3 ER CURSO LATINO AMERICANO DE CICATRIZACIÓN AVANZADA EN HERIDAS

WOUND DIAGNOSIS AND TREATMENT BY ETIOLOGY

ARTERIAL, VENOUS, NEUROPATHIC/DIABETIC

Tammy Luttrell MSPT, PhD, CWS , FACCWS

Profesora AdjuntoColorado Univerisity, Anschutz Medical Campus

National Jewish Health

WOUND HEALING PHASES

• Acute wounds heal by predictable and timely course of events• Hemostasis• Inflammation• Proliferation

• Granulation• Epithelialization

• Remodeling

CHRONIC WOUNDS

“those wounds that fail to progress through a normal, orderly, and timely sequence of repair or wounds that pass through the repair process without restoring anatomic and functional results”Lazarus, GS, et al. (1994) Definitions and guidelines for assessment for wounds and evaluation of healing. Arch of Derm. 130, 489-493.

CHRONIC WOUNDS

• Characteristics• Necrotic tissue• Bioburden• Chronic inflammation• Impaired hemodynamics• Senescent fibroblasts and keratinocytes• Chronic wound fluid with growth inhibiting proteases• Overgrowth of epithelium with lack of underlying

connective tissue => rolled edges

DIAGNOSING WOUNDS

• By tissue involvement (to determine local care)• Superficial• Partial thickness• Full thickness

• By etiology (to determine systemic care)• Arterial • Venous insufficiency• Neuropathic• Pressure• Atypical

CHRONIC WOUNDS: 90% BELONG TO ONE OF 4 CATEGORIES

Arterial

Venous Insufficiency

Neuropathic/Diabetic

Pressure

04/08/2023 Comprehensive Exam

• Ischemia• Micro or Macro Vascular Disease• Smoking

• Deep Vein Thrombosis (37%)• Recent Surgery, Ankle fusion• Prolonged standing, Pregnancy• Congestive heart failure

• Pressure or Shear• Immobility, Moisture• Decreased Sensation• Poor Nutrition

• Diabetes• Peripheral Vascular Disease• Hansen’s Disease

ARTERIAL WOUNDS

• Caused by ischemia• Usually located at the peripheral extremities• Caused by macro- or microvascular disease

• Macro – obstruction of the larger named arteries by PVD, embolus, thrombus, trauma

• Micro – disease of the small unnamed arterioles and capillaries, usually with diabetes or small emboli after some type of vascular surgery

PERIPHERAL VASCULAR DISEASE

• Arteriosclerosis• abnormal thickening and hardening of the artery

walls• Smooth muscle cells and collagen fibers migrate

into the inner arterial wall and cause it to harden

• Atherosclerosis• Arteriosclerosis in which fat and fibrin deposit on the

inner walls of the arteries• Begins with a fatty streak and then becomes a

fibrous plaque

ARTERIOSCLEROSIS

T H I C K E N I N G O F T H E A RT E R I A L WA L L S

ATHEROSCLEROSIS

C H O L E S T E R O L / FAT D E P O S I T S – S I T E O F M I C R O I N F L A M M AT I O N

PVD – CRITICAL PHASES

1. Collateral circulation insufficient for metabolic needs => shunting of blood to muscles where there is less resistance => delayed healing of traumatic wounds

2. Claudication - pain with activity – most effectively treated with exercise

a. thigh and buttock claudication = aortoiliac or iliac involvement

b. calf claudication = femoral or popliteal involvement

3. Rest pain – requires revascularization surgery• May have “dependent leg syndrome”• May be accompanied by signs of ischemia at distal

digits

MICROVASCULAR DISEASE

• Occlusion of the small arteries too small to be named (<0.5mm)

• Most frequently seen in patients with diabetes• Cannot be treated with vascular surgery• May result in non-healing wounds even after

revascularization

ARTERIAL WOUNDS

• Evaluation• Pulses• Capillary refill time• Rubor of dependency• Skin appearance – shiny, thin, pale, NO hair growth• Condition of nails and hair• Location – distal toes or fingers• Edges – even, punched out appearance• Tissue – dry, necrotic, little or no granulation

ARTERIAL SCREENING

• Pulses• Upper extremity

• Brachial• Radial• Ulnar

• Lower extremity• Femoral• Popliteal• Dorsalis pedis• Posterior tibialis

• Grading• 0 = no pulse• 1+ = barely felt• 2+ = diminished• 3+ = normal• 4+ = bounding

(indicative of aneurysm)

Doppler signal is NOT equal to a palpable pulse!!!

