Leg Ulcer

Leg ulcers are treated by different forms of dressings by the family physicians. It is extremely important to know what the cause for the ulcer is? 80% 0f the ulcers in the legs are due to vascular insufficiency. Healing and preventing recurrences can only be achieved by correcting the vascular cause. Dressings do play an important role in aiding ulcer healing.

Aetiology

Venous 75%
Arterial 22%
Rheumatoid arth 12%
Diabetes 05%
Multifactorial 15%

Venous Ulcer

Causes of Venous Ulcers

Calf pump failure
Calf muscle disuse
Peripheral neuropathy
Orthopaedic disorder etc
Out flow obstruction
Pregnancy, obesity, tumours & DVT
Incompetent valves
Superficial, deep, communicating veins

Pathophysiology of Venous Ulcer

Increased cap/venous pressure
Leakage of fibrinogen into interstitial spaces
Formation of pericapillary fibrin layer
White cell trapping theory
Anoxia and Malnutrition
Accelarated by trauma

Initial Assessment

History & Clinical examination
Hand held Doppler
Colour Doppler scan
Ankle-Brachial index

Treatment of Venous Ulcer

Topical treatment
Four layer compression bandaging
Corrective venous surgery
Maintenance treatment

Dressings

Following extensive randomised controlled studies, involving different dressing types used in conjunction with the four layer bandage, it was found that dressings had little influence on ulcer healing.

Therefore, a simple low adherent dressing such as Sofratule, Inadine is used

Four layer Compression Bandaging

Graduated Compression Has Shown to

Increase blood velocity in the deep veins
Reduce oedema and therefore reduce pressure differential between the capillaries and the tissues.
Reduce distention of the superficial veins and reverse venous hypertension.
Improve the healing rate of chronic venous ulcers.

Stemmer et al

Demonstrated that 40 mm Hg pressure is required at the ankle to reverse chronic venous hypertension.
The four layer bandage system is developed to apply 40 mm Hg pressure at the ankle graduated to 17 mm Hg at the knee using bandages of differing properties.

All bandages used are 10 cms. in width and should be applied from the base of the toes to the knee joint.

Layer I

Orthopaedic wool

This is used to absorb exudate and redistribute pressure around the ankle, protecting the bony prominences from excessive pressure.
It also fills in the troughs behind the malleoli where little pressure is exerted.
The bandage is applied without tension in a loose spiral.

Layer II

Cotton crepe

Its main function is to increase absorbency and to smoothen the orthopaedic wool layer, thereby preserving the elastic energy of the main compression layers.
The crepe is also applied in a spiral.

Layer III

Elasticated crepe

This is the most important layer achieving compression.
It is applied at mid-stretch in a figure of eight with a 50% overlap.

Layer IV

Coban

It is a lightweight, elastic, cohesive bandage.
It maintains the four layers in place and adds durability to the system.
It is applied at mid-stretch with a 50% overlap.

Contraindication

Peripheral vascular disease.
Oedema secondary to heart failure.
Thin calves and narrow ankles.
Rheumatoid arthritis and Diabetes mellitus.

Dr. Pankaj Patel a vascular surgeon has expertise in peripheral vascular diseases, varicose veins and deep vein thrombosis