Wound Series Part 1: Assessing Chronic Wounds on Lower Extremities (FL Autonomous Practice INITIAL Diff. Diagnosis)

Wounds have been occurring for thousands of years. The ancient Babylonians, Sumatrans, Egyptians and Chinese (from 2600 b.c. to 1500 b.c.) described several types of wounds and common treatments that included "lint" (some kind of plant fiber), oil, grease, animal fat, honey, resins, or wine (Majno, 1975). Scientific advances have provided modern man with a plethora of evidence-based wound treatment methodologies. While technology has vastly improved, medical treatment science has also demonstrated the effectiveness of similar wound care principles used over 2000 years ago: keep the wound clean, keep the wound bed moist, and protect the wound from infection (Sibbald et al., 2014). However, throughout history and, unfortunately, in modern-day healthcare, far too many approaches to wound care are steeped in tradition rather than scientific evidence (Cowan & Stechmiller, 2009; Gillespie et al., 2014). This educational course is intended to provide the health care clinician with a general overview of evidence-based wound care, focusing on lower extremity wounds. This course is a basic review of acute versus chronic wound healing and a simple initial approach for differentiating and diagnosing common chronic wounds of the lower extremity.

The depth of the wound classifies wounds as either partial thickness in nature (depth of injury only involves the epidermis and sometimes the dermis but not beyond the subcutaneous tissue) or full thickness in nature (damaged tissue which extends down thru the epidermis, dermis, and involves at least some subcutaneous tissue, muscle, tendon or bone (Zulkowski, 2015). Most partial thickness wounds heal without scar tissue formation because they heal by re-epithelialization (Orstedet al., 2018). A superficial epidermal tissue loss is experienced, and this epidermal skin is regenerated by cells readily available at the skin's surface or within hair follicles (mainly keratinocytes). These partial thickness wounds heal faster than full thickness wounds, which involve greater tissue loss and more extensive cellular damage (requiring more complex mechanisms of repair, with many more cell types and chemical messengers involved in the process to coordinate the healing efforts within the wound bed) (Orstedet al., 2018).

Full thickness wound healing takes place by one of three main mechanisms:

1. Primary intention (example: a surgical wound or incision is made in the skin, then the cut edges are brought together and closed with stitches, staples, adhesive strips, or some kind of skin bond).
2. Secondary intention (example: a wound is left open to heal from the inside out and form new/scar tissue).
3. Tertiary intention (example: a surgical wound left open for a time and is surgically closed/approximated at a later date).

Wounds healing by primary intention tend to heal faster than wounds left open to heal by secondary intention. They may heal as fast as partial thickness wounds because the wound edges have been approximated, and the body does not have to build or produce as much new tissue or extracellular matrix (scaffolding) or granulation tissue necessary for scar tissue formation. Since the body is repairing a defect similar to sewing together a torn garment, it takes less resources than manufacturing a patch, filling in the hole, and holding it all together (Norman et al., 2016).

In an acute wound (such as when a teenager falls while skateboarding, causing a small amount of full thickness tissue loss), the pathway to healing is expected to follow progressive phases of wound healing. Some scientists have described three phases or steps, and others describe four or more overlapping phases or steps, but the mechanisms are the same.

Below is an example of one possible approach:

Chief Complaint

Evaluate the patient's chief complaint (wound on the lower leg that is not healing). Note the duration/date of onset (2 months duration).

Possible Etiologies

How did the patient say he got the wound (trauma, stepped on a dirty nail, animal or human bite, maybe the patient does not know)? Mr. Jones says he thinks he must have hit the outer part of his leg on his lawnmower 2 months ago but cannot remember how the wound started. When considering possible etiologies, asking the patient how he thinks he got the wound and why he believes the wound is not healing is important (but realize the patient is not always correct about this). Other information to ascertain about the patient includes what treatments he/she has tried so far and any changes in the wound since wounding.

