-:f~¥~:ffJS~~<

Review

LEG ULCER MANAGEMENT IN

Chronic oedema is a long-term condition as its title suggests. It causes disruption to patients' lives

and can be costly to treat if managed inappropriately. Leg ulcers in patients with chronic oedema

occur more frequently than acknowledged by many healthcare professionals. This client group

requires a specific management plan if the oedema is to be controlled and the ulceration healed.

wound healing (Mortimer andBrowse, 2003). This is due tothe reduced oxygenation ofthe tissues resulting from thepresence of oedema (Casley­Smith and Casley-Smith, 1997

As such, skin damage to anoedematous limb may leadto ulceration. Ulceration can

also follow superficial infection(Figure 1).

Approximately 70% of leg ulcersare caused by venous disease(Callum, 1992). The underlyingcause is venous hypertension,which can with time result inchronic oedema. It is therefore

Figure 1. Ulceration can follow a superficial infection in the oedematous limb(Courtesy of St. Giles Hospice).

provided care for patients withnon-cancer related lymphoedema(Moffatt et ai, 2003).

A further study by Morgan etal (2005) assessed communitynurses' knowledge and skill in thecare and management of patientswith lymphoedema as adequateor poor. It was found thatcommunity nurses were uncertainof their role in conjunction withother professions caring for thispatient group.

Although chronic oedema isnot directly responsible forulcer development, it will affect

Tracy Green isa Macmillan

LymphoedemaClinical Nurse

Specialist, Calderdale& Huddersfield NHSFoundation Trust

Lymphoedema is a chronic(long-term) condition, that is alsoreferred to as chronic oedema. It

is characterised by swelling of anypart of the body resulting fromfailure of the lymphatic system. Itis often thought of as a sequel tocancer treatment, predominantlyin breast cancer patients (Armeret ai, 2004; Stanton et ai, 2006).However, a study carried out in aLondon primary care trust (PCT)concluded that chronic oedema

is as common as leg ulceration,with a crude prevalence of 1.33per 100,000 people, rising toone per 200 people over theage of 65 years (Moffatt et ai,2003). Furthermore, the studyidentified that more than half of

all patients were suffering fromchronic oedema associated with

poor venous function (also knownas Iymphovenous oedema) andprimary lymphoedema.

The study also highlighted thata number of patients were notreceiving adequate treatment.This appeared to be due to theprovision of services for cancer­related lymphoedema but poorly

46 Wound Essentials' Volume 2 • 2007

Wound Essentials. Volume 2 • 2007 47

Secondary lymphoedema isdue to damage or long-termoverload of the lymphaticsystem by extrinsic factorsincluding:~~Cancer treatment, e.g.

surgery and/or radiotherapy~~Recurrent infection~~Trauma~~Parasitic infection

~~Obstruction by tumour~~Immobility~~Venous disease, which will be

described now in more detail.

~ymphovenous oedemaLymphovenous oedemaoccurs when chronic venous

disease associated with deepvein thrombosis, venous

hypertension and chronic legulceration influences capillary

p6'/m6'8.D/..if,tY 8/7cf/nc.rB8SBS

.cq.offi/8-CY ffJ/78//0/7 .1016'S

Venous hypertension is causedby failure of the calf muscle

pump to return blood back upthe leg. Incompetent valvesin the deep, perforating orsuperficial veins lead to thebackflow of blood and the

veins elongate and becometortuous. The resulting increasein pressure leads to leakageof blood particles and fluidinto the tissues. This is usuallycompensated for by a healthylymphatic system.

However, a sustained increase

in capillary filtration leads toan overload of the lymphaticsystem, which will ultimatelyresult in oedema. Thus, acombined lymphatic andvenous oedema results;Iymphovenous oedema. Aslymphatic drainage becomesfurther compromised,Iymphostatic fibrosis begins to

that the forces resulting inoedema come into effect.

Evidence has shown that the

majority of interstitial fluid isreturned to the blood circulation

via the lymphatic system andnot, as initially thought, byabsorption directly into venouscapillaries (Mortimer andLevick, 2004). The absorptionof interstitial fluid is the crucial

role of the lymphatic syste~ inmaintaining fluid balance. Whenthe lymphatic system is unableto maintain this role, oedemaoccurs.

Lymphoedema'-'.

