Volume 26 Number 3

Key messages

• Through this case, we emphasise the importance of multidisciplinary collaboration, the significance of internal team communication, and to reinforce the need for repeating clinical examinations.
• The management of lower limb oedema is challenging and there is a lack of sufficient expertise in this area. It is important to invest in training for oedema management.
• In the treatment of necrotic wounds, circulation must be repeatedly assessed. If necrosis develops, even after good circulation, its cause must be considered, and a dermatologist should be consulted.

Introduction

This case report describes a patient whose chronic wounds revealed an atypical wound and factors requiring a multidisciplinary team. This case illustrates the importance of multidisciplinary collaboration, internal team communication and the need for repeated clinical examinations.

Methods

Our institution does not require ethical approval for reporting individual cases or case series. The patient gave her verbal and written informed consent for publication and for using the pictures taken from the ulcers.

Our patient is a 69-year-old obese (BMI 35.43 kg/m-sq) woman with a history of hypertension and smoking. She lives alone and due to fear of COVID-19 infection, she has not left home for three years.

She was brought to the regional hospital emergency department due to a decline in her general condition.

In the emergency department, cellulitis and deep wounds were found around the left ankle (Figures 1 and 2). According to the first status report her limbs were warm, and pulses were reported palpable, (ATP ADP +/+). The wound was surgically debrided bedside, and bacterial culture was taken.

 

Figure 1. Left lower limb medial view in the emergency department

 

Figure 2. Left lower limb anterior view

 

The patient was transferred to the surgical ward. Wound revision was performed twice, every other day, in the operating room. After each surgery, necrotic tissue developed rapidly (Figure 3).

 

Figure 3. Necrotic tissue developed rapidly after surgical revision

 

On the sixth day, leg and wound pain worsened. The foot became cold, the temperature border was at mid-shin, and the toes turned blue. No pulse was felt in the left femoral artery. Computed tomography angiography (CTA) revealed chronic arterial occlusions in the left external iliac artery (EIA) and the superficial femoral artery (SFA).

The patient was transferred to the university hospital emergency department, where a vascular surgeon diagnosed chronic limb-threatening ischemia, but the wounds appeared atypical to be solely ischemic. Ulcers with ischemic etiology are located usually in the distal parts or pressure areas (tips, sides, or between the toes, at the bone prominences, or the heel).¹ In this case the wounds were around the left ankle.

Circulation correction was performed as a hybrid procedure: EIA stenting and bypass surgery (fem-pop) along with a new wound revision.

Negative pressure wound therapy (NPWT) was started. On the 10th day of treatment, a dermatologist was consulted. Clinical findings were consistent with Martorell’s disease, and sodium thiosulfate 10g/day was started intravenously. Later, the pathologist’s report confirmed the diagnosis. The arteriolar walls were thickened, and their lumens were partly occluded. There was calcinosis in the subcutis and lipodegeneration.

In wound care, the principles of antimicrobial treatment were considered,² and an infectious disease specialist was consulted. The treatment of infection was based on swabs and clinical characteristics. Other possible underlying diseases were ruled out by the geriatrician, who also started the patient on protein supplements and optimised pain medication. The patient was moved to a municipal health center hospital with NPWT, from where she returned to the university hospital 36 days later for a skin graft.

After skin grafting, instead of continuing NPWT, mild compression therapy was started. The patient experienced pain relief and improved mobility with mild compression therapy.

Results

At the follow-up on the 72nd day, the skin graft had attached well and the Martorell ulcer had healed (Figure 4).

 

Figure 4. Left lower limb medial view on treatment day 72.

 

Overall, the patient was diagnosed with wound infection upon hospital admission, peripheral arterial disease (PAD) on the 6th day and Martorell’s ulcer on the 10th day of treatment. Sodium thiosulfate treatment continued for 2.5 months until the skin graft had attached and the Martorell’s ulcer activation had subsided.

This case highlights the importance of multidisciplinary care for Martorell’s patients.³ This patient was treated by doctors from seven different medical fields in five different wards and one outpatient clinic. Wound-related interventions, care and treating units are summarised in Figure 5, and the treating professionals are presented in Figure 6.

