top of page

LOWER EXTREMITY

WOUNDS

 

If you are a nurse and would like to learn more about wound care and become wound certified, please contact us at(866) 968-6380 to register for a live course or register for our online course at https://www.collegeltc.com/online-course

Dry Eschar

818fef_5dfc6c32b38a407caaff5700667df322~mv2.jpg.avif

This is a dry eschar of the heel. The eschar acts as a biologic dressing and should not be debrided, unless there is underlying infection as noted by draining pus. Patients who have lower extremity ulcers of any kind should always have peripheral arterial disease, venous insufficiency, and diabetic disease ruled out as a a cause prior to classifying the wound as a pressure ulcer. The appropriate assessment for vascular disease can be seen below. Recommended treatment is to offload the heel with proper devices or pillows. Heel protectors are not a recommended form of offloading. The site should be kept clean, dry, and intact. Certain dressings and ointments can be used on these wounds which include but are not limited to 1. Granulex, 2. Xenaderm, 3. Proderm, 4. Betadiene (controversial), 5. Iodosorb (controversial), or cover with gauze without ointments or creams.

Prevalon Boots

818fef_3ce41561ccd74de4a81d409f365b67ad~mv2.jpg.avif

Prevalon boots are appropriate offloading devices for lower extremity wounds, as they remove pressure contact from the surface of the heel and malleolus.

Dry Gangrene

818fef_e45d79e17cbe4dd2b80ccca71162634a~mv2.jpg.avif

Dry Gangrene of the lower extremity and distal toes must be managed carefully, as it can rapidly decline into wet gangrene, which is life threatening. In general Dry Gangrene is a localized process without evidence of cellulitis, no purulent drainage, no evidence of systemic infection, with fever, or septic symptoms. Dry gangrene can be managed expectantly, but may decline. Wet gangrene must be treated with systemic antibiotics and removal of infection either with amputation or aggressive debridement. Proper treatment for Dry Gangrene is to protect the area from trauma, and can be managed by keeping the area dry and clean. Because the majority of these wounds result from vascular disease, all pressure should be removed with specialized cages for bed sheets, do not use socks, etc.

The Medial Malleolar Artery 

818fef_ca82029249c24d20b350d223f063ca78~mv2.jpg.avif

Palpation of Medial Malleolus pulse to assess for clinical arterial disease. The medial malleolar artery is located  behind the tendons of the extensor hallucis longus and tibialis anterior muscles, to the medial side of the ankle.

After Treatment

818fef_47f76b991fd846668dee641fcac00723~mv2.jpg.avif

Heel protectors are not an appropriate offloading device, as they do not offload the heel from the mattress surface.

Advanced Healing Cases

818fef_5c67828d923042e7b1b073d83c904983~mv2.jpg.avif

Debridement procedure

Advanced Healing Cases

818fef_8e7ce68eee0347efba903e88d2ca3dfc~mv2.jpg.avif

Healing process

Advanced Healing Cases

818fef_c2fbb93834f74bdb9a0f9b349a05f189~mv2.jpg.avif

The case above was initially referred for lower extremity amputation. After the family refused amputation and the patient was admitted to a nursing facility, the case was referred to Skilled Wound Care for limb salvage. Vascular work-up demonstrated complete occlusion of the lower extremity arterial supply. The wound was initially debrided to remove infected tissue, not healing. However, after a month of bedside treatment with serial surgical debridement, application of enzymatic debriding agent Santyl, the wound started to heal and develop granulation tissue. After approximately 3 months greater than 80% of the wound epithelialized and the wound eventually re-epithelialized. The case above once again represents healing even in the most challenging arterial wounds, antithetical to what is normally taught in medical texts.

Advanced Healing Cases

818fef_0ab9745788064b2aa33c6c559f5bb80b~mv2.jpg.avif

The case above was initially referred for lower extremity amputation. After the family refused amputation and the patient was admitted to a nursing facility, the case was referred to Skilled Wound Care for limb salvage. Vascular work-up demonstrated complete occlusion of the lower extremity arterial supply. The wound was initially debrided to remove infected tissue, not healing. However, after a month of bedside treatment with serial surgical debridement, application of enzymatic debriding agent Santyl, the wound started to heal and develop granulation tissue. After approximately 3 months greater than 80% of the wound epithelialized and the wound eventually re-epithelialized. The case above once again represents healing even in the most challenging arterial wounds, antithetical to what is normally taught in medical texts.

Advanced Healing Cases

818fef_5e6726462b56482e8279e1097ae9d1e4~mv2.jpg.avif

The wound on the left is a characteristic Venous Stasis Ulcer (VSU). VSUs are typically wet, draining wounds in the lower leg; versus arterial ulcers which are typically dry wounds. VSUs are usually located on the medial aspect of the leg and malleolus.

Blister

818fef_d11453277ebf4191a0e3941d877ddd78~mv2.jpg.avif

This is a blood filled blister of the heel. Blood blisters are classified as suspected Deep Tissue Injury according to the NPUAP guidelines. In general these should not immediately be classified as pressure ulcers, as they may be caused by underlying vascular or diabetic disease. A proper assessment and work-up must be done prior to diagnosis. These blisters should not be popped, opened, or unroofed. They must be left intact, clean, and dry. Certain dressings and ointments can be used on these wounds which include but are not limited to 1. Granulex, 2. Xenaderm, 3. Proderm, 4. Betadiene (controversial), 5. Iodosorb (controversial), or cover with gauze without ointments or creams.

