Radiology

1. Welcome..

2. Break in the continuity of the covering
epithelium with molecular death
(necrosis) – skin or mucous membrane.
Chronic ulcer > 6 weeks

3. Clinically and pathologically
 Clinically –
 Spreading ulcer
 Healing ulcer
 Callous or chronic ulcer
 Pathologically –
 Infective ulcers
 Non-infective ulcers
 Malignant ulcers

4. CLINICALLY
 Spreading ulcer
 Surrounding skin – inflamed
 Floor – slough
 Edge – inflamed and ragged
 No granulation tissue
 Healing ulcer
 Floor – healthy granulation tissue
 Edge – reddish with granulation
 Margin – bluish and growing
 Discharge – slight and serous

5.  Callous or chronic ulcer
 No tendency towards healing
 Floor – pale granulation tissue
 Discharge is scanty or absent
 Base, edge and skin is indurated

6. PATHOLOGICALLY
 Non-infective ulcers
 Venous ulcers (MC)
 Arterial ulcers
 Neurogenic ulcers (Trophic)
 Traumatic ulcers
 Associated with malnutrition
 Associated with systemic disease
 Miscellaneous

7.  Miscellaneous
 Vasculitis
 Hematological
 Emboli
 Drugs / Therapy
 Skin conditions
 Genetic conditions

8.  Infective ulcers
 Tuberculous
 Mycetoma
 Tropical
 Meleney’s
 Malignant ulcers
 Epithelioma (Squamous cell)
 Melanoma
 Rodent ulcer (Basal cell)
 Marjolin’s ulcer

10. Ulceration of the lower leg occurring as the result of
persistently elevated venous pressure and its secondary
effects on the microvascular system.
 Causes:
 Deep-vein valvular incompetence or post thrombotic
damage
 Incompetence superficial or communicating veins
 Elderly women
 Genetic ?

11.  Venous ulcers are the end result of superficial venous
insufficiency or the post-thrombotic syndrome (PTS)

12.  Associated skin changes –

14. Death of the skin following occlusion of its arterial blood supply.
 Atheroma of the abdominal and limb vessels is the single most
common cause of ischemic ulceration
 Three main causes:
 Extramural strangulation
 Mural thickening or accretion
 Intramural restriction of blood flow
 There is often considerable overlap, and the exact pathology is not
well defined

15.  Extramural causes
 Scar tissue and radio-dermatitis cause a fibrotic
strangulation of the arterioles
 Dermal sclerosis
 Compression by tumors
 Mural causes (speed of occlusion)
 Vasculitis – sudden
 Hypertension – slower
 Atherosclerosis

16.  Intramural causes (Microvascular occlusion)
 Change in blood viscosity
 Defective clotting mechanisms
 Peripheral arterial disease and poor peripheral circulation
 Atherosclerosis
 Buerger’s disease
 Raynaud’s disease

18. Neuropathic ulcer is a form of chronic ulceration, also known as
‘perforating ulcer’ which develops in anaesthetic skin.
 Characteristically neuropathic ulcers are –
 Painless
 persistent and uninflamed
 appearing on areas subject to trauma or pressure

19.  Causes
 Type II DM (most common)
 Leprosy
 Peripheral neuropathy
 Alcoholism
 Vitamin deficiencies
 Pernicious anemia
 Syringomyelia
 Tabes dorsalis
 Spinal dysraphism
 Spinal cord injury
 Hereditary sensory and autonomic neuropathies

20.  Neuropathic ulcers result from a distal polyneuropathy
encompassing motor, sensory and autonomic components
 Increased pressure under the metatarsal heads and heel – 90%
ulcers

21.  Autonomic neuropathy
 Loss of sweating, dryness with fissuring and cracking
 Changes in the normal microcirculatory autoregulation

24.  ‘Multifactorial’
 Neuropathy
 Macro and microvascular disease
 Infection
 Connective tissue abnormalities
 Hematological disturbances
 Neuropathic / Ischemic / Neuroischemic
 Any one factor may predominate
 Identification of the dominant factor

25. NEUROPATHY
 Glove and Stocking distribution of diabetic somatic sensory
neuropathy
 Somatic motor nerves
 Autonomic nervous system
Causes of neuropathy
 Metabolic factors
 Microvascular disease

27.  Effect of neuropathy
 Extrinsic neuropathic foot ulceration
 Intrinsic neuropathic foot ulceration
 Extrinsic – loss of somatic sensory
 Intrinsic – loss of somatic motor and autonomic

