Synopsis
Assess a lower-limb ulcer systematically, establish venous and arterial contributions, apply safe effective compression, and refer early for venous intervention.
- At first assessment document ulcer site, length, width, depth, edge, bed, exudate, pain, surrounding skin and limb oedema; examine pulses and the contralateral limb.
- Perform objective arterial assessment before compression with ankle pressure and ABPI, adding toe pressure when ABPI is unreliable; avoid sustained compression below ankle pressure 60 mmHg, toe pressure 30 mmHg or ABPI 0.6.
- For an active venous ulcer with adequate perfusion, trained staff should apply multilayer or inelastic bandaging or an adjustable garment targeting at least 40 mmHg at the ankle to improve healing.
Key red flags
Rest pain, a cold or pale foot, gangrene, rapidly increasing necrosis, absent pulses or abrupt pain after compression requires urgent arterial assessment and cessation of sustained compression.
Fever, hypotension, rapidly spreading redness, crepitus or severe pain out of proportion suggests sepsis or necrotising fasciitis and requires hospital referral.
Exposed or probeable bone, deep persistent pain, sinus formation or failure despite appropriate care raises concern for osteomyelitis and needs specialist assessment.
An atypical site, rolled or everted edge, excessive granulation, rapid growth or failure to improve despite adequate compression should prompt biopsy or dermatology assessment for malignant or inflammatory ulceration.
Sudden unilateral swelling or chest symptoms in a patient with an ulcer requires urgent VTE assessment rather than attribution to chronic venous disease.
Investigation priorities
Quantify arterial perfusion before compression and detect a mixed arterial-venous ulcer requiring modified or deferred pressure.
Management branches
Use at initial presentation before assuming venous causation, prescribing antibiotics or selecting compression pressure.
- Record duration and recurrence, pain, mobility, VTE and arterial history, diabetes, smoking, medicines and previous treatment; measure and describe the wound and examine both legs.
- Identify serious infection, acute ischaemia, DVT and atypical ulcer features requiring urgent or specialist care.