1. 3 ER CURSO LATINO AMERICANO DE
CICATRIZACIÓN AVANZADA EN HERIDAS

2. WOUND DIAGNOSIS AND
TREATMENT BY ETIOLOGY
ARTERIAL, VENOUS, NEUROPATHIC/DIABETIC
Tammy Luttrell MSPT, PhD, CWS , FACCWS
Profesora Adjunto
Colorado Univerisity, Anschutz Medical Campus
National Jewish Health

3. WOUND HEALING PHASES
• Acute wounds heal by predictable and timely
course of events
• Hemostasis
• Inflammation
• Proliferation
• Granulation
• Epithelialization
• Remodeling

4. CHRONIC WOUNDS
“those wounds that fail to progress through a normal,
orderly, and timely sequence of repair or wounds
that pass through the repair process without
restoring anatomic and functional results”
Lazarus, GS, et al. (1994) Definitions and guidelines for assessment for
wounds and evaluation of healing. Arch of Derm. 130, 489-493.

5. CHRONIC WOUNDS
• Characteristics
• Necrotic tissue
• Bioburden
• Chronic inflammation
• Impaired hemodynamics
• Senescent fibroblasts and keratinocytes
• Chronic wound fluid with growth inhibiting proteases
• Overgrowth of epithelium with lack of underlying
connective tissue => rolled edges

6. DIAGNOSING WOUNDS
• By tissue involvement (to determine local
care)
• Superficial
• Partial thickness
• Full thickness
• By etiology (to determine systemic care)
• Arterial
• Venous insufficiency
• Neuropathic
• Pressure
• Atypical

7. CHRONIC WOUNDS:
90% BELONG TO ONE OF 4 CATEGORIES
• Ischemia
• Micro or Macro Vascular Disease
• Smoking
Arterial
• Deep Vein Thrombosis (37%)
• Recent Surgery, Ankle fusion
Venous Insufficiency • Prolonged standing, Pregnancy
• Congestive heart failure
• Diabetes
• Peripheral Vascular Disease Neuropathic/Diabetic
• Hansen’s Disease
• Pressure or Shear
• Immobility, Moisture
Pressure • Decreased Sensation
• Poor Nutrition
9/19/2012 Comprehensive Exam

8. ARTERIAL WOUNDS
• Caused by ischemia
• Usually located at the peripheral extremities
• Caused by macro- or microvascular disease
• Macro – obstruction of the larger named arteries by
PVD, embolus, thrombus, trauma
• Micro – disease of the small unnamed arterioles and
capillaries, usually with diabetes or small emboli after
some type of vascular surgery

9. PERIPHERAL VASCULAR DISEASE
• Arteriosclerosis
• abnormal thickening and hardening of the artery walls
• Smooth muscle cells and collagen fibers migrate into
the inner arterial wall and cause it to harden
• Atherosclerosis
• Arteriosclerosis in which fat and fibrin deposit on the
inner walls of the arteries
• Begins with a fatty streak and then becomes a fibrous
plaque

10. ARTERIOSCLEROSIS
THICKENING OF THE ARTERIAL WALLS

11. ATHEROSCLEROSIS
CHOLESTEROL/FAT DEPOSITS – SITE OF MICROINFLAMMATION

12. PVD – CRITICAL PHASES
1. Collateral circulation insufficient for metabolic needs =>
shunting of blood to muscles where there is less resistance
=> delayed healing of traumatic wounds
2. Claudication - pain with activity – most effectively
treated with exercise
a. thigh and buttock claudication = aortoiliac or
iliac involvement
b. calf claudication = femoral or popliteal
involvement
3. Rest pain – requires revascularization surgery
• May have “dependent leg syndrome”
• May be accompanied by signs of ischemia at distal digits

13. MICROVASCULAR DISEASE
• Occlusion of the small arteries too small to be
named (<0.5mm)
• Most frequently seen in patients with diabetes
• Cannot be treated with vascular surgery
• May result in non-healing wounds even after
revascularization

14. ARTERIAL WOUNDS
• Evaluation
• Pulses
• Capillary refill time
• Rubor of dependency
• Skin appearance – shiny, thin, pale, NO hair growth
• Condition of nails and hair
• Location – distal toes or fingers
• Edges – even, punched out appearance
• Tissue – dry, necrotic, little or no granulation

15. ARTERIAL SCREENING
• Pulses • Grading
• Upper extremity • 0 = no pulse
• Brachial • 1+ = barely felt
• Radial • 2+ = diminished
• Ulnar • 3+ = normal
• 4+ = bounding
• Lower extremity (indicative of
• Femoral aneurysm)
• Popliteal
• Dorsalis pedis Doppler signal is NOT
• Posterior tibialis equal to a palpable
pulse!!!

