Episode 11: Wounds & Swelling

Hello, this is Professor Mark Whitely, consultant venous surgeon for the Whitely Clinics in the UK. I'm delighted to be giving you this podcast today. I've been invited by the Lindsay Leg Clubs to give three podcasts and this is the third of the three. This one is entitled what treatments help or hinder leg wounds and swelling. So we're going to divide this talk into first of all talking about the treatments of leg wounds and then we're going to talk about leg swelling. Firstly when we think about leg wounds we have to think about what we mean. We're talking about a break in the skin. Now of course most people who are healthy who get a break in the skin have no worries at all because any break in the skin such as scratch or a cut will heal. What we're really concerned about when we talk about these sorts of leg wounds are ones that we get a scratch or a cut which doesn't heal. If a wound has stayed open for more than two weeks and it doesn't look like the skin or epithelium as we call it medically is going to close over it, it becomes an open sore or what we call a leg ulcer and the definition of an ulcer is a breach in an epithelial surface and if it goes on for more than two weeks on the legs this is called a leg ulcer. So we may have a break in the skin on the leg for more than two weeks we have a leg ulcer. Now why would this happen as I've already alluded to a normal person wouldn't get this so something abnormal is happening and this means that there's an underlying cause and usually the underlying cause for a leg ulcer is that the veins are not working properly. So the venous blood is not getting out of the leg properly and we've got inflammation in the lower leg from venous disease and this is 90% of leg ulcers. 10% is because there isn't a good artery supply and then there's a few very very small and rarer causes such as malignancies or underlying infections such as an osteomyelitis or maybe lymphedema but we really can look at those in another light at a different time because those are quite rare and really we just want to concentrate today on venous leg ulcers and a little bit on arterial leg ulcers. One of the most important things you should have noticed straight away is we're already talking about why the wound stayed open in other words there's an underlying cause that stopped the normal healing process from happening. Now everyone particularly nurses who spend all of their times looking after such leg ulcers and some doctors who get involved with this what everyone would like is to have a dressing or a cream or a potion that you could put on the wound because you can see it on the surface and it would magically heal but unfortunately this can't happen because if it was just a surface problem we wouldn't have an underlying problem it's very simple so if there's an underlying condition that's causing the leg ulcer we have to correct that first before we think about what we can put on the surface. As we've said 90% of all of the leg ulcers are venous in nature and so clearly we have to treat the underlying veins to get it to heal. Most people who have venous leg ulcers have incompetent veins that means the valves aren't working in their saphenous veins which the veins that cause varicose veins or their incompetent perforators which are other veins that also cause varicose veins but doctors in the UK don't really concentrate on very much apart from those of us who specialize in venous disease. So what we know is if you have got these incompetence of venous veins or perforators you have either varicose veins or hidden varicose veins and although we used to think that was only a cosmetic problem we now know that if this is left for long enough you get red stains, swelling of the legs, brown stains and leg ulcers. And if you want to reverse that process you just treat these veins using something like endovenous laser ablation, trollop and foam sclerotherapy. But basically it's treating the underlying venous reflux. Under each of the venous ulcers there's also a little network of veins that are dilated where you have blood that just sits still called stasis blood which is very acidic and burns the skin and this is called the sub-ulcer plexus and that needs to be treated with firm sclerotherapy. In some patients there are pelvic vein problems that either need to be blocked off using coils or there are blocked pelvic veins that need to be opened with stents. So if we look at 90% of the people with these venous leg ulcers most of those can now be treated if we treat the underlying veins and we don't even have to think about anything at all about what we have to do on the surface of the ulcer itself. On the arterial side similarly if the leg ulcer is due to the fact there's not enough blood going down the arteries then the ideal thing to do is to get more blood going down to the foot through the arteries and this means either stenting which is putting little metal tubes to hold the arteries open or a bypass operation to put more blood down through a bypass bypassing any blocks in the arteries if that's impossible sometimes it is more possible just to dilate the arteries up by destroying the sympathetic nervous system a thing called the sympathectomy and this sometimes can increase the blood flow and therefore cause healing of leg ulcers. So when we talk about leg wounds or chronic leg wounds we're talking about leg ulcers and we must always identify the underlying cause first which is almost always venous and then we must treat it. Once we've done that and we have treated it now we can start looking at the leg wound and really the sad thing is for all the people who concentrate so much on what sort of dressings to use in reality the Cochrane report that was written on this many years ago has shown that really there's very very few things that speed up healing there's lots of things that hinder healing but through a few things that speed up healing that you put onto the wound itself many people like certain products such as Manuka honey this is a very nice thing that you can smooth on patients love the idea of it because bugs can't grow in it but the reality is even manuka honey has got no effect at all if you haven't corrected the underlying condition and so therefore really all that the dressings on the surface tend to do is they tend to only assist normal healing once you've treated the underlying cause or If you haven't treated the underlying cause if you then try and correct it by simple things such as compression or elevation which has a temporary effect which you can start getting an improvement but of course once you reverse that take the compression off or put the leg back down of course you get a reversal and the ulcer opens up again. So therefore there's very very little that can actually promote healing on a leg wound. In fact some of the things that worsen the leg wounds and leg ulcers are occlusive dressings, dressings that allow the moisture from the wound to spread out onto the adjacent skin, the skin next door to the wound or the ulcer which causes maceration and a breakdown of the skin causing the ulcer to get bigger. And I've had several people who have come in with massive leg ulcers and it's clear that most of it is actually just from the fluid being kept next to the skin by using dressings that don't let the water escape, they're very sodden or they just hold the water and the plasma on the skin and with those patients I often put them into a hospital bed for a few days, elevate the leg, leave it open to the air to let it dry give the patient heparin so that they're not going to get deep vein thrombosis and what you see all of the skin healing and the size of the ulcer reduces dramatically just down to the small ulcer that is the original