How to Examine UlcersHow to Examine Ulcers

Ali SabbourAli SabbourProf. of General & Vascular Surgery, Ain Shams UniversityProf. of General & Vascular Surgery, Ain Shams University

DefinitionsDefinitionsAn ulcer is a break in the continuity of an epithelium

Chronic ulcers are those that persist for more than 4 weeks

What prevents an ulcer to heal? What prevents an ulcer to heal?

What are the causes of chronic ulcers?What are the causes of chronic ulcers?

InfectionInfection Repeated /Persistent Repeated /Persistent traumatrauma

IschemiaIschemiaCCh.h. V Venousenous I Ins.ns.

Specific

•TB

• Syphilis

Non Specific

•Osteomyelitis

Localized destructive Localized destructive D/sD/s

•TB

•Gamma

•MalignancyDenervationDenervation

Peripheral nerve lesionsDM, Nerve injury, Leprosy

Spinal cord lesions

HistoryHistory

CauseCause e.g. Minor traumae.g. Minor trauma

DurationDuration More than 4 weeks is considered chronicMore than 4 weeks is considered chronic

Main Main symptomsymptom

Pain, Discharge,….Pain, Discharge,….

CourseCourse •Increasing in size or depth Increasing in size or depth

•Became painful Became painful (infected?)(infected?)

•Discharging Discharging (infected?)(infected?)

•Recurrent Recurrent (healing & breaking down)(healing & breaking down)

Similar ulcer Similar ulcer (same site or elsewhere)(same site or elsewhere)

ExaminationExamination

SiteSite ShapeShape SizeSize

FloorFloor

EdgeEdge

DepthDepth

DischargeDischarge

RelationsRelations (adherent to deeper tissues)(adherent to deeper tissues)

Skin Skin (or tissues)(or tissues) around around

Draining LNsDraining LNs

Floor

Edge

ExaminationExaminationSiteSite

ShapeShape

SizeSize

Some ulcers have characteristic locationsSome ulcers have characteristic locations

e.g. Venous ulcer situated in the gaiter area of the leg

Are important in follow up of ulcer healingAre important in follow up of ulcer healing

ExaminationExaminationSiteSite ShapeShape SizeSize

FloorFloorBy inspection you may notice:By inspection you may notice:

•Granulation tissue

•Sloughs

•Gangrenous tissue

•Deeper tissues as tendon or bone

Solid brownish or blackish tissue indicates full thickness skin death

Sloughs in ischemic foot ulcer

Healthy granulation tissue. The red colour reflects good vascularity

Gamma 3ry syphilis. Sloughs (wash-leather)

Gangrenous tissue & tendons in ischemic ulcer

ExaminationExaminationSiteSite ShapeShape SizeSize

FloorFloor

DepthDepth

Venous ulcers are superficial

Neuropathic ulcers are deep

ExaminationExaminationSiteSite ShapeShape SizeSize

FloorFloor

Edge Edge (5 types)(5 types)

DepthDepth

1- Sloping

The ulcer is shallow & the epithelium is The ulcer is shallow & the epithelium is growing in from the edge in an attempt to growing in from the edge in an attempt to

healheal

ExaminationExaminationEdge Edge (5 types)(5 types)

1- Sloping

2- Punched-out

or square cutsquare cut: It results from rapid death & loss of the whole thickness of the skin with minimal attempt of healing

Gamma of 3ry syphilis Leprosy Neuropathic ulcer in the

sole of foot

ExaminationExaminationEdge Edge (5 types)(5 types)

1- Sloping

2- Punched-out

3- Undermined edge

When infection is affecting the subcutaneous tissue more than the skin, the edge becomes

undermined

Pressure bed sore in the buttock.

Subcutaneous fat is more susceptible to pressure

than the skin

Tuberculous ulcer

Undermined edge in Pyoderma gangrenosa

Undermined edge in diabetic foot infection

ExaminationExaminationEdge Edge (5 types)(5 types)

1- Sloping

2- Punched-out

3- Undermined

4- Rolled

Develops when there is slow growth of tissue in the edge of the ulcer

Basal cell carcinoma (rodent ulcer): Pale pink edge with clumps & clusters of cells visible through the

paper thin superficial covering of squamous cells

ExaminationExaminationEdge Edge (5 types)(5 types)

1- Sloping

2- Punched-out

3- Undermined

4- Rolled

5- Everted edge

Develops when the tissue in the edge of the ulcer is growing quickly and spilling out of

the ulcer to overlap the normal skin.

This edge is typical of carcinoma at any site

Malignant ulcer colon carcinoma

Malignant transformation in a chronic venous ulcer

“Marjulin” ulcer

ExaminationExaminationSiteSite ShapeShape SizeSize

FloorFloor

EdgeEdge

DepthDepth

DischargeDischargeMay be: serous, sanginous, serosanguinous or purululent

A dry discharge forms a scab that covers the ulcer

Purulent discharge from infected bed sore

Serosanguinous discharge from infected diabetic foot

ulcer

Dry scab covering the ulcer

ExaminationExaminationSiteSite ShapeShape SizeSize

FloorFloor

EdgeEdge

DepthDepth

DischargeDischarge

Skin Skin (or tissues)(or tissues) around aroundCellulitis around the ulcer

Hyperpigmentation of ch. Recurrent infection

Pigmentation around venous ulcer

ExaminationExaminationSiteSite ShapeShape SizeSize

FloorFloor

EdgeEdge

DepthDepth

DischargeDischarge

RelationsRelations (adherent (adherent to deeper tissues)to deeper tissues)

Skin Skin (or tissues)(or tissues) around around

It is important to know if the ulcer is adherent to the

deep structures

ExaminationExamination

SiteSite ShapeShape SizeSize

FloorFloor

EdgeEdge

DepthDepth

DischargeDischarge

RelationsRelations (adherent to deeper tissues)(adherent to deeper tissues)

Skin Skin (or tissues)(or tissues) around around

Draining LNsDraining LNs

The draining LNs may be enlarged 2ry to infection or 2ry to tumour deposits.

Infected LNs may be tender