Assessment of Leg Ulceration

Chapter 5 Assessment of Leg Ulceration Karen Staines, Karen StainesSearch for more papers by this authorAby Mitchell, Aby MitchellSearch for more papers by this author Karen Staines, Karen StainesSearch for more papers by this authorAby Mitchell, Aby MitchellSearch for more papers by this author Book Editor(s):Aby Mitchell, Aby MitchellSearch for more papers by this authorGeorgina Ritchie, Georgina RitchieSearch for more papers by this authorAlison Hopkins, Alison HopkinsSearch for more papers by this author First published: 11 April 2024 https://doi.org/10.1002/9781119908241.ch5 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onEmailFacebookTwitterLinkedInRedditWechat Summary A leg ulcer is a break in the skin below the knee that has not healed within a two-week period. It is essential to establish the underlying cause of leg ulceration to avoid misdiagnosis and unnecessary delays in healing. Good history taking is pivotal to decision-making and will form the basis for multifaceted diagnoses including medical, psychosocial and psychological. Practitioners who manage people with leg ulceration need to be competent in recognising clinical signs and symptoms of peripheral arterial disease (PAD) and chronic venous insufficiency. While venous leg ulceration is reportedly the most commonly occurring type of ulceration, healthcare practitioners need to develop competence in recognising clinical symptoms of PAD, ischaemic changes and arterial pain. The holistic assessment of a wound is essential to identify causative and contributory factors, support diagnosis and determine factors that may contribute to delayed wound healing. The skin surrounding wounds often has compromised integrity caused by tissue inflammation. REFERENCES Atkin , L. ( 2019 ). Venous leg ulcer prevention 1: identifying patients who are at risk . Nursing Times 115 ( 6 ): 24 – 28 . https://www.nursingtimes.net/clinical-archive/tissue-viability/venous-leg-ulcer-prevention-1-identifying-patients-who-are-at-risk-28-05-2019/ Google Scholar Atkins , E. , Mughal , N.A. , Place , F. , and Coughlin , P.A. ( 2020 ). Varicose veins in primary care . BMJ 370 , m2509 . https://doi.org/10.1136/bmj.m2509 . 10.1136/bmj.m2509 PubMedGoogle Scholar Belczak , S. , Ramos , R. , and Pereira de Godoy , J. ( 2021 ). Association between obesity and the aggravation of limited range of ankle mobility in chronic venous disease . Phlebology 37 ( 3 ): 196 – 199 . 10.1177/02683555211055350 PubMedWeb of Science®Google Scholar Beldon , P. ( 2011 ). How to … Ten top tips for doppler ABPI . Wounds international 2 ( 4 ): https://woundsinternational.com/journal-articles/how-toten-top-tips-for-doppler-abpi . Google Scholar Birkhäuer , J. , Gaab , J. , Kossowsky , J. et al. ( 2017 ). Trust in the health care professional and health outcome: a meta-analysis . PLoS One 12 ( 2 ): e0170988 . https://doi.org/10.1371/journal.pone.0170988 . 10.1371/journal.pone.0170988 PubMedWeb of Science®Google Scholar Blomgren , L. , Johansson , G. , Dahlberg-Åkerman , A. et al. ( 2004 ). Recurrent varicose veins: incidence, risk factors and groin anatomy . European Journal of Vascular and Endovascular Surgery 27 ( 3 ): 269 – 274 . 10.1016/j.ejvs.2003.12.022 CASPubMedWeb of Science®Google Scholar Brown , A. ( 2017 ). Managing exudate and maceration in venous leg ulceration within the acute health setting . British Journal of Nursing 26 ( Sup20 ): S18 – S24 . https://doi.org/10.12968/bjon.2017.26.sup20.s18 . 