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Identify and Treat the Cause - Assessment

Identify Risk Factors and Etiology of Venous Leg Ulcers (VLUs)

History of:

  • Deep vein thrombosis, lower leg fractures, lower leg injuries, varicose veins
  • Protein C, S or Factor 5 clotting disorders
  • Venous insufficiency
  • Episodic chest pain, pulmonary emboli or hemoptysis
  • Heart disease, stroke, transient ischemic attack
  • Diabetes mellitus
  • Peripheral vascular disease (intermittent claudication)
  • Smoking
  • Rheumatoid arthritis
  • Ischemic rest pain
  • Prolonged sitting or standing
  • Bed rest
  • Obesity (causes outflow obstruction)
  • Pregnancy
  • Fixed ankle joint/loss of calf muscle pump
  • Previous vascular tests or surgeries
  • Malignancy
  • Radiotherapy

Odds Ratio of Venous Leg Ulcer NOT Healing in 24 Weeks

Research demonstrates that several factors will influence whether the ulcer is going to heal, which include the initial size of the ulcer and the length of time that the ulcer has been present. For this reason, it may be prudent to ensure that there is a wound care specialist consult for all patients with venous ulcers that are >5 cm² (length X width in cm) and/or if the wound is older than 6 months as these wounds will not generally heal with only moist wound healing, debridement and appropriate compression therapy.

Factors that may affect healing potential

  • Presence of necrosis, foreign body and/or infection
  • Disruption of microvascular supply
  • Cytotoxic (toxic to cells) agents
  • Co-morbidities (i.e. inflammatory conditions, nutritional insufficiencies, peripheral vascular or coronary artery disease)
  • Adherence to plan of care by patient and caregivers
  • Cultural and personal belief systems
  • Access to care
  • Family support
  • Healthcare sector
  • Geographic
  • Socioeconomic status
Predictors of delayed healing
  • ABPI < 0.8
  • Fixed ankle joint
  • Wound base has more than 50% yellow fibrin
  • Wound has been present longer than 6 months
  • Wound is larger than 5cm² (L x W=>5cm²)
  • Patient had previous hip or knee surgery
  • Patient has history of vein ligation or stripping

In addition, the practitioner must assess whether the person with the leg ulcer is willing to wear compression bandages and/or stockings to heal, and then to wear compression ongoing.

Common Signs and Symptoms of Chronic Venous Insufficiency and Venous Leg Ulcers

  • Venous ulcers are may be circumferential and are often located over medial malleolus or gaiter area of leg
  • Ulcers are usually shallow and moist
  • Edema may be pitting or firm
  • Exudate from wound may be minimal or copious
  • Skin changes may include hyperpigmentation, atrophie blanche, lipodermatosclerosis, dermatitis (eczema), woody fibrosis and corona phlebectatica (ankle flare)

Table 2 - Signs and Symptoms of Venous Disease1

Signs and Symptoms of Venous Disease Examples

Varicosities (Varicose Veins)

  • Either small or larger vessels
  • First indicator of chronic venous insufficiency is often the presence of a dilated long saphenous vein on the medial aspect of the calf
Image of varicose veins2

Hemosiderin Staining

  • Brown or brownish red pigmentation and purpura (purplish discoloration of the skin produced by small bleeding vessels near the surface)
  • Caused by extravasation (leaking) of red blood cells into the dermis
  • Insoluble form of storage iron collects within the macrophages and melanin deposition occurs
  • Will not disappear over time (internal cause)
Image of hemosiderin staining3

Chronic Lipodermatosclerosis

  • Lower 1/3 of leg becomes sclerotic (hardened tissue) and woody
  • Leg becomes champagne bottle or bowling-pin shaped
  • Venous ulcers surrounded by extensively fibrotic (excess connective tissue ) skin
  • Ulcers are more difficult to heal
Image of chronic lipodermatosclerosis4

Acute Lipodermatosclerosis

  • Hyperpigmentation and hypopigmentation interspersed with telengectasia or tiny blood vessels on the surface
  • Painful and tender panniculitis (inflammation of adipose tissue)
  • Ulcers can occur within the lesion
  • Becomes intensely fibrotic over time
Image of acute lipodermatosclerosis5

