• Arterial Ulcer
• Caused due to peripheral vascular disease
• LL : Atherosclerosis & TAO
• UL : Cervical Rib, Raynauds
• Chief complaint : Severe Pain
• Toes, Feet, Legs & UL Digits
• Venous ulcers
Medial aspect of lower 3rd of lower limb
Ankle ( Gaiters Zone ) : Chronic Venous HTN
Ulcers are Painless
Varicose Veins or Post Phlebitic limb ( PTS )
• Trophic Ulcer
• Pressure Sore or Decubitus Ulcer
• Punched out edge with slough on the floor
• Ex: Bed Sores & Perforating ulcers
• Develop as a result of Prolonged Pressure
• Sites : Ischial Tuberosity > Greater Trochanter > Sacrum >
Heel > Malleolus > Occiput
• Tropical ulcer
• Tropical regions : Africa, India, S.America
• Trauma or Insect Bite
• Fusobacterium fusiformis & Borrelia vincentii
• Abrasions, Redness, Papules & Pustules
• Severe Pain
• Diabetic Ulcer
It may be caused due to
• Diabetic Neuropathy
• Diabetic Microangiopathy
• Increased Glucose : Increased Infection
• Foot ( Plantar ), Leg, Back, Scrotum, Perineum
• Ischemia, Septicemia, Osteomyelitis,
Squamous cell ca
Basal cell ca
Location, size, shape, floor, edge, discharge, surrounding area.
Tenderness, local rise of temperature, bleeding on touch, consistency
of the ulcer, edge, surrounding area - oedema, mobility.
REGIONAL LYMPH NODES
FUNCTION OF THE JOINT
LOCATION OF THE ULCER
FLOOR OF THE ULCER
DISCHARGE FROM THE ULCER
LOCATION OF THE ULCER
Arterial ulcer Tip of the toes, dorsum of
Long saphenous varicosity
Medial side of the leg.
Short saphenous varicosity
Lateral side of the leg.
Perforating ulcers Over the sole at pressure
Nonhealing ulcer Over the shin
FLOOR OF THE
ULCERDEF : This is the part of the ulcer which is exposed or seen.
Red granulation tissue Healing ulcer
Necrotic tissue, slough Spreading ulcer
Pale, scanty granulation
Wash-leather slough Gummatous ulcer
DISCHARGE FROM THE ULCER
Serous discharge Healing ulcer
Purulent discharge Spreading ulcer
Bloody discharge Malignant ulcer
Discharge with bony
Greenish discharge Pseudomonas
DEF: This is between the floor of the ulcer and the margin.
The margin is the junction between the normal epithelium and
These two parts represent areas of maximum activity.
Stage of ex-tension.
Stage of transition.
Stage of repair.
A. Sloping edge All healing ulcers like
traumatic ulcers, venous
B. Punched out
ulcers and trophic
D. Raised edge
Rodent ulcers or
E. Everted edge
Thin and dark Arterial ulcer.
like diabetic ulcer.
Induration (hardness) of the edge is very char-
acteristic of squamous cell carcinoma.
It is said to be a host defense mechanism.
Tenderness of the edge is characteristic of
infected ulcers and arterial ulcers.
It is the area on which ulcer rests.
Marked induration at the base is diagnostic of
squamous cell carcinoma.
• The edge, base and the surrounding area should be examined for
Maximum induration Squamous cell carcinoma
Minimal induration Malignant melanoma.
Brawny induration Abscess.
Cyanotic induration Chronic venous congestion
as in varicose ulcer.
Gentle attempt is made to move the ulcer to
know its fixity to the underlying tissues.
Malignant ulcers are usually fixed, benign
ulcers are not.
Malignant ulcer is friable like a cauliflower. On
gentle palpation, it bleeds.
Granulation tissue as in a healing ulcer also
Thickening and induration is found in
squamous cell carcinoma.
Tenderness and pitting on pressure
indicates spreading inflammation
surrounding the ulcer.