Lymphoedema is defined asswelling of a limb or part ofthe body due to failure of the

Y/77p/7a#c .5;Ys/&/n g/6'svgs

f/'r7r??cPr7~ffr?&r? <'f?&~/-??~r?

drainage system fa/Is toadequately drain fluid from theinterstitial spaces. This failure

leads to an accumulation of

fluid and proteins in the tissues,resulting in swelling or oedema.It can affect any part of the bodybut usually affects the limbs and/or the adjacent quadrant of thebody (Board and Harlow, 2002).

Lymphoedema is classified asprimary or secondary. Primarylymphoedema is due to anintrinsic abnormality of thelymphatic system. It may becaused by insufficient numbersof lymphatic collectors (resulting

in aplasia or hypoplasia). Itmay result from an abnormalityof the lymphatic vessels suchas hyperplasia or valvularincompetence (Mortimer, 1998).It may be congenital (present atbirth but not hereditary), or candevelop at puberty or any agethereafter.

--==-s. and--==-=_:?[ and::-: -::ssue

_:- --::-s space.=- -~ oe-=: :rJe

:.ssue-= :'le

_c.:: lIaries.-- :: 80ace

ortant role in maintainingbalance. It carries fluid, fats

proteins back to the generalulation from the tissues that'Id otherwise accumulate

- :E 1-'aKs'O,O/OM7&S

_~::;:17grca/

Review

-"'Iy that patients with co-existing:3dema and leg ulcers, either::~a result of trauma or venous

::sease, will be encountered

:;quently in practice.

- is article aims to promote-=-::ognition of chronic oedema::cd lymphoedema in patients

_hleg ulceration, and willuss what implications the

:: 3gnosis of chronic oedema will-~le on the management of the:~:ient with leg ulcers.

e lymphatic system--'" lymphatic system has an

Recognising chronic oedemA thorough assessment of thtpatient will help to identify risvfactors for the development 0=

chronic oedema and aid in its

diagnosis. A careful history ar.=.examination should be carriecout to include:

~~General medical history,including identification ofconditions that may affectthe outcome of treatment

such as a history of venousinsufficiency, deep veinthrombosis and cardiac

history~~Limb volume measurement tc

assess the degree of swellin(;:~~Assessment of the skin and

tissues to identify changesassociated with chronic

oedema, noting factors thatmight affect the outcome oftreatment, such as repeatedepisodes of cellulitis, fungalinfections, papillomatosis,and skin allergies, such asdermatitis

~~Psychosocial assessment todetermine the impact of theswelling on the patient

~~Circulatory assessment- ankle brachial pressureindex (ABPI) or toe brachialpressure index (TBPI). AnABPI must be calculated to

exclude significant arterialdisease. An ABPI must be

greater than 0.8 before highcompression can be appliedIf below 0.8 refer for further

vascular investigations(Stevens, 2004) beforeundergoing compressiontherapy.

a swollen foot or toes, incre8.:=exudate from an ulcer site or =.

poorly healing wound may bEsigns that oedema is not beir;adequately controlled (Figure ~

standing oedema that hasbeen present for at least threemonths and does not reduceon elevation of the affected

part of the body (Green andMason, 2006). With continuedfluid accumulation, skin and

tissue changes occur (Table

1). Chronic oedema has beenshown to affect a significantnumber of patients with legulceration (Moffatt et ai, 2004).In such patients, impairedlymphatic drainage may beidentified around the ulcer site

by the presence of oedema andlocalised swelling at the ulceredge (Figure 2). The presence of

" Positive Stem mer's sign (Figure ~

'1 Dry, flaky skin

Skin creases around the ankles and toes (Figure n

Hyperkeratosis (Figure n

Lymphangioma

Papillomatosis

» Increased subcutaneous fat.

Table 1.......~~ ~ ~.•...•..••••.•..

Visible signs of long-te oedema in the lower limb

develop leading to a chronicoedema (Green and Mason,2006).

Chronic oedema is

characterised as a long-

Figure 3. Swollen toes (Courtesy of St. Giles Hospice).

Figure 2. Ulceration and maceration of the surrounding shin and oedema around theulcer.

48 Wound Essentials. Volume 2 • 2007

""

Figure 5. Toe bandaging.

Lymphatic drainage

Manual lymphatic drainage

Simple lymphatic drainage

Exercise

Maintain joint mobility

Enhance lymphatic andvenous flow

tllUI;lU;',m

Compression therapy

Multilayer lymphoedema

bandaging (MLLB)

Compression hosiery

Skin care

Moisturisation/hydration of

the skin

Maintain skin integrity

Prevent infection

Figure 4. Four components of lymphoedema management(Adapted from BLS, 2002).

