4. Parts of Ulcer
A. Margin: It may be regular or irregular. It may be rounded or oval.
B. Edge: Edge is the one which connects floor of the ulcer to the margin. Different
edges are:
-Sloping edge. It is seen in a healing ulcer.
Its inner part is red because of red, healthy granulation tissue.
Its outer part is white due to scar/fibrous tissue.
Its middle part is blue due to epithelial proliferation.
5. -Undermined edge is seen in a tuberculous ulcer. Disease process
advances in deeper plane (in subcutaneous tissue) whereas (skin)
epidermis proliferates inwards.
-Punched out edge is seen in a gummatous (syphilitic) ulcer and trophic
ulcer. It is due to endarteritis.
6. -Raised and beaded edge is seen in a rodent ulcer (BCC). Beads are due to
proliferating active cells.
-Everted edge (rolled out edge): It is seen in a carcinomatous ulcer due to spill
of the proliferating malignant tissues over the normal skin.
7. C. Floor: It is the one which is seen. Floor may contain discharge,
granulation tissue or slough.
D. Base: Base is the one on which ulcer rests. It may be bone or soft
tissue.
8. Classification of an Ulcers
1) Based on Duration :
- Acute ulcer—duration is less than 2 weeks.
- Chronic ulcer—duration is more than 2 weeks (long).
2) Pathological Classification :
A- Specific ulcers: eg : TB, Syphilis, Actinomycosis ..etc
B- Malignant ulcers:
Carcinomatous ulcer.
Rodent ulcer.
Melanotic ulcer.
C- Non-specific ulcers:
Traumatic ulcer: It may be mechanical, physical, chemical—
common.
Arterial ulcer : Atherosclerosis, TAO
Venous ulcer: Gravitational ulcer, post-phlebitic ulcer.
Trophic ulcer/Pressure sore.
Infective ulcers: Pyogenic ulcer.
9. VENOUS ULCER
Venous disease is responsible for between 60 and 70
per cent of all ulcers in the lower leg. There are many
other causes of leg ulcers and these must be excluded
in any patient presenting with ulceration:
venous disease: superficial incompetence; deep venous
damage (post-thrombotic);
arterial ischaemic ulcers;
rheumatoid ulcers;
traumatic ulcers;
neuropathic ulcers (diabetes);
neoplastic ulcers (squamous cell carcinoma and basal
cell carcinoma);
infections, especially in Third World countries.
10. • Gaiter region is the area between the muscles
of the calf and the ankle. This is the region
where many of the Cockett perforators join the
posterior tibial vein to the surface vein, known
as the posterior arch vein.
• The majority of ulcers develop on the medial
side of the calf but ulcers associated with lesser
saphenous incompetence may develop on the
lateral side of the leg. Ulcers can develop on
any part of the calf skin in patients with
postthrombotic legs; however, venous ulcers
rarely extend onto the foot or into the upper calf
and, if there is ulceration at these sites,
other diagnoses should be seriously considered.
VENOUS ULCER
It is common around ankle (gaiter’s zone) due to ambulatory chronic
venous hypertension. It is due to varicose vein (long saphenous
vein/short saphenous vein/perforators) or post- phlebitic limb.
11. • Many patients notice some itching, perhaps
associated with mast cell degranulation, before
the ulcers develop. Almost all venous ulcers
have surrounding haemasiderosis (seen as
pigmentation) and the more chronic ulcers
develop lipodermatosclerosis with associated
fibrosis of the subcutaneous tissue.
• Post-phlebitic limb consists of veins that is
been partially recanalised following deep
venous thrombosis which causes increased
venous pressure around ankle through
perforators.
• Varicose veins are common in females. 50% of
venous ulcers are due to varicose veins; 50%
are due to post-phlebitic limb (previous DVT).
Pain, discomfort, pigmentation, dermatitis,
lipodermatosclerosis, ulceration, talipes
equinovarus deformity and Marjolin’s ulcer are
the problems of varicose veins and later of
venous ulcer
Clinical Features
12. Investigations
Most vascular surgeons will carry out a
duplex scan when the patient with an
ulcer is first seen to assess the state of
the deep and superficial veins.
