Leg ulceration: a complex case scenario

Keywords: Chronic venous ulceration; ABPI; chronic infection; pain management; compression therapy.

Case history

Barbara is an 80 year old woman with severe chronic venous ulceration. She developed her first ulcer in her late 20s. Since then she has had more than 10 episodes of ulceration, each event taking longer to heal. The current ulcer has been present for over seven years with little evidence of healing. Barbara has repeated bouts of infection for which she is given broad spectrum antibiotics, but the intervals between infections are becoming shorter and the chronic oedema increasingly difficult to control. Barbara presented to a community ulcer clinic for assessment of her worsening condition. She was accompanied by her daughter.

On presentation the ulcers were found to extend across the dorsum of the foot and over the malleoli. They were partially sloughy with areas of granulation. The site of ulceration is relatively rare in venous ulcer patients and was due to previous infection and maceration from wound exudate, which ran over her foot. She had a foot deformity and fixed ankle joint. Shortening of her Achilles tendon prevented her placing her foot on the floor and she had considerable muscle wasting. Barbara rated the pain in her leg on a visual analogue scale (VAS 1-10) as extreme (9), but commented that the pain increased if she attempted to move her ankle joint. Her daughter said that her mobility had decreased dramatically and that she spent most of the day in a chair. Further questioning revealed that she experienced pain over the plantar surface and there were extensive callouses under the metatarsal heads. Barbara had received numerous treatments over the years with little effect.

Assessment

Assessment included an evaluation of the patient's resting ankle brachial pressure index (ABPI). However, it was recorded in the notes that Barbara was unable to lie completely flat during the ABPI assessment due to osteoarthritis of the spine. This can increase the risk of an inaccurate reading (see Doppler assessment and ABPI). In addition, the nurse was unable to palpate the pedal pulses due to the presence of fibrotic tissue.

Table 1: Assessment of ABPI

Right ABPI (0.95)		Left ABPI (0.95)
Brachial	140	Brachial	143
Dorsalis pedis	150	Dorsalis pedis	149
Posterior tibial	142	Posterior tibial	140
Anterior tibial	139	Anterior tibial	139
Peroneal	143	Peroneal	145

During the Doppler ultrasound, the nurse noted that there was a good triphasic flow in all vessels, indicating the absence of arterial disease. Barbara's previous medical history revealed no other cardiovascular disease and that she was a non-smoker. A full blood screen revealed an elevated ESR (erythrocyte sedimentation rate), possibly indicative of a chronic infection and reduced haemoglobin of 10 g.

Barbara was underweight and complained of feeling tired; her skin appeared dry and flaky. Her daughter informed staff that she had a very small appetite and was experiencing colicky abdominal pain and diarrhoea intermittently.

In view of her long history of unhealed ulceration and following discussion with the general practitioner, Barbara was referred for vascular assessment. Duplex ultrasonography revealed an incompetent long saphenous vein at the sapheno-femoral junction on both limbs and evidence of a previous deep vein thrombosis in the popliteal vein of the ulcerated limb. Back flow due to loss of function of the valves in this vein had resulted in venous stasis and oedema, making Barbara very susceptible to leg ulceration. Venous surgery, however, was not undertaken due to her fixed ankle (which also dramatically reduces venous return), poor wound healing potential and general condition.

Outcome

The aim of the treatment programme was to identify factors that were delaying healing and attempt to correct them.

Management of diarrhoea

There was little clinical evidence of cellulitis and wound bacteriology failed to identify a pathogenic organism or why Barbara had received long-term, broad spectrum antibiotics. These were discontinued with a subsequent improvement in her diarrhoea.

Poor nutrition and anaemia

A nutritional assessment revealed a number of problems and the patient was referred to a dietitian for advice. An iron supplement was commenced to correct her anaemia.

Anxiety and depression

Assessment revealed the degree of helplessness and hopelessness the patient felt concerning her condition. She completed the Hospital Anxiety and Depression scale - a useful tool to identify patients with anxiety and depression. Although the scores were quite high (8 and 9) they were not in the range to suggest the presence of clinical anxiety or depression. However, close monitoring of Barbara revealed a deterioration in her condition. Many of the issues raised by the patient related to the intrusion of symptoms such as pain and decreasing mobility. She expressed demoralisation with the professionals who promised healing, but yet did not achieve this.

Reduced mobility

A number of professionals were involved in the treatment programme. Physiotherapy was started in an attempt to improve ankle function. However, only a 10% increase in movement was achieved and Barbara found sessions very painful. Hydrotherapy was suggested but was not carried out because of the issues of infection control. Barbara was taught a range of active and passive movements to try and maintain residual mobility. An orthopaedic consultant was unwilling to operate given her long-term wound healing problems.

Orthotic and podiatry assessment proved useful. Callus removal was undertaken on a monthly basis and pressure off-loading insoles were prescribed. Barbara was then fitted with made-to-measure boots that incorporated the insoles and accommodated her bandages.

Pain and oedema

Treatment of the ulcer involved the use of siliconised wound dressings to prevent pain and trauma. Barbara was advised concerning the appropriate use of analgesia as it was apparent that she normally waited until the pain became severe before taking her medication. Regular use of paraffin-based emollients helped to increase skin hydration and prevent complications such as varicose eczema. Compression was applied using a four-layer bandage system. Elastic (long-stretch) bandages, which exert high compression during rest and exercise, were chosen in view of her poor level of mobility.

Barbara's ulcer took nine months to heal, during which time she experienced considerable improvement in her quality of life. Pain improved within the first few weeks of treatment and although her mobility remains very poor, she is now able to go out and socialise. She remains at great risk of reulceration and continues to attend for follow-up compression and hosiery.

Conclusion

This case history gives an insight into the consequences of poor practice. This resulted in the protracted length of time in achieving healing in this patient. Effective care, involving the multidisciplinary team, can dramatically improve outcome in patients with chronic venous ulceration and in so doing reduce the months and years of needless suffering.