MLLB comprises of toebandaging (Figure 5), tubularstockinette, padding (usingeither soft bandage padding orpadding with foam) and layersof short-stretch bandages. Thebandages are usually appliedto the whole leg (toe to thigh)to prevent displacement ofoedema into these areas.

This system provides a rigid'structure' around the limb and

provides low resting pressuresand high working pressures.Low resting pressure meansthat the bandage appliesconstant low pressure to theskin when the limb is at rest.

Patients who require anintensive (decongestive) oedematreatment, i.e. those patientswith large, swollen, distortedlimbs with skin problems, wouldusually be treated with a courseof multilayer lymphoedemabandaging (MLLB) and possiblymanual lymphatic drainage (MLD),along with skin care, an exerciseprogramme, psychosocialsupport and education. Thisintensive therapy programmeis used to 'decongest' the limband/or trunkal region by removingfluid from the congested tissues,encouraging the movementof fluid through the lymphaticpathways and reshaping theoedematous limb.

Management ofchronic odema

Lymphoedema managementcomprises four componentsused in combination to providethe most effective reduction

and maintenance of swelling.The British Lymphology Society(BLS) recommends a minimumstandard of care for patientswith lymphoedema (Figure 4).

50 Wound Essentials' Volume 2 • 2007

Figure 6. Positive Stemmer~ sign.

When the muscles contract and

expand (e.g. during exercise)they press against the bandageand the pressure in the limbtemporarily increases. Thisincreased 'working' pressurestimulates lymphatic pumpingand reabsorption of lymph(Moffatt , 2000).

Management of legulcersA graduated, sustainedcompression therapy istraditionally used in themanagement of leg ulcers, witha wound dressing selected asappropriate for the specificwound. A layered bandagingsystem is used and is said tobe more effective than singlelayer systems (Fletcher et ai,1997). These systems are onlyapplied below the knee anddo not incll,1de the toes. The

bandages are left in situ forup to one week. The choiceof dressing and bandagingsystem will depend upon thepatient's condition, assessmentand patient choice (Dowsett,2005).

52 Wound Essentials' Volume 2 • 2007

Managementofleg ulcersand chronic oedema: which

bandaging system?Patients with chronic oedema

and ulceration require a differentapproach to treatment thanthose with venous ulceration

alone. The specific issuesassociated with managing thepatient with Iymphoedematousulceration include:

~~Limb shape distortion~~Care of skin creases and folds

~~Swelling of the toesand forefoot.

These issues require a modifiedapproach to the usual venousleg ulcer bandaging regimens(Moffatt et ai, 2005).

Patients with limb distortionand skin folds or creases will

require a more specialisedapproach to their careand, if available, workingin conjunction with alymphoedema specialist serviceis useful. The use of paddin9or foams is needed to correct

the limb shape, pad out the

skin creases and even out the

bandage shape to ensure thelimb retains a cylindrical shapein order to maintain the correct

compression gradient(Todd, 2000).

In many cases where traditionalvenous leg ulcer bandaging isused for patients with chronicoedema, oedema of the toes

and forefoot develops. Oedemaof the toes occurs when the

bandages cause pressure onthe dorsum of the foot, pushingfluid down into the toes. Where

venous leg ulcer bandages havenot been applied far enoughdown the foot, dorsal swellingmay occur. If the Iymphaticsin this area become stagnant,secondary skin changes maytake place (Tiwari, 2003), suchas a positive Stem mer's sign(Figure 6), thickened skin, orpapillomatosis.

It has been suggested thattraditional venous ulcer

bandaging systems used forpatients with chronic oedemamay result in persistent oedemaof the toes, knees and thighs,exacerbating ulceration andpreventing healing (Williams,2003). 'Slippage' of thebandage due to a reduction inswelling, particularly in the earlydays of treatment can lead to atourniquet effect and can causefurther distortion in the shapeof the limb. Hence, MLLB maybe more appropriate for thispatient group.

Skin care

Care of the skin is a majorconcern when managingpatients with ulceration

Review

Figure 8. Lymphonhoea. (Courtesy of St.

Ciles Hospice).

