This document provides an overview of common and less common ulcers of the lower limb, including venous, arterial, and neuropathic ulcers. It describes the approach to examining a patient with a leg ulcer, including taking a detailed history and performing a physical exam focusing on the ulcer site, surrounding skin, pulses, and other relevant systems. A number of potential investigations are outlined to determine the etiology of the ulcer, such as wound culture and biopsy. Principles of ulcer management include determining the cause, addressing comorbidities, treating the underlying condition, wound care including debridement and dressings, and reconstruction if needed.

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.