Describe Past Medical History/Co-morbid Conditions and Physical Limitations

Review important past medical history: Comorbid conditions can lead you to suspect certain etiological factors. Diabetes, hypertension, high cholesterol, or cardiac diagnoses? Peripheral arterial disease (PAD) is likely in patients with an existing diagnosis of coronary artery disease (CAD) or related risk factors (diabetes, smoking, high cholesterol, and hypertension). The distal blood vessels are the smallest, so, logically, the atherosclerotic arterial disease would first affect distal blood vessels before the involvement of the larger coronary arteries is obvious. Respiratory or pneumonia (cardiovascular problems and anemia) are associated with potential wound oxygenation/perfusion issues. Rheumatoid arthritis, Crohn's disease, ulcerative colitis and other autoimmune diseases are associated with impaired wound healing and a higher incidence of pyoderma gangrenosum (an autoimmune disease typically causing chronic wounds, especially of the lower extremities).

Physical limitations are important to note because neuropathies and arthritis in the hands could make dexterity an issue in the patient's self-care of wounds.

Document Allergies

Allergies may lead you to consider why treatment may not have been very successful and what treatments to avoid in the future.

Vaccination History

It is important to ask about (and document) the patient's last tetanus shot, especially if it has been 10 years or more since the last tetanus vaccine or the wound was traumatic/dirty (stepped on a nail, hit lower leg on the lawnmower). Tetanus is a bacterial infection that is now rare (thanks to vaccination) but still very dangerous, and there is no cure. Two out of every 10 people who get it will die. In the United States, deaths attributed to tetanus have dropped by 99% since 1947, largely due to current CDC vaccination guidelines.

Social and Dietary History

Assess and document all pertinent information, including social and current dietary/nutritional information. Pertinent social information (literacy level, health insurance, smoker, place of residence, electricity, running water, a caregiver at home, heavy alcohol or illegal drug use) is important to note and can influence the clinician's diagnosis and treatment options. Management approaches are available to the clinician and the patient. Assess the patient's current nutritional intake and dietary habits (3 meals per day versus 1 meal per day, portion size, types of food). Poor nutritional intake is often overlooked even though adequate nutrition (especially protein and essential micronutrients and amino acids) is imperative for wound healing (Stechmiller & Cowan, 2007).

Medications

The patient's medications (even over-the-counter medications) are also important to document. Corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) are common medications that may impair wound healing (McNichol & Doughty. 2016).

General Exam and Vital Signs

While a focused exam of the wound is reasonable if that is the main purpose of the patient's visit, it is good to document general findings (especially general appearance, hygiene, skin lesions or rashes, edema) and vital signs (blood pressure, pulse, respiration, and temperature), height and weight (useful to calculate body mass index or BMI).

Assess the Wound

Document the wound's location, size and characteristics (left lateral lower leg – you inspect it and note it is just above the malleolus/ankle). The wound size and characteristics should be noted as length x width x depth at deepest point in centimeters (cm) (for our case example: 2.0cm Length x 2.0cm Width x 0.4cm Depth at 6 o’clock). The clock face is visualized over the wound with 12 o'clock always pointing towards the head of the body and 6 o'clock pointing at the foot of the body - as a way to document the exact location of particular features of the wound such as tunneling, undermining, etc. When the wound is measured (Length in cm x Width in cm x Depth in cm), take care to note any tunneling or tracking in the wound bed (and where it tracks to if possible, for instance, if wound #1 tracks to/communicates via tunneling to wound #2) or any undermining present (a "lip" or "shelf" under unattached wound edges). Note the wound bed appearance for the presence of non-viable tissue and describe the color (white, grey, yellow, or black non-living tissue) versus healthy pink or red "granulating" tissue. List the amounts of these tissues in estimates of percentages covering the wound bed. Note any exposed bone, muscle, tendons or ligaments in the wound bed. Be careful not to confuse any exposed tendons or ligaments, which have a linear flat white or yellow appearance, as non-living tissue Drainage is documented as the amount, color and odor (for example, scant amount of clear yellow fluid with no remarkable odor). The location and appearance of the wound provide the clinician with important clues about the etiology or contributing factors to the wound. Physically assess the wound as described above, as well as the surrounding skin and the whole extremity (for example, are there any rashes, lesions or other remarkable findings?).

