Trophic ulcers develop due to impaired wound healing caused by issues like poor circulation, neuropathy or prolonged pressure. They are classified based on their underlying cause such as diabetic ulcers, pressure sores or venous stasis ulcers. Treatment involves identifying the cause, wound debridement, dressing, offloading pressure, and correcting nutritional deficiencies or vascular issues. For non-healing ulcers, surgical reconstruction with flaps may be needed along with patient education on self-care. A multidisciplinary team approach is required for managing trophic ulcers.

1. Trophic ulcer
Moderator: Dr Puneet Bhargava Sir
Presenter: Dr Gangadhar

2. Ulcer
• An ulcer is a break in the continuity of the covering
epithelium - skin or mucous membrane.
• It may either follow molecular death of the surface
epithelium or its traumatic removal.

3. Aetiology
 Venous Disease (Varicose Veins)
 Arterial Disease ; Large vessel (Atherosclerosis) or
Small vessel (Diabetes)
 Arteritis: Autoimmune (Rheumatoid Arthritis, Lupus)
 Trauma
 Chronic Infection: TB/Syphilis
 Neoplastic: Squamous or BCC, Sarcoma
 Neurogenic cause

4. Wagner's Grading of ulcers
 Grade 0 - Preulcerative lesion/healed ulcer
 Grade 1 - Superficial ulcer
 Grade 2 - Ulcer deeper to Subcutaneous tissue
exposing soft tissue or bone
 Grade 3 - Abscess formation or osteomyelitis
 Grade 4 - Gangrene of part of tissues/limb/foot
 Grade 5 - Gangrene of entire one area/foot

5. • The word ‘Trophic’ is derived from the Greek
word Trophe = nutrition.
• American Heritage Medical Dictionary 2007 defines
trophic ulcers as ‘an ulcer due to impaired nutrition of
the part’.
• Mosby's Medical Dictionary 2009 defines trophic
ulcer as ‘a pressure ulcer caused by external trauma
to a part of the body that is in poor condition
because of disease, vascular insufficiency or loss of
afferent nerve fibres’.

6. Classification of trophic ulcers

7. 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

8. 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.

10. Venous Disease
Pathogenesis: increase ambulatory venous hypertension
with microcirculatory abnormalities.
(a)Ulcer in a patient with PVD and venous
disease showing skin changes, (b) skin changes
persist after reconstruction with sural artery flap

11. NEUROGENIC ULCER
• These include all ulcers in insensate hands and feet
in patients with neuropathy.
• Protective pain and pressure perception being
absent, they do not relieve pressure and hence the
repetitive trauma leads to skin breakdown and
ulceration.

13. EXAMINATIONS
INSPECTION
Location, size, shape, floor, edge, discharge, surrounding area.
PALPATION
Tenderness, local rise of temperature, bleeding on touch,
consistency of the ulcer, edge, surrounding area - oedema,
mobility.
REGIONAL LYMPH NODES
SENSATIONS
PULSATIONS
FUNCTION OF THE JOINT
SYSTEMIC EXAMINATION

14. Management
The key to successful management of a chronic ulcer
would be to correctly identify the etiology as well as the
local and systemic factors that could be contributing to its
non healing nature.

15. Investigations
• Complete blood picture: Hb%, TLC, DLC, ESR,
• Urine and blood examination to rule out diabetes
• Chest X-ray - PA.
• Pus for culture/sensitivity
• Lower limb angiography in cases of arterial diseases
• X-ray of the part to see for Osteomyelitis
• Biopsy: Non-healing/malignant ulcers

16. Treatment
• Address cause
• Correct deficiencies
• Control pain, infection
• Debridement, dressing
• Closure of defect

17. Debridement
• Surgical debridement should be aggressive to include
removal of all surrounding hard callus, hyperkeratotic
skin, all dead necrotic tissue, infected soft tissue and
bone.
• Activation of platelets for control of haemorrhage leads
to release of growth factors which begins the process
of healing.

18. (a) Neuropathic bone deep ulcer, (b) radiograph showing bone destruction
Osteomyelitis

20. • Wound bed preparation
• Moist wound dressing: Hydrogel and Alginate
Dressing material selection :Silver
• HBOT(Hyperbaric oxygen therapy)
• NPWT (Negative pressure wound therapy )
• Growth factors: local application of PDGF

21. Off Loading Measures
• Strict bed rest
• Use of crutches, Wheel chair , Walkers
• Pressure reducing measures like air cushion, waterbeds,
Plaster boot
• Removable contact casting, half shoes or specialised
footwear.

22. • The best off loading device is a total contact
cast(TCC).
TCC should be applied only after debridement and
removal of all dead tissue.

23. Surgical Reconstruction
• Surgical options for reconstruction should be
considered for
 ulcers which have exposed bone, tendons
• When the area of the ulcer has not decreased by
more than 10% after sincere conservative
management for 2 months.

24. Common flaps done for foot ulcers are
• local transposition flaps,
• medial plantar artery flap,
• fillet flaps,
• distally based sural neurocutaneous flaps,
• VY plantar flaps local muscle
flaps.

25. Neuropathic ulcer reconstructed with local flap (a) pre-, (b)
intra- and (c) postop views

26. • Tendon imbalance correction, particularly
Achilles or gastro-soleus tightness correction
can help address foot problems and avoid
ulcers.
• Flexor tenotomies have also been suggested to
decrease metatarsal head ulcers in patients with
claw toes.

27. Nerve decompression
• Nerve decompression as an adjunct therapy to medical
treatment should be used when there is clinical and / or
electrodiagnostic evidence of compression neuropathy.
• Prevention of limb loss in chronic diabetes mellitus, for
diminishment of pain and for restoration of sensory/
motor function.

28. Objective wound measurement
• Keeps the treating surgeon and the patient aware
of progress.
• Record keeping should be done by two methods-
• photographic record of the ulcers
• document the length, breadth and depth
measurements of the ulcer at weekly
intervals.
• It helps to objectively analyse healing and
motivates patients towards self-care.

29. Patient education and home care
1. Explanation in simple terms about their specific pathology.
2. Understanding that changing habits and making a few
lifestyle changes could go a long way to keep progression
of disease and its consequences in check, e.g. leg elevation
whenever possible, changing position to keep pressure off
one point.
3. Cessation of smoking.
4. Regular chiropodist care (foot and nail grooming).

30. 5. Strict glycaemia control for diabetics.
6.Compression for venous diseases.
7.Daily end of day check of hands and feet for signs of
breakdown.
8.Self-monitoring of sole/fingertip temperature.
9.Specialized footwear for off-loading pressure.
10.Regular follow-up with physician even in periods of no
ulcer stage.

32. THANK YOU

33. Conclusion
Care of patients with trophic ulcers needs to be
multidisciplinary involving a large team which
includes Dermatologist.physician, general surgeon,
plastic surgeon, endocrinologist, vascular surgeon,
interventional radiologist, dietician, physiotherapist
and chiropodist.