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Rapid resolution of a lower leg ulcer with evidenced-based practice, and the
discovery of a rare underlying condition causing recurrence
Alison Vallejo RN, Grad Dip Wound Care
Blue Care/University of the Sunshine Coast (USC) Wound Solutions Clinic
• Gina - 46 year old lady
• Presented to the Wound Solutions Clinic (WSC) with 6 month Hx of a non-healing left
medial gaiter leg ulcer following a scratch in the garden. Same area as a previous ulcer.
• The WSC team performed a comprehensive and holistic assessment in order to obtain an
accurate diagnosis and identify patient concerns. This allowed application of evidence-
based Mx tailored to Gina’s needs. Appropriate management led to a rapid healing
response, patient satisfaction, healthy lifestyle changes and the discovery of a rare health
condition; thought to be the underlying cause of ulceration and recurrence.
Medical Hx & Health status:
• Medical Hx includes: morbid obesity, recurrent bilateral lower leg thrombophlebitis,
varicose veins, cellulitis L) lower leg, bilateral DVTs and Antithrombin 3 deficiency.
• Current medications include: Clindamycin for a confirmed localised wound infection (on
and off for 6 months) and Ferrograd to assist with haemoglobin formation.
• Lives in a supportive social environment with no obvious emotional, mental or physical
problems, other than pain in the wound, associated anxiety, and morbid obesity. Gina
maintains a job at a school canteen and local news agency, where she is on her feet most of
the time and admits to not wearing her compression stockings prescribed a few years ago.
• Gina had minimal insight about her Antithrombin condition, was not on any therapy, had
ceased Xarelto a couple of years ago and was not aware of the risks involved or the damage
her previous DVTs had caused.
Wound assessment: Initial presentation = 25.9.14
Local wound assessment =“MEASURE” method = a thorough and simple systematic
wound assessment that captures vital information for baseline data and assists with
developing short and long-term goals and appropriate interventions (Keast et al., 2004).
M–L =1.5cmxW=0.8cm,A =1.4cm2viaVisitrak
E – Moderate, thick, non-malodorous haemopurulent exudate
A – Soft dried exudate covers a suspected shallow wound bed, approximate 80%
granulation, 20% brown slough
S – Severe pain, 10/10 to touch - Numerical Rating Scale (NRS) 0-10
U - No undermining suspected
R – Review weekly for wound bed preparation, monitor pain, establish wound regime,
follow up on Ix in conjunction with GP
E - Hyperpigmented, almost purple peri-wound, with a dry circular edge of debris
extending 2cm. Surrounding skin healthy & intact
Oedematous L) lower leg with visible varicosities. L) ankle = 33cm, L) calf = 47 cm, 2 cm
larger than the R) leg. Localised erythema, no heat detected, normal hair growth and
healthy toe nails, indicating no signs of spreading infection and adequate arterial supply
(Carville, 2012). A hyperpigmented scar on the medial gaiter of the contralateral limb is
prominent and consistent with the presenting ulcer ’s discolored appearance.
Intense procedural pain was observed and at non-specific times reported by Gina;
measured using the NRS 0-10. Pain caused anxiety and stress at dressing change. Pain was
described as shooting, stabbing, burning pain that could waken Gina and impact on her
daily activities. Pain limited thorough inspection of the wound at initial visit and had
reduced Gina’s tolerance to compression. Panadeine was her analgesia of choice, used with
• Arterial and venous duplex ultrasounds (a hand-held Doppler was not appropriate due to
significant oedema and wound associated pain at cuff location).
• Intense pain and a suspicious purple peri-wound prompted haematological investigations,
to exclude an inflammatory ulcer type: ESR, CRP, Lupus anticoagulant, ANA, ANCA.
Duplex US = deep venous incompetence in the L) common femoral vein and long
saphenous vein, with an incompetent perforator 18cm above the heel at medial gaiter
(ulcer site). PPG toe pressures = 0.7, indicating normal arterial perfusion (Carville, 2012).
Blood tests = normal, with slightly elevated ESR of 21, normal value = <20 (Medline Plus,
Research on Antithrombin 3 deficiency revealed that this anticoagulant deficiency was the
cause of recurrent DVTs and thrombophlebitis, increasing Gina’s risk of developing future
DVTs and pulmonary embolisms due to obesity (Lipe & Ornstein, 2011).
Pain, insufficient/nil compression and lack of wound bed preparation were immediate
factors affecting healing. Obesity, poor lifestyle habits and Gina’s haematological
condition increased the risk of recurrence and complications.
3rd visit/2nd week – Gina reported 3/10 pain, minimal wound exudate,
product changed to a hydrocolloid, 3 layer Tubigrip continued.
4th visit/3rd week – reduced anxiety and trust established, hosiery
commenced -Venosan Medi Plus Class 2, hydrocolloid dressing continued.
5th visit/5th week – 100% epithelialisation, pain 0/10, Gina self caring and
concordant with hosiery and regime.
7th week – complete closure, patient satisfaction and improved QOL. Best
practice skin care and compression therapy education given.
6 weeks post healing – intact skin/healed wound, patient remains
concordant with care, second pair of hosiery ordered.
A holistic team approach with relevant Ix assisted with the rapid healing of
Gina’s ulcer and identified the underlying cause of recurrence. Evidence-
based management of compression therapy, wound bed preparation,
appropriate product choice, education, trust and patient concordance,
enabled a consistent and targeted regime. Acute needs of pain and anxiety
were quickly relieved and long-term healthy lifestyle habits adopted.
Ongoing haematological investigations continue for Gina with firm advice
to lose weight and continue compression to prevent ulcer recurrence and
Carville, K. (2012). Wound care manual (6th ed.) . Osborne Park, Australia: Silver Chain Foundation.
Keast, D., Bowering, K., Evans, A., Mackean, G., Burrows, C., & D’Souza, L. (2004). Measure: A proposed assessment framework for developing best practice recommendations for
wound assessment. Wound Repair and Regeneration, 12(3), S1-S17.
Lipe, B., & Ornstein, D.L. (2011). Deficiencies of natural anticoagulants, Protein C, Protein S, and Antithrombin. Circulation, 124, 365 -368 . doi: 10.1161/CIRCULATIONHA.
MedlinePlus. (2014). ESR levels: normal results. Retrieved from:
• Pain Rx = topical anaesthetic - LMX4 & Lyrica for neuropathic pain.
• Devitalised tissue removed via low-frequency ultrasonic debridement
(LFUSD) by the WSC podiatrist and antimicrobial hydrofibre applied to â
the confirmed heavy growth of S. aureus.
• Compression commenced with a 3 layer Tubigrip approach for ease of
patient application and bathing. Lower limb measurements were taken and
prompt liaison with the Venosan representative for appropriate hosiery was
• The WSC dietitian provided nutritional advice for weight loss and healthy
eating habits to prevent complications and promote wound healing.
Permission was granted for the information and photos used
in this case study. The name used is fictitious.
Thanks to: Gina for the use of information and photos; the WSC team for the
multidisciplinary support; the Venosan rep for prompt and efficient product
advice. Thanks to: USC and Blue Care, for making the Wound Solutions Clinic a
reality and a success, and help our community members regain their QOL.
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