Pain and Sensation

It is also important to ask the patient about any wound pain and to document their answers. What are relieving or aggravating factors (pain worse at night, when the leg is elevated, or worse after all day on feet and better when elevated at night?) What is their pain level on a scale of 1 to 10, and what is the character of the pain (constant, intermittent, throbbing, etc.)? Also, assess sensation and pain in the affected extremity, especially if the patient has diabetes (McNichol & Doughty. 2016).

Pulses: Check Dorsalis Pedis and Posterior Tibial Pulses

Always assess dorsalis pedis (DP) and posterior tibialis (PT) pulses for any lower extremities wound! Check Popliteal pulses if warranted. In general, if there are strong DP and PT pulses (and capillary refill of the distal affected extremity appears normal/no other circulatory warning signs of arterial, venous or lymphatic insufficiency), they probably do not need further vascular evaluation by a specialist. However, if there are no palpable pulses in the affected lower extremity below the wound level, perform an Ankle Brachial Index (ABI) of both lower extremities. This is a quick screening assessment for arterial insufficiency (Mavrogenis et al., 2018). If this is difficult to obtain, consider referral for further vascular studies such as doppler arterial blood flow studies or transcutaneous oxygen tension (TcPO2) testing to the peri-wound skin (> 40 mmHg is desired) to determine adequate arterial blood supply or perfusion to the affected extremity/wound area (Mavrogenis et al., 2018).

Venous (common characteristics may include):

• In the gaiter area of the lower leg
• May be large wound(s)
• Shallow
• Irregular borders
• Wound bed may be red, and slough (white to yellow non-viable tissue) may be present
• Wound bed may be painful to touch
• Moderate to heavy wound drainage
• Maceration is frequently seen at wound edges
• Pitting edema of the affected leg is common
• Hemosiderin staining is often noted in the involved lower extremity between the ankle and knee
• Pulses of the lower extremity may be normal
• Pain in/around ulcers and affected lower extremity tends to be worse after standing for long periods and when legs are dependent

Arterial (common characteristics may include):

• May first appear as a dark spot on the toes or around the ankles
• May be deeper wound
• Round, punched-out appearance of the wound
• Wound bed may be pale
• More regular-shaped borders which may be smooth or rolled
• Tend to be dry or have minimal drainage
• Hair on the lower leg may be absent or sparse
• Pain is common
• Skin of the affected lower extremity may be shiny and taut
• Pulses in the involved lower extremity may be diminished or absent
• Affected foot/lower leg may demonstrate dependent rubor
• Pain in/around ulcers and affected lower extremity tends to be worse with exercise/walking and when legs are elevated

Diabetic Neuropathic (common characteristics may include):

• Frequently (~50% of the time) seen on the plantar aspect of the foot
• Patient may demonstrate reduced sensation to one or more points of the foot
• Wound bed color, size and depth of wound may be variable
• Wound drainage may be small to moderate
• May start as a blister or injury due to repetitive trauma (pebble in the shoe)
• Callus may precede the wound or accompany the wound
• Musculoskeletal/foot deformities may be noted

Mixed Etiology:

• May have several characteristics of any of the above in combination.
• For instance, diabetics may also have venous insufficiency or diabetic ulcers often have some degree of ischemia / arterial insufficiency.

Atypical Etiology:

• Atypical etiologies for non-healing lower extremity wounds are not discussed in this brief course but may include Pyoderma Gangrenosum, Vasculopathies, Allergic Dermatitis, Previous injury with retained foreign body, Insect bite, Parasitic involvement, or even Cancer (to name a few).

Chief Complaint: Wound on the lower leg that is not healing for 2 months.

Possible Etiologies and Current Treatments: He thinks he originally injured the area by accidentally hitting the edge of the lawnmower. He reports that the wound at the time was dirty with grass clippings, and the lawnmower was rusted at the edges. He reports he cleaned the wound immediately with lots of soap and water and then applied hydrogen peroxide. He does not think he had any retained foreign bodies from the lawnmower because he could not see any part of the lawnmower edge that may be missing. He reports washing it with tap water daily for the past 8 weeks and applying an over-the-counter non-stick pad, securing it with paper tape. He has not used anything else in the wound. He states it seemed better for 1-2 weeks but seems the same, "maybe with a little redness at the edges."

