The lower limb is a vulnerable area of the body and often subjected to minor or major trauma. In the presence of underlying systemic disease, especially with comorbidities related to arterial blood supply and simple venous backflow compromise, traumatic injury may trigger an acute lower limb skin injury to become a chronic ulcer.1
Regardless of the cause of skin breakdown, the majority of chronic lower limb wounds often have an underlying venous etiology2 that can be managed successfully with compression therapy.3 However, not all leg wounds present in the same way nor should they be treated equally. The subtle presence of arterial compromise in a predominantly venous etiology may change the appearance of the wound, the pain experience of the patient, and patient adherence to the treatment protocol (mixed venous-arterial etiology).4 Equally challenging may be lower limb edema in the limb of a person with arterial insufficiency who is not eligible for full compression therapy (mixed arterial-venous etiology).5 These mixed clinical presentations often have subtle differences and, if those are missed, clinical outcomes may not be achieved. The importance of interprofessional team involvement in managing challenging wounds that do not heal at the expected rate cannot be emphasized enough.6
Accordingly, the aim of this bedside enabler is to help clinicians recognize different clinical presentations of lower limb ulcers and assessment markers (Table 1). Recognizing these nuances in day-to-day clinical practice will promote correct initiation of adapted intervention protocols, leading to improved patient outcomes. The Table in this Practice Points column includes markers associated with blood flow etiologies of venous, arterial, mixed arterial-venous, mixed venous-arterial, and the combined neuroischemic diabetic foot.
By empowering clinicians to use multiple markers associated with lower leg and ischemic-related foot ulcers, early detection of complex lower limb ulcers with potential healing difficulties can be established from the outset. Clinicians should prioritize the correction of underlying etiologies and form an interprofessional team centered around the patient. Appropriate interventions should be initiated as needed, such as correction of arterial blood supply, smoking cessation, edema control, and weight loss, as well as metabolic control of blood glucose in persons with diabetes. Astute clinical assessment promotes timely wound treatment, lowering cost while improving patient quality of life.
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