Can you tell which is a VLU, arterial ulcer, mixed venous-arterial ulcer, and DFU?

Arterial ulcers are found on the foot and appear punched out with a dry, pale, or necrotic wound bed. The skin may be shiny and hairless with trophic nail change (thickening) due to a lack of circulation.

Can you tell which is a VLU, arterial ulcer, mixed venous-arterial ulcer, and DFU?

DFUs are found on the bottom of the foot, especially on pressure points (e.g., heels or balls of the feet) (DynaMed, 2024a). They can look round or punched out with varying depths. A callus or dry skin often surrounds the wound.

Can you tell which is a VLU, arterial ulcer, mixed venous-arterial ulcer, and DFU?

Mixed venous-arterial ulcers are a combination of both venous and arterial insufficiencies, meaning the veins and arteries are compromised (Jais, 2023). They are more complex because they involve both venous stasis and ischemia.

Can you tell which is a VLU, arterial ulcer, mixed venous-arterial ulcer, and DFU?

VLUs are usually highly exudative, painful, shallow wounds with irregular edges between the ankle and shin, often in the gaiter area. They may be covered with fibrous slough and/or ruddy granulation tissue. The lower extremity (LE) will be edematous and often has hemosiderin staining around the wound.

T

I

M

E

R

S

Tissue management

Infection control and inflammation

Moisture balance

Edges of wound

Repair/regeneration

Social factors

• The TIMERS framework addresses key aspects of wound care: Tissue management, infection control, moisture balance, wound edge care, repair/regeneration, and social factors.

Debriding Eschar

The need to debride eschar should be assessed with every dressing change * Remember that:

• Removal of eschar may be considered if wound infection is suspected.
• Dry eschar should be left alone in ischemic limbs and heels.
• Unstable eschar may need immediate surgical debridement.

Moisture Maintenance: Ensure a moist wound environment for optimal healing. Dressings should align with wound characteristics. Some examples include:

• Exudative: Use calcium alginate, collagen, foam
• Infected: Silver, iodine, polyhexamethylene biguanide (PHMB)
• Necrotic: Collagenase, honey-impregnated
• Dry: Collagen gel, hydrogel

Debridement should be appropriate to the patient’s condition and consistent with overall management goals. Types of debridement include:

• Surgical (sharp)
• Autolytic
• Bio-surgical
• Enzymatic
• Mechanical

What is a TCC and what does it do?

TCCs are the gold standard for offloading most DFUs and can be used for certain arterial ulcers (DynaMed, 2024a). A TCC redistributes pressure across the entire foot and lower leg, which can:

• Reduce pressure on the ulcer site.
• Allow the patient to walk.
• Promote healing by immobilizing the foot.
• Reduce movement that can exacerbate the ulcer.

Removable Cast Walkers and Boots

Removable cast walkers and boots can be adjusted to the patient’s comfort level. They allow for easier access to inspect the wound and provide wound care, especially in the infected wound or ischemic wound where TCC is not indicated. Types include (Bowers & Franco, 2020):

• Pneumatic or controlled ankle motion (CAM) walker
• Half-wedge shoe
• Heel relief shoe

These devices are easier to use than TCCs. However, patients may remove them, which ultimately hinders pressure reduction and can minimize healing (DynaMed, 2024a). Therefore, it is important to remind patients to wear their walkers or boots as much as possible. What is it?

Removable cast walkers and boots

What is iTCC

Instant Total Contact Casting (iTCC) is a modified approach to traditional TCC that offers many of the same benefits but is faster and easier to apply. iTCC involves converting a removable cast walker into an offloading device that mimics the effects of a traditional TCC by making it non-removable—typically by wrapping it with cohesive or casting material

Key Takeaways:

* Key aspects of wound care

The TIMERS framework addresses key aspects of wound care: Tissue management, infection control, moisture balance, wound edge care, repair/regeneration, and social factors.

Key Takeaways:

Moisture

Maintaining moisture balance is essential for wound healing, using dressings that manage drainage or add moisture depending on the wound's condition, ensuring it never dries out or becomes overly moist.

Key Takeaways:

Pressure relief

Offloading provides pressure relief, pain reduction, and protection against further trauma to the ulceration. Total contact casts (TCCs) are considered the “gold standard” for offloading DFUs.

Compression is a primary therapy for ___s.

VLUs

While compression alone may not heal every VLU, it is essential for promoting healing and reducing recurrence. The effectiveness of compression therapy depends on the skill of the person applying it and patient adherence to wearing compression garments or bandages, a frequent challenge with patients with VLU.

