus over the first metheads bilaterally, and she has dry feet.

She's your typical mess. Right? Okay, what about pain? It's minimal in the morning. That's worse at the end of the day.

She describes it as aching pain relief by elevation in ibuprofen. She says she has occasional burning pain in the legs at night, but that's relieved by walking.

So looking at her pain pattern, minimal in the morning, worse at the end of the day. Aching. That's consistent with venous burning. Pain relieved by walking is consistent with neuropathy. Where is the ulcer?

Remember, location is a major consideration, so it's located around the medial malleolus on the left leg. Look at the dimensions, 8.5 by 6.6 by 0.0. So very shallow. Ultra bed is 80% red, 20% yellow fill.

She has large amounts of clear yellow etude, which is resulting in maceration of the surrounding skin. Okay, so now let's try to put it all together. Risk factors don't help. She's got risk factors for arterial venous neuropathy.

Now, the ulcer location and characteristics, the volume of the exudate, are consistent with venous. So remember those three critical factors. Where is it? What does it look like? How much exudate is there? Those are all consistent with venous.

The pain pattern, another critical finding consistent with venous and also with neuropathy. So it looks like her primary issue is venous insufficiency. And standard management of a venous ulcer would be compression plus elevation.

But when we go back to our vascular assessment to rule out any contraindications and to be sure that our impression is correct, we find that the ABI is less than 0.8. So we need modified compression, light compression. What about topical therapy? Well, clearly she's going to need protection of the periwoon skin.

She's going to need an absorptive, probably antimicrobial dressing, for example, an alginate or a foam with silver, or another antimicrobial like your methylene blue, crystal violet polyvinyl alcohol combination. And she needs light compression. When you look back at her sensory motor assessment, then you're like, but that's not all she needs.

Yes, this is a venous ulcer.

And yes, we have to modify our management a little bit based on the fact that she has mild to moderate arterial disease, but she has significant neuropathy. So she needs aggressive foot care, education, she needs correctly fitted footwear. She needs tight glucose control.

We need to teach her to inspect her feet daily and to take the temperature of her foot daily in order to prevent neuropathic ulcers. So you think she was complicated enough, but actually a lot of our patients are just like that.

Typically, the location of the wound, the appearance of the wound, and the pain pattern will point you toward the primary etiology.

Careful review of your vascular assessment data and your sensorimotor assessment data will give you additional information in terms of how you might need to modify your treatment plan and whether or not there are additional factors that need to be to be addressed in comprehensive management. So you always start with a comprehensive assessment. Your vascular status, sensory motor status, ulcer and periwound characteristics and pain pattern.

You determine primary etiology based on wound location, wound characteristics, and pain pattern. You review your data to verify your impression of the primary etiology.

You determine the standard management plan based on the primary etiology, and you modify your primary management plan based on the your vascular assessment data. And then you look back to see is there anything else that needs to be addressed?

And you look at ulcer status to determine appropriate topical therapy. You'll get some more experience in doing this when you do your case studies. You'll get lots of experience once you get to clinical practice.

We just wanted to go over with you the basic guidelines for how you put all your data together. It.