Figure 7. Hyperkeratosis and shin creases (courtesy of St Ciles Hospice).

and oedema. Patients withchronic oedema are at anincreased risk of infection if

the skin is dry and cracked.This can lead to cellulitis andfurther deterioration in their

oedema. The skin integrity ofthe unaffected skin must bemaintained. Moisturisation ofthe skin is essential to maintain

its hydration. An appropriatedressing should be used toprotect the skin around thewound (peri-wound) frommaceration (breakdown causedby moisture), which can occurif excess fluid (exudate) fromthe wound is left in contactwith the skin. Consultation

with tissue viability specialistwill be of benefit in patientswith complicated ulcers.Referral should be made if

there is any doubt concerningmanagement.

Compression and support

Compression and supportare the foundations of goodoedema management and canbe used to reduce swellingand maintain the reduction

(BLS, 2002). Often describedas containment (Todd,2000), external support in

54 Wound Essentials. Volume 2 • 2007

combination with muscular

activity stimulates both venousand lymphatic drainage. MLLBis recognised as an essentialcomponent of the intensivephase of lymphoedemamanagement (Casley-Smithand Casley-Smith, 1997).In addition to the reduction

of oedema, MLLB restoreslimb shape, reduces the riskof skin changes and canhelp to soften subcutaneoustissues and support stretchedskin (Williams, 2003). MLLBenhances lymph formationby increasing movement ofinterstitial fluid into the initial

Iymphatics by increasing tissuepressure when the patientmoves (Leduc et ai, 1990;Thomas, 1996; Casley-Smithand Casley-Smith 1997).

MLLB is indicated for patientswith:

~~Fragile/damaged or ulceratedskin

~~Fibrotic skin changes, e.g.hyperkeratosis, papillomatosis

~~Lymphangioma~~Lymphorrhoea (Figure 8)~~Solid, non-pitting, fibrotic

subcutaneous tissues~~Skin folds/creases.

MLLB is contraindicated for

patients with:~~Acute infection, e.g. cellulitis~~Arterial insufficiency~~Deep vein thrombosis (DVT)~~Severe cardiac failure.

Components of the MLLBsystem such as padding,toe bandaging and full legbandaging may be incorporatedinto venous bandaging systems,as they may help to reduce theoedema thereby enhancinghealing by improving deliveryof nutrients to the cells and

speeding up the removal ofwaste products (Williamsand Keller, 2005). However,bandaging the full leg doesrequire some skill and the four­layer system may not lend itselfreadily to this technique dueto the high resting pressuresexerted by the bandages at theknee joints and thigh.

Ideally, MLLB should bereapplied daily especially inthe early stages of treatmentas the bandages may becomeloose or slip due to reductionin limb volume. However, asthe treatment continues theuse of cohesive short -stretch

bandages within the MLLBsystem can reduce slippage

Figure 10. Compression hosielY wasused to maintain limb volume reduction.

loss in both thighs following acrush injury. He consequentlydeveloped lymphoedemaof both legs and underwenta course of decongestivelymphatic therapy to reducethe swelling to his right legin 1999. Following the useof compression hosiery onboth limbs, the swellingwas contained. In 2005

he developed a deep veinthrombosis (DVT) in his leftthigh and went on to developsymptoms of chronic venousinsufficiency in addition tolymphoedema. He developeda small ulcer to the medial

aspect of the ankle abovethe mallelous of his left legthat was treated successfully.

Figure 9. Ulcer healing after 2 weeks oftreatment.

This may accelerate andstabilise the treatment results

(Strossenreuter, 2003). MLDmay also be performed onthe ulcer site. This will requirereferral to a lymphoedemaspecialist practitioner forappropriate treatment.

thereby removing fluid from thetissues.

Mortimer et al (1990) and Goodyet al (2001) suggest that passivemovement of the foot can cause

significant volume change in thelower limbs (Vaqas and Ryan,2003). Foot and ankle exercisesshould be encouraged topromote calf pump action andthigh and hip exercises can helpwith fluid movement from thethigh.

Manual lymphatic drainage

In some cases it may beappropriate to include manuallymphatic drainage (MLD) inthe treatment plan of patientswith ulceration and chronic

oedema. Manual lymphaticdrainage is a type of massagewhich is designed to utilisethe skin lymphatic drainageroutes to redirect fluid from

the oedematous regions toareas with healthy Iymphatics.It requires specific gentlemovements on the skin to

stimulate lymph flow and openup collateral lymphatic vessels.

A case study will now bepresented that demonstratesthe effective management ofa patient with Iymphovenousoedema and leg ulceration.

