The ABC’s of Wound Care

Peripheral Vascular Disease (M Shishehbor, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Peripheral Vascular Disease


Non-healing wounds represent a challenging problem for physicians and patients alike. Although treatment strategies are aimed at specific causes, there are basic management principles that apply to all wounds. The purpose of this article is to review these core management principles as they apply to lower extremity wounds. Key points include a multidisciplinary approach and individualized plans of care as per specific patient needs. A comprehensive treatment plan will lead to faster healing and improved outcomes.


Chronic wound Peripheral arterial disease Leg edema Offloading Infection Wound care 


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Olin JW, Beusterien KM, Childs MB, Seavey C, McHugh L, Griffiths RI. Medical costs of treating venous stasis ulcers: evidence from a retrospective cohort study. Vasc Med. 1999;4:1–7.PubMedGoogle Scholar
  2. 2.
    Cawley MI. Vasculitis and ulceration in rheumatic diseases of the foot. Baillieres Clin Rheumatol. 1987;1:315–33.PubMedCrossRefGoogle Scholar
  3. 3.
    Meyer V, Kerk N, Meyer S, Goerge TJ. Differential diagnosis and therapy of leg ulcers. Dtsch Dermatol Ges. 2011;9:1035–51.Google Scholar
  4. 4.
    Tang JC, Vivas A, Rey A, Kirsner RS, Romanelli P. Atypical ulcers: wound biopsy results from a university wound pathology service. Ostomy Wound Manage. 2012;58:20–2. 24, 26–9.PubMedGoogle Scholar
  5. 5.
    Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg. 2000;31(1 Pt 2):S1–S296.PubMedGoogle Scholar
  6. 6.
    Rosero EB, Kane K, Clagett GP, Timaran CH. A systematic review of the limitations and approaches to improve detection and management of peripheral arterial disease in Hispanics. J Vasc Surg. 2010;51(4 Suppl):27S–35S.PubMedCrossRefGoogle Scholar
  7. 7.
    Aboyans V, Ho E, Denenberg JO, et al. The association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects. J Vasc Surg. 2008;48:1197–203.PubMedCrossRefGoogle Scholar
  8. 8.
    Apelqvist J, Elgzyri T, Larsson J, Löndahl M, Nyberg P, Thörne J. Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients. J Vasc Surg. 2011;53:1582–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Budoff MJ, Achenbach S, Blumenthal RS, Carr JJ, Goldin JG, Greenland P, et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation. 2006;114:1761–91.PubMedCrossRefGoogle Scholar
  10. 10.
    "Diabetes In America," 2nd Ed. National Diabetes Data Group, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95–1468, 1995. Diabetes Atlas, 3rd ed. International Diabetes Federation, 2006.Google Scholar
  11. 11.
    Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113–41.PubMedCrossRefGoogle Scholar
  12. 12.
    Alexandrescu V, Söderström M, Venermo M. Angiosome theory: fact or fiction? Scand J Surg. 2012;101:125–31.PubMedGoogle Scholar
  13. 13.
    Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg. 2006;117(7 Suppl):261S–93S.PubMedGoogle Scholar
  14. 14.
    Varela C, Acin F, Haro JD, et al. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model. Vasc Endovasc Surg. 2010;44:654–60.CrossRefGoogle Scholar
  15. 15.
    • Neville RF, Attinger CE, Bulan EJ, Ducic I, Thomassen M, Sidawy AN. Revascularization of a specific angiosome for limb salvage: does the target artery matter? Ann Vasc Surg. 2009;23:367–73. This article offers statistically significant differences in ulcer healing rate when the angiosome corresponding to ulcer location is revascularized, compared with a boundary angiosome, supporting the significance of the theory. PubMedCrossRefGoogle Scholar
  16. 16.
    Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Semin Plast Surg. 2009;23:80–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Mutluoglu M, Uzun G, Turhan V, Gorenek L, Ay H, Lipsky BA. How reliable are cultures of specimens from superficial swabs compared with those of deep tissue in patients with diabetic foot ulcers? J Diabetes Complications. 2012;26:225–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Peters EJ, Lipsky BA, Berendt AR, Embil JM, Lavery LA, Senneville E, et al. A systematic review of the effectiveness of interventions in the management of infection in the diabetic foot. Diabetes Metab Res Rev. 2012;28 Suppl 1:142–62.PubMedCrossRefGoogle Scholar
