History and examination

1. ULCER
Dr. Shalu Gupta
MS (Surgery), FMAS, FAIS, FIAGES
SMS medical college, Jaipur

2. DEFINITION
 Wound- A breach in the continuity of skin/mucous membrane
 Ulcer- Persistent breach in the continuity of skin or mucous membrane
associated with cell death or its traumatic removal.

3. Anatomy / Parts of an ulcer
Margin- Junction between the ulcer &
normal epithelium / Boundary of the
ulcer
Edge- Area between the margin & floor
Floor- Exposed surface of the ulcer
Base- On which the ulcer rests

8. Spreading Ulcer
• Inflamed surrounding
skin
• Slough covered floor
• No evidence yet of
granulation tissue
• Purulent discharge

9. Healing Ulcer
Surrounding skin is not
inflammed.
Floor is covered with
granulation tissue.
Edges shows bluish outline
of growling epithelium.
Serous discharge.

10. Callous Ulcer
Floor is covered with pale
granulation tissue.
Considerable induration at
base.
No tendency to heal.

11. Pathological Classification
• Specific
• Non-specific
• Malignant

12. Specific Ulcer
• Tubercular
• Syphilitic
• Actinomycosis
• Meleney`s

13. Non-Specific
• Traumatic ulcer - mechanical/physical/chemical
• Arterial ulcer
• Venous ulcer
• Pressure sore/ trophic ulcer
• Infective- pyogenic
• Tropical
• Chill bains/ frost bites
• Martorell`s hypertensive ulcers
• Bazin`s ulcer
• Diabetic ulcer
• Cortisol ulcer

14. Malignant ulcers
• Carcinomatous – SCC, Adeno ca
• Rodent - BCC
• Melanotic

15. Patho-physiology of An Ulcer
 Natural history of an ulcer consists of 3 phases :-
• Extension
• Transition
• Repair

16. Extension Phase :-
• Floor – covered with exudates
• Discharge- purulent
• Indurated base

17. Transition phase :-
• Prepares for healing.
• Induration diminishes.
• Discharge becomes more serous.
• Granulation tissue appears.

18. Repair phase :-
• Granulation
• Fibrous tissue
• Scar
• Epithelium extends from the healing edges to floor (1mm/day)

19. Healing edge consists of 3 zones :-
• Inner/ reddish – granulation tissue
• Middle/ blue – growing epithelium
• Outer/ white – developing scar

20. Wagner`s grading of Ulcer
• Grade 0 – Pre-ulcerative lesion/ healed ulcer
• Grade 1 – Superficial ulcer
• Grade 2 – Ulcer deeper to subcutaneous tissue, exposing soft
tissue/bone
• Grade 3 – Abscess formation / osteomyelitis
• Grade 4 – Gangrene of part of tissue / limb
• Grade 5 – Gangrene of entire one area / limb

21. History Taking
 Mode of onset -
• How has it developed??
Traumatic / Spontaneous
• Traumatic ulcer generally heals by themselves after removal of traumatic
agent
• Ulcers originating spontaneously may follow swelling (tubercular lymph
node/ malignant ulcers) , they may present with varicose vein, may
follow burn/Scar (marjolin ulcer)

22.  Duration -
• How long is the ulcer present there???
Acute / chronic
 Pain -
• Painful- ulcers associated with inflammation
• Painless- syphilitic ulcers, Trophic ulcer associated with nerve disease,
Ulcers associated with malignant diseases

23.  Discharge -
If the ulcer is associated with discharge ???
If Yes, then what is the Nature of discharge?????
Serous / Purulent / Bloody
 Associated Diseases -
• Nervous diseases as tabes dorsalis, transverse myelitis, peripheral neuritis
may result in an ulcer.
• Generalised TB, Nephritis, DM may lead to ulcer
formation

24. General Physical Examination
• Complete head to toe examination must be done as ulcer may very well
be sequal of various generalised / systemuic diseases as Malnutrition /
Syphilis / TB / Atherosclerosis /

25. Local Examination
 Inspection -
 Size & Shape -
• To record the size & shape a sterile gauge can be pressed against the
ulcer
• Tubercular – Generally oval, may become irregular after coalescence
• Syphilitic – Circular / Semi-circular to start with then become
serpiginious after uniting
• Varicose – Vertically oval
• Carcinomatous - Irregular