16. ARTERIAL SCREENING
• Rubor of dependency
• Elevate the lower extremity 45 , note slight blanching of
plant surface
• Place in dependent position, redness or rubor that takes 30
secs or more to occur
• Indicative of arterial disease, usually advanced

17. ARTERIAL SCREENING
• Capillary refill
• Detects microvascular disease
• Press the end of any toe for 2-3 seconds and observe for
blanching
• Normal refill is less than 3 seconds

19. PAD
PUNCTATE WOUNDS

20. SMALL TOE NECROSIS DUE TO PAD

21. BUERGER DISEASE
• Also known as thromboangiitis obliterans
• Disease of macrovascular circulation
• Occurs in feet and/or hands
• More common in men, especially heavy
smokers
• Pathology
• Inflammation of the peripheral arteries with thrombi
and vasospasm

22. BUERGER DISEASE
• Symptoms
• Pain and tenderness
• Redness
• Cyanotic skin
• Thin shiny skin
• Thick malformed nails
• Gangrene or ulcers (advanced cases)
Age may assist in diagnosis – usually younger than
typical patient with arterial wounds.
Arterial wounds in younger patients indicative of
some other pathology.

24. INVASIVE TESTS FOR PVD
• Arteriogram
• Radiographs of
vascular system after
injection of
radiopaque dye
• Used to determine
specific site of lesion
prior to by-pass
surgery

25. NON-INVASIVE TESTS FOR
MACROVASCULAR DISEASE
• Ankle-brachial index
• Doppler arterial waveforms
• Ultrasound duplex scanning
• Ultrasound
• Doppler
• Color flow doppler scanning
• Great toe pressure
• Plethysmography (measures volume)
• Segmental blood pressure recordings
• Exercise stress test

26. ABI ---ANKLE BRACHIAL INDEX
(ABPI-ANKLE BRACHIAL PRESSURE INDEX)
• Where PLeg is the systolic blood pressure of dorsalis
pedis or posterior tibial arteries and
• PArm is the highest of the left and right arm brachial
systolic blood pressure

27. ANKLE-BRACHIAL INDEX
• Ratio of ankle systolic pressure to brachial systolic pressure
• Indicates the severity of PVD
• Interpretations
• 1.0– 1.2 – normal
• 0.8-1.0 – minimal peripheral arterial disease.
Compression for edema control is safe to use.
• 0.5-0.8 – moderate peripheral arterial disease, often
accompanied by intermittent claudication. Referral to
a vascular specialist is advised. Compression therapy is
contraindicated if <0.6; modified compression is
indicated if 0.6-0.8.
• <0.5 – severe ischemia with resting pain. Compression
therapy is always contraindicated.
• <0.2 – tissue death will occur.

28. Presión máxima tobillo
Indice
Presión en el tobillo-brazo = derechoPresión máxima
brazo derecho derecho brazo (mm Hg)
e izquierdo
Presión máxima
tobillo 92 mm Hg Obstrucción
= = 0.56= moderada
Presión braquial 164 mm Hg
máxima
Presión en la arteria Interpretación del índice
tibial posterior y calculado
pedia del tobillo Por encima de 0.90 – normal
derecho e izquierdo 0.71 – 0.90 – obstrucción leve
0.41 – 0.70 – obstrucción moderada
0.00 – 0.40 – obstrucción severa
N Engl J Med 355; august 3, 2006

29. ANKLE-BRACHIAL INDEX
• ABI > 1.3 is not reliable
• Frequently seen in diabetics
• Caused by calcification of the arteries resulting in
artificially high systolic pressure
• Great toe pressure and toe/brachial index used
instead of ABI
• Normal > 55 mmHg pressure
• Normal TBI – 0.8-0.99
• < 30 mmHg – pt will need revascularization

30. Indice Tobillo-Brazo

31. PREVENTION OF ARTERIAL WOUNDS
• No smoking
• Control blood sugars
• Control hypertension, hyperlipidemia,
hypercholesterolemia
• Provide proper foot care (Goodman, p454)
• Exercise (Goodman, p 455)

