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A PRESENTATION ON
WOUND ULCER
BY:
NURSE ABIODUN O.O.
AND
STUDENT NURSE LAWRENCE
Wounds are injuries that break the skin or
other body tissues. They include cuts,
scrapes, scratches, and punctured skin. They
often happen because of an accident, but
surgery, sutures, and stitches also cause
wounds. Minor wounds usually aren't serious,
but it is important to clean them. Serious and
infected wounds may require first aid
followed by a visit to the doctor.
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Depending on the healing time of a wound, it
can be classified as acute or chronic. Acute
wounds heal uneventfully (with no
complications) in the predicted amount of
time. Those classified as chronic wounds
take a longer time to heal and might have
some complications.
Wounds can be open or closed. Open
wounds are wounds with exposed underlying
tissue and/or organs that are open to the
outside environment (like penetrating
wounds). Closed wounds have damage that
occurs without exposing the underlying
tissue and organs (non-penetrating wounds).
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Closed wounds have damage that occurs
without exposing the underlying tissue and
organs (non-penetrating wounds).
Another way to classify wounds is to
determine if the wound is clean or
contaminated. Clean wounds have no foreign
materials
or
debris
inside,
whereas
contaminated wounds or infected wounds
might have dirt, fragments of the causative
agent, bacteria or other foreign materials
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Wound origin can be either internal or
external.
Internal wounds result from impaired
immune and nervous system functions
and/or decreased supply of blood, oxygen
or nutrients to that area; such as in cases of
chronic
medical
illness
(diabetes,
atherosclerosis, deep vein thrombosis).
External wounds are usually caused by
penetrating objects or non-penetrating
trauma,
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a.
b.
c.
d.
and other miscellaneous causes as follows:
Non-penetrating wounds: These are usually the
result of blunt trauma or friction with other
surfaces; the wound does not break through
the skin, and may include:
Abrasions (scraping of the outer skin layer)
Lacerations (a tear-like wound)
Contusions
(swollen
bruises
due
to
accumulation of blood and dead cells under
skin)
Concussions (damage to the underlying organs
and tissue on head with no significant external
wound)
Penetrating wounds: These result from
trauma that breaks through the full thickness
of skin; reaching down to the underlying
tissue and organs, and includes:.
 Stab wounds (trauma from sharp objects,
such as knives)
 Skin cuts
 Surgical wounds (intentional cuts in the skin
to perform surgical procedures)
 Gunshot wounds (wounds resulting from
firearms)
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Miscellaneous wounds may include:
 Thermal wounds: Extreme temperatures, either
hot or cold, can result in thermal injuries (like
burns, sunburns and frostbite)
 Chemical wounds: These result from contact with
or inhalation of chemical materials that cause
skin or lung damage
 Bites and Stings: Bites can be from humans,
dogs, bats, rodents, snakes, scorpions, spiders
and tick
 Electrical wounds: These usually present with
superficial burn-like or sting-like wounds
secondary to the passage of high-voltage
electrical currents through the body, and may
include more severe internal damage.
An ulcer is a sore on the skin or a mucous
membrane, accompanied by the disintegration of
tissue. Ulcers can result in complete loss of the
epidermis and often portions of the dermis and even
subcutaneous fat . Ulcers are most common on the
skin of the lower extremities and in the
gastrointestinal tract. An ulcer that appears on the
skin is often visible as an inflamed tissue with an area
of reddened skin. A skin ulcer is often visible in the
event of exposure to heat or cold, irritation, or a
problem with blood circulation. They can also be
caused due to a lack of mobility, which causes
prolonged pressure on the tissues. This stress in the
blood circulation is transformed to a skin ulcer,
commonly known as bedsores or decubitus ulcers .
Ulcers often become infected , and pus forms.