Levels of Compression Therapy

Compression therapy is available in varying degrees of pressure, measured in millimeters of mercury (mmHg).

Level Pressure Amount (mmHg)

High

30 to 40

Level Pressure Amount (mmHg)

Medium

20 to 30

Level Pressure Amount (mmHg)

Low

14 to 17

What condition best describes this image?

Cellulitis

Bacterial infection of deeper skin tissue

What condition best describes this image?

Erysipelas

Bacterial infection of the upper dermis, presents as bright red skin with induration and sharply demarked edges

What condition best describes this image?

Lymphangitis

Infected lymph vessels with distinctive red streak traveling along the lymphatic vessels

What condition best describes this image?

Bacterial or Fungal infection & Lymphangitis

Infected lymph vessels with distinctive red streak traveling along the lymphatic vessels

Deep skin folds from swelling can get infected by bacteria or fungus

What condition best describes this image?

Lymphatic papillomatosis

Lumpy, cobblestone-looking, firm, raised projections resulting from dilated surface lymphatic vessels or lymph accumulation

What condition best describes this image?

Lymphorrhea

Weeping of light, amber-colored, protein-rich, lymph fluid through the skin

Peripheral artery disease

Arterial ulcers develop because there is not enough blood flow to the area. This must be addressed. Otherwise, tissue viability may decrease, and wound healing may be delayed. Multiple strategies are employed to improve the conditions for wound healing. Goals of treatment should include:

• Preservation of viable tissue.
• Preventing infection.
• Wound healing.

Revascularization

Adequate arterial blood flow is required for wound healing in the lower limb. Surgical methods and less invasive measures can improve the vascularization of the affected limb. Endovascular procedures, such as angioplasty or stent placement, open narrowed arteries. Bypass surgery (e.g., femoral-popliteal bypass) helps create a new route for blood flow around blocked arteries.

Both open surgery and endovascular repair are valid approaches, depending on the disease severity and patient-specific factors (Bryant & Nix, 2024). The decision to pursue surgery must balance the procedure's risks against the potential benefits of improved blood flow and healing.

Margaret's revascularization surgery is successful. What is the next best step in managing her arterial ulcer post-surgery?

Use a non-occlusive, moisture-balancing dressing to promote healing.

The patient with diabetes and a wound presents a complex situation when it comes to healing. The statistics are sobering (Armstrong et al., 2023):

• Around 50 to 60% become infected.
• Of all infections, around 20% lead to lower extremity amputations.
• The 5-year mortality rate is approximately 30% for those with a DFU.
• The 5-year mortality rate is over 70% for those who undergo a major amputation.

DFUs result from biochemical (e.g., glycemic control), peripheral neuropathy, and vascular factors.

Checking for Charcot Neuroarthropathy (CNO)

Charcot neuroarthropathy (i.e., Charcot Foot) is a sterile inflammatory condition affecting individuals with diabetes who have neuropathy. This condition leads to damage in bones, joints, and soft tissues in the foot, presenting as a red, hot, swollen foot (Senneville et al., 2023).

If left untreated, Charcot foot can progress to fractures and dislocations, resulting in a severely deformed foot. Diagnosis is often delayed, leading to worsened damage and lengthening treatment time.

Geraldo, a 60-year-old with CVI and PAD, presents with a mixed venous-arterial ulcer. His ABI is 0.7. What type of compression therapy would be BEST?

Low-level compression

Low-level compression between 23 and 30 mmHg would be BEST for those with an ABI of 0.7 as it helps improve venous return without reducing arterial flow. Complete avoidance of compression would allow venous hypertension to persist, leading to the worsening of the venous component of the ulcer. Therapeutic compression between 30 and 40 mmHg is too high for a patient with an ABI of 0.7 and could worsen ischemia.

While IPC is helpful in some cases, it is not typically considered when traditional compression methods are not tolerated or effective, and low-level compression is still needed.

A 58-year-old man presents with the wound seen in the image on the heel of his foot. The wound is deep with necrotic tissue, heavy slough, and some areas of exposed tissue. The surrounding skin is inflamed, erythematous, and appears swollen. The patient has a history of uncontrolled diabetes and reports difficulty feeling sensations in his feet. His pulses are diminished, but he denies any rest pain. Upon palpation, the area is warm and tender, and there is moderate purulent drainage. The ABI is 0.85.

What is the BEST action you should consider FIRST for managing this DFU?

Refer for revascularization to improve blood flow to the foot.