RELEVANT CLINICAL EXAMINATION
REGIONAL LYMPH NODES
Tender and enlarged Acute secondary
Non-tender and hard Squamous cell
Non-tender, large, firm,
1) Complete blood picture: Hb%, TC, DC, ESR, PS
2) Urine and blood examination to rule out diabetes
3) Chest X-ray - PA. view to rule out P.TB
4) Pus for culture/sensitivity
5) Lower limb angiography in cases of arterial diseases
6) X-ray of the part to see for Osteomyelitis
7) Biopsy: Non-healing/malignant ulcers
Control pain, infection
Closure of defect
TREATMENT OF THE ULCERS
Treatment of Spreading Ulcers
Treatment of Healing Ulcers
Treatment of Chronic Ulcers
Treatment of The Underlying Disease
TREATMENT OF SPREADING ULCERS
Pus Culture/Sensitivity report,
Solutions to treat the Slough : H₂O₂ & EUSOL - Edinburgh
University Solution (Hypochlorite solution)
Excessive Granulation Tissue (Proud Flesh) : Excision or
Application of Copper Sulphate or Silver Nitrate
TREATMENT OF HEALING ULCER
Regular dressings are done for a few days
Antiseptic creams like Liquid Iodine, Zinc Oxide or Silver
Culture swab is taken to rule out Streptococcus
Haemolyticus ( contraindication for skin grafting )
Ulcer is small - Heals by itself ( Epithelialization )
Large - Free Split Skin Graft applied
TREATMENT OF CHRONIC ULCERS
These do not respond to conventional methods of treatment.
The following are tried:
Infrared radiation, short-wave therapy, ultraviolet rays decrease the
size of the ulcer.
Amnion helps in epithelialization.
Chorion helps in granulation tissue.
These ulcers ultimately may require skin grafting.
Blind track lined by granulation tissue leading from
epithelial surface down into the tissues.
Latin: Hollow (or) a bay
ABNORMAL communication between lumen of one viscus
and lumen of another (INTERNAL FISTULA)
between lumen of one hollow viscus to the
exterior (EXTERNAL FISTULA)
between any two vessels
Congenital AV fistula
(A) following surgery : eg., intestinal fistulas
(B) following instrumental delivery (or) difficult
Intestinal actinomycosis, TB
when growth of one organ penetrates into the
e.g., Rectovesical fistula in carcinoma rectum
Cimino fistula- AVF for hemodialysis
ECK fistula- to treat esophageal varices in portal HTN
Causes for persistence of sinus (or) fistula
Presence of a foreign body. e.g., suture material
Presence of necrotic tissue underneath. e.g.,sequestrum
Insufficient (or) non-dependent drainage.
e.g., TB sinus
Distal obstruction. e.g., faecal (or) biliary fistula
Persistent drainage like urine/faeces/CSF
Lack of rest
Epithelialisation (or) endothelisation of the track. e.g.,
Specific causes. e.g., TB, actinomycosis
Drugs. e.g., steroids
Interference by the patient
Usually asymptomatic but when infected manifest as-
• Recurrent/ persistent discharge.
• Constitutional symptoms if any deep seated origin.
1. Location: usually gives diagnosis in most of the cases.
SINUS: pre-auricular- root of helix of ear.
median mental- symphysis menti.
FISTULA: branchial- sternomastoid ant border.
parotid- parotid region
thyroglossal- midline of neck below hyoid.
2. Number: usually single but multiple seen in HIV
patients (or) actinomycosis.
a) sprouting with granulation tissue-foreign body.
b) flushing with skin- TB
4. Surrounding area:
pigmented- chronic sinus/fistulae.
a) Temperature and tenderness:
b) Discharge: after application of pressure over the
c) Induration: present in chronic fistulae/sinus as in
TB Sinus induration absent.
e) Palpation at deeper plane:
lymph nodes- TB
Thickening of bone underneath- OM
CBP- Hb, TLC, DLC, ESR.
Discharge for C/S , AFB, cytology, Gram staining.
X-RAY of the part to rule out OM, foreign body.
X-RAY KUB and USG abdomen in cases of lumbar fistula
to rule out staghorn calculi.
BIOPSY from edge of sinus
• For knowing the exact extent/origin of sinus (or)fistula.
• Water soluble or ultrafluid lipoidal iodine dye is used.
• Lipoidal iodine is poppy seed oil containing 40%
After excision specimen SHOULD be sent for HPE.