  19. 19.
    Ely JW et al. Approach to leg edema of unclear etiology. J Am Board Fam Med. 2006;19:148–60.PubMedCrossRefGoogle Scholar
  20. 20.
    Young JR. The swollen leg. Clinical significance and differential diagnosis. Cardiol Clin. 1991;9:443–56.PubMedGoogle Scholar
  21. 21.
    • Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. J Vasc Surg. 2012;55:122–8. This study determined a safe level of compression in mixed arterial/venous ulcers, while improving venous return, which has not previously been established. PubMedCrossRefGoogle Scholar
  22. 22.
    Falanga V. The chronic wound: impaired healing and solutions in the context of wound bed preparation. Blood Cells Mol Dis. 2004;32:88–94.PubMedCrossRefGoogle Scholar
  23. 23.
    Ennis WJ, Foremann P, Mozen N, Massey J, Conner-Kerr T, Meneses P. Ultrasound therapy for recalcitrant diabetic foot ulcers: results of a randomized, double-blind, controlled, multicenter study. Ostomy Wound Manag. 2005;51:24–39.Google Scholar
  24. 24.
    Voigt J, Wendelken M, Driver V, Alvarez OM. Low-frequency ultrasound (20–40 kHz) as an adjunctive therapy for chronic wound healing: a systematic review of the literature and meta-analysis of 8 randomized controlled trials. Int J Low Extrem Wounds. 2011;10:190–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Driver VR, Yao M, Miller CJ. Noncontact low-frequency ultrasound therapy in the treatment of chronic wounds: a meta-analysis. Wound Repair Regen. 2011;19:475–80.PubMedCrossRefGoogle Scholar
  26. 26.
    Kavros SJ, Liedl DA, Boon AJ, Miller JL, Hobbs JA, Andrews KL. Expedited wound healing with noncontact, low-frequency ultrasound therapy in chronic wounds: a retrospective analysis. Adv Skin Wound Care. 2008;21:416–23.PubMedCrossRefGoogle Scholar
  27. 27.
    Medrano S, Beneke MJ. Acoustic pressure wound therapy to debride unstageable pressure ulcers in the acute care setting: a case series. Ostomy Wound Manag. 2008;54:54–8.Google Scholar
  28. 28.
    Hopf HW, Ueno C, Aslam R, Burnand K, Fife C, Grant L, et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair Regen. 2006;14:693–710.PubMedCrossRefGoogle Scholar
  29. 29.
    Mulder GD, Lee DK, Jeppesen NS. Comprehensive review of the clinical application of autologous mesenchymal stem cells in the treatment of chronic wounds and diabetic bone healing. Int Wound J. 2012;9(6)595–600.Google Scholar
  30. 30.
    Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Offloading the diabetic foot wound: a randomized clinical trial. Diabetes Care. 2003;24:1019–22.CrossRefGoogle Scholar
  31. 31.
    Katz IA, Harlan A, Miranda-Palma B, Prieto-Sanchez L, Armstrong DG, Bowker JH, et al. A randomized trial of 2 irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care. 2005;28:555–9.PubMedCrossRefGoogle Scholar
  32. 32.
    • Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Executive summary: heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:188–97. This article provides current statistical data on CVD, obesity, and diabetes, as well as current vascular surgical procedure trends and usage, and quality and cost of cardiovascular associated costs of care. PubMedCrossRefGoogle Scholar
  33. 33.
    Mitchell ME. Lower extremity major amputations. In: Sidawy AN, editor. Diabetic foot, lower extremity arterial disease and limb salvage. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 341–50.Google Scholar
  34. 34.
    Game FL, Hinchliffe RJ, Apelqvist J, Armstrong DG, Bakker K, Hartemann A, et al. A systematic review of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev. 2012;28 Suppl 1:119–41.PubMedCrossRefGoogle Scholar
  35. 35.
    Kavalukas SL, Barbul A. Nutrition and wound healing: an update. Plast Reconstr Surg. 2011;127 Suppl 1:38S–43S.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Orthopedic SurgeryCleveland ClinicClevelandUSA
  2. 2.Lower Extremity Wound ClinicCardiovascular Medicine, Cleveland ClinicClevelandUSA

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