problem so therefore the quite often things that hinder the healing of wound ulcers and in fact make them bigger are dressings that get very very wet and hold the wetness next to the healthy skin and let it break down. The only thing that is very exciting at the moment is whether plasma-rich protein PFP or PRP rather it can be injected on top of the wounds. There's some case reports appearing suggesting that that might help promote healing in these ulcers again unless you're causing a change of the underlying problem this won't work there may be one or two other things coming around but really the this the one thing that we know now about venous and arterial leg ulcers is cure the underlying circulation and most things will get better all you need to do is avoid things that actually worsen the problem keeping the infections in or letting the water and plasma macerate the skin around the ulcer itself. So now turning away from venous leg ulcers and venous wounds we're now looking at the swelling of the leg and again most swelling certainly that is interesting is from venous disease. Many people do get swelling from stasis if they sit, especially the elderly, sitting in unstimulating environments, if they sit in chairs watching TV all day and aren't encouraged to move around. There can be no venous disease as such when you scan the patient but still have the appearance of venous disease with swollen legs just due to inactivity and that's called gravitational ulceration or some people do call it venous ulceration because it looks the same even though the veins are normal. There are some other causes swelling such as heart failure, low protein states and so these must all be looked at and also if the swelling goes right to the toes then this may well be lymphedema. Now whenever we have swelling in the legs the first thing we must do is just check there isn't a medical cause such as heart failure make sure the heart is working well, making sure also that the proteins are normal and the patient has good nutrition and provided all of that is normal and the next thing is then is the patient moving. Now if the patient is not moving then we have a gravitational problem. If the patient is moving then there really should be less swelling and swelling is more of a concern. The easiest way to get rid of swelling of any sort around the ankles is to elevate the legs because gravity is the major thing that will cause fluid to pool and therefore if the lowest point is the legs then we will get swollen ankles and feet just due to gravity whereas if there's an elevation then quite often we will get edema around the back and the sacrum and the buttocks because that's the becomes the lowest point so we can elevate the legs and that will certainly help the ankles but it may not help the whole patient. What we have to think about is what the underlying cause is. So as we've said all of the other general causes heart failure can be treated with some diuretics and help supporting the heart with medication, low protein states, better nutrition will help that and any other medical conditions we're finding. But when we're coming to venous diseases and lymphedema diseases or gravitational, elevation is the first thing we do as we've discussed. The second thing and one of the mainstays of course is compression and this can be by graduated compression stockings which is a very controlled way of performing compression but bandaging done by an expert with the bandage being tightest at the lowest part of the leg and up to the knee sometimes higher is a very good way of getting compression and pushing the fluid back from the extra vascular compartment that amongst the cells so the interest at the extracellular fluid back into the veins and the lymphatics hopefully to be pumped back to the heart. So compression is obviously very very important to these patients. However just as important really and often not thought about is muscle action and the best muscle action of course is walking. Anybody who's walking should get the coordinated pumping from the foot pump round the ankle joint up through the calf pump. There's actually two calf pumps at least and then thigh pump and back to the heart. So we should encourage patients to walk as much as possible but if they either can't walk or are unsafe walking even just rocking the feet on the several different products that can be used or just moving the feet up and down keeping the ankle joint moving will helps get the venous pump working to get the pump to pump all the blood back up through the veins superficial and deep to the heart. Now if we can get the movement and compression together of course then that's going to help things even more and it has been shown that with lymphedema in particular if you can get very good compression and then walking even severe lymphedema can markedly improve certainly for a few days if we can get a good amount of walking going with a very tight compression which doesn't have much in the way of elasticity. It does get a bit complex but that's just the basics really of the combination between walking and compression. If we then think about patients who can't walk either temporarily because they're ill in hospitals or permanently because they're unable to do so, then we can actually simulate walking to an extent. We're using neuromuscular stimulation, so these are usually electronic devices that stimulate the muscles in the feet or lower legs or stimulate the nerves that then stimulate the feet in the muscles in the feet and the lower legs. These cause a natural sort of pumping in the veins and once again pumping the blood up the veins towards the heart and helping in this venous return. If the patient is either unable or unwilling or finds that uncomfortable there are external pumps that can be used. Usually these external pumps are pneumatic so the cuffs go sometimes around the feet almost always around the calf and sometimes around the thigh as well and the external pumps can actually inflate these usually in order in which case it's called a sequential pump sometimes if it's any one pump then it just pumps up and down and these pumps push on the area compressing as I say foot, calf, thigh or any combination of those helping the blood be pumped up in a passive way back to the heart. So in conclusion of this podcast when we're talking about leg wounds always always always look for the underlying cause for a chronic leg wound first and treat that a long time before thinking about putting anything on the surface of it or else you're just wasting your time and when it comes to swelling always identify the cause of the swelling and what becomes your friend if you haven't got a biochemical cause for it or a cardiac cause for it if we're talking about a pumping type cause of venous or a lymphatic type cause your friends at elevation, compression and increasing activity particularly at the ankle joint in principle. This is has all venous disease a very complex area and this podcast has only been a summary as have been my last two podcasts however this whole area is a fascinating subject that is very deep and there are great many different texts around and there are great different websites around and all of the time there are new papers being published on the different areas of venous disease, venous leg ulcers. I'd encourage you to keep up to date with what the latest ideas are and the latest randomised studies and it's always good no matter how good your traditional training has been to keep supplementing it with the latest ideas. And finally, if you have enjoyed any of my talks, please do not hesitate to contact me or look up any of my books, research papers, websites or articles to find out more about these fascinating areas of venous disease and leg oscillation.