A leg ulcer is simply a break in the skin of the
leg, which allows air and bacteria to get into the
underlying tissue. This is usually caused by an
injury, often a minor one that breaks the skin. In
most people such an injury will heal up without
difficulty within a week or two. However, when
there is an underlying problem the skin does not
heal and the area of breakdown can increase in
size. This is a chronic leg ulcer.
Wounds on the lower leg are often caused by
problems with veins or arteries, or a combination
of both. The further away from the heart, the
longer wounds may take to heal, particularly in
people over 50 years of age.
Chronic leg ulcers affect 0.6–3% of those aged
over 60 years, increasing to over 5% of those
aged over 80 years. CLU is a common cause of
morbidity, and its prevalence in the community
ranges from 1.9% to 13.1%.
It is thought that the incidence of ulceration
is rising as a result of aging population and
increased risk factors for atherosclerotic
occlusion such as smoking, obesity, and
diabetes. In the course of a lifetime, almost 10%
of the population will develop a chronic wound,
with a wound-related mortality rate of 2.5%
ACUTE LEG ULCER
Acute ulcers are sometimes defined as
those that follow the normal phases of
healing; they are expected to show signs of
healing in less than 4 weeks and include
traumatic and postoperative wounds.
CHRONIC LEG ULCER
Chronic leg ulcer (CLU) also known
as chronic lower limb ulcer is a chronic
wound of the leg that shows no tendency to
heal after 3 months of appropriate treatment
or is still not fully healed at 12 months
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Venous ulcer
Arterial ulcer
Diabetic ulcer
Neuropathic ulcer
VENOUS ULCER
They usually affect older people and are
more common in women. It affects about 1 in
1,000 people in the UK at some stage in their
lives. It gets more common as you get older
and 20 in 1,000 people become affected by
the time they are in their 80s. Venous leg
ulcers can develop after a minor injury, where
persistently high pressure in the veins of the
legs has damaged the skin. They are the
major occurrence of chronic wounds,
occurring in 70% to 90% of leg ulcer cases.
Venous ulcers develop mostly along the
medial distal leg, and can be very painful. A
venous skin ulcer is a shallow wound that
occurs when the leg veins don't return blood
back toward the heart the way they should.
This is called venous insufficiency. These
ulcers usually form on the sides of the lower
leg, above the ankle and below the calf .
Venous skin ulcers are slow to heal and often
come back if steps are not taken to prevent
them. A venous skin ulcer is also called a
stasis leg ulcer.
A venous leg ulcer occurs secondary to
underlying venous disease whereby damage
to the superficial, deep or perforating veins
leads to venous hypertension. The ulcer
usually presents within the gaiter (ankle)
region of the leg and is superficial with
irregular edges. The tissue within the ulcer is
predominantly viable tissue. Exudate volumes
tend to be moderate to high until the
generalised oedema throughout the limb is
controlled through sustained graduated
compression therapy.
Approximately 10% of all ulcers are
arterial ulcers, where there is an inadequate
blood supply to the tissues due to arterial
disease. Feet and legs often feel cold and may
have a whitish or bluish, shiny appearance.
Arterial leg ulcers arise as a result of arterial
disease whereby perfusion through the lower
limb results in a cycle of tissue damage
(ischaemia, hypoxia, necrosis) and the
development of an ulcer.
Arterial disease is either small vessel or
large vessel in origin. Arterial leg ulcers are
usually located from the malleolus (ankle)
level down throughout the foot. They have a
uniform edge and present as a cavity. The
base tissue within the wound bed is often non
viable or pale. Unlike venous leg ulcers,
compression therapy is NOT appropriate for
treatment of arterial ulcers and referral is
required to a vascular specialist. Where
possible the aim will be to revascularise the
limb. If surgical intervention is not
appropriate, wound management products
will be utilised.
The commonest cause of neuropathic
ulceration is diabetes, although they can
affect anyone who has an impaired
sensation of the feet. and many diabetic
patients with neuropathic ulceration will
also have an arterial problem that requires
correction. The principles behind treatment
are to optimise blood supply, debride callus
and dead tissue, treat active infection, and
protect the ulcerated area so that healing
can occur.
