Assessment and management of leg ulcers including ankle brachial pressure index (ABPI) (G126)

A chronic leg ulcer is defined as an open lesion between the knee and the ankle joint that remains unhealed for at least four weeks (Vascular Society 2019)¹, however more up to date evidence suggests that a leg ulcer can be described as “a break on the skin that fails to heal within 2 weeks”(NICE 2016) ².

Current best practice and national guidelines recommend the use of compression therapy for patients who have leg ulceration due to venous disease. It is important that prior to commencing any treatment and applying compression therapy that a full holistic leg ulcer assessment is carried out; this includes Doppler ankle brachial pressure index (ABPI) measurement.

A comprehensive assessment should include; full past medical history, examination of the leg(s) and ulcers for signs of venous and arterial disease or ulceration due to other causes. See Appendix 1.

The aim of the guideline is to ensure that staff will appropriately manage patients presenting with new and existing leg ulcers, and identifying those who would benefit from compression therapy at the earliest possible opportunity.

Staff managing patients with leg ulcers or require an ABPI Doppler must:-

• Provide a full holistic leg ulcer assessment and diagnose leg ulcer type
• Provide patients with evidence based care
• Recognise that if wounds fail to progress by 12 weeks, reassessment is paramount and referral made to the appropriate service is made i.e. Dermatology, Vascular or Tissue Viability
• Provide treatment up to healing and then provide secondary prevention options suitable to the patient
• Educate and encourage patients to self-manage skin once healed
• Effectively manage patients with postural hypotension using compression hosiery, when no ulcer present.

Venous ulceration accounts for 80% of leg ulcers, arterial ulceration is 15% and all other ulceration caused by trauma, vasculitis or malignancy make up the remaining 5% (Vascular Society 2019)¹.

3.1 Venous ulceration

Venous ulceration presents with one or more of the following clinical signs:-

• varicose veins
• ankle flare
• venous dermatitis
• oedema
• lipodermatosclerosis
• hemosiderin staining
• scarring from previous wounds/surgeries
• induration which may result in inverted champagne bottle shaped leg
• the limb is usually warm and well perfused.

Venous ulceration is most commonly found on the medial gaiter area of the lower limb, typically singular and oval shaped. The ulcer is usually flat with shallow edges and may present with some lipodermatosclerosis to the peri-wound skin. The patient may or may not present with pain in the wound. The ulcer may be any size but will increase slowly if left untreated. The ABPI in patients with venous ulceration will generally be 1.0 - 1.3 and foot pulses will be triphasic or biphasic sounding.

3.2 Arterial ulceration

Arterial ulceration presents with one or more of the following clinical signs:-

• cold legs or feet in a warm environment
• dependent rubor (redness)
• whiteness on elevation
• trophic changes i.e. pale, shiny, hairless skin
• intermittent claudication, rest pain and/or night pain
• signs of critical limb ischaemia i.e. blue or white feet, gangrenous toes.

Arterial ulceration usually begins over pressure points and usually involves the lower leg, foot and toes. Usually round and may appear in clusters they may be deep and have punched out edges. In severe cases tendon may be exposed. The skin will appear cool, shiny and hairless. The wounds will be described as being very painful often at night or on elevation. The pain will settle when legs are lowered, another feature that may be described is intermittent claudication. These ulcers will develop rapidly, ABPI will be < 0.8 or > 1.3 and monophasic sounds present or pulse sounds absent. If the ABPI is >1.3 the individual may have calcified vessels and should be referred to a Vascular Consultant for further investigations (Wounds UK, 2019)³.  

3.3 Mixed aetiology ulceration

Patients may present with symptoms of both venous and arterial ulcers. These types of ulcers are common in people who have underlying health conditions such as arterial insufficiency, diabetes mellitus or rheumatoid arthritis. Patients with mixed aetiology ulceration will have an ABPI of between 0.8 and 1.0 and are suitable to be treated with reduced compression.

Doppler assessment is a non-invasive way of assessing a patient’s vascular status and confirming or excluding the presence of peripheral arterial disease (PAD) (Wounds UK, 2019)³. This is an essential part of the assessment process as it helps to determine the type of ulcer the patient is presenting with. Care must be taken when interpreting results of an ABPI. See Appendix 2.

If the ABPI is unobtainable due to calcification of the vessels, patients must be referred to a Vascular Consultant for further investigations such as toe Doppler’s or arterial duplex scanning prior to considering compression.

Patients with an ABPI <0.8 or >1.3 should be assumed to have a degree of arterial disease, therefore should refer to a Vascular Consultant for further investigations.

4.1 Staff who may perform ABPI

Registered nursing staff must have the knowledge, skills and competencies necessary to manage patients with leg ulceration by undertaking additional leg ulcer training.

Other staff groups that may be required to perform an ABPI Doppler and interpret results to ensure patient safety are:-

• Podiatrists - should ensure a patient has their circulation checked prior to carrying out debridement on any part of the foot.
• Lymphoedema specialists - prior to commencing compression to reduce chronic oedema/lymphoedema.
• Staff managing patients with postural hypotension - prior to commencing compression hosiery to reduce the risk of effects of postural hypotension (Papismadov et al, 2019)⁴ .
• Clinical Physiology Technicians – trained in carrying out ABPI Doppler’s including toe Doppler’s for patients that may have difficult or unobtainable ABPI readings.

All guidelines and policies require review using the NHS Ayrshire and Arran Impact Assessment Toolkit by staff trained in this process.

Staff are reminded that they may have patients who require communication in a form other than English e.g. other languages or signing. Additionally, some patients may have difficulties with written material. At all times, communication and material should be in the patients preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on this guideline e.g. choice of gender of healthcare professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made.