Figure 5. Wound-related interventions, care and treating units

 

Figure 6. The treating team

 

Discussion

Martorell’s ulcer, also known as hypertensive leg ulcer (Martorell hypertensive ischemic leg ulcer/HYTILU/) is a challenging chronic ulcer form and often underdiagnosed.⁴ It can be misdiagnosed as Pyoderma gangrenosum and starting immunosuppression can deteriorate the ulcers.⁵ However, with early recognition and initiation of treatment, the prognosis can be good. Identification and treatment often require a multidisciplinary approach.³ Martorell’s ulcer patients always have underlying hypertension.⁶ Histology shows thrombosis of small arterioles and venules in the subcutaneous tissue, arteriolosclerosis, intimal hyperplasia, calcinosis and surrounding inflammatory infiltration.^3,7 Skin biopsy can be a valuable tool in differential diagnosis but is not mandatory.^3,6 The diagnosis is based on medical history and clinical findings, which include a fibrotic/necrotic wound base, “red lipstick” sign, purple edge and surrounding skin livedo racemosa. These clinical features can be found simultaneously, but the absence of simultaneous manifestation does not rule out the possibility of Martorell’s ulcer.⁶

In the treatment of Martorell’s ulcer, in addition to surgical revisions and compression therapy, intravenous sodium thiosulfate treatment can be considered. Sodium thiosulphate converts calcium into a soluble form, dissolving and removing calcifications from blood vessels and soft tissues through the kidneys.⁸

Negative pressure wound therapy (NPWT) is a popular wound care method.⁹ It promotes the formation of granulation tissue and removes swelling from the wound area through suction.¹⁰ However, NPWT can increase pain in some cases.¹¹ On the other hand, properly implemented compression therapy relieves pain and promotes wound healing.¹² NPWT can also be combined with compression therapy, but care must be taken to ensure that NPWT tubes do not press against the skin.

In this case the patient’s lower limb oedema posed a significant challenge. Mild compression therapy was recommended by dermatologist, but it was resisted in other units due to fear of NPWT tubes pressing the skin. Wound pain was also considered an obstacle. During the regional hospital treatment period, leg oedema increased with NPWT. Additionally, the elevated position of the leg was not maintained during patient transport and oedema worsened with each transfer.

Diagnostic delays

During the initial treatment, lower limb pulses were checked only once in the emergency department. The need for rechecking circulation was recorded on the fourth day of treatment, but this check was not performed. The CTA findings suggest that the possibility of PAD could have been considered earlier. It is important to note that the examination conditions in the emergency department are not always ideal due to the urgency. Identifying lower limb pulses can be challenging due to the risk of feeling one’s own pulse. In the surgical ward doctors changed daily, which may have led to reliance on previous examination results. However, it is crucial that each ward doctor performs the necessary examinations themselves. The diagnosis was also delayed due to the patient’s isolation.

To minimise delays, it is important that there is good consultation and communication opportunities between departments and professionals. It is important to have clear documentation of the treatment plan, such as the implementation of oedema treatment, as it can shorten the treatment period and improve the quality of care. It is optimal to print the treatment plan, as different hospitals may use different client software, and an electronically recorded plan may not be visible in the next care unit. The receiving unit may also call the referring unit for additional support, but this can be challenging due to time constraints.^9–12

Conclusion and Implications for clinical practice

This case highlights the importance of managing oedema in pain control and wound healing. The management of lower limb oedema is challenging and there is a lack of sufficient expertise in this area. Investing in training for oedema management is recommended. It is advised to familiarise oneself with the EWMA Compression Therapy in Wound Management e-learning course.¹³

Clear, concise and concrete instructions aid the work of the receiving care unit.

Additionally, in the treatment of necrotic wounds, circulation must be repeatedly assessed. If necrosis develops even after good circulation, its cause must be considered, and a dermatologist should be consulted. Wound care requires multidisciplinary collaboration, as no single doctor or nurse can manage everything alone.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

The authors received no financial support for the authorship or publication of this article.

Author(s)

Réka Sayeda MD*¹, Katariina Noronen MD², Isoherranen Kirsi MD^1,3
1 Helsinki Wound Healing Centre, Helsinki University Hospital, PL 281 00029 HUS, Finland
² Vascular Surgery Department, Helsinki University Hospital, Finland
³ Inflammatory Center, Helsinki University Hospital, Finland

*Corresponding author email reka.sayeda@luvn.fi

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