This often requires the use of a
protective plaster boot with a window
cut out at the site of the ulcer. Once
healing has occurred, the patient is
fitted with footwear designed to
minimise trauma and protect bony
prominences.
Diabetic ulcers are sores on the leg that
occur in 15% of diabetic patients some time
during their lifetime. The risk of lowerextremity amputation is increased 8-fold in
these patients once an ulcer develops. The
long-term effect of diabetes on the nerves
increases the likelihood of trauma to the feet.
It causes a lack of sensation in the feet, which
makes ulcers more likely to appear. But these
ulcers are often neglected because they don't
cause pain.
If ulcers aren't treated, they can lead to
more serious problems. Diabetic ulcers have
similar characteristics to arterial ulcers but
are more notably located over pressure points
such as heels, tips of toes, between toes or
anywhere the bones may protrude and rub
against bedsheets, socks or shoes. In
response to pressure, the skin increases in
thickness (callus) but with a minor injury
breaks down and ulcerates. Infected ulcers
characteristically have yellow surface crust or
green/yellow pus and they may smell
unpleasant. There may be surrounding tender
redness, warmth and swelling (cellulitis).
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Ulcers may be caused by injury or pressure.
They may also be caused by bacterial
infection and cellulitis, which is an infection
of the skin and its underlying connective
tissues.
Chronic leg ulcers may also be due to skin
cancer, which can be diagnosed by a skin
biopsy of a suspicious lesion.
There are also many less common causes of
ulcers including systemic diseases such as:
scleroderma (hardening of the skin and
tissue), vasculitis (inflammation in a blood
vessel), and various other skin conditions.
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The most common underlying problem
causing chronic leg ulcers is disease of the
veins of the leg. Venous disease is the main
reason for over two thirds of all leg ulcers.
Arterial Disease (caused by the arteries not
working) – about 15% of leg ulcers
Other
causes
(includes
diabetes
and
rheumatoid arthritis as well as some rare
conditions) – about 5% of leg ulcers.In some
cases two or more conditions may be causing
damage at the same time.
Certain conditions have been linked with the
development of leg ulcer
Venous ulcers
 Varicose veins
 History of leg swelling
 History of blood clots in deep veins, i.e. deep vein
thrombosis (DVT) causing post-thrombotic syndrome
(in 5% of cases)
 Sitting or standing for long periods
 High blood pressure
 Multiple pregnancies
 Previous surgery
 Fractures or injuries
 Obesity
 Increasing age and immobility
Arterial ulcers
 Diabetes
 Smoking
 High blood fat/cholesterol
 High blood pressure
 Renal failure
 Obesity
 Rheumatoid arthritis
 Clotting and circulation disorders
 History of heart disease, cerebrovascular disease
or peripheral vascular disease
Diabetic ulcers are more likely occuring if diabetes
is not well controlled by diet and/or medication.
Ulcers are also more likely if there is poor care of
the feet, badly fitting shoes and continued
smoking.
It needs first to be emphasized that if
there is any of the signs or symptoms of leg
ulcers or suspected ulceration, the Doctor
should be consulted first. The features of
venous and arterial ulcers differ somewhat
but usually
will have the following
characteristics.
Venous ulcers
Characteristics of venous ulcers include:
 Located below the knee and most often on
the inner part of the ankles but can be
anywhere around the ankles
 Relatively painless unless infected
 Associated with aching, swollen lower legs
that feel more comfortable when elevated
 Surrounded
by mottled brown or black
staining and/or dry, itchy and reddened skin
(eczema)
 Usually associated with varicose veins due to
incompetence of the superficial venous
system
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May be associated with lipodermatosclerosis,
which is loss of tissue under the skin and in
which the lower part of the leg is hardened
This skin is brown because of leakage of the
capillaries of protein and red blood cells
(hemosiderin) that stain the tissue brown.