10.12968/bjon.2017.26.Sup20.S18 PubMedGoogle Scholar Buerger , L. ( 1924 ). The Circulatory Disturbances of the Extremities: Including Gangrene, Vasomotor and Trophic Disorders . Philadelphia, PA : W.B. Saunders . Google Scholar Cai , P. and Forsyth , J. ( 2022 ). Acute limb ischaemia. Vascular surgery – II . Surgery 40 ( 7 ): 450 – 459 . Google Scholar Carruthers , T.N. , Farber , A. , Rybin , D. et al. ( 2014 ). Interventions on the superficial venous system for chronic venous insufficiency by surgeons in the modern era: an analysis of ACS-NSQIP . Vascular and Endovascular Surgery 48 : 482 – 490 . 10.1177/1538574414561226 PubMedWeb of Science®Google Scholar Cirqui , M. , Denenberg , J. , Bergan , J. et al. ( 2007 ). Risk factors for chronic venous disease: the San Diego Population Study . Journal of Vascular Surgery 46 ( 2 ): 331 – 337 . 10.1016/j.jvs.2007.03.052 PubMedWeb of Science®Google Scholar Collares , F. and Faintuch , C. ( 2017 ). Varicose Veins: Practical Guides in Interventional Radiology . New York : Thieme Medical Publishers . Google Scholar Cutting , K.F. ( 2004 ). Exudate: composition and functions . In: Trends in Wound Care: Volume III (ed. R. White ), 41 – 49 . London : Quay Books . Google Scholar Cutting , K.F. and White , R.J. ( 2002 ). Avoidance and management of peri-wound maceration of the skin . Professional Nurse 18 ( 1 ): 33 – 36 . PubMedGoogle Scholar Danielsson , G. , Eklof , B. , Grandinetti , A. , and Kistner , R.L. ( 2002 ). The influence of obesity on chronic venous disease . Vascular and Endovascular Surgery 36 ( 4 ): 271 – 276 . https://doi.org/10.1177/153857440203600404 . 10.1177/153857440203600404 PubMedGoogle Scholar Deptuła , M. , Zieliński , J. , Wardowska , A. , and Pikuła , M. ( 2019 ). Wound healing complications in oncological patients: perspectives for cellular therapy . Advances in Dermatology and Allergology 36 ( 2 ): 139 – 146 . https://doi.org/10.5114/ada.2018.72585 . 10.5114/ada.2018.72585 Google Scholar Dini , V. , Janowska , A. , Oranges , T. et al. ( 2020 ). Surrounding skin management in venous leg ulcers: a systematic review . Journal of Tissue Viability 29 : 169 – 175 . 10.1016/j.jtv.2020.02.004 PubMedWeb of Science®Google Scholar Eder , S. , Dissemond , J. , Vanscheidt , W. et al. ( 2019 ). Buergers test/pole test: simple clinical tests to screen the arterial perfusion before compression therapy . Phlébologie 49 ( 02 ): 108 – 110 . https://doi.org/10.1055/a-0865-7947 . 10.1055/a?0865?7947 Google Scholar Edward-Jones , V. ( 2018 ). Microbiology and malodourous wounds . Wounds UK 14 ( 4 ): 72 – 75 . Google Scholar Eklof , B. , Rutherford , R.B. , Bergan , J.J. et al. ( 2004 ). Revision of the CEAP classification for chronic venous disorders: consensus statement . Journal of Vascular Surgery 40 ( 6 ): 1248 – 1252 . 10.1016/j.jvs.2004.09.027 PubMedWeb of Science®Google Scholar Finlayson , K.J. , Parker , C.N. , Miller , C. et al. ( 2018 ). Predicting the likelihood of venous leg ulcer recurrence: the diagnostic accuracy of a newly developed risk assessment tool . International Wound Journal 15 ( 5 ): 686 – 694 . 10.1111/iwj.12911 PubMedWeb of Science®Google Scholar Frescos , N. ( 2011 ). What causes wound pain? Journal of Foot Ankle Research 4 ( Suppl 1 ): P22 . https://doi.org/10.1186/1757-1146-4-S1-P22 . 