Describe Past Medical History/Co-morbid Conditions and Physical Limitations

A review of the history and physical assessment of Mr. Jones reveals he has a history of diabetes, hypertension, and high cholesterol. His most recent labs (a basic metabolic panel and complete blood count 2 months ago) were all within normal limits, including his last glycosylated hemoglobin (hemoglobin A1c), which was 6.5% 2 months ago, indicating adequate glycemic control. The American Diabetes Association recommends that diabetics maintain a hemoglobin A1c level of 6.5% to 7% to minimize complications of diabetes.

Allergies: Mr. Jones reports no known allergies.

Vaccination history: Mr. Jones's medical record indicates he is up to date on his immunizations, including a Tetanus vaccination 5 years ago.

Social and dietary history: He states he has a high school education, his wife is his caregiver, but he drives himself to his health care visits. He reports that he and his wife have changed their wound dressings daily. He reports having a good appetite and eating 3 meals per day with a hand-sized portion of protein at each of these meals plus 2 small snacks (usually a handful of almonds or 3 to 4 peanut butter crackers or wheat crackers) and cheese).

Medications: He is on standard medication for his hypertension (an ACE inhibitor), a statin for his high cholesterol, and oral diabetes medication (a biguanide). He denies taking any over-the-counter medications recently (such as NSAIDs). He reports taking these medications as ordered for over 2 years with no recent dosage changes.

General exam and vital signs: General impression is a 70-year-old male that appears his stated age. He is neatly dressed, and his appearance suggests good daily hygiene. His skin is thin and somewhat dry, with a leathery appearance on sun-exposed surfaces. His vital signs today are: Oral temperature 98.8 Fahrenheit, blood pressure (BP) is 128/70, radial pulse is 72 beats per minute, respirations are 18 per minute and appear unlabored. He weighs 175 lbs and is 5 foot 10 inches tall.

Wounds Assessment: Mr. Jones has a full thickness wound on his left lateral lower extremity just above the ankle, which measures 2.0cm Length x 2.0cm Width x 0.4cm Depth. The wound bed is 100% pale pink and slightly dry. Drainage is a scant amount of clear yellow fluid with no remarkable odor. The surrounding skin is clear and intact, with slight erythema noted where the tape was securing the dressing to the surrounding skin. Furthermore, the wound is noted to have a "punched out" appearance. Sparse hair growth is noted on both lower legs, and the skin's general appearance on the lower extremities is taught and somewhat shiny. There is no noticeable edema. The skin of his feet and toes feels slightly cooler to touch than the rest of his body. Mr. Jones is also noted to have a hard callus over the plantar aspect of the 2nd metatarsal head on his left foot, but no open wound or drainage was noted in this area.

Pain and Sensation: Mr. Jones also demonstrates decreased sensation in the plantar aspect of both feet. A 10 g Semmes Weinstein monofilament examination (SWME) of at least 3 points (the plantar aspect of the big toe, 3rd metatarsal, and 5th metatarsal) is used in diagnosing diabetic peripheral neuropathy (DPN). Some texts recommend 4 to 10 sites for this test on each foot (1st, 3rd, and 5th toes and metatarsal heads, medial and lateral foot, and dorsal surface between 2nd toe and great toe). This test has a positive predictive value of 87% to 100% (95%CI of 74% to 100%). Mr. Jones demonstrated decreased sensation in 2 out of four touchpoints, indicating he is at risk for diabetic foot ulcer and amputation and a need for protective footwear. Most diabetic foot ulcers occur on the plantar aspect of the feet, particularly over the metatarsal heads and heels. These are frequently (but not always) preceded by callus formation (Mavrogenis et al., 2018). Mr. Jones reports wearing "work boots" at home most of the time and is wearing sneakers today.

Pulses: Capillary refill of his toes seems to be around 3 seconds or perhaps slightly more sluggish in the toes of the left foot. Both left and right pedal pulses and posterior tibial pulses are very weak and difficult to palpate (the right is slightly stronger than the left), and an ABI is performed, which reveals ABI on the left of 0.70 and ABI on the right of 0.80. An ABI of <0.9 indicates mild arterial insufficiency; ABI of less than 0.8 indicates moderate arterial insufficiency, and an ABI of < 0.6 indicates severe arterial insufficiency (ischemia). If ABI results were over 1.2, one would expect a false high due to decreased elasticity of the blood vessels, which may occur in diabetics and with atherosclerotic changes. In that case, we would have considered transcutaneous oxygen tissue perfusion (TCPO2) tests (requiring expensive equipment) or simple toe pressures as the screening test of choice (toe systolic blood pressure of at least 40mm/hg would indicate adequate arterial blood flow to the lower extremity).