26.  Number -
Tubercular/ Syphilitic / Varicose ulcers may be more than 1 in
number.
 Position -
It can often itself give clue to diagnosis.
• Medial malleolus – ? Varicose ulcer
• Upper part of face - ? Rodent ulcer
• Neck / Axilla - ? Tubercular
• Lupus ( a form of cutaneous TB) - on the face / fingers/ hand
• External Genitalia - ? Hunterian
• Tibia - ? Gummatous
• Heel of foot - ? Trophic / Perforating

27.  Edge -
Can give clue to diagnosis
as well as condition of the ulcer.
Inflammed, edamatous – Spreading
ulcer
3 Zones ( Red/blue/white) -Healing
ulcer
oUndermined edge
oPunched out edge
oSloping edge
oRaised, pearly white beaded edge
oRolled out/ everted edge

28.  Undermined edge –
Disease destroys the
subcutaneous tissue faster
than it destroys skin
(TUBERCULAR)

29.  Punched out -
• The edge drops down
at right angle to the
skin surface.
• Disease doesn’t spread
to surrounding skin.
• GUMMATOUS,
TROPHIC

30.  Sloping Edge-
Seen typically in -
Healing Ulcers
Traumatic Ulcers
Venous Ulcers

31.  Raised & Pearly white
Beaded edge -
• Typical of Rodent
Ulcer
• Invasive cellular
diseases with central
necrosis

32.  Rolled out / Everted
edge -
• Typical of Squamous
Cell Ca. / Ulcerated
Adeno Ca.
• Growing portion of
the edge heaps up and
spills over the normal
skin

33. Floor -
Exposed surface of the ulcer.
• Red granulation tissue – Healthy & Healing
• Pale granulation tissue – Slowly healing
• Slough – Infected ulcer
• Wash leather slough – Gummatous ulcer
• Bone – Trophic ulcer
• Black mass - Malignant melanoma

35.  Pale granulation -
Slowly healing ulcer

36.  Slough – Infected Ulcer

37.  Black mass - Melanoma

38.  Discharge -
? Character
? Amount
? Smell

39.  Surrounding area -
• Red , edematous – Acutly inflammed ulcer
• Eczematous, pigmented - ? Varicose ulcer
• Scar , wrinkling - ? TB
 Examination Whole limb to check for -
• Presence of Varicoe Vein / DVT
• Presence of Neurological insufficiancy

40.  Palpation -
 Tenderness -
• Tender - Acutely inflammed ulcer
• Slightly tender - ? TB
• Non- tender – Malignant ulcers, ? Varicose ulcers
 Edge & Margin -
• Corroborated with the findings of Inspection
• Marked induration (hardness) – characteristic feature of Carcinoma
(SCC / Adeno)

41.  Base -
On which ulcer rests.
• Floor is exposed surface of ulcer.
• Base is better felt while floor is better seen.
• Marked induration – Carcinoma
• Slight Induration – chronic ulcer

43. Depth -
Trophic ulcers can be as deep as bone.
 Bleeding –
Bleed on touch is a common feature of Malignant ulcer.
 Relation with deeper structures -
Whether it is fixed to deeper structure or not???
Malignant ulcer will be fixed.
A gummatous ulcer over a subcutaneous bone ( sternum /
tibia) will often be fixed to it

44.  Surrounding Skin -
• Increased temperature ( felt with back of the hand) & tenderness in the
surrounding skin suggest acute inflammation.
• Mobility of surrounding skin is assessed – fixity indicates malignancy.
• Skin is tested for nerve lesions ( loss of sensory /motor).
• Palpate the Peripheral Pulses (to look for arterial diseases)

45.  Examination of lymph nodes -
• Acutely inflammed ulcers – regional lymph node will show acute
lymphadenitis, later the nodes can become softer and form an abscess
• In Tubercular ulcers – lymph node become enlarged, matted and slightly
tender
• In Hunterian ulcers - regional lymph node remains discrete , firm & shotty
• In Gummatous ulcer – lymph nodes are not usually involved
• In Rodent ulcers - lymph nodes are not usually involved because early
obliteration of the lymphatics by neoplastic cells
• In Malignant Ulcers – Stony Hard and fixed lymph nodes

46.  Examination For Vascular Insufficiancy -
• If the ulcer is situated on lower leg one should always check for
varicosities.
• The condition of proximal arteries should also be examined because
variety of arterial conditions as Buerger`s, atherosclerosis, Raynaud`s are
frequent cause of ulcerations.