10.1186/1757-1146-4-S1-P22 PubMedWeb of Science®Google Scholar Godeberge , P. , Sheikh , P. , Zagriadskiĭ , E. et al. ( 2019 ). Hemorrhoidal disease and chronic venous insufficiency: concomitance or coincidence; results of the chorus study (chronic venous and Hemorrhoidal Diseases Evaluation and Scientific Research) . Journal of Gastroenterology and Hepatology 35 ( 4 ): 577 – 585 . https://doi.org/10.1111/jgh.14857 . 10.1111/jgh.14857 PubMedWeb of Science®Google Scholar Gouin , J.P. and Kiecolt-Glaser , J.K. ( 2011 ). The impact of psychological stress on wound healing: methods and mechanisms . Immunology and Allergy Clinics of North America 31 ( 1 ): 81 – 93 . https://doi.org/10.1016/j.iac.2010.09.010 . 10.1016/j.iac.2010.09.010 PubMedWeb of Science®Google Scholar Green , J. , Corcoran , P. , Green , L. , and Read , S. ( 2018 ). A new quality of life wound checklist: the patient voice in wound care . Wounds UK 14 ( 4 ): 40 – 45 . Google Scholar Guest , J.F. , Gerrish , A. , Ayoub , N. et al. ( 2015 ). Clinical outcomes and cost-effectiveness of three alternative compression systems used in the management of venous leg ulcers . Journal of Wound Care 24 ( 7 ): 300 – 310 . 10.12968/jowc.2015.24.7.300 CASPubMedWeb of Science®Google Scholar Guest , J. , Fuller , G. , and Vowden , P. ( 2018 ). Venous leg ulcer management in clinical practice in the UK: cost and outcomes . International Wound Journal 15 ( 1 ): 29 – 37 . 10.1111/iwj.12814 PubMedWeb of Science®Google Scholar Guo , S. and DiPietro , L.A. ( 2010 ). Factors affecting wound healing . Journal of Dental Research 89 ( 3 ): 219 – 229 . https://doi.org/10.1177/002203450935912 . 10.1177/0022034509359125 CASPubMedWeb of Science®Google Scholar Harding , K. , Dowsett , C. , Fias , L. et al. ( 2015 ). Simplifying venous ulcer management: consensus recommendations . Wounds International London . https://woundsinternational.com/consensus-documents/simplifying-venous-leg-ulcer-management-consensus-recommendations Google Scholar Harper , C. and Crane , J. ( 2022 ). Atrophie blanche . In: StatPearls . Treasure Island, FL : StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK544285 . Google Scholar Haughton , W. and Young , T. ( 1995 ). Common problems in wound care: malodorous wounds . British Journal of Nursing 4 ( 16 ): 959 – 963 . https://doi.org/10.12968/bjon.1995.4.16.959 . 10.12968/bjon.1995.4.16.959 CASPubMedGoogle Scholar Hess , C.T. ( 2020 ). Checklist for successful wound healing outcomes . Advances in Skin & Wound Care 33 ( 1 ): 54 – 55 . https://doi.org/10.1097/01.asw.0000617008.87552.bc . 10.1097/01.ASW.0000617008.87552.bc PubMedWeb of Science®Google Scholar Iannuzzi , A. , Panico , S. , Ciardullo , A.V. et al. ( 2002 ). Varicose veins of the lower limbs and venous capacitance in postmenopausal women: relationship with obesity . Journal of Vascular Surgery 36 : 965 – 968 . 10.1067/mva.2002.128315 PubMedWeb of Science®Google Scholar International Wound Infection Institute (IWII) ( 2016 ). Wound infection in clinical practice . Wounds International . https://woundsinternational.com/consensus-documents/wound-infection-in-clinical-practice-principles-of-best-practice Google Scholar Ismail , L. , Normahani , P. , Standfield , N. , and Jaffer , U. ( 2016 ). A systematic review and meta-analysis of the risk for development of varicose veins in women with a history of pregnancy . Journal of Vascular Surgery: Venous Lymphatic Disorders 4 ( 4 ): 518 – 524 . 