Chronic Wounds and Lymphoedema

Chronic Wounds

This is usually a break in the skin with an ulcer over any part of the body.  Some of these wounds may have been present for over 1 month and have been unable to heal on their own. These wounds may also have secondary bacterial infections resulting in pus discharge, bad odours and surrounding redness and pain.

Common sites and risk factors for developing Chronic Wounds

Chronic wounds are usually found at sites where:

  • there is persistent pressure on the skin (e.g lower back, buttocks, heel of foot), especially in patients who are not mobile and laying down for long periods of time
  • the blood arterial supply is poor e.g lower limbs, foot and toes of patients with peripheral artery disease
  • there is an infection underlying the wound e.g chronic bone infections resulting is a wound on the surface and discharge

Patients who have diabetes or are immunocompromised are also at risk of developing chronic non-healing wounds.

Investigations and Diagnosis

  • The aim of these investigations is to determine the cause of the wound as well as to guide treatment of the wound
  • Wound bacterial swabs and cultures are usually taken to determine presence of bacteria in the wound as well as to guide anti-biotic therapy
  • Some patients may require x-rays, CT scans or MRI scans to determine underlying bone and/or soft tissue infections

Treatment

For a chronic wound to heal, we must treat 2 key components – the underlying cause and the actual wound itself. For example, if there is underlying peripheral artery disease causing poor blood supply to the region of the wound, then the patients should undergo surgery to treat the artery disease (e/g angioplasty/ stenting) to improve the blood flow to the wound. If there is underlying infection, then the wound may need to be cleaned surgically and antibiotics started.

We then use different techniques with various types of dressing preparations to treat the wound itself.  The dressings range from simple gels applied to the wound to complex types like Vacuum Assisted Closure (VAC) or maggot therapy.  Our aim is to have complete healing of these wounds with return of functionality.

Lymphoedema

Lymphoedema is swelling which affects the limbs due to failure of the lymphatic channels.  Lymphatic channels serve to help drain fluid from the extremities as well as act as an immune gatekeeper (lymph nodes).  

 

Causes of lymphoedema

  • Primary lymphoedema is rare and often due to congenital absence of lymphoedema or the failure of the lymphatic system to work over time.  Patients can present with swollen limbs at birth (congenital absence of lymphatics) or in their teenage years (delayed primary failure).  
  • Secondary lymphoedema is more common and is often the result of surgery to remove the lymph nodes (e.g surgery for breast cancer and axilla lymph node clearance ) or radiation therapy to the lymph nodes (e.g radiation to the groin or pelvic lymph nodes)  Sometimes recurrent skin infections (cellulitis) can also damage the lymphatic drainage of the limbs.

Diagnosis

  • Diagnosis requires obtaining a history of duration of limb swelling.
  • Exclusion of other cause of limb swelling such as associated vein disease, muscle and soft tissue infections and injury.
  • A lymphoscintigraphy (specialized scan) may be done to determine primary vs secondary lymphoedema as well as extent of disease.

Treatment

The main aim of treatment is to reduce the limb swelling and allow return of function.  Lymphatic drainage massage as well as compression dressings help reduce swelling significantly, but both have to be done on a regular basis (usually 3 times a week) .  Newer therapies include surgery to connect the blocked lymph drainage channels to small veins (lymphovenous bypass) or lymph node transplants to the affected limb.