Wound – Patient presenting with wound +/- lower limb symptoms


  • Patient presenting with wound +/- lower limb symptoms
  • First assessment to triage and book full clinical assessment

Out of scope

  • Does not include management of ingrowing toenails


Signs and Symptoms

Assess for presence of red flag symptoms and book into full assessment appointment within 2 weeks.

Red Flags


Distal ulceration or gangrene with:

  • Nocturnal pain or rest pain
  • Pain relieved by dependency

Rapidly progressing ulcer or rolled edges

  • Consider pyoderma or malignancy

Consider dermatology referral

Critical Ischaemia

  • Distal ulcerations/gangrene
  • Nocturnal or rest pain
  • Pain relieved by dependency
  • +/- pain in calf, thighs or buttocks

Urgent discussion with vascular team

Cellulitis (Cellulitis guideline)

  • Erythema, increased pain, heat
  • Remember bilateral red legs are usually stasis eczema - cellulitis is almost always unilateral.
  • Suspect stasis eczema if bilateral red legs


  • Acute swollen, erythematous, unilateral

Charcots Neuroarthropathy

  • Diabetic with peripheral neuropathy
  • Can affect people with Type 1 or Type 2 diabetes. The patient can often recall no history of trauma or only a very minor episode (e.g. twisted the ankle a few weeks ago)
  • Typically, the foot suddenly becomes very swollen and warm to touch
    • The first clue to the diagnosis is the disproportionate lack of pain
    • The second clue is the slowness of recovery. (i.e. the swelling does not go away) NB these can be painful in an insensate foot
    • There may not be any evidence of skin damage or portal of infection
    • The diagnosis of Charcot's Neuroarthropathy must be considered in any person with diabetes who presents with unilateral swelling, redness and warmth with or without pain in an intact foot exclude other pathologies such as gout, infective arthritis orosteomyelitis
    • Infection and gout are the two most common mistaken diagnoses. However in the presence of foot ulceration infection is highly likely to be the cause. If there is any doubt, treatment for both conditions should be commenced until one can be ruled out. In patients with diabetes, their blood sugars usually remain unchanged from the norm
  • Urgent discussion with podiatry/multidisciplinary foot team (within 24hrs)

Podiatry services

  • Any other ulceration in a diabetic foot

Ulceration in someone who has diabetes has the potential to become limb or life threatening very rapidly - refer to Cellulitis guidelines


Clinical assessment

  • Please review chronic disease control, and inform GP if could contribute to wound healing.
  • Please arrange blood tests for FBC , U_E LFT, HBA1C (all patients), in addition if ABPI less than O.9 fasting Chol

Complete leg wound assessment form

  • ABPI
    • Consider analgesia before undertaking
    • Do not inflate above 200mmHg
  • An ABPI less than 0.9 indicates likely peripheral vascular disease (may be symptomatic or asymptomatic).Evidence suggest that these patients benefit from secondary CVD prevention
  • An ABPI is only part of the overall assessment and must not be used in isolation from clinical assessments


Full assessment - Complete leg wound assessment proforma and review red flags

Do ABPI and Clinical assessments match, if yes and venous and ABPI 0.80-1.30

  • An ABPI OF less than 0.9 indicates PVD or a patient who may benefit from secondary vascular prevention.
  • For the purpose of dressings, and ABPI between 0.8 and 1.3 is called venous, as a wound will respond to compression with ABPI within this range

Compress and follow dressing as per North and East Formulary - wound management

Undertake six weekly formal assessment of progress.

Wound is improving (Should be measurable and ongoing reduction in wound size, wound bed, level of pain)

  • continue regular dressing changes.

If wound has healed (most heal in 12 to 24 weeks)

Long term prevention

  • ensure patient is enrolled in necessary preventative pathways (e.g. regular diabetic review) and recommend hosiery if compression used
  • If foot related consider referral to podiatry
  • Consider referral to orthotist for specialist footwear/insole
  • Consider routine vascular referral as venous surgery may be of benefit

Wound not improving (swabs or antibiotics are not indicated if no evidence of cellulitis) consider the following:

  • Is this a foot ulcer? – discuss with Podiatry
  • Measure wound dimensions at least weekly
  • Poor compliance with dressings – GP/Nurse review with the patient
    • Discuss e.g. importance of compliance
    • Explore reasons for non-compliance
    • Consider non-formulary dressing options
    • Consider routine tissue viability referral
  • Other health problems that may compromise healing
    • FBC: Is the patient anaemic?
    • U+E: What is the fluid status of the patient?
    • Albumin: Is albumin low/ nutrition poor?
    • HBA1C: Is patient diabetic or diabetic control poor?
    • Chol: If ABPI less than 0.9 or existing CVD, aim for Chol less than 5.0

GP Review

  • Healing may not be a realistic goal in patients with multiple comorbidities/compliance issues
  • Consider terminating pathway - discussion with tissue viability may be helpful.

Consider contact dermatitis

  • if eczema that is not controlled by topical steroids, or seems to be getting worse despite treatment, or where the nurse or patient suspects that dressings or topical medicament's are making the problem worse.
  • Leg ulcer patients are at particularly high risk of developing contact sensitivities to dressings and topical medicaments - and this may delay healing of ulceration.

Patch testing can help give specific information on what substances they are allergic to.

Consider dermatology referral or topical steriods (Use steroid ointment not cream. Consider different dressings)

In all other cases discuss with appropriate service - If asymptomatic consider starting reduced compression in mixed disease and dressings as per North and East Devon Formulary - wound management.Follow clinic advice for dressings where appropriate.

If the clinical assessment and ABPI do not match - Note ABPI unreliable in diabetes

  • Are there other reasons for deterioration (e.g. not taking diuretics)
    • Consider discussion with tissue viability (If necessary, tissue viability to consider arranging duplex scan and advise GP to refer to vascular team), vascular surgery or podiatry.
    • Urgent referral if ABPI less than 0.6 or symptoms, otherwise routine referral

Complete leg wound assessment proforma (Including ABPI), with referral letter and send to appropriate service.


Referral Criteria

Referral to include

Referral Instructions

Critical Ischaemia

Contact details for the vascular team:- For Urgent referrals fax to 01271 335917

Weekdays contact vascular surgery secretaries to arrange discussion with vascular surgical consultant

Tel:- 01271 322424 or 01271 322423

Weekends discuss with on call surgical team. Call NDDH switchboard 01271 322577 and ask for the on call surgical team

Contact details for Tissue Viablity• Northern Devon Healthcare Trust 01271 322577,

Fax 01271 311756 email: ndht.tissueviablity@nhs.net

Contact details for Podiatry

Referral to orthotist

Referral to Podiatry

Podiatry referral form

Referral Forms

Healthcare Professional Podiatry referral form

Supporting Information

Patient Information

Barnstaple Leg Club - Contact details

Barnstaple Leg Club - You Tube video

Orthotic department information

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: June 2015


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