32. Cuidado Pre-Operatorio
 No haga desbridamiento.
 Mantenga el área seca; proteja los dedos con
algodón o gaza estéril entre ellos.
 Use una cuna para los piés
 Descargue los talones con
almohadas
 Eschar management – Dry and intact, paint with
Betadine, use of dry topical silver. Eschar is the
“barrier” substitute.
 Do not debride
 Keep area dry; protect toes with
cotton or sterile gauze between toes
 Use foot cradle
 Off-load heels with pillows

33. Cuidado Pre-Operatorio
 No haga desbridamiento.
 Mantenga el área seca; proteja los dedos con
algodón o gaza estéril entre ellos.
 Use una cuna para los piés
 Descargue los talones con
almohadas
 Disminuya elevación de la extremidad
 Eleve la cabecera de la cama 5-7 grados
 Mantenga la extremidad caliente
 Evite ejercicio en exceso

34. TRATAMIENTO DESPUÉS DE CIRUGÍA
 Desbride la herida con tejido necrótico
cuando haya tejido de granulación visible en
sus bordes. (D. Armstrong)
 Provea un medio ambiente húmedo con el
apósito avanzado apropiado.
 Proteja los piés con almohadas debajo de las
pantorrillas.
• Debride wound of necrotic tissue when granulation tissue is visible
at the edges (D. Armstrong)
• Provide moist wound environment with the appropriate advanced
dressing
• Protect foot with pillows under calves

35. Apósitos

37. Protector
Posicionador

38. TRATAMIENTO DESPUÉS DE CIRUGÍA
 Descargue la herida con ortóticos, zapatos
especiales, dispositivos.
 Controle el edema post-operatorio para
prevenir dehiscencia de sutura.
 Cubra la incisión con gaza estéril seca
 Aplique vendaje de corta elasticidad en forma de
espiral
• Off-load wound with orthotic, special shoes, assistive device
• Control post-op edema to prevent incisional dehiscence
• Cover incision with dry sterile gauze
• Apply short stretch elastic bandage in spiral wrap

42. GIVE AND TAKE OF ARTERIAL
WOUNDS
• GIVE
• Blood supply
• Protection
• TAKE
• Any cause of trauma
• Necrotic tissue if signs of infection are
present

43. VENOUS WOUNDS
• Relate to ≈70% of LE wounds
• 500,000-1,000,000 in US
• 40% occur before the age of 50
• Recurrence rate is as high as 72%
• Estimated cost of care $40,000/case

44. VENOUS SYSTEM
• Superficial veins
• Great saphenous
• Small saphenous
• Deep veins
• Femoral
• popliteal
• Perforator veins
• Lymphatic system

45. CHRONIC VENOUS INSUFFICIENCY
• Causes
• Reflux as a result of incompetent valves in the perforator,
superficial, or deep veins
• Obstruction – e.g. chronic deep vein thrombosis
• Lack of venous pump activation during the gait cycle
• Dorsiflexion – calf muscles compress deep veins with up to 250
mmHg pressure
• Plantarflexion – deep vein pressure falls and allows blood to flow
from superficial veins to deep veins, through perforators
• Does not occur with ankle hypomobility or gastrocsoleus
weakness/paralysis
• Results in venous hypertension and excessive moisture in
the interstitial tissue
• Prevents adequate oxygen and nutrients from reaching the
skin

46. VENOUS PUMP
James, R et.al.: Incompetent venous valves: ultrasound imaging and exo-
stent repair
Phlebolymphology N°56

47. PATHOPHYSIOLOGICAL CHANGES
• Vessel dilatation and elongation
• Increased collagen deposition in both vein walls
and skin
• Plasma protein leaks into interstitial space with
resulting fibrin cuff around arterioles
• Increased leukocytes with decreased immune
function
• Increased inflammatory cells resulting in tissue
remodeling and dermal fibrosis

48. RISK FACTORS
• Hx of DVT (37%)
• Hx of hip/knee/calf surgery
• Ankle hypomobility/fusion
• Employment involving prolonged standing
• Morbid obesity
• Pregnancy
• Congestive heart failure
Systemic disorders will cause bilateral
edema; extremity dysfunctions will
cause unilateral edema.