47.  Examination For Nerve Lesions -
• Trophic ulcers develop as a result of repeated trauma to an insensitive
part of the patient`s body mostly sole.
• So presence of trophic ulcer indicates some neurological (mainly
sensory) disturbances which can be in the form of tabes dorsalis,
transverse myelitis or peripheral neuritis.

48. Investigations
Routine blood examinations -
• CBC
• TLC
• DLC
• ESR
• B. Sugar - to rule out DM

49. Urine examination – to rule out DM
Study of discharge -
 Culture & sensitivity
 AFB
 Dark ground illumination
 Cytology
Edge biopsy- biopsy is taken from edge as edge is the most active part
and contains multiplying cells.
Chest x-ray – to look for TB locus

50. X-ray bone / joint – to rule out underlying bony lesion / Osteomyelitis
Contrast radiography -
 Arteriography – to diagnose ischemic ulcers, arterial pathology
 Phlebography – to diagnose DVT
 Imaging -
 Radioactive Fibrinogen test – to diagnose DVT
 Tc99 clearance to know blood flow of calf muscles.
 Tc99 arterial imaging

51. Assessment
 ? Cause - DM/arterial/venous
 ? Clinical type - Spreading/ healing
 ? location, size, depth, mobility, induration, surrounding area
 ? Nodal involvement
 ? Functional / Vascular status of limb
 ? Bone / Joint involvement
 ? Systemic Condition
 ? Specific investigation

52. Management
Cause should be found & treated.
Correct the deficiencies if any like anaemia, protein / vitamin
deficiency.
Pain control
Infection control – Topical/Systemic antibiotics

53.  Care of Ulcer -
• Debridement
• Ulcer cleaning
• Dressing
Once Ulcer granulates – Closure of defect (suturing / grafting)

54. Debridement of Ulcer -
 Removal of all devitalized tissue
 It Can be -
• Surgical
• Mechanical – hydrotherapy, dressings
• Enzymatic - Collagenase

55. Cleaning of ulcer -
 Povidine iodine
 Hydrogen peroxide
 EUSOL (Edinburgh university solution containing hypochlorite)
 Normal Saline

56. Dressing of Ulcer -
 To keep ulcer moist
 To keep surrounding skin dry
 To reduce pain
 To soothen the tissue
 To protect the wound
 To absorb the discharge

57. Different Dressings -
 Cotton dressing
 Paraffin dressing
 Polyurethane dressing
 Alginates ( Seaweed) dressing
 Type 1 collagen dressing
 Foam dressing
 Hydrocolloid dressing
 Transparent film dressing
 Hydrogel dressing

58. Different method of closures -
 Suturing
 Vaccum assisted closure (VAC)
 Grafting
 Flaps

59. Why an Ulcer becomes chronic ???
 Recurrent infection
 Trauma
 Absence of rest
 Poor blood supply
 Hypoxia
 Oedema
 Loss of sensation
 Malignancy
 Osteomyelitis of underlying bone

63. Traumatic ulcer
Mechanical – dental ulcer
Physical – electric burn
Chemical – alkali injury
Generally acute, superficial, painful
Footballer`s ulcer – over shin
Can become chronic if traumatic agent
like tooth is not removed or du to
secondary infections, poor blood supply

64. Trophic Ulcer / Pressure Sore/ Decubitus
ulcer
 Pressure sore – ulceration due to prolonged pressure
 When external pressure becomes more than 30 mmHg (capillary
pressure )
 Sites -
Ischial tuberosity > Greater trochanter >
Sacrum > Heel > Malleolus > Occiput
(descending order)

66. Due to presence of
neurological deficit it is
also called as
Neuropathic /
Neurogenic Ulcer
Can extend to deeper
plane, up to the bone –
Perforating /
Penetrating Ulcer

67. Martorell`s ulcer
 Seen in Hypertensive patients
 Site – calf
 Often B/L, painful
 Punch out ulcers
 Peripheral pulses are present
 Treatment – skin grafting with
lumbar sympathectomy