Given the above clinical information, Mr. Jones' open full-thickness wound on his left lower leg just above the ankle is most likely a non-healing ulcer with some arterial insufficiency. However, it is also likely complicated by his diabetes and wound care (see another CEUfast, Inc. wound course for evidence-based wound dressing selection tips). Diabetes affects the human body's sensory, motor and autonomic factors, which may impair wound healing. Sensory factors include hyperglycemia disrupting myelin sheaths (which protect nerves). This demyelination can slow down nerve conduction and impair sensory perception. Motor factors: Diabetes is also known to increase atrophy of the foot muscles and may cause contractures of the Achilles tendon and subluxation of metatarsophalangeal joints, resulting in foot deformities and gait abnormalities.

Regarding Autonomic factors: Diabetes is associated with loss of some vasomotor control, impaired skin microvascular perfusion, bone flow hyperemia, and arterial-venous shunting, which may lead to anhidrosis, skin fissure formation, fungal skin and toenails, peripheral edema, callus formation, and Charcot formation. Other factors that may impair wound healing in diabetic foot ulcers may be related to the chronic wound microbiome or bacterial load in the diabetic foot (Zhao et al., 2013). The fact that he has kept the wound bed mostly dry and just covered it with a non-stick pad daily may also have impaired wound healing (moist wound beds tend to improve faster than dry wound beds).

Mr. Jones' plantar callus indicates a diabetic neuropathic etiology and requires immediate preventive attention (off-loading shoes) before additional ulcer development in this area. If the open wound were on the plantar aspect of his foot, especially over a callused or insensate area such as a metatarsal head, the etiology would most likely be diabetic peripheral neuropathy. If the wound was over a toe in a diabetic, it could likely be a mixed etiology (peripheral neuropathy and arterial insufficiency) unless a clear mode of injury could be established in a foot with strong pulses or good toe pressures but sensory impairment. Recommendations for Mr. Jones could include referral to a wound specialist, podiatrist, or vascular specialist. In the meantime, reinforcing Mr. Jones has been doing very well at his medication and diet compliance, compliment him and his wife for trying to walk a mile 2-3 times per week. Studies indicate that progressive walking may improve peripheral arterial circulation and claudication symptoms (Treat-Jacobson et al., 2018). Key components for any treatment plan for Mr. Jones should include addressing his arterial insufficiency and evaluating it further, addressing wound care principles and wound care education with the patient and his wife, and asking him to record his fasting blood sugars daily for 2 weeks (diabetics may see a rise in their blood sugars as one of the first indicators of infection). Recommendations may also include repeating labs that will check his CBC (looking for anemia and any elevation of White Blood Cells), zinc and vitamin D levels (deficiencies may impair wound healing), and prealbumin (prealbumin is a serum biomarker of nutritional status) of < 20 may indicate a higher risk of impaired healing or infection (Salvetti et al., 2018).

Chief Complaint: Mrs. Smith is a 68-year-old non-smoking female seen in urgent care for worsening edema of both legs and a large open wound on her right leg of 6 months duration.

Possible Etiologies and Current Treatments: Mrs. Smith reports she does not know what caused the wound. She denied any injury and reported it showed up on her right leg one day as about a quarter-sized sore but has gotten bigger. Her edema has gotten worse too. She states she has been wrapping gauze around her legs a few times daily and trying to stay off her feet. She says she sits at home with her legs under a desk, sewing.

Describe Past Medical History/Co-morbid Conditions and Physical Limitations: Mrs. Smith is overweight with a BMI of 35 and a history of hypertension and hypothyroidism. Other than hypertension (well controlled), she has no known history of cardiovascular disease or congestive heart failure (CHF). Mrs. Smith reports she has had "problems with swelling in my legs for a few years." She says the swelling grows worse as the day progresses but is better when she first wakes up or keeps her legs elevated for several hours. She reports she has not been wearing her compression stockings, which her primary care health care provider ordered last year, because she could no longer pull them on herself. She denied any recent fever, chills or severe pain.