Stasis (Venous) Dermatitis

  • Erythema
  • Scaling
  • Pruritis (itchy)
  • Sometimes weeping
  • May develop cellulitis - portal of entry small breaks in the skin
Image of stasis (venous) dermatitis6

Atrophie Blanche

  • Located on the ankle or foot
  • Ivory white lesions, atrophic plaques
  • Caused by scarring from previous injuries
  • Ulcerations in areas of atrophie blanche tend to be exquisitely painful
Image of atrophie blanche7

Woody Fibrosis

  • Deposits of fibrin in the deep dermis and fat results in a woody induration of the gaiter area (lower 1/3 of calf) of the leg
  • Peri-wound skin is often hardened and indurated, may be thickened
Image of woody fibrosis8

Ankle (Submalleolar) Flare (Corona Phlebectatica)

  • Incompetence in perforating vein valve which results in venous hypertension
  • Causes dilation of the venules
  • Venule sometimes forms tiny bleb that will rupture with +++bleeding
Image of ankle (submalleolar) flare (corona phlebectatica)9

Ulcer Base Moist

  • Shallow
  • Sloping edges
  • Shape serpiginous or “geographic” shape
  • Yellow slough or fibrin
  • Buds of granulation may grow through the yellow fibrin
  • Rarely have black eschar
Image of moist ulcer base10

Ulcer Located In Gaiter Region (Lower 1/3 of Calf)

  • Ulceration is usually on the medial lower leg superior to malleolus but can be on lateral aspect as well or may encircle the entire ankle or leg
  • Ulcers occurring above the mid-calf or on the foot likely have other origins, but may be caused by trauma in a leg with existing venous insufficiency
Image of ulcer located in gaiter region (lower 1/3 of calf)11

Scarring From Previous Ulcer(s)

  • Areas of pale skin and possible fibrosis can indicate previous ulcerations
Image of scarring from previous ulcer(s)12

Brawny Edema

  • A change typical of chronic venous insufficiency, characterized by: thickening, induration, lipodermatosclerosis and non-pitting edema stopping above the ankle
  • the brawny color is due to hemosiderin from lysed red blood cells (RBCs) with chronic ischemia
  • the skin undergoes atrophy, necrosis, and stasis ulceration, surrounded by a rim of dry, scaling, and pruritic skin
Image of brawny edema13

Pitting Edema

  • Can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger x 10 – 15 seconds. If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema
  • It is graded based on the depth of the indentation:
    1+ = 0 - ¼” ; 2+ = ¼” – ½” ; 3+ = ½ - 1” ; 4+ = takes several minutes to rebound
Image of pitting edema14

In Non-pitting Edema

  • Pressure that is applied to the skin does not result in a persistent indentation.
  • Can occur in certain disorders of the lymphatic system such as lymphedema, where edema is particularly prominent on the dorsum of the feet and in the toes.
Image of non-pitting edema15

Fixed Ankle Joint / Impaired Calf Muscle Pump

  • Fibrous or bony ankylosis at the ankle can occur because of immobility (joint assumes the least painful position and becomes fixed)
  • In chronic venous insufficiency, fibrotic tissue deposits due to lipodermatosclerosis also decrease ankle mobility—lose ability to dorsiflex (upper illustration) or rotate (lower illustration)the foot at the ankle.
  • Possible loss of ability to walk normally may occur resulting in ‘shuffling’ and calf muscle not being pumped effectively with the activity of walking
  • This may decrease the chance of healing by 70%
Image of fixed ankle joint / impaired calf muscle pump16


  • Feel pain with deep palpation
  • Describe that their pain is relieved with elevation
  • Describe ache in the leg(s) when standing or walking for long periods of time
Image of leg elevation via cushion17

Identify and Treat the Cause - Obtain a Comprehensive Patient History and Perform a Physical Assessment
  1. Sibbald RG, Orstead HL, Coutts PM, Keats DH. Best Practice Recommendations for Preparing the Wound Bed: Update 2006. Wound Care Canada. Volume 4 Number 1. 2006
  4. Used with permission of Dr. V. Falanga
  8. Photo courtesy of Janine Ahearn
  14. Photo courtesy of Hermell Products Inc

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