10.1016/j.jvsv.2016.06.003 PubMedWeb of Science®Google Scholar Kawano , Y. ( 2010 ). Physio-pathological effects of alcohol on the cardiovascular system: its role in hypertension and cardiovascular disease . Hypertension Research 33 ( 3 ): 181 – 191 . https://doi.org/10.1038/hr.2009.226 . 10.1038/hr.2009.226 CASPubMedWeb of Science®Google Scholar Lurie , F. , Passman , M. , Meisner , M. et al. ( 2020 ). The 2020 update of the CEAP classification system and reporting standards . Journal of Vascular Surgery and Venous Lymphatic Disorders 8 ( 3 ): 342 – 352 . https://doi.org/10.1016/j.jvsv.2019.12.075 . 10.1016/j.jvsv.2019.12.075 PubMedWeb of Science®Google Scholar Lymphoedema Framework ( 2006 ). International consensus: Best practice for the management of lymphoedema . https://www.lympho.org/uploads/files/files/Best_practice.pdf Google Scholar Matic , M. , Matic , A. , Djuran , V. et al. ( 2016 ). Frequency of peripheral arterial disease in patients with chronic venous insufficiency . Iranian Red Crescent Medical Journal 18 ( 1 ): e20781 . https://doi.org/10.5812/ircmj.20781 . 10.5812/ircmj.20781 PubMedWeb of Science®Google Scholar McVittie , E. and Holloway , S. ( 2015 ). Aetiology and management of atrophie blanche in chronic venous insufficiency . British Journal of Community Nursing 20 ( Supp 12 ): S8 – S13 . 10.12968/bjcn.2015.20.Sup12.S8 PubMedGoogle Scholar Minasian , R.A. , Samaha , Y. , and Brazio , P.S. ( 2022 ). Post-traumatic lymphedema: review of the literature and surgical treatment options . Plastic and Aesthetic Research 9 : 18 . https://doi.org/10.20517/2347-9264.2021.128 . 10.20517/2347?9264.2021.128 Google Scholar Mintz , B. , Jaff , M. , and Mintz , J. ( 2013 ). Atlas of Clinical Vascular Medicine . Chichester : Wiley . 10.1002/9781118618189 Google Scholar Mioc , M.-L. , Prejbeanu , R. , Vermesan , D. et al. ( 2018 ). Deep vein thrombosis following the treatment of lower limb pathologic bone fractures – a comparative study . BMC Musculoskeletal Disorders 16 : 213 . 10.1186/s12891-018-2141-4 Google Scholar Mitchell , A. ( 2017 ). Assessing the value of practice-based leg ulcer education to inform recommendations for change in practice . British Journal of Community Nursing 22 ( Supp 12 ): S28 – S34 . 10.12968/bjcn.2017.22.Sup12.S28 PubMedGoogle Scholar Mitchell , A. ( 2018 ). Adult pressure area care: preventing pressure ulcers . British Journal of Nursing 27 ( 18 ): 1050 – 1052 . https://doi.org/10.12968/bjon.2018.27.18.1050 . 10.12968/bjon.2018.27.18.1050 PubMedGoogle Scholar Mitchell , A. ( 2020 ). Assessment of wounds in adults . British Journal of Nursing 29 ( 20 ): S18 – S24 . 10.12968/bjon.2020.29.20.S18 PubMedGoogle Scholar Mitchell , A. ( 2022 ). Skin assessment in adults . British Journal of Nursing 31 ( 5 ): 274 – 278 . https://doi.org/10.12968/bjon.2022.31.5.274 . 10.12968/bjon.2022.31.5.274 PubMedGoogle Scholar Mitchell , A. and Elbourne , S. ( 2020 ). Lower limb assessment . British Journal of Nursing 29 ( 1 ): 18 – 21 . 10.12968/bjon.2020.29.1.18 PubMedGoogle Scholar Mitchell , A. and Hill , B. ( 2020 ). Moisture-associated skin damage: an overview of its diagnosis and management . British Journal of Community Nursing 25 ( 3 ): S12 – S18 . https://doi.org/10.12968/bjcn.2020.25.Sup3.S12 . 10.12968/bjcn.2020.25.Sup3.S12 PubMedGoogle Scholar Mitchell , A. and Llumigusin , D. ( 2021 ). The assessment and management of hypergranulation . British Journal of Nursing 30 ( 5 ): S6 – S10 . https://doi.org/10.12968/bjon.2021.30.5.S6 . 