49. PROGRESSION OF VENOUS DISEASE
• Heavy, aching
feeling in legs
• Telegentsia or
reticular veins
• Varicose veins
• Edema without
ulceration
• Skin changes
without ulceration
• Skin changes with
ulceration

50. COMMON SKIN CHANGES – CRITICAL IN
DIAGNOSING CVI
• Hyperpigmentation (hemosiderin)
• Lipodermatosclerosis
• Dilated long saphenous vein
• Atrophie blanche
• Unlateral or bilateral edema
• Dermatitis
• Thickened skin
• Cellulitis

54. WHERE ARE ALL THE
WOUNDS LOCATED???

55. WHERE ARE VENOUS WOUNDS
LOCATED?
In the gaiter area

56. VENOUS WOUND EVALUATION
• Girth of arch, malleoulus, calf
• Type and amount of drainage
• Edges (uneven) and location (gaiter,
above the ankle)
• Pulse exam/ABI in case of absent pulses,
severe pain, failure to heal with
standard care
• Other components of any wound
evaluation

59. VASCULAR TESTS - SCREENING
• Approximation of central venous pressure
• Screens for cardiac incompetence as cause of
edema
• Jugular distention
• Indicates right ventricular failure
• Valve competency with Doppler
• Percussion test for saphenous vein
competency
• Homan’s sign – not reliable
• Ankle-brachial index – r/o arterial component

60. VASCULAR TESTS/VALVE
COMPETENCY
• Place probe over
distended vein
• Compress vein 10-15 cm
proximally
• Audible sound (reflux)
means valves between
compression and probe
are incompetent
• Compress vein distal to
probe
• NO audible sounds
indicates venous
obstruction

61. TREATMENT - PREVENTION
• Compression hosiery
• Elevation (higher than heart)
• Exercise to activate venous pump
• Avoid prolonged sitting or standing
• Avoid crossing the legs
• Skin lubrication

62. COMPRESSION HOSE
• Class I
• 20-30 mmHg pressure
• Used for venous disease with skin changes
• Class II
• 30-40 mmHg pressure
• Used for history of ulceration or severe skin changes
• Class III
• 40-50 mmHg pressure
• Used for lymphedema, pts who reulcerate with Class II, pts who work
standing (e.g. dentists)
• Class IV
• > 60 mmHg pressure
TED hose used for DVT prophylaxis are NOT sufficient for
treatment of Chronic Venous Ulcers I!!!

64. CIRCAID COMPRESSION GARMENT

65. COMPRESSION HOSE WITH ZIPPER

66. MAN’S COMPRESSION
SOCK

67. VENOUS WOUND TREATMENT
• Cleanse and debride wound
• Apply appropriate primary dressing
• Compression therapy
• Support systems – Unna boot
• Multi-layer compression bandages – Profore
• Long-stretch bandages – Seto-press
• Short-stretch bandages – Comprilan
• Circ-Aid
• Intermittent compression therapy

68. LAPLACE EQUATION
• P = (TN x 4630) / CW
• P = pressure in mmHg
• T = bandage tension (in kgf)
• N = number of layers applied
• C = circumference of the limb (in cm)
• W = bandage width(in cm)
The pressure gradient between the ankle and calf makes the
compression effective in managing the edema.

72. Compresión Modificada
Cast Padding Conforming Gauze
Short Stretch Bandages
Modified Compression

74. INTERMITTENT COMPRESSION THERAPY
• Used as adjunct for wounds that do not
respond to other compression methods or for
maintenance in severe lymphedema
• Applies compression in sequence, distal to
proximal
• Pressure must be less than the diastolic BP
(usually ≈50 mmHg)
• Recommend 1-2 hours daily or bid, depending
on severity

76. GIVE AND TAKE OF VENOUS
WOUNDS
• GIVE
• Protection
• Compression
• Exercise
• TAKE
• Edema
• Bacteria
• Devitalized tissue

77. DIABETIC / NEUROPATHIC WOUNDS
• Occur on the foot, usually plantar surface or toes
• Caused by mechanical forces or minor trauma
• Occur in patients with diabetes, PVD, or Hansen’s
disease because of peripheral neuropathies

78. INCIDENCE IN DIABETICS
• 18.2 million people in US have DM (6.3% of the total
population)
• In certain ethnic groups, % is as high as 14.5%
• 15% of people with DM will have neuropathic ulcer
• 14-24% of those with ulcer will have amputation

79. NEUROPATHIES
• Motor – muscle weakness => changes in the
shape of the foot => high peak pressures during
weight bearing activities
• Caused by damage to large nerve fibers
• Sensory – diminished sensation => lack of
protective sensation
• Caused by damage to small nerve fibers
• Autonomic – decreases sweat and oil
production => dry, inelastic skin
• Caused by damage to the large nerve fibers and the
sympathetic ganglion