ARTERIAL SCREENING

• Rubor of dependency• Elevate the lower extremity 45°, note slight blanching of

plant surface• Place in dependent position, redness or rubor that takes

30 secs or more to occur• Indicative of arterial disease, usually advanced

ARTERIAL SCREENING

• Capillary refill

• Detects microvascular disease• Press the end of any toe for 2-3 seconds and observe for

blanching• Normal refill is less than 3 seconds

PAD

P U N C TAT E W O U N D S

SMALL TOE NECROSIS DUE TO PAD

BUERGER DISEASE

• Also known as thromboangiitis obliterans• Disease of macrovascular circulation• Occurs in feet and/or hands• More common in men, especially heavy

smokers• Pathology

• Inflammation of the peripheral arteries with thrombi and vasospasm

BUERGER DISEASE

• Symptoms• Pain and tenderness• Redness• Cyanotic skin • Thin shiny skin• Thick malformed nails• Gangrene or ulcers (advanced cases)

Age may assist in diagnosis – usually younger than typical patient with arterial wounds.

Arterial wounds in younger patients indicative of some other pathology.

INVASIVE TESTS FOR PVD

• Arteriogram• Radiographs of

vascular system after injection of radiopaque dye

• Used to determine specific site of lesion prior to by-pass surgery

NON-INVASIVE TESTS FOR MACROVASCULAR DISEASE

• Ankle-brachial index• Doppler arterial waveforms• Ultrasound duplex scanning

• Ultrasound• Doppler

• Color flow doppler scanning• Great toe pressure• Plethysmography (measures volume)• Segmental blood pressure recordings• Exercise stress test

ABI ---ANKLE BRACHIAL INDEX(ABPI-ANKLE BRACHIAL PRESSURE INDEX)

• Where PLeg is the systolic blood pressure of dorsalis pedis or posterior tibial arteries and

• PArm is the highest of the left and right arm brachial systolic blood pressure

ANKLE-BRACHIAL INDEX

• Ratio of ankle systolic pressure to brachial systolic pressure

• Indicates the severity of PVD• Interpretations

• 1.0– 1.2 – normal• 0.8-1.0 – minimal peripheral arterial disease.

Compression for edema control is safe to use.• 0.5-0.8 – moderate peripheral arterial disease, often

accompanied by intermittent claudication. Referral to a vascular specialist is advised. Compression therapy is contraindicated if <0.6; modified compression is indicated if 0.6-0.8.

• <0.5 – severe ischemia with resting pain. Compression therapy is always contraindicated.

• <0.2 – tissue death will occur.

Presión en el brazo derecho e izquierdo

Presión en la arteria tibial posterior y pedia del tobillo derecho e izquierdo

Presión máxima tobillo

derechoPresión máxima

brazo (mm Hg)

Indice tobillo-brazo

derecho=

92 mm Hg

164 mm Hg

=

Presión máxima

tobillo

Presión braquial

máxima

= 0.56=Obstrucción moderada

Por encima de 0.90 – normal

0.71 – 0.90 – obstrucción leve

0.41 – 0.70 – obstrucción moderada

0.00 – 0.40 – obstrucción severa

Interpretación del índice calculado

N Engl J Med 355; august 3, 2006

ANKLE-BRACHIAL INDEX

• ABI > 1.3 is not reliable• Frequently seen in diabetics• Caused by calcification of the arteries resulting in

artificially high systolic pressure• Great toe pressure and toe/brachial index used

instead of ABI• Normal > 55 mmHg pressure• Normal TBI – 0.8-0.99• < 30 mmHg – pt will need revascularization

Indice Tobillo-Brazo

PREVENTION OF ARTERIAL WOUNDS

• No smoking• Control blood sugars• Control hypertension, hyperlipidemia,

hypercholesterolemia• Provide proper foot care (Goodman, p454)• Exercise (Goodman, p 455)

Do not debride Keep area dry; protect toes with

cotton or sterile gauze between toes

Use foot cradle Off-load heels with pillows

Cuidado Pre-Operatorio

No haga desbridamiento. Mantenga el área seca; proteja los

dedos con algodón o gaza estéril entre ellos.

