37 but due to the progressive nature and clinical presentation of arterial disease , vascular intervention to resolve arterial insufficiency is often required to prevent ischaemia . 7 In practice , this often means treatment decisions for underlying arterial disease will take precedence over those for venous disease . However , in most cases , mild compression can offer relief of venous symptoms in the meantime . 2
Lower-limb assessment and ulcer diagnosis Assessment of the lower limb All patients with leg ulceration should receive a holistic assessment by a competent health professional within two weeks of presentation to a service . 2 The aim of this assessment is to identify underlying risk factors to healing and to diagnose the vascular disease process ( aetiology ).
A comprehensive lower-limb assessment , along with lifestyle , overall health and relevant medical history , can direct management plans via a collaborative approach with the patient . 10 The assessment demands a systematic approach to identify risk factors to healing and avoid longer-term issue . Timely diagnosis of vascular disease is crucial to avoid delayed management . 10
The assessment should proceed in the following order : 1 The whole person , considering intrinsic and extrinsic risk factors to healing ( see Table 1 ). 2 The whole limb , looking for skin changes relating to venous or arterial insufficiency 8 with an ankle-brachial pressure index ( ABPI ) reading in order to exclude arterial disease . 3 Comprehensive wound assessment to understand wound-bed health and inform a management plan . During examination of the lower limb :
• Where possible , expose and assess both limbs from foot to upper thigh . Aim to identify any potential issues on the intact limb for preventive measures .
• Identify and document skin changes relating to venous insufficiency . 8
• Look for oedema from toes to above the knee joint , which is indicative of venous disease . Note the areas affected and the shape and severity of the swelling , as this will guide compression therapy selection .
• Assess calf muscle strength and tone , and patient mobility and flexibility in the ankle joint .
• Check overall skin condition for the presence of dead skin plaques ( hyperkeratosis ) across the lower limb , fungal infection and dermatological conditions such as varicose eczema , as these factors will cause further skin deterioration .
• Assess for arterial disease – note and compare changes in colour and temperature of both limbs , working systematically from toes to top of thigh . 11
• Observe for inflammation ( erythema ) and / or pale , cool peripheries ( pallor / cyanosis ). Be aware of variance in skin presentation in different skin tones . 8 Capillary refill is often measured in practice to test arterial perfusion . Arterial disease can affect the results so they should not be judged in isolation .
• Assess for key red flags of peripheral arterial disease ( PAD ): 11
– Does the patient report intermittent pain on exercise or walking , resolving on rest ( intermittent claudication )?
– Does the patient report pain at night or at rest , resolving on walking or hanging the limb over the side of the bed ( rest pain )?
• If competent to do so , perform a Doppler assessment to establish ABPI .
Table 1 Risk factors for venous leg ulceration 8
Obesity
Reduced mobility or walking
History of DVT
Varicose veins
Trauma or surgery to the lower limb
Can increase pressure within lower-limb veins
Can reduce activation of the calf pump , which helps the blood return to the heart
The obstruction of a blood clot ( thrombosis ) can damage the valves in the veins
Vessels walls stretch due to increased pressure in the veins ( venous hypertension )
Tensile strength of healed skin is reduced , making the tissue more fragile . Surgery can damage veins and reduce ankle mobility / gait
Increasing age Reduced mobility , autoimmune diseases such as arthritis , physiological changes in ageing skin
Chronic oedema
Family history of leg ulceration
History of intravenous drug use
Pregnancy
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Causes inflammatory responses in the skin , can compromise overall skin condition
Although leg ulceration is not hereditary , underlying diseases that cause ulceration often are
Leg ulceration commonly over regular injection sites . Can cause irrevocable damage to vessels
Can increase pressure on the venous lymphatic system . Lowerleg oedema is common in pregnancy and can cause long-term damage to the vessels and valves
Doppler assessment The handheld or automated Doppler assessment is a fundamental element of holistic lower-limb assessment as it helps determine the presence and significance of arterial disease and guides safe compression therapy practice . 11 Despite this , it is estimated that in the UK only 15 % of patients with leg or foot ulcers have a Doppler ABPI recorded in their notes . 3 On completing the Doppler procedure , performing a simple calculation using readings from the ankle and arm provides a ratio figure . Referencing this against a local or national framework of ranges ( see Table 3 ) 1 informs the next steps towards compression therapy and / or referrals for specialist vascular assessment .
A normal range for safe , strong compression therapy is often referenced as 0.8-1.3 . 12 However , obtaining an accurate ABPI can be sometimes be difficult , such as in patients with severe lower-limb oedema or diabetes . 12 Results should therefore never be considered in isolation . 13 Health professionals should be competent in this procedure and use local protocols and referral pathways . 14
Wound assessment The ulcer should be assessed in a systematic way to identify and address factors within the wound bed environment that could contribute to delayed healing . The assessment should begin with history taking as this will help guide the direction of conversation with the patient . 15
Ulcer measurement The size of the ulcer at four-weekly intervals is seen as
17 , 10 a key indicator of progress or deterioration .