~ase studyPatient X, a 45-year-old malehad significant skin and muscle

For every patient, the clinicianneeds to assess limb shape,tissue condition, and the extentof oedema in order to decide

which bandage techniqueshould be used. If in doubt,

management should bediscussed with a specialist.

For immobile patients, acombination of venous

bandaging that produces ahigher resting pressure may bemore useful than MLLB due

to the reduced muscle activity(Moffatt et ai, 2005).

and allow bandages to stayin place for longer (Williams,2006), thereby reducing nursingtime and frequency of dressingchange.

The choice of ulcer dressingshould also be considered

to prevent skin irritation andreaction. Using a tubularbandage over the dressingand under the padding shouldhelp to reduce skin reactionsand provide protection tothe tissues. Toe bandagingin conjunction with venousbandaging systems can help toreduce toe swelling. However, itis also important that bandagesare applied from toe to kneewith the correct technique toavoid forefoot swelling.

Exercise and movement

Mobility and exercise playan important role in themanagement of patients withlymphoedema and ulceration,especially if the patient isundergoing MLLB. Movementcan improve lymph flow byenhancing the muscle pumpaction which has an effect on

lymphatic and venous flow,

56 Wound ES5!intials • Volume 2 • 2007

~'lfortunately, early in 2006 he:Bveloped further ulceration to-s left limb. He was seen by::.healthcare professional whori'ormed him that he could not

'sceive compression bandaging:3Cause he had lymphoedema.-:: that point a hydrocolloid:'9ssing was applied to the_ :er site. Patient X was told

-: remove the dressing seven-:.a.yslater and come back if-= had further problems. After- u days he was experiencing= .::;ruciating pain at the__er site and contacted the

.phoedema service. On~.sessment he had an ulcer to

-3 gaiter area of the left leg that::'5 odorous and producing

=- Jdate. The skin surrounding--= ulcer was macerated and-"amed.

=::'-:ent X's leg was oedematous:.- !:ne foot and from mid-calf

: :.igh, but the ankle area was--:.lrated and he had developed.::.:-_uical'inverted champagne

::-,..!e'appearance. This was a::Jrem because when normal

=-:Jus leg ulcer bandaging.s.sapplied, the shape of his

=; caused the bandages to slip:::1d further distort the shape of

lower leg.

--,PI was normal and there

are no signs of arterial-~ufficiency. A swab was taken-:' micro-culture and sensitivity.-Ion-adhesive dressing was::':2Dliedto the ulcer. The limb

~s bandaged using a modified- Jltilayer system comprising-:a bandages, tubifast, soft

01 padding and cohesive::~ort-stretch bandages. A full

=;; bandage was not applied~ Patient X had restricted

-:wement in his right leg

due to the rigidity of his kneefollowing the accident. It wasimportant not to impede hismobility further by restrictingthe movement in his left knee

through bandage application. Itwas also necessary to pad outthe distorted shape at the ankleto avoid excessive pressure.The wound swab came back

positive for Staphylococcusaureus and Patient X was

prescribed flucloxacillin. Th._edistrict nurses replaced hisbandages a few days later andhe returned to the clinic a week

after his first appointment.There were already signs thatthe ulcer was healing and hehad not experienced any painsince having the bandagesapplied. This treatment planwas continued for a furthertwo weeks with the ulcer

beginning to heal very quickly(Figure 9). He was monitoredfor signs of swelling to theknee or thigh and, after threeweeks, was fitted with custom­

made compression hosiery tomaintain limb volume reduction

(Figure 10).

,ConclusionRecognition ot chronic oedemain patients with ulcerationis essential if treatment is

to be managed effectively.A combined approach tomanagement is essentialto facilitate successful

outcomes for this client group.Assessment and correct

diagnosis is crucial to therecognition of lymphoedema.Referral to the lymphoedemaspecialist and/or tissue viabilityservices will benefit the

patient in the long-term andis an essential component ofmultidisciplinary teamwork.

Chronic oedema affects a significant

proportion of the population.

Chronic oedema and ulceration

require a modified, succinct

approach to management.

Thorough assessment of a

chronically swollen limb is essential

if the appropriate treatment is to be

carried out.

Simple changes to bandagingtechniques to address thelymphatic component of

swelling can bring about a quickresponse to treatment. This

not only improves the patients'quality of life but reduces the

costs of dressings and nursingtime (Stalbow, 2004). Leg ulcerpractioners and lymphoedemaservices should adopt anintegrated approach to meetthe needs of patients withlymphoedema/chronic oedemaand leg ulcers. WE

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