Allergies: Allergic to bananas and possible latex allergy (gets a rash).

Vaccination History: Current vaccinations are up to date, except there is no record of recent tetanus vaccines within the past 10 years.

Social and Dietary History: Non-smoker, widow, lives alone with 2 cats. Reports eating 2 meals daily (tends to be heavy carbohydrates and low on protein) and frequent snacks (more carbohydrates like cookies and chips with occasional fruit).

Medications: Beta-blockers for hypertension, levothyroxine for hypothyroidism. The patient reports rarely missing any doses.

General Exam and Vital Signs: Overweight appearing female who looks slightly older than 68 years. Walking with unsteady gait and slightly disheveled appearance with musty odor noted. Vital signs: Temperature is 98.6 degrees Fahrenheit, a radial pulse is 88 beats per minute, blood pressure is 138/84, and respirations are 22 per minute. Height is 5 feet and 3 inches, weight is 200 lbs.

Wound Assessment: The exam reveals a 5cm L x 4cm W x 0.2 cm D wound on the anterior-lateral aspect of her right lower leg above the ankle but below the knee in the gaiter area of the leg). The wound bed is 80% red/viable tissue and 20% scattered yellow, loose slough/non-viable tissue (resembles chicken fat). The skin around the wound is macerated (white edges from excessive moisture), and a moderate amount of clear/serous wound drainage is noted to have saturated the gauze wrap and dressing that was removed from the wound, which Mrs. Smith says has only been on the wound for a few hours. In addition, Mrs. Smith has 2+ pitting edema bilaterally, and the skin on her legs appears tight with a brownish discoloration noted (hemosiderin staining) to the skin just above the ankles to about one handbreadth below the knees bilaterally. The skin temperature of her feet and toes is warm but not warmer than the skin of the rest of her body, and no unusual erythema is noted in either lower extremity. She also reports that the wound on her lower right leg has been "weeping an awful lot," so she must change the bandages frequently/several times daily.

Pain and sensation: Mrs. Jones reports her pain level is a dull "aching pain" that worsens as the day progresses (currently about a "2" or "3" on a scale of 1 to 10), but she reports it feels better when her legs are elevated.

Pulses: Bilateral pulses of her lower extremities are all 3+ and equal. Capillary refill is <3 seconds in all toes.

Given the above clinical information, Mrs. Smith's wound is likely a venous leg ulcer due to venous insufficiency. The gold standard treatment includes compression therapy, which the patient states have been ordered for her in the past. She may need to be re-measured for the correct size compression stockings (2 pair every 6 months is typical), and consideration for zippered stockings or some sort of device which may help her apply them herself could be helpful. A wound specialist consult could address these issues. Recommendations to be considered for Mrs. Smith also include (but are not limited to):

1. Updating her vaccinations (offering a tetanus vaccine since it has been over 10 years).
2. Dietary consult / patient education addressing nutrition and weight.
3. Reviewing her medical records or evaluating labs for recent CBC, any nutritional deficiencies (e.g., serum zinc, vitamin D, B-12), and current thyroid hormone levels (under-treated hypothyroidism is linked to poor wound healing).
4. Evaluating her wound care and hygiene practices (does she know she can remove the dressing and get in the shower?).
5. Patient education (help develop an exercise plan; review venous insufficiency contributing factors such as sitting long periods, dependent feet, lack of calf-pumping movement; the need for compression (on in am and off in pm when going to bed).
6. Appropriate wound dressings under compression that will promote wound healing and help manage peri-wound maceration (if any treatment is started, she should be re-checked in 2 weeks, and if the wound is not improved, other etiologies could be considered as well as more in-depth evaluation related to possible infection and compliance with treatment/compression).

This concludes a fundamental overview of the 3 most common etiologies for lower extremity ulcers (diabetic neuropathy, venous insufficiency and arterial insufficiency). Other etiological considerations such as lymphedema, vasculitis, or atypical/unusual etiologies may be discussed in future wound modules.

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