Treating the cause.
e.g., ATT for TB sinus.
removal of any foreign body.
sequestrectomy for OM.
TUBERCULAR SINUS OF NECK
Causative organism: mostly M.tuberculosis
but also M.bovis
Site and mode of infection:
a) lymph nodes in anterior triangle from tonsils.
b) lymph nodes in posterior triangle from adenoids.
c) supraclavicular nodes from apex of the lung.
Stage of cold abscess:
due to caseating necrosis.
non-tender, cystic, fluctuant swelling not
adherent to overlying skin.
Sternocleidomastoid contraction test-
present deep to deep fascia
trans illumination negative
Zig-zag aspiration by wide bore needle in non-dependent
area to avoid a persistent sinus.
Instillation of 1g streptomycin +/- INH in solution with
closure of wound without placing a drain.
NOTE: I&D not done-persistent TB sinus.
Stage of collar stud abscess:
cold abscess ruptures through deep fascia forming an
another swelling in sub-cutaneous plane.
Fluctuant, adherent to skin.
Treated like a cold abscess.
Stage of sinus:
collar stud abscess bursts out leading to a persistent
Can be multiple, wide opening, undermined edges,
Bluish discoloration around the edges.
• Hematocrit, ESR , S.albumin , S.globulin
• FNAC of lymph nodes and smear for AFB and C/S
• Open node biopsy of lymph nodes.
• Edge biopsy of sinus- granuloma.
• mantoux test
• Chest X ray
• Sputum for AFB
Sometimes, USG neck to detect cold abscess.
Hypoechoeic lesions with internal echoes S/O debris
Guided aspiration of cold abscess.
Excision of sinus tract with excision of diseased lymph
Chronic abnormal communication usually lined to some
degree by granulation tissue, which runs outwards from
anorectal lumen (internal opening) to skin of perineum
or the buttocks (external opening)
(relation of primary tract to external sphincter)
• Inter sphincteric (45%)
• Trans sphincteric (40%)
• Supra sphincteric
• Extra sphincteric
low level fistula- open into anal canal below
the internal ring.
high level fistula- at/ above the internal ring.
Simple- without any extensions
Complex- with extensions
multiple- TB, ulcerative colitis, crohn’s, HIV, LGV
• Intermittent discharge
(which increases until temporary relief
occurs when pus discharges)
• Pruritus ani
• Previous h/o anal gland
HISTORY: full medical history incl. obstetric,anal,
gastrointestinal, surgical, continence
DRE: area of induration, fibrous tract and internal
opening may be felt (“button-hole” defect in
To evaluate rectal mucosa for any underlying
• If external opening in anterior half of anus, fistula
usually runs directly into anal canal.
• If external opening in posterior half of anus, fistula
usually curves midline of the anal canal posteriorly.
In inter-sphincteric and low trans-sphincteric fistulas.
Identification of tract with probe followed by division of all
structures between external and internal openings.
Secondary tracts laid
least chance of recurrence
relatively easy procedure
minor degree of incontinence.
results in large and deep wounds that
might take months to heal.
• All chronic (low) and also for posterior horse-shoe shaped
• Excision of entire fibrous tissue and tract and wound kept
• Sphincter repair +/- advancement flap.
• High anal fistulas
SETON SUTURE PLACEMENT
• Preferable surgical option for high variety.
• Setons are usually made from rubber slings
• 2 types of seton suture can be placed
• Draining Seton
Facilitates draining of sepsis
Left loose and allows fistula to heal by fibrosis
• Cutting Seto
Slowly "cheese-wires" though the sphincter muscle
Allows fibrosis to take place behind as it gradually cuts
Multi component system containing mainly human
plasma fibrinogen and thrombin.
Injected into fistula track which hardens in few minutes
and fills the track.
ANAL FISTULA PLUG
The Anal fistula plug is a minimally invasive and
sphincter-preserving alternative to traditional fistula
The plug is a conical device and is placed by drawing it
through the fistula tract and suturing it in place.
the plug, once implanted, incorporates naturally over
time into the human tissue (human cells and tissues will
'grow' into the plug), thus facilitating the closure of the