Use una cuna para los piés Descargue los talones con

almohadas Eschar management – Dry and intact, paint with

Betadine, use of dry topical silver. Eschar is the “barrier” substitute.

Disminuya elevación de la extremidad

Eleve la cabecera de la cama 5-7 grados

Mantenga la extremidad caliente Evite ejercicio en exceso

Cuidado Pre-Operatorio

No haga desbridamiento. Mantenga el área seca; proteja los

dedos con algodón o gaza estéril entre ellos.

Use una cuna para los piés Descargue los talones con

almohadas

TRATAMIENTO DESPUÉS DE CIRUGÍA

• Debride wound of necrotic tissue when granulation tissue is visible at the edges (D. Armstrong)

• Provide moist wound environment with the appropriate advanced dressing

• Protect foot with pillows under calves

Desbride la herida con tejido necrótico cuando haya tejido de granulación visible en sus bordes. (D. Armstrong)

Provea un medio ambiente húmedo con el apósito avanzado apropiado.

Proteja los piés con almohadas debajo de las pantorrillas.

Apósitos

Posicionador

Protector

TRATAMIENTO DESPUÉS DE CIRUGÍA

• Off-load wound with orthotic, special shoes, assistive device• Control post-op edema to prevent incisional dehiscence

• Cover incision with dry sterile gauze• Apply short stretch elastic bandage in spiral wrap

Descargue la herida con ortóticos, zapatos especiales, dispositivos.

Controle el edema post-operatorio para prevenir dehiscencia de sutura. Cubra la incisión con gaza estéril seca Aplique vendaje de corta elasticidad en

forma de espiral

GIVE AND TAKE OF ARTERIAL WOUNDS

• GIVE • Blood supply• Protection

• TAKE• Any cause of trauma• Necrotic tissue if signs of infection are

present

VENOUS WOUNDS

• Relate to ≈70% of LE wounds• 500,000-1,000,000 in US• 40% occur before the age of 50• Recurrence rate is as high as 72%• Estimated cost of care $40,000/case

VENOUS SYSTEM

• Superficial veins• Great saphenous• Small saphenous

• Deep veins• Femoral • popliteal

• Perforator veins• Lymphatic system

CHRONIC VENOUS INSUFFICIENCY

• Causes• Reflux as a result of incompetent valves in the perforator,

superficial, or deep veins• Obstruction – e.g. chronic deep vein thrombosis• Lack of venous pump activation during the gait cycle

• Dorsiflexion – calf muscles compress deep veins with up to 250 mmHg pressure

• Plantarflexion – deep vein pressure falls and allows blood to flow from superficial veins to deep veins, through perforators

• Does not occur with ankle hypomobility or gastrocsoleus weakness/paralysis

• Results in venous hypertension and excessive moisture in the interstitial tissue

• Prevents adequate oxygen and nutrients from reaching the skin

VENOUS PUMP

James, R et.al.: Incompetent venous valves: ultrasound imaging and exo-stent repairPhlebolymphology N°56

PATHOPHYSIOLOGICAL CHANGES

• Vessel dilatation and elongation• Increased collagen deposition in both vein

walls and skin• Plasma protein leaks into interstitial space

with resulting fibrin cuff around arterioles• Increased leukocytes with decreased immune

function• Increased inflammatory cells resulting in

tissue remodeling and dermal fibrosis

RISK FACTORS

• Hx of DVT (37%)• Hx of hip/knee/calf surgery• Ankle hypomobility/fusion• Employment involving prolonged standing• Morbid obesity• Pregnancy• Congestive heart failure

Systemic disorders will cause bilateral edema; extremity dysfunctions will cause unilateral edema.

PROGRESSION OF VENOUS DISEASE

• Heavy, aching feeling in legs

• Telegentsia or reticular veins

• Varicose veins• Edema without

ulceration• Skin changes

without ulceration• Skin changes with

ulceration

COMMON SKIN CHANGES – CRITICAL IN DIAGNOSING CVI

• Hyperpigmentation (hemosiderin)• Lipodermatosclerosis• Dilated long saphenous vein• Atrophie blanche • Unlateral or bilateral edema• Dermatitis• Thickened skin• Cellulitis

WHERE ARE ALL THE WOUNDS LOCATED???