Often associated with swelling, which may be
caused by local inflammation. Chronic
(constant or long lasting) inflammation
destroys
underlying
lymphatic
vessels,
causing lymphedema and increased pressure
in the lower leg.
Thickened skin, scaliness, tiny rough bumps
on the lower legs and feet, fissuring, oozing
Arterial ulcers
Characteristics of arterial ulcers include:
 Usually found on the lateral side of the
ankles, feet, heels, toes but not always just
lateral ankle
 Frequently painful, particularly at night in bed
or when the legs are at rest and elevated.
This pain is relieved when the legs are
lowered with feet on the floor and it is
postulated that gravity causes more blood to
flow into the legs, but we do not really know.
Sufferers may find they will hang their legs
over the side of the bed at night, or sit or
stand for relief. (Rest pain)
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The borders of the ulcer appear as though
they have been ‘punched out’ and have a
gray base
Associated with cold white or bluish, shiny skinned feet
There may be cramp-like pains in the legs
when walking, known as intermittent
claudication, as the leg muscles do not
receive enough oxygenated blood to function
properly. Resting just a few minutes will
relieve this pain.
Diabetic ulcers
Characteristics of diabetic ulcers include:
 Diabetic ulcers have similar characteristics to
arterial ulcers but are more notably located
over pressure points such as heels or
between toes or anywhere on the bottom of
the feet where the bones may protrude and
rub on wrinkles in socks or improper fitting
shoes
 In response to pressure, the skin increases in
thickness (or forms a callus) but with a minor
injury breaks down and thus an ulcer is
formed.
 Infected ulcers may have surrounding tender
redness, warmth and swelling (cellulitis).
i.
ii.
iii.
The possibilities of arterial, venous and
neuropathic ulcers have already been mentioned.
Rheumatoid arthritis can produce a vasculitic
ulcer. It is typically deep, well demarcated and
punched-out on the dorsum of the foot or calf.
They may also have venous disease due to poor
mobility, and neuropathy, and possibly
impaired healing due to use of steroids
Systemic vasculitis often causes multiple leg
ulcers that are necrotic and deep. There is
usually an atypical distribution with vasculitic
lesions elsewhere such as nail-fold infarcts and
splinter haemorrhages
Associated diseases include systemic lupus
erythematosus , scleroderma , polyarteritis
nodosa , or Wegener's granulomatosis
iv.
v.
vi.
vii.
Diabetic ulcer is typically on the foot over a
bony prominence. Neuropathic, arterial and
venous components may all contribute
Hypertensive ulcer, due to arteriolar occlusion,
is painful with necrotic edges and is usually on
the lateral aspect of the lower leg
A malignant ulcer may be a basal cell
carcinoma,
squamous
cell
carcinoma
,
malignant melanoma of skin , or Bowen's
disease. They are rare but must be considered if
ulceration does not respond to treatment
Metabolic and hematological disease can also
cause ulcers.
Some of the investigations done for ulcer are:
1. Study of discharging fluid: Culture and
sensitivity
2. Edge biopsy : Edge contains multiplying cells
3. Radiograph of affected area to look for
periostitis or osteomyelitis
4. FNAC (fine needle aspiration cytology) of
lymph node
5. Chest X-ray and Mantoux test in suspected
tuberculous ulcer
6. Check urine for glucose unless the patient is
known to have diabetes. In those with known
diabetes, check the records for diabetic care
and the level of control
7.
7.
8.
If there is any suggestion of active infection take
swabs; however, routine swabs are not
recommended. Active infection should be
suspected if there is
a. Increased pain
b. Enlarging ulcer
c. Cellulitis
d. Pyrexia
Get
blood
tests
for
FBC,
erythrocyte
sedimentation rate (ESR), U&E and creatinine
Patch testing using the leg ulcer series should
be considered for leg ulcer patients who have
eczema or dermatitis
10.