10.12968/bjon.2021.30.5.S6 PubMedGoogle Scholar Miteva , M. , Romanelli , P. , and Kirsner , R. ( 2010 ). Lipodermatosclerosis . Dermatologic Therapy 23 ( 4 ): 375 – 388 . 10.1111/j.1529-8019.2010.01338.x CASPubMedWeb of Science®Google Scholar Moffatt , C. , Franks , P.J. , Doherthy , D.C. et al. ( 2009 ). Psychological factors in leg ulceration: a case-control study . British Journal of Dermatology 161 ( 4 ): 750 – 756 . https://doi.org/10.1111/j.1365-2133.2009.09211.x . 10.1111/j.1365-2133.2009.09211.x CASPubMedWeb of Science®Google Scholar National Institute for Health and Care Excellence (NICE) ( 2020 ). Leg ulcer infection: antimicrobial prescribing . NICE guideline [NG152]. https://www.nice.org.uk/guidance/ng152/chapter/Recommendations#treatment Google Scholar National Institute for Health and Care Excellence (NICE) ( 2021 ). Leg ulcer – venous . https://cks.nice.org.uk/topics/leg-ulcer-venous Google Scholar National Institute for Health and Care Excellence (NICE) ( 2022 ). Venous eczema and lipodermatosclerosis: how should I assess the person ? https://cks.nice.org.uk/topics/venous-eczema-lipodermatosclerosis/diagnosis/assessment Google Scholar National Institute for Health and Care Excellence (NICE) ( 2023 ). Leg ulcer – venous . https://cks.nice.org.uk/topics/leg-ulcer-venous Google Scholar NHS ( 2020 ). Universal personalised care: implementing the comprehensive model . https://www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf Google Scholar NHS ( 2022 ). Causes: Peripheral neuropathy . https://www.nhs.uk/conditions/peripheral-neuropathy/causes Google Scholar NHS Inform ( 2022 ). Varicose eczema . https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/varicose-eczema Google Scholar Nicholls , S.C. ( 2005 ). Sequelae of untreated venous insufficiency . Seminars in Interventional Radiology 22 ( 3 ): 162 – 168 . 10.1055/s-2005-921960 PubMedGoogle Scholar Nichols , E. ( 2016 ). Wound assessment part 2: exudate . Wound Essentials 11 ( 1 ): 36 – 44 . Google Scholar Nickles , M.A. , Ennis , W.J. , O'Donnell , T.F. Jr. , and Altman , I.A. ( 2023 ). Compression therapy in peripheral artery disease: a literature review . Journal of Wound Care 32 ( Supp 5 ): S25 – S30 . https://doi.org/10.12968/jowc.2023.32.sup5.s25 . 10.12968/jowc.2023.32.Sup5.S25 PubMedGoogle Scholar Oh , D.M. and Phillips , T.J. ( 2006 ). Sex hormones and wound healing . Wounds 18 ( 1 ): 8 – 18 . Google Scholar Onida , S. and Davies , A. ( 2016 ). Predicted burden of venous disease . Phlebology 31 ( 1 ): 74 – 79 . 10.1177/0268355516628359 PubMedGoogle Scholar Ortega , M.A. , Fraile-Martínez , O. , García-Montero , C. et al. ( 2021 ). Understanding chronic venous disease: a critical overview of its pathophysiology and medical management . Journal of Clinical Medicine 10 ( 15 ): 3239 . https://doi.org/10.3390/jcm10153239 . 10.3390/jcm10153239 PubMedWeb of Science®Google Scholar Ousey , K. and Cook , L. ( 2012 ). Wound assessment made easy . Wounds UK . https://wounds-uk.com/made-easy/wound-assessment-made-easy Google Scholar Platsidaki , E. , Kouris , A. , and Christodoulou , C. ( 2017 ). Psychosocial aspects in patients with chronic leg ulcers . Wounds: A Compendium of Clinical Research and Practice 29 ( 10 ): 306 – 310 . https://doi.org/10.25270/wnds/2017.10.306310 . 