approach to a patient of leg ulcer

1. Dr. Anup Kumar Sarkar
MS-Part 2 Trainee ( CVTS)

2. Common ulcer in lower limb
• Venous ulcer
• Arterial ulcer
• Neuropathic ulcer

3. Less common ulcer in lower limb
 Traumatic ulcer
 Malignant ulcer-Malignant melanoma, Marjolin’s ulcer
 Trophic ulcer- Pressure sore
 Infective ulcer- Tubercular

4. Approach to a patient of leg ulcer
History
 Age: Certain ulcer types more common in certain age groups e.g.
Burger’s disease usually under age of 30 years.
 Occupation: Venous ulcers are more common in individuals like
-Surgeon
-Nurses
-Traffic police
-Bus conductors

5.  Duration: Determines the chronicity of ulcer.
Venous ulcer- chronic.
Traumatic ulcer- acute.
 Mode of onset: H/O trauma.
H/O cellulites.
Over pre-existing scar.
Varicose vein or vascular insufficiency.

6.  Progression
 Pain
-Painful-Inflammatory
-Painless- Neuropathic, Malignant
 Discharge- Serous, serosanguinous, blood mixed.

7.  Associated disease
-Varicose vein.
-Claudication or rest pain.
- DM/TB/Spinal trauma or diseases.
 Personal history
- Alcohol consumption.
-Smoking.
- Tobacco chewing.

8. Examination
General Examination
 Anemia/Oedema/ Nutritional status
 Peripheral pulses
 Blood pressure

9. Local examination:
Inspection
 Site: Venous-Around ankle ( Gaiter area).
Arterial- Toes, feet, legs.
Neuropathic- Heads of 1st and 2nd metatarsal.
Traumatic- Over the shin.
 Size: Assessed vertically and horizontally.
 Shape: Venous- Vertically oval.
Malignant- Irregular.

10.  Number- Venous ulcer can be multiple.
 Edge
Sloping- Healing
Punched out- Trophic
Undermined- Tubercular
Everted- Malignant

11.  Floor of ulcer
Red granulation tissue- Healing ulcer.
Unhealthy granulation tissue- Non-healing ulcer.
Slough without granulation tissue- Chronic ulcer.
Pigmented tissue- Malignant melanoma, pigmented SCC.

12.  Discharge
Serous- healing
Serosanguinous, bloody- Malignant
Purulent- Infective
 Surrounding skin/area- Edema, pigmentation, eczema, scar, visible veins.

13. Palpation
 Tenderness
 Temperature- Warm surrounding area- acute inflammation.
 Edge for tenderness and induration
Thick fibrosis- Chronic ulcer.
Marked induration- Carcinomatous ulcer.

14.  Base for fixity
Reduced mobility implies fixity to underlying structure- Malignant.
Varicose ulcer attached to tibia.
 Bleeding on touching
Malignancy/ Healthy granulation tissue.

15.  Examinations of adjacent joint
Both active and passive movements
 Examination of regional lymph node
Tender- Acute infection
Stony hard- Secondaries from carcinoma
Matted, firm- Tubercular
 Examination of varicose vein

16.  Examination of peripheral pulses.
 Examination of spine and neurological system.
 Gait of the patient.
 Relevant systemic examination.

17. Investigations of an ulcer
 Study of discharge: Culture and sensitivity, AFB.
Cytology- Suspected malignancy.
 Wedge biopsy: From edge.
 Imaging:
X-ray of affected part-periostitis or osteomyelitis.
-Infiltration in malignancy.
-Involvement in tropic ulcer.
Doppler imaging- Arterial or venous ulcer.
Angiogram- certain vascular cases.

18.  Imaging of specific diseases
CXR- Tuberculosis.
MRI spine- Spinal diseases causing trophic ulcer.
 Other tests
FNAC of regional LN- Suspected malignancy
MT test- TB
Blood tests- CBC, S. Albumin, HbA1C

19. Principles of ulcer management
 Determination of etiology- History/examination/investigation.
 Assessment of ulcer.
 Identify and correction of co-morbid factors- Anemia, malnutrition.
 Treatment of underlying cause- DM, Venous, Arterial.

20.  Treatment of ulcer- Adequate desloughing.
 Broad spectrum antibiotic- According to C/S.
 Proper dressing.
 Reconstruction- Secondary suturing, skin grafts or flaps.