29. MICROVASCULAR DISEASE
 Structural changes in basement membrane
 Increased capillary permeability to albumin
 Absolute hyperperfusion Relative hypoperfusion
 Less ability to vasodilate and increase blood flow
 Endothelial dysfunction
MACROVASCULAR DISEASE
 Atherosclerosis – tibial and peroneal arteries
 Arteriosclerosis – calcification of the media

30. INFECTION
 Not generally the primary cause except ‘fungal’ infection
 Why increased propensity?
 Intrinsic abnormalities of immune system
 Favorable environment
 Infection determines the outcome of lesion
 Polymicrobial in nature

32. CONNECTIVE TISSUE ABNORMALITIES
 Non-enzymatic glycosylation of proteins
 Advanced glycosylation end products
 Hemoglobin, collagen and keratin
 Rigid, inflexible and resistant to digestion

33. HEMATOLOGICAL DISTURBANCES
 RBCs are less deformable
 Tendency towards hypercoagubility
 Impaired WBC function

35. TUBERCULOUS ULCER
 Tuberculous chancre – Primary inoculation of the skin usually
following trauma in the non-immune host
 Tuberculosis verrucosa cutis – Primary infection in the immune
host
 Lupus vulgaris – Hematogenous, lymphatic or contiguous
spread but can occur following inoculation

36.  Scrofuloderma – Contiguous involvement of the skin overlying
tuberculosis in a deeper structure
 Metastatic tuberculous abscesses (tuberculous gumma) –
Hematogenous spread from a primary focus
 Erythema induratum of Bazin (Bazin’s disease) – Chronic
disorder characterized by recurrent hard subcutaneous
nodules over calves.

37. Erythema induratum
Tuberculous cutis
verrucosa

38. MYCETOMA FOOT / MADURAMYCOSIS
A localized chronic infection caused by various species
of fungi or actinomycetes, and characterized by the
formation of aggregates of the causative organisms
(grains) within abscesses.
 Fungi (eumycetoma) – Madurella mycetomatis (MC)
 Aerobic actinomycetes (actinomycetoma)

40. TROPICAL ULCERS
 Synergistic bacterial infection
 Following invasion of the skin by at least two organisms
 Fusobacterium spp.(F. ulcerans)
 Spirochetes or other anaerobic bacteria
 Develops at a site of potential trauma, a scratch, cut or insect
bite
 SCC develops after 10 years or more in some such cases.

42. MELENEY’S ULCER
Bacterial synergistic gangrene extending rapidly and has
a burrowing, bluish, undermined and painful edge.
 Symbiotic action of micro-aerophilic non hemolytic
streptococci and staphylococcus aureus
 De-novo – Ulcerative colitis
 Complicating previous ulcer
 Toxemia

44. BAZIN’S ULCER / ERYTHROCYANOID ULCER
 Erythrocyanoid frigida
 Exclusively women
 Predisposing factors
 Subcutaneous fat
 Thick ankle pad
 Poor arterial supply
 Sensitivity to extremes of temperature

45. YAWS
 Treponema Pertenue
 Bare-foot injury
 Painless ulcers
 Healing with tissue paper like scar

47. SQUAMOUS CELL CARCINOMA
A malignant tumor arising from the keratinocytes of the
epidermis
 Most common skin cancer
 Etiology
 sun exposure
 trauma
 Albinism
 Burn scars and thermal radiation
 ionizing radiation
 chronic inflammation
 chronic discoid lupus erythematosus

48. MALIGNANT MELANOMA
 Acral lentiginous melanoma (palmoplantar malignant
 melanoma)
 Commonest type of melanoma
 Sole of the foot, palm of the hand
 Etiology
 Genetic and ethnic
 Familial - autosomal dominant gene with incomplete
penetrance
 Environmental - intermittent sun exposure
 Melanocytic naevi

50. BASAL CELL CARCINOMA
 A malignant tumor that rarely metastasizes, composed of cells
similar to those in the basal area of the epidermis and its
appendages
 BCC in lower limb is uncommon
 Secondary to
 Lipodermatosclerosis
 Burn scars, vaccination scars
 Ionizing radiation
 Damage by sunlight

52. MARJOLIN’S ULCER
 SCC arising from long standing benign ulcer or scar
 MC – venous ulcer
 Slow growing, painless

54. MARTORELL’S ULCER
Association with longstanding, often poorly controlled,
hypertension, and healing response to specific
antihypertensive agents.
 Bilateral superficial painful ulceration
 Presence of peripheral pulses
 Absence of atherosclerosis
 Subendothelial hyaline degeneration
 Smooth muscle hyperplasia

55. TRAUMATIC ULCERS
 Mechanical injury
 Rat bite
 Physical e.g. burns, electrical or X-ray
 Chemical e.g. caustics