Start systemic antibiotics to control the infection and offload with a TCC.

Debride, irrigate, apply calcium alginate to open areas and start offloading with TCC.

Check CRP and ESR for the presence of infection before next action.

Check CRP and ESR for the presence of infection before next action.

*

The image and description suggest there is an infection in this wound. However, signs of infection are often masked in patients with diabetes, making the use of serum biomarkers like CRP, ESR, and PCT useful in identifying the presence of infection. Debridement is appropriate, however, in the presence of infection, a TCC is contraindicated. The patient's ABI is 0.85, indicating mild PAD, not critical limb ischemia requiring revascularization. Systemic antibiotics should not be used for suspected infection and should be culture driven, making the best option checking for infection via chemical biomarkers.

Which type of ulcer is typically associated with brownish discoloration, swelling, and shallow wounds with irregular edges?

Diabetic foot ulcer

Arterial ulcer

Venous leg ulcer

Mixed venous-arterial ulcer

Venous Leg Ulcer

Which of the following dressings is most appropriate for an exudative venous leg ulcer?

Hydrogel

Honey-impregnated dressing

Transparent film

Calcium alginate

Calcium alginate

What is the MAIN reason for using compression therapy in patients with venous leg ulcers?

To reduce arterial pressure

To debride necrotic tissue

To prevent tissue ischemia

To promote venous blood return

To promote venous blood return

What advice should a healthcare provider give a patient with venous leg ulcers to prevent recurrence?

Avoid walking long distances.

Wear compression stockings daily.

Keep legs elevated for 30 minutes once a week.

Avoid wearing tight-fitting shoes.

Wear compression stockings daily.

Which of the following therapies would be BEST for a deep arterial ulcer that will not heal?

Electrical stimulation

Negative Pressure Wound Therapy (NPWT)

Enzymatic debridement

Hyperbaric Oxygen Therapy (HBOT)

Negative Pressure Wound Therapy (NPWT)

Note:

* HBOT is beneficial in specific conditions like acute arterial insufficiency related to crush injury, but it is not routinely used as the primary therapy for deep arterial ulcers. NPWT supports wound healing in deep, non-healing ulcers by reducing wound size, improving perfusion, and managing exudate

When applying a compression bandage, where should you start to wrap?

At the knee

At the base of the toes

At the mid-calf

At the ankle

At the base of the toes

Which condition must be stabilized before applying compression therapy in patients with a mixed venous-arterial ulcer?

Neuropathy

Diabetes mellitus

Peripheral arterial disease (PAD)

Hypertension

Peripheral arterial disease (PAD)

What should patients with diabetic foot ulcers do daily to prevent worsening of the condition?

Use tight-fitting shoes for support

Walk barefoot around the house

Apply bandages directly to ulcers

Inspect their feet for signs of injury or infection

Inspect their feet for signs of injury or infection

In what situation should dry eschar be left intact rather than debrided?

On venous leg ulcers

When the wound is infected

When the patient is on antibiotics

In ischemic limbs

In ischemic limbs

Note:

* Infected wounds require eschar removal to prevent further complications. Dry eschar should be left intact in ischemic limbs to prevent further damage and potential infection.

Which of the following strategies is recommended to reduce pressure on diabetic foot ulcers and promote healing?

Topical antibiotics

Footwear modifications

Exercise therapy

Heat therapy

Footwear modifications

What is a typical characteristic of an arterial ulcer?

Punched-out appearance

Brownish discoloration

Round with callused edges

Shallow wounds with irregular edges

Punched-out appearance

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What is the main benefit of using negative pressure wound therapy (NPWT) for chronic wounds?

Provides high moisture balance

Promotes granulation tissue formation

Reduces bacterial load

Removes necrotic tissue

Promotes granulation tissue formation HOW: The suction creates mechanical forces that stimulate cellular growth, rapidly building new, healthy tissue to fill deep

NPWT also reduces bacterial load. It draws out bacteria and creates an optimal moist, closed environment, which reduces the risk of recurrent infections

What role does glycemic control play in the management of diabetic foot ulcers (DFUs)?

Enhances immune system function

Increases vascular resistance

Encourages the formation of calluses

Reduces oxygen levels in tissues

Enhances immune system function

* Uncontrolled hyperglycemia delays healing by causing nerve damage, impairing circulation, and weakening the body's ability to fight off bacterial infections

For patients with venous leg ulcers, how often should compression stockings be replaced to ensure effectiveness?

Once a month

Every 6 months

Every 12 months

Every 2 years

Every 6 months