Leg Ulcers - Clinical diagnosis

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A comprehensive clinical guide to diagnose leg ulcers

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Leg Ulcers - Clinical diagnosis

  1. 1. How to Examine Ulcers Ali Sabbour Prof. of General & Vascular Surgery, Ain Shams University
  2. 2. DefinitionsAn ulcer is a break in the continuity of an epitheliumChronic ulcers are those that persist for more than 4 weeks What prevents an ulcer to heal? What are the causes of chronic ulcers? Ch. Venous Ins. Ischemia Infection Localized destructive Repeated /Persistent D/s trauma Non Specific Specific •TB •Malignancy •TB •Gamma Denervation•Osteomyelitis • Syphilis Peripheral nerve lesions DM, Nerve injury, Leprosy Spinal cord lesions
  3. 3. HistoryDuration More than 4 weeks is considered chronic Cause e.g. Minor trauma Main Pain, Discharge,….symptomCourse •Increasing in size or depth •Became painful (infected?) •Discharging (infected?) •Recurrent (healing & breaking down) Similar ulcer (same site or elsewhere)
  4. 4. Examination Site Shape Size Floor Floor Edge Depth Edge Discharge Skin (or tissues) aroundRelations (adherent to deeper tissues) Draining LNs
  5. 5. Examination SiteSome ulcers have characteristic locationse.g. Venous ulcer situated in the gaiter area ofthe legShape SizeAre important in follow up of ulcer healing
  6. 6. Examination Solid brownish or blackish tissue indicates full thickness skin death Site Shape Size FloorBy inspection you may notice:•Granulation tissue Gamma 3ry syphilis. Sloughs (wash-leather)•Sloughs•Gangrenous tissue•Deeper tissues as tendon or bone Sloughs in ischemic foot ulcer Healthy granulation tissue. The red colour reflects good vascularity Gangrenous tissue & tendons in ischemic ulcer
  7. 7. ExaminationSite Shape Size Floor Depth Neuropathic ulcers are deep Venous ulcers are superficial
  8. 8. Examination 1- SlopingSite Shape Size Floor Depth The ulcer is shallow & the epithelium is growing in from the edge in an attempt to Edge (5 types) heal
  9. 9. Examination 2- Punched-out Edge (5 types)1- Sloping or square cut: It results from rapid death cut & loss of the whole thickness of the skin with minimal attempt of healing Gamma of 3ry Neuropathic ulcer in the syphilis Leprosy sole of foot
  10. 10. Examination 3- Undermined edge Edge (5 types) 1- Sloping When infection is affecting the subcutaneous 2- Punched-out tissue more than the skin, the edge becomes underminedUndermined edge in diabetic foot infection Tuberculous ulcer Pressure bed sore in the buttock. Subcutaneous fat is more Undermined edge in susceptible to pressure Pyoderma gangrenosa than the skin
  11. 11. Examination 4- Rolled Edge (5 types)1- Sloping2- Punched-out Develops when there is slow growth of3- Undermined tissue in the edge of the ulcer Basal cell carcinoma (rodent ulcer): Pale pink edge with clumps & clusters of cells visible through the paper thin superficial covering of squamous cells
  12. 12. Examination 5- Everted edge Edge (5 types)1- Sloping2- Punched-out3- Undermined Develops when the tissue in the edge of the4- Rolled ulcer is growing quickly and spilling out of the ulcer to overlap the normal skin. This edge is typical of carcinoma at any site Malignant transformation in Malignant ulcer colon a chronic venous ulcer carcinoma “Marjulin” ulcer
  13. 13. Examination Site Shape Size Floor Depth Edge Purulent discharge from Discharge infected bed sore Serosanguinous dischargeMay be: serous, sanginous, from infected diabetic footserosanguinous or purululent ulcerA dry discharge forms a scabthat covers the ulcer Dry scab covering the ulcer
  14. 14. Examination Site Shape Size Floor Depth Edge Discharge Cellulitis around the ulcerSkin (or tissues) around Pigmentation around venous ulcer Hyperpigmentation of ch. Recurrent infection
  15. 15. ExaminationSite Shape Size Floor Depth Edge It is important to know if the Discharge ulcer is adherent to the Skin (or tissues) around deep structuresRelations (adherent to deeper tissues)
  16. 16. ExaminationSite Shape Size Floor The draining LNs may be enlarged 2ry to infection or Depth 2ry to tumour deposits. Edge Infected LNs may be Discharge tender Skin (or tissues) aroundRelations (adherent to deeper tissues) Draining LNs

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