The presence of reflux in these veins
does not confirm a venous ulcer but
supports the diagnosis in the absence of
another cause and helps direct
treatment.
All patients presenting for the first time
with a new leg ulcer should have a full
blood count, blood glucose, erythrocyte
sedimentation rate (ESR) or C-reactive
protein (CRP).
13. Management
- When the diagnosis of a ‘probable
venous ulcer’ has been made,
patients are initially treated by a
compression bandaging regimen,
which can be applied in a specialized
clinic or by a trained
district or practice nurse.
-Ulcer Care.
-Special consideration.
Prognosis
- Nearly all venous ulcers can be healed
but, even in those who
have successful surgery or wear their
stockings religiously, there
is a 20–30 per cent incidence of
reulceration by five years. The
greatest risk of reulceration is in the
post-thrombotic leg.
14. ARTERIAL/ISCHAEMIC ULCER
It is common in toes, feet or legs.
It is due to poor blood supply following blockage
of the digital or medium sized arteries.
Atherosclerosis and TAO (Thromboangiitis
obliterans) are common causes in lower limb
Ulcer is very painful, tender and often
hyperaesthetic. Digits may often be gangrenous.
Intermittent claudication, rest pain are common.
Other features of ischaemia are obvious in the
adjacent areas. They are—pallor, dry skin, brittle
nail, patchy ulcerations, and loss of hair.
15. Ulcer is usually deep, destructs the deep fascia,
exposing tendons, muscles and underlying bone.
Dead tendons look pale/greenish with pus over it.
Management : Specific investigations like
arterial Doppler, angiogram, lipid profile, and
blood sugar are done.
Treatment is done accordingly—drugs like
vasodilators; arterial surgeries may be needed.
16. TROPHIC ULCER (PRESSURE
SORE/DECUBITUS
ULCER)
Pressure sore is tissue necrosis and ulceration due to
prolonged pressure. Blood flow to the skin stops once
external pressure becomes more than 30 mmHg (more than
capillary occlusive pressure) and this causes tissue
hypoxia, necrosis and ulceration. It is more prominent
between bony prominence and an external surfaces
17. It is due to :
Impaired nutrition.
Defective blood supply.
Neurological deficit.
Sites :
Over the ischial tuberosity.
Sacrum.
In the heel.
In relation to heads of
metatarsals.
Buttocks.
Over Med. & Lat. Malleolus
Over the shoulder.
Occiput.
18.
19. DIABETIC ULCER
Causes
Increased glucose in the tissue precipitates
infection.
Diabetic microangiopathy which affects
microcirculation.
Increased glycosylated haemoglobin decreases the
oxygen dissociation.
Increased glycosylated tissue protein decreases
the oxygen utilization.
Diabetic neuropathy involving all sensory, motor
and autonomous components.
Associated atherosclerosis.
20.
21. Investigations
Blood sugar both random and fasting.
Urine ketone bodies.
Discharge for culture and sensitivity.
X-ray of the part to see osteomyelitis.
22. Treatment
Control of diabetes using insulin.
Antibiotics.
Nutritional supplements.
Regular cleaning, debridement, dressing. Once
granulates, the ulcer is covered with skin graft or flap.
Revascularisation procedure is done by endarterectomy
or thrombectomy or balloon angioplasty or arterial
bypass graft. But if distal vessels are involved then
success rate is less.
Toe/foot/leg amputation.
Care of foot , Leg.
23. Assessment of an ulcer
Cause of an ulcer should be found—diabetes/ venous/ arterial/ infective
Clinical type should be assessed
™
Assessment of wound is important—anatomical site; size and depth of
the wound; edge of the wound; mobility; fixity; induration; surrounding
area; local blood supply. Wound perimeter may be useful in assessing
this
™
™
Presence of systemic features; regional nodal status; function of the
limb/part; joint movements; distal pulses; sensations should be assessed
™
Severity of infection should be assessed—culture of discharge
™
Specific investigations like wedge biopsy; X-ray of part; blood sugar;
arterial/venous Doppler; angiogram