10.25270/WNDS/2017.10.306310 PubMedGoogle Scholar Robertson , L.A. ( 2013 ). Incidence of varicose veins, chronic venous insufficiency and venous reflux in the general population and associated risk factors: the Edinburgh Vein Study follow up . PhD thesis, Edinburgh Research Archive . https://era.ed.ac.uk/handle/1842/8149 . Google Scholar Robinson , T. and Scullion , J.E. ( 2021 ). Oxford Handbook of Respiratory Nursing . Oxford : Oxford University Press . 10.1093/med/9780198831815.001.0001 Google Scholar Ruggiero , M. , Grande , R. , Naso , A. et al. ( 2016 ). Symptoms in patients with skin changes due to chronic venous insufficiency often lead to emergency care service: an Italian observational study . International Wound Journal 13 ( 5 ): 967 – 971 . 10.1111/iwj.12498 PubMedWeb of Science®Google Scholar Salomé , G. ( 2020 ). Body image of people with venous ulcers . Journal of Contemporary Nursing 9 ( 2 ): 225 – 230 . https://doi.org/10.17267/2317-3378rec.v9i2.2930 . 10.17267/2317?3378rec.v9i2.2930 Google Scholar Salomé , G.M. , de Almeida , S.A. , de Jesus Pereira , M.T. et al. ( 2016 ). The impact of venous leg ulcers on body image and self-esteem . Advances in Skin & Wound Care 29 ( 7 ): 316 – 321 . https://doi.org/10.1097/01.asw.0000484243.32091.0c . 10.1097/01.ASW.0000484243.32091.0c PubMedGoogle Scholar Seitz , C.S. , Berens , N. , Brocker , E.B. , and Trautmann , A. ( 2010 ). Leg ulceration in rheumatoid arthritis–an underreported multicausal complication with considerable morbidity: analysis of thirty-six patients and review of the literature . Dermatology 220 ( 3 ): 268 – 273 . https://doi.org/10.1159/000284583 . 10.1159/000284583 PubMedWeb of Science®Google Scholar Sharpe , A ., Dowsett , C. , Welch , D. et al., ( 2022 ). Wound preparation by cleansing and debridement using Alprep® Pad . Wounds UK . https://wounds-uk.com/best-practice-statements/wound-preparation-by-cleansing-and-debridement-using-alprep-pad Google Scholar Smith , D. , Team , V. , Barber , G. et al. ( 2018 ). Factors associated with physical activity levels in people with venous leg ulcers: a multicentre, prospective, cohort study . International Wound Journal 15 ( 2 ): 291 – 296 . https://doi.org/10.1111/iwj.12868 . 10.1111/iwj.12868 PubMedWeb of Science®Google Scholar Staines , K. ( 2018 ). Safe compression and accurate ABPI – overcoming barriers . Wounds UK 14 ( 1 ): 64 – 67 . Google Scholar Steven , L. , Hill , K. , Williams , D. et al. ( 2012 ). A review of the scientific evidence for biofilms in wounds. Wound repair and regeneration . Wound Repair and Regeneration 20 : 647 – 657 . 10.1111/j.1524-475X.2012.00836.x PubMedWeb of Science®Google Scholar Stoodley , P. , Sauer , K. , Davies , D.G. , and Costerton , J.W. ( 2002 ). Biofilms as complex differentiated communities . Annual Review of Microbiology 56 : 187 – 209 . https://doi.org/10.1146/annurev.micro.56.012302.160705 . 10.1146/annurev.micro.56.012302.160705 CASPubMedWeb of Science®Google Scholar Suehiro , K. , Morikage , N. , Murakami , M. et al. ( 2014 ). A study of leg edema in immobile patients . Circulation Journal 78 ( 7 ): 1733 – 1739 . https://doi.org/10.1253/circj.cj-13-1599 . 10.1253/circj.CJ-13-1599 PubMedWeb of Science®Google Scholar Tavadia , S. , Bianchi , J. , Dawe , R.S. et al. ( 2003 ). Allergic contact dermatitis in venous leg ulcer patients . Contact Dermatitis 48 ( 5 ): 261 – 265 . 