80. COMMON FOOT DEFORMITIES
• Pes aquinas – short Achilles tendon
• Hallux limitus/rigidus
• Hallux valgus
• Hammer toes
• Cock-up deformity
• Varus deformities of toes
• Tailors bunion on 5th metatarsal head
• Charcot foot – collapse of arch

81. NEUROPATHIC WOUND
CLASSIFICATION
Wagner scale
• 0 – at risk due to skin and foot changes
• 1 – full thickness skin loss, no infection
• 2 – subcutaneous tissue loss, infection
• 3 – deep ulceration, infection, osteomyelitis or abscess
• 4 – partial foot gangrene or necrosis
• 5 – full foot gangrene

82. WAGNER GRADE 0
AT RISK DUE TO SKIN AND FOOT CHANGES

83. WAGNER GRADE 1
FULL THICKNESS SKIN LOSS

84. WAGNER GRADE 2
SUBCUTANEOUS TISSUE LOSS, INFECTION

85. WAGNER GRADE 3
D E E P U L C E R AT I O N , I N F E C T I O N , O S T E O M Y E L I T I S O R A B S C E S S

86. WAGNER GRADE 4
PA R T I A L F O O T G A N G R E N E O R N E C R O S I S

87. WAGNER GRADE 5
FULL FOOT GANGRENE

88. EVALUATION
• Risk factors
• Recent trauma, diet, footwear, poor foot hygiene, medications,
comobidities
• Subjective history
• Skin inspection
• Dry skin with fissures
• Calluses
• Discoloration in dermal layer (RBCs from deep injury)
• Lack of toe and dorsal hair
• Heel inspection
• Toe inspection
• Nail condition
• Interdigital spaces
• Foot deformities
• Shoe assessment

90. EVALUATION
• Sensory assessment
• Vibration test
• Pressure assessment with Semmes-Weinstein
monofilaments
• Skin temperature - 3 discrepancy is significant
• Reflexes
• Musculoskeletal assessment, especially ROM
• Dorsiflexion - 10
• Hallux extension – 50-60

91. PREDICTORS OF COMPLICATIONS
• Semmes-weinstein monofilaments
• 3.61 (0.4g) = normal
• 5.07 (10g) = loss of protective sensation
• 6.10 (100g) = total loss of sensation
• Vibration
• 128 Hz tuning fork
• Measures only yes/no response
• Test end of great toe, medial malleolus, tibial
tuberosity
• Reflexes
• Diminished due to large motor nerve involvement
• Predictable pattern (LE>UE, distal>prox,
symmetrical pattern)

92. NON-INVASIVE VASCULAR ASSESSMENT
• Pulses
• Capillary refill time
• Ankle brachial index
• May be unreliable in diabetic if >1.3
• Great toe pressure
• Normal is 60-90% of the brachial pressure
• Normal TBI is 0.8-0.99
• Exercise stress test
• Transcutaneous oxygen tension
• Color flow Doppler imaging

93. TREATMENT - PREVENTION
• Patient education
• Blood glucose control
• Properly fitting shoes
• Nail and callus care
• Skin care
• Diabetic or molded shoes if foot
deformities are severe

94. BLOOD GLUCOSE CONTROL
• Normoglycemia – fasting <110mg/dl
• Impaired fasting glucose – 110-126
• Diagnosis of diabetes - >126
• Wound healing requires <200
• HB1Ac – < 6.5 for diabetics

95. PROPER FOOT CARE
• Properly fitting shoes
• Daily foot inspection
• Check for red spots, blisters, calluses
• Use mirror or family member if necessary
• Proper foot care
• Never walk barefoot
• Avoid soaking and hot surfaces
• Lubricate skin well
• Do not use adhesives on skin
• Wear thick white cotton socks
• Cut nails straight across

96. TREATMENT OF WOUNDS
• Treat infection (systemic vs topical)
• Revascularize if needed
• Control blood sugars
• Debride wound
• Provide moist wound environment
• OFF-LOAD
• Pressure redistribution
• Special shoes, total contact casting, assistive devices

98. OFF LOADING
TOTAL CONTACT CAST APPLICATION

99. OFF LOADING
TOTAL CONTACT CAST WITH WALKING SOLE

100. Zapatos

101. Apósito Acomodativo

102. GIVE AND TAKE OF NEUROPATHIC WOUNDS
• GIVE
• Antibiotics
• Blood supply
• Moist wound dressing
• Protection
• Patient education
• TAKE
• Bacteria
• Necrotic tissue
• Calluses
• Pressure
• Friction

103. ¿Preguntas?
• Comaeu Pass, Glacier National Park