WHERE ARE VENOUS WOUNDS LOCATED?

In the gaiter area

VENOUS WOUND EVALUATION

• Girth of arch, malleoulus, calf• Type and amount of drainage• Edges (uneven) and location (gaiter, above the ankle)

• Pulse exam/ABI in case of absent pulses, severe pain, failure to heal with standard care

• Other components of any wound evaluation

VASCULAR TESTS - SCREENING

• Approximation of central venous pressure• Screens for cardiac incompetence as cause of

edema• Jugular distention

• Indicates right ventricular failure• Valve competency with Doppler• Percussion test for saphenous vein

competency• Homan’s sign – not reliable• Ankle-brachial index – r/o arterial component

VASCULAR TESTS/VALVE COMPETENCY

• Place probe over distended vein

• Compress vein 10-15 cm proximally• Audible sound (reflux)

means valves between compression and probe are incompetent

• Compress vein distal to probe• NO audible sounds

indicates venous obstruction

TREATMENT - PREVENTION

• Compression hosiery• Elevation (higher than heart)• Exercise to activate venous pump• Avoid prolonged sitting or standing• Avoid crossing the legs• Skin lubrication

COMPRESSION HOSE

• Class I• 20-30 mmHg pressure• Used for venous disease with skin changes

• Class II• 30-40 mmHg pressure• Used for history of ulceration or severe skin changes

• Class III• 40-50 mmHg pressure• Used for lymphedema, pts who reulcerate with Class II, pts who

work standing (e.g. dentists)• Class IV

• > 60 mmHg pressure

TED hose used for DVT prophylaxis are NOT sufficient for treatment of Chronic Venous Ulcers I!!!

CIRCAID COMPRESSION GARMENT

COMPRESSION HOSE WITH ZIPPER

MAN’S COMPRESSION SOCK

VENOUS WOUND TREATMENT

• Cleanse and debride wound• Apply appropriate primary dressing• Compression therapy

• Support systems – Unna boot• Multi-layer compression bandages – Profore• Long-stretch bandages – Seto-press• Short-stretch bandages – Comprilan• Circ-Aid• Intermittent compression therapy

LAPLACE EQUATION

• P = (TN x 4630) / CW• P = pressure in mmHg• T = bandage tension (in kgf)• N = number of layers applied• C = circumference of the limb (in cm)• W = bandage width(in cm)The pressure gradient between the ankle and calf makes

the compression effective in managing the edema.

Compresión Modificada

Short Stretch Bandages

Cast Padding Conforming Gauze

Modified Compression

INTERMITTENT COMPRESSION THERAPY

• Used as adjunct for wounds that do not respond to other compression methods or for maintenance in severe lymphedema

• Applies compression in sequence, distal to proximal

• Pressure must be less than the diastolic BP (usually ≈50 mmHg)

• Recommend 1-2 hours daily or bid, depending on severity

GIVE AND TAKE OF VENOUS WOUNDS

• GIVE• Protection• Compression• Exercise

• TAKE• Edema• Bacteria• Devitalized tissue

DIABETIC / NEUROPATHIC WOUNDS

• Occur on the foot, usually plantar surface or toes• Caused by mechanical forces or minor trauma• Occur in patients with diabetes, PVD, or Hansen’s

disease because of peripheral neuropathies

INCIDENCE IN DIABETICS

• 18.2 million people in US have DM (6.3% of the total population)

• In certain ethnic groups, % is as high as 14.5%• 15% of people with DM will have neuropathic

ulcer• 14-24% of those with ulcer will have amputation

NEUROPATHIES

• Motor – muscle weakness => changes in the shape of the foot => high peak pressures during weight bearing activities• Caused by damage to large nerve fibers

• Sensory – diminished sensation => lack of protective sensation• Caused by damage to small nerve fibers

• Autonomic – decreases sweat and oil production => dry, inelastic skin• Caused by damage to the large nerve fibers and the

sympathetic ganglion

COMMON FOOT DEFORMITIES

• Pes aquinas – short Achilles tendon• Hallux limitus/rigidus• Hallux valgus• Hammer toes • Cock-up deformity• Varus deformities of toes • Tailors bunion on 5th metatarsal head• Charcot foot – collapse of arch