10.1034/j.1600-0536.2003.00111.x CASPubMedWeb of Science®Google Scholar Taylor , K.J. and Holland , S. ( 1990 ). Doppler US. Part I. Basic principles, instrumentation, and pitfalls . Radiology 174 ( 2 ): 297 – 307 . https://doi.org/10.1148/radiology.174.2.2404309 . 10.1148/radiology.174.2.2404309 CASPubMedWeb of Science®Google Scholar Theochari , C.A. , Theochari , N.A. , Mylonas , K.S. et al. ( 2022 ). Venous thromboembolism following major abdominal surgery for cancer: a guide for the surgical intern . Current Pharmaceutical Design 28 ( 10 ): 787 – 797 . https://doi.org/10.2174/1381612828666220217140639 . 10.2174/1381612828666220217140639 CASPubMedWeb of Science®Google Scholar Thomson , L. ( 2016 ). Sclerotherapy of telangiectasias or spider veins in the lower limb: a review . Journal of Vascular Nursing 34 ( 2 ): 61 – 62 . 10.1016/j.jvn.2016.04.002 PubMedGoogle Scholar Tummala , S. and Scherbel , D. ( 2018 ). Clinical assessment of peripheral arterial disease in the office: what do the guidelines say? Seminars in Interventional Radiology 35 ( 5 ): 365 – 377 . 10.1055/s-0038-1676453 PubMedWeb of Science®Google Scholar Upton , D. , Andrews , A. , and Upton , P. ( 2014 ). Venous leg ulcers: what about well-being? Journal of Wound Care 23 ( 1 ): 14 – 17 . https://doi.org/10.12968/jowc.2014.23.1.14 . 10.12968/jowc.2014.23.1.14 CASPubMedWeb of Science®Google Scholar Van Rij , A.M. , De Alwis , C.S. , Jiang , P. et al. ( 2008 ). Obesity and impaired venous function . European Journal of Vascular and Endovascular Surgery 35 ( 6 ): 739 – 744 . https://doi.org/10.1016/j.ejvs.2008.01.006 . 10.1016/j.ejvs.2008.01.006 CASPubMedWeb of Science®Google Scholar Vascular Society for Great Britain and Ireland ( 2023 ) Lymphoedema and limb swelling . https://www.vascularsociety.org.uk/patients/conditions/1/lymphoedema_and_limb_swelling Google Scholar Vowden , P. and Vowden , K. ( 2018 ). The importance of accurate methodology in ABPI calculation when assessing lower limb wounds . British Journal of Community Nursing 23 ( Sup3 ): S16 – S21 . https://doi.org/10.12968/bjcn.2018.23.Sup3.S16 . 10.12968/bjcn.2018.23.Sup3.S16 PubMedGoogle Scholar Vuolo , J. ( 2010 ). Hypergranulation: exploring possible management options . British Journal of Nursing Tissue Viability 19 ( Suppl. 2 ): S4 – S8 . PubMedGoogle Scholar Walburn , J. , Weinman , J. , Norton , S. et al. ( 2017 ). Stress, illness perceptions, behaviors, and healing in venous leg ulcers: findings from a prospective observational study . Psychosomatic Medicine 79 ( 5 ): 585 – 592 . https://doi.org/10.1097/psy.0000000000000436 . 10.1097/PSY.0000000000000436 PubMedWeb of Science®Google Scholar Wang , X.-H. , Leineweber , C. , Kirkeeide , R. et al. ( 2006 ). Psychosocial stress and atherosclerosis: family and work stress accelerate the progression of coronary disease in women. The Stockholm Female Coronary Angiography study . Journal of Internal Medicine 261 ( 3 ): 245 – 254 . 10.1111/j.1365-2796.2006.01759.x Web of Science®Google Scholar Wang , W. , Zhao , T. , Geng , K. et al. ( 2021 ). Smoking and the pathophysiology of peripheral artery disease . Frontiers in Cardiovascular Medicine 8 : 704106 . https://doi.org/10.3389/fcvm.2021.704106 . 