11.
12.
Having checked the brachial blood pressure
in the usual way, check the blood pressure
with a cuff around the calf. A larger cuff will
probably be needed.
Measure both sides. This enables the anklebrachial pressure index (ABPI) to be
calculated and is a more sensitive
assessment of arterial disease than simply
palpating peripheral pulses. Even if the ulcer
is thought to be venous this is important
before pressure bandages are applied
Hand-held Doppler gives a much more
sensitive
assessment
of
ABPI
than
auscultation
13.
Venography gives little functional
information and has been superseded by
duplex imaging, which is indicated for
patients with recurrent or complicated
varicose veins, short saphenous
incompetence, or suspected deep venous
disease. This technique can give a good
functional assessment and can be used to
track abnormalities of the venous
circulation from the ulcer to the site of
incompetence at the proximal vessels.
Superficial venous incompetence is almost
universal and is the predominant cause of
venous hypertension in approximately half
of limbs with venous ulcers, particularly in
younger patients with good mobility.
14.
15.
Venous function in patients with mixed deep
and superficial disease should be
investigated by ambulatory venous pressure
measurements. This involves cannulation of
a foot vein and the use of tourniquets to
occlude incompetent superficial veins to
select those patients who may benefit from
superficial venous surgery
Magnetic resonance Venography has been
used to produce three- dimensional images
that can contribute considerably to the
management of recurrent varicosities
16.
17.
18.
19.
Angiography may be helpful in assessing the
viability of tissue if plastic surgery or
revascularization is considered
Magnetic resonance arteriography can also
be useful
Computerised tomography may also have a
role in both arterial and venous disease
Intravascular ultrasound can be used to
determine plaque volume within the wall of
an artery and/or the degree of stenosis. It
can also discriminate between normal and
diseased components.
Medical treatment aims to improve blood
flow to the area and promote healing of the
ulcer. The type of treatment depends on whether
the wound is caused by problems with veins or
with arteries.
Treatment for arterial ulcers is often urgent.
 Compression bandages must not be used, as this
will reduce the blood supply even further
 Surgery may be needed to clear out the blocked
artery (angioplasty). In some cases, the section of
blocked artery may require surgical replacement
(by-pass surgery)
 In severe cases, the lower leg may have to be
amputated.
Treatment for chronic venous ulceration
includes:
 cleaning the wound: using wet and dry
dressings and ointments, or surgery to
remove the dead tissue
 specialised dressings: a whole range of
products are available to help the various
stages of wound healing. Dressings are
changed less often these days, because
frequent dressing changes remove healthy
cells as well
 occlusive (air- and water-tight) dressings:
ulcers heal better when they are covered.
These dressings should be changed weekly
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compression treatment: boosts internal
pressure, using either elasticized bandages or
stockings. This is particularly effective if
multiple layers are used
medication:
includes
pain-relieving
medication and oral antibiotics if infection is
present
supplements: there is evidence that leg ulcers
may heal faster with mineral and vitamin
supplements, but only if the person suffers
from a deficiency. Zinc, iron and vitamin C
may be used
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skin graft: is a surgical procedure, where
healthy skin is grafted onto the prepared
wound site
skin cancer and infection – if ulcers fail to
heal or if they increase in size, both these
conditions will need to be ruled out
hyperbaric oxygen – this is now an accepted
treatment for ulcers that resist other methods
of healing, such as diabetic ulcers..
Surgery: Very occasionally, for the largest or
very resistant ulcers either a skin graft or an
operation on the veins may be necessary. If
the ulcer is due to varicose veins then these
may be treated, usually once the ulcer has
healed.
