Your patient has a lower extremity wound. You aren’t sure what exactly you are dealing with. You know you need to do that ABI to be sure, but while you are waiting to have that done some of your wound assessment findings will help clue you in as well.
Let’s start with the venous ulcer, typically found on the medial lower leg, medial malleolus and superior to the medial malleolus. Seldom will you see them on the foot or above the knee. They tend to be irregular in shape, are superficial, have a red wound bed, have moderate to heavy amount of exudate and the patient may have no pain or a moderate level of pain. Surrounding skin can be warm to the touch, edematous, scaly, weepy and you may see hemosiderin staining present. Your ABI will be the definitive answer and will come back at 0.9.
The arterial ulcer is typically found on the lateral malleolus, over the phalangeal heads, between the toes, tips of toes and areas that are subject to trauma and rubbing. They tend to be regular in shape, round punched out in appearance. Deep pale wound beds with necrotic tissue present are common in the arterial patient. There will typically be minimal amounts of exudate, and the patient will have complaints of extreme pain. The pain typically starts out as intermittent claudication or cramping in the lower extremities and then continues to progress. Surrounding skin will be cool to the touch, pale, cyanotic, hairless on ankle and foot with thickened toenails. The ABI will come back abnormal and low at 0.5, indicating significant arterial disease.
Unfortunately sometimes the answer isn’t so clear, the patient with a lower extremity ulcer may present with signs and symptoms of both arterial and venous issues. You may see a full thickness wound, irregular in shape with minimal exudate on a cool pale lower extremity. What then? Then we go back to the gold standard of bedside tests, our ABI to determine what we are dealing with for sure. Here most likely the patients ABI will fall somewhere between 0.6-0.8, this reading is indicative of a “mixed” lower extremity ulcer.
Our assessment skills can help guide us in differentiating these lower extremity wounds, but it is important to remember that not every ulcer always follows the rules. For example you may have a venous ulcer on the lateral side, it would not be unheard of. This is why ultimately the ABI is the gold standard of care and must be done to rule out arterial disease. We always need to do a full comprehensive assessment, and one that includes the ankle brachial index (ABI) for our patients with lower extremity wounds.
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