10.3389/fcvm.2021.704106 CASPubMedWeb of Science®Google Scholar Whayman , N. ( 2014 ) ' Doppler assessment: getting it right ', Wounds UK . https://wounds-uk.com/wound-essentials/doppler-assessmentgetting-it-right Google Scholar Wilson , M. ( 2012 ). Understanding the basics of wound assessment . Wound Essentials 7 ( 2 ): 8 – 12 . Google Scholar Winter , G.D. ( 1962 ). Formation of the scab and the rate of epithelialisation of superficial wounds in the skin of domestic pig . Nature 193 : 293 – 294 . 10.1038/193293a0 CASPubMedWeb of Science®Google Scholar Winterborn , R.J. , Foy , C. , and Earnshaw , J.J. ( 2004 ). Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein . Journal of Vascular Surgery 40 ( 4 ): 634 – 639 . 10.1016/j.jvs.2004.07.003 PubMedWeb of Science®Google Scholar Wittens , C. , Davies , A.H. , Baekgaard , N. et al. ( 2015 ). Editor's choice – management of chronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery (ESVS) . European Journal of Vascular and Endovascular Surgery 49 ( 6 ): 678 – 737 . https://doi.org/10.1016/j.ejvs.2015.02.007 . 10.1016/j.ejvs.2015.02.007 CASPubMedWeb of Science®Google Scholar Woelk , C.J. ( 2012 ). Management of critical limb ischemia . Canadian Family Physician/Le médecin de famille canadien 58 ( 9 ): 960 – 963 . PubMedWeb of Science®Google Scholar World Union of Wound Healing Societies ( 2007 ). Wound Exudate and the Role of Dressings: A Consensus Document . London : MEP . Google Scholar Wounds UK ( 2013 ). Best practice statement: effective exudate management . https://wounds-uk.com/best-practice-statements/best-practice-statement-effective-exudate-management . Google Scholar Wounds UK ( 2016 ). Quick guide: Management of hyperkeratosis of the lower limb . https://www.wounds-uk.com/resources/details/quick-guide-management-of-hyperkeratosis-of-the-lower-limb Google Scholar Wounds UK ( 2019a ). Best practice statement: Ankle brachial pressure index (ABPI) in practice . https://wounds-uk.com/best-practice-statements/ankle-brachial-pressure-index-abpi-practice Google Scholar Wounds UK ( 2019b ). Best practice statement: Addressing complexities in the management of venous legs ulcers . https://wounds-uk.com/best-practice-statements/addressing-complexities-management-venous-leg-ulcers Google Scholar Wounds UK ( 2020 ). Best practice statement: Management of lower limb skin tears in adults . https://wounds-uk.com/best-practice-statements/management-lower-limb-skin-tears-adults . Google Scholar Wounds UK ( 2021 ). Best practice statement: Addressing skin tone bias in wound care: assessing signs and symptoms in people with dark skin tones . https://wounds-uk.com/best-practice-statements/addressing-skin-tone-bias-wound-care-assessing-signs-and-symptoms-people-dark-skin-tones . Google Scholar Wounds UK ( 2022 ). Best practice statement: Holistic management of venous leg ulceration . https://www.wounds-uk.com/resources/details/holistic-management-venous-leg-ulceration-second-edition Google Scholar Young , T. ( 2015 ). Unit 5. How to undertake a doppler ultrasound . Practice Nursing 22 ( 11 ): 1 – 4 . 10.12968/pnur.2011.22.11.CPD5 Google Scholar Young , T. ( 2020 ). Leg ulceration in sickleell disease . Wounds UK 16 ( 1 ): 72 – 77 . Google Scholar Zegarra , T. and Tadi , P. ( 2022 ). CEAP classification of venous disorders . In: StatPearls . Treasure Island, FL : StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK557410/ . Google Scholar Zemaitis , M. , Boll , J. , and Dreyer , M. ( 2022 ). Peripheral Arterial Disease . Bethesda, MD : National Library of Medicine . Google Scholar Lower Limb and Leg Ulcer Assessment and Management ReferencesRelatedInformation