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Controlling risk factors can help to prevent
ulcers from developing or getting worse. Here
are some common and sensible ways to reduce
risk factors and promote healing of ulcers and
prevent new ulcers or old ulcers from recurring:
Quit smoking
Management of blood pressure
Control blood cholesterol and triglyceride levels
by making dietary changes and taking
medications as prescribed
Limit the intake of salt (sodium)
Manage diabetes and other health conditions
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Develop a true exercise program for both
arterial and venous problems. For venous
problems walk and exercise daily to keep the
calf muscle pump working properly
Lose weight if you are overweight. If you are
significantly
overweight,
swelling
improvement will be limited until you have
lost weight.
Ask your doctor about aspirin therapy or
other medications to prevent blood clots.
Be very careful not to injure your legs.
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Check your feet and legs regularly by looking
for cracks, sores or changes in color
Moisturize after bathing
Wear comfortable well-fitting shoes and
socks. Avoid socks with a tight garter or cuff.
Check the inside of shoes for small stones or
rough patches before you put them on. You
may require special shoes, such as diabetic
shoes.
If you have to stand for more than a few
minutes, try to vary your stance as much as
possible by shifting weight to different areas
of your feet.
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When sitting, wiggle your toes, pump your
feet up and down and take frequent walks.
If your legs are swollen, elevate you legs
higher than your heart as often as possible
but for at least one hour a couple of times
daily. Water and blood run downhill. A
swollen leg does not heal.
Avoid extremes of temperature such as hot
baths or sitting close to a heater unless you
have checked the temperature with your
fingers.
Keep cold feet warm with socks (SmartWool
brand are great), wear slippers and never go
barefoot even in the house.
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Consult a podiatrist to remove callus or hard
skin.
Only wear compression stockings prescribed
by your doctor. The compression could be
too little or too strong. This is particularly
important for post-thrombotic syndrome, leg
swelling or discomfort and for long-distance
flights or long car trips.
Have vascular ultrasound assessment and
consult a vascular specialist to determine
whether any vein treatment should be carried
out to improve blood flow back to your heart.
Have the arteries checked that carry blood to
your feet to be sure they are adequate for
healing.
Leg ulcer can result in several complications,
including loss of mobility and the risk of
infection.
Immobility
People may find it difficult and painful to
move around if they have a venous leg ulcer. This
immobility can make the ulcer worse, as blood
pressure rises when they are immobile,
aggravating the ulcer. Living with a venous leg
ulcer can also be difficult. Ulcers can be painful
and take a long time to heal, and people may find
out that they need a lot of time off work. For
some people, the loss of independence and
social isolation can cause emotional and
psychological distress. They may be offered
long- term psychological support if it is needed.
Infection
Venous leg ulcers can become infected, so
it is important to look out for any signs of
infection. These include swelling, redness,
pus and increased pain. There may also be
fever and feel generally unwell. If venous leg
ulcer becomes infected, it can be treated
using antibiotics, such as flucloxacillin.
In rare cases, or if an infection is left
untreated, the bacteria could spread and lead
to other conditions such as:
 osteomyelitis - an infection of the nearby
bone which causes fever, nausea and severe
pain in the affected bone.

blood poisoning (septicaemia) - if there is
blood poisoning, you may develop a fever
and headaches, and have vomiting, diarrhea
and rapid breathing.
If there is osteomyelitis or blood
poisoning, you will need to be admitted to
hospital in order to receive treatment with
antibiotics,
which
are
usually
given
intravenously (directly into the vein through a
drip).
Malignant change
In a venous ulcer that has been present
for many months or years, a malignant
tumour may arise. These have many different
appearances but if an ulcer gets worse and
extends despite appropriate treatment, this
diagnosis should be considered.
Your doctor will refer you to a hospital
specialist for a biopsy so that the ulcer can be
examined under a microscope. The treatment
includes removal of the ulcer, including the
malignant area. Sometimes skin grafting is
necessary as part of this treatment.
When Is Amputation Necessary?
Even with preventative care and prompt
treatment of infection and complications,
there are instances when amputation is
necessary to remove infected tissue, save a
limb, or even save a life.
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