Wound Care

818fef_e75a236447b143c981e38417809bf7ee~mv2.jpg.avif

Great care must be taken when applying wound dressings in the form of kerlix gauze wraps to wound dressings. If the wrapping is too tight it may cause further arterial occlusion and the formation of additional wounds.

Dorsalis Pedis Pulse

818fef_47be62ca602342a299b958eff0d8f755~mv2.jpg.avif

Assessment of the dorsalis pedis pulse is an important component in determining the etiology of the lower extremity chronic wound. The dorsalis pedis artery can be palpated or found lateral to the extensor hallucis longus tendon on the dorsal surface of the foot, distal to the navicular bone.

Foot Ulcers

818fef_d42625424801423bb682c021f4f26191~mv2.jpg.avif

Diabetic foot ulcers are notoriously difficult to heal. Diabetes is a disease which leads to insulin resistance and elevated blood sugars. Over time the disease causes medium and small sized arterial calcification, visual impairment, sensorimotor decline, and impaired immunity. Diabetic ulcers result from trauma in patients who have advanced diabetes. The wounds must be protected and kept clean. Diabetes is the leading cause of amputations in the United States. Poorly controlled blood sugars can lead to further worsening of lower extremity diabetic ulcers. The wound above is a chronic wound with 100% granulation tissue in the wound and a calloused edge. Calloused edges are a result of over growth of keratinocytes, important wound healing cells. These edges must be sharply debrided for ingrowth of new tissue. In addition healthy granulating tissue beds like those above can be treated with hydrogels, collagens, and other dressings. Regranex, Platelet Derived Growth Factor, is an optional FDA approved ointment for healing diabetic ulcers.

Advanced Healing Cases

818fef_a82f770ede6846a4a1d636ac3cb9a490~mv2.jpg.avif

Before treatment

Advanced Healing Cases

818fef_6e7e6748759944cd84509100f1d40947~mv2.jpg.avif

After debridement

Advanced Healing Cases

818fef_b692209034b34ad29d392097601cbf60~mv2.jpg.avif

The wound above was treated by the SWC practice over a year after it was found to have underlying infection and lifting eschar. This PAD ulcer was challenging to heal. The wound was healed over a year with multiple bedside serial surgical debridements, aggressive offloading, and Medihoney as the dressing. Contrary to the standard dogma, vascular ulcers in the lower extremity can heal with aggressive care. SWC has pioneered techniques using advanced dressings and bedside staff education to allow healing in even the most challenging cases.

Advanced Healing Cases

818fef_94a1e5c14e2340fb82baeb3919c71eff~mv2.jpg.avif

The case above was initially referred for lower extremity amputation. After the family refused amputation and the patient was admitted to a nursing facility, the case was referred to Skilled Wound Care for limb salvage. Vascular work-up demonstrated complete occlusion of the lower extremity arterial supply. The wound was initially debrided to remove infected tissue, not healing. However, after a month of bedside treatment with serial surgical debridement, application of enzymatic debriding agent Santyl, the wound started to heal and develop granulation tissue. After approximately 3 months greater than 80% of the wound epithelialized and the wound eventually re-epithelialized. The case above once again represents healing even in the most challenging arterial wounds, antithetical to what is normally taught in medical texts.

Advanced Healing Cases

818fef_2a7951fb2cff41b98985c87d4191708b~mv2.jpg.avif

Advanced case of a right lateral foot wound with exposed bone noted with slough and necrosis. It was debrided at bedside in the nursing facility setting. The 5th metatarsal bone was excised to reveal healthy bleeding tissue. Although it has been noted that wound healing cannot occur over exposed bone, Skilled Wound Care has proven the opposite here.

References

  1. Peripheral Vascular Disease Author: Everett Stephens, MD, Medscape Reference.

  2. Prevalence of peripheral arterial disease in patients at non-high cardiovascular risk. Rationale and design of the PANDORA study Claudio Cimminiello, Claudio Borghi, Serge Kownator, Jean Claude Wautrecht, Christos P Carvounis, Stefanus E Kranendonk, Beat Kindler, Mario Mangrella BMC Cardiovasc Disord. 2010; 10: 35. Published online 2010 August 5. doi: 10.1186/1471-2261-10-35

  3. Alzamora et al, Peripheral Arterial Disease Study (PERART): Prevalence and predictive values of asymptomatic peripheral arterial occlusive disease related to cardiovascular morbidity and mortality BMC Public Health 2007, 7:348

  4. Joseph E Grey and Keith G Harding. Venous and arterial leg ulcers. BMJ. 2006 February 11; 332(7537): 347–350.

  5. The treatment of venous ulcers of the lower extremities. Lonnie L. Whiddon Proc (Bayl Univ Med Cent) 2007 October; 20(4): 363–366.

  6. Vincent Rowe. Diabetic Ulcers. Online Medscape Reference.

  7. Edwards J et al. Debridement of Diabetic Foot Ulcers. Cochrane Database Syst Rev.2010 Jan 20;(1):CD003556

bottom of page