68. Bairnsdale Ulcer
 Causative agent –
Mycobacterium ulcerans
 Chronic, undermined ulcer
 Deep sever form – Buruli
ulcer
 Treatment - ATT

69. Marjolin Ulcer
 Well differentiated
Squamous cell Ca. Occuring
in an unstable Scar of long
duration.
 Commonly seen in chronic
venous ulcer.
 Painless

70. Carcinomatous ulcer /
Squamous cell ca. /
Epithelioma
 Rolled out / everted edge
 Bleeds on touch.
 Becomes fixed
 Treatment- wide local
excision with skin grafting

71. Rodent Ulcer
 Ulcerative from of Basal
Cell Ca.
 Common in face
 Beaded edge
 Treatmetn – wide excision

72. Melanotic Ulcer
 Ulcerative from of
melanoma.
 Very aggressive
 Treatment – wide excision

73. Diabetic Ulcer
 Caustive mechanism -
• Diabetic microangiopathy
• Diabetic neuropathy
• Increased glucose in tissue precipitates
infection.
• Increased glycosylated Hb & increased
glycosylated protein in tissue decreases O2
utilisation.
• Associated atherosclerosis.
 Most common Site – Foot (plantar aspect)
 Other sites- Leg, back, scrotum, perineum

74. Meleney`s Ulcer
 Also called as Postoperative
synergistic gangrene
 Seen in postoperative wounds
 Rapidly spreading ulcer with
burrowing of subcutaneous tissue
 Caused by – streptococci, staph.
Anaerobes (Polymicrobial)

75. Lupus Vulgaris
 Its Cutaneous
Tuberculosis
 Commonly seen on face
 Starts as apple jelly nodule
 Treatment – ATT, excision
with skin grafting

76. Bazin`s disease / Erythrocyanosis Frigida
/ Erythema Induratum
 Localised area of fat necrosis
with chronic ischemia of
ankle skin affecting
exclusively adolescent girls.
 May be due to TB
 Painful superficial ulcers
 Treatment – ATT with
lumbar sympethectomy

77. Venous Ulcer
 Gravitational ulcer
 Due to chronic venous
hypertention
 Common around ankle
(Gaiter zone), medial side of
lower leg
 50% due to varicose vein
 50% due to post DVT

78. Syphilitic ulcer
 Treponema pallidum
 Hunterian chancre / Hard chancre / Genital
chancre –
• Primary syphilis
• Painless, hard, button like, indurated , non-
bleeding
 Secondary syphilis - superficial snail track ulcer
 Gummatous ulcer -
• Deep, punched-out, painless
• Wash-leather slough
• Silvery tissue-paper like scar around

79. Soft chancre / Ducrey`s ulcer / Chancroid /
Bubo
 Haemophillus ducreyi.
 Multiple, painful, non-
indurated.
 Purulent discharge

80. Ulcers due to
chilblains
 Also known as Perniosis
 Intense cold
 Arteriolar vasoconstriction
 Superficial ulcer

81. Ulcers due to
Frost bite
 Exposure to wet cold
 Arteriolar spasm, cell
destruction
 Deep ulcers
 Gangrene

83. QUESTIONS

84. 1) Diabetic ulcer is a trophic ulcer - True / False
2) Most common malignancy found in marjolin ulcer is -
A. Squamous cell ca.
B. Adeno ca.
C. Basal cell ca.
D. Melanoma
3) Ulcer with undermined edges are seen in -
A. Tubercular
B. Malignant ulcer
C. Venous ulcer
D. Trophic ulcer

85. 4) Gaiter`s zone is associated with -
A. Venous ulcer
B. Arterial ulcer
C. Chilbains
D. Syphilitic ulcer
5) What is the pressure in Vaccume assisted closure (VAC) -
A. -85 mmHg
B. -105 mmHg
C. -125 mmHg
D. -145 mmHg

86. 6) Agents used in ulcer cleaning all Except -
A. Povidine iodine
B. EUSOL
C. Normal saline
D. Distilled water
7) Most common site of decubitus ulcer is -
A. Occiput
B. Heel
C. Sacrum
D. Ischial tuberosity