NEUROPATHIC WOUND CLASSIFICATION

Wagner scale• 0 – at risk due to skin and foot changes• 1 – full thickness skin loss, no infection• 2 – subcutaneous tissue loss, infection• 3 – deep ulceration, infection, osteomyelitis or abscess• 4 – partial foot gangrene or necrosis• 5 – full foot gangrene

WAGNER GRADE 0

AT R I S K D U E T O S K I N A N D F O O T C H A N G E S

WAGNER GRADE 1

F U L L T H I C K N E S S S K I N LO S S

WAGNER GRADE 2

S U BC U TA N E O U S T I S S U E LO S S , I N F E C T I O N

WAGNER GRADE 3

D E E P U L C E R AT I O N , I N F E C T I O N , O S T E O M Y E L I T I S O R A B S C E S S

WAGNER GRADE 4

PA RT I A L F O O T G A N G R E N E O R N E C R O S I S

WAGNER GRADE 5

F U L L F O O T G A N G R E N E

EVALUATION• Risk factors

• Recent trauma, diet, footwear, poor foot hygiene, medications, comobidities

• Subjective history• Skin inspection

• Dry skin with fissures• Calluses• Discoloration in dermal layer (RBCs from deep injury)• Lack of toe and dorsal hair

• Heel inspection• Toe inspection

• Nail condition• Interdigital spaces

• Foot deformities• Shoe assessment

EVALUATION

• Sensory assessment• Vibration test• Pressure assessment with Semmes-Weinstein

monofilaments• Skin temperature - 3° discrepancy is

significant• Reflexes • Musculoskeletal assessment, especially ROM

• Dorsiflexion - 10°• Hallux extension – 50-60°

PREDICTORS OF COMPLICATIONS

• Semmes-weinstein monofilaments• 3.61 (0.4g) = normal• 5.07 (10g) = loss of protective sensation• 6.10 (100g) = total loss of sensation

• Vibration• 128 Hz tuning fork• Measures only yes/no response• Test end of great toe, medial malleolus, tibial

tuberosity• Reflexes

• Diminished due to large motor nerve involvement• Predictable pattern (LE>UE, distal>prox,

symmetrical pattern)

NON-INVASIVE VASCULAR ASSESSMENT

• Pulses• Capillary refill time• Ankle brachial index

• May be unreliable in diabetic if >1.3• Great toe pressure

• Normal is 60-90% of the brachial pressure• Normal TBI is 0.8-0.99

• Exercise stress test• Transcutaneous oxygen tension• Color flow Doppler imaging

TREATMENT - PREVENTION

• Patient education• Blood glucose control • Properly fitting shoes• Nail and callus care• Skin care• Diabetic or molded shoes if foot

deformities are severe

BLOOD GLUCOSE CONTROL

• Normoglycemia – fasting <110mg/dl• Impaired fasting glucose – 110-126• Diagnosis of diabetes - >126• Wound healing requires <200• HB1Ac – < 6.5 for diabetics

PROPER FOOT CARE

• Properly fitting shoes• Daily foot inspection

• Check for red spots, blisters, calluses• Use mirror or family member if necessary

• Proper foot care• Never walk barefoot• Avoid soaking and hot surfaces• Lubricate skin well• Do not use adhesives on skin• Wear thick white cotton socks• Cut nails straight across

TREATMENT OF WOUNDS

• Treat infection (systemic vs topical)• Revascularize if needed• Control blood sugars• Debride wound• Provide moist wound environment• OFF-LOAD

• Pressure redistribution• Special shoes, total contact casting, assistive

devices

T O TA L C O N TAC T C A S T A P P L I C AT I O N

OFF LOADING

OFF LOADING

T O TA L C O N TAC T C A S T W I T H WA L K I N G S O L E

Zapatos

Apósito Acomodativo

GIVE AND TAKE OF NEUROPATHIC WOUNDS

• GIVE• Antibiotics• Blood supply• Moist wound dressing• Protection• Patient education

• TAKE• Bacteria• Necrotic tissue• Calluses• Pressure• Friction

• Comaeu Pass, Glacier National Park

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