Patient’s sexuality may or may not be relevant to the implementation of this guideline however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional Equality & Diversity issues were identified.

“Gold Standard” treatment for managing patients with leg ulcers is compression therapy (Heatly et al 2020)⁵. The sooner a patient has a full holistic leg ulcer assessment carried out to determine their suitability for compression the better.

Once the aetiology of the ulcer has been identified it is vitally important that the correct management pathway is followed.

Please see:-

Appendix 1 Leg Ulcer Assessment

Appendix 2 Analysing ABPI Recordings

Appendix 3 Leg Ulcer Management

Appendix 4 Treatment Room Nurse Management

Appendix 5 Patient Admitted to Hospital with a Leg Ulcer

Appendix 6 Patient in Compression Bandaging Being Discharged From Hospital.

Once all of the above information has been collected, perform an ABPI.

An ABPI alone does not determine the status of an ulcer.

“We must treat the whole patient and not just the hole in the patient” (Lindsay et al 2017⁶)

ABPI plays a major role in determining which patients are suitable for compression bandaging or support stockings or compression wraps. 

If a patient has normal ABPI recordings but abnormal flow, it is important that the individual gets referred to vascular for further investigations.

Management of leg ulcers pathway

Treatment Room nurse leg ulcer guidance pathway

OR use the Q&A tool.

Please follow Scottish Wounds Assessment Action Guide (SWAAG)  for appropriate dressing choice.

For infected wounds please follow Scottish Ropper Ladder for Infected Wounds. (Reproduced with kind permission of NHS Lothian)

Use the Q&A tool Patient admitted to hospital with a leg ulcer or follow steps below.

Ward staff to obtain diagnosis, full history and care plan recent ABPI results from

• district nurse/practice nurse/ care home
• patient
• carer
• dressings clinic
• health care record

If ABPI over 12 months old or is unknown - doctor to request ABPI (Resting Doppler) from Cardiac Physiology Department.

Patient not in compression bandage:-

Basic leg care pathway

• Leg can be washed either by showering or with warm tap water using a basin lined with a plastic bag or a disposable basin and using warm water.
• Prontosan soak - 10 mins to the wound bed.
• Apply emollient to surrounding skin e.g. 50/50 (50% white soft paraffin/50% liquid paraffin), zerobase, QV cream/ointment.
• Assess ulcer for suitable primary dressing in concordance with NHS Ayrshire & Arran Formulary and wound pad if low exudate, zetuvit plus if high exudate. Secure with toe to knee cotton stockinette or comfifast.
• Apply wool bandage toe to knee with 50% overlap.
• Apply top layer of cotton stockinette or comfifast toe to knee to secure.
• Record in Wound Assessment Chart
• Check with patient for known sensitivities or allergies
• Ensure leg is elevated on foot stool when patient sitting out of bed as this will help reduce oedema

• If required, make referral to Tissue Viability Service on PMS.

Patient in compression bandages no infection

• Remove bandages
• Follow basic leg care pathway.

Infected leg ulcer in or out of compression bandages

• In compression remove bandages
• Follow basic leg care pathway then proceed to The Scottish Ropper Ladder for Infected Wounds.

Always refer to NHS Ayrshire & Arran formulary for appropriate dressing selection.

1. Discuss the patients wound care with the Tissue Viability Nurse if they have been involved in their care. Ensure correct information is being passed onto the community/care home staff:

   • ABPI results
   • sounds
   • primary and secondary dressings
   • compression bandage system
   • frequency of dressing changes.
2. Ensure patient is sent home with a minimum of 7 days dressings including primary and secondary dressings and compression bandages.
3. Call the district nurses/practice nurse/care home staff prior to discharge date and schedule an estimated discharge to allow them to order dressing supplies as this can take up to 1 week. If the discharge date changes then the care provider must be notified.

If the Tissue Viability Team has been involved in the patient’s care our number can be provided to the community staff for further information - 01563 825840

If care home staff feel the wound is too complex and require support they must contact the district nurses attached to the care home in the first instance.

1. Vascular Society. https://www.vascularsociety.org.uk/ 2019. [Accessed 07.08.2020]
2. NICE. Leg ulcer - venous. 2016. 
3. Wounds UK. Best Practice Statement - Addressing complexities in the management of venous leg ulcers. 2019. Available from: https://www.wounds-uk.com/resources/details/best-practice-statement-addressing-complexities-management-venous-leg-ulcers [Accessed 14.02.2023]
4. Papismadov B, Tzur I, Izhakian S, Barchel D, Swaka M, Phatel H, Livshiz-Riven I and Goelik O. High compression leg bandaging prevents seated postural hypotension among elderly hospitalized patients. Ger. nurs. 2019 40(6):558-564. Available from:https://pubmed.ncbi.nlm.nih.gov/31078324/ DOI:10.1016/j.gerinurse.2019.04.004.
5. Heatly F, Saghadaoui LB, Salim S, Onida S, Davies AH. Primary care survey of venous leg ulceration management and referral pre-EVRA trial. Br. j. comm. nurs. 2020 25(Sup 12):S6-S10. Available from: https://pubmed.ncbi.nlm.nih.gov/33300844/ DOI:10.12968/bjcn.2020.25.Sup12.S6
6. Lindsay E, Renyi R, Wilkie P, Valle F, White W, Maida V, Edwards H, Foster D. Patient-centred care: a call to action for wound management. J. wound care. 2017. 26(11):662-677.  Available from:https://pubmed.ncbi.nlm.nih.gov/29131749/ DOI:10.12968/jowc.2017.26.11.662.