Ulcer Foot
By
Dr R.N.M. Francis M.S Prof of surgery SBMC
Defenition
A breach in continuity of skin or epithelium, due to molecular
death of tissue.
Parts of an ulcer
Margin
Edge
Floor
Discharge
Base
Margin of the ulcer denotes the junction between the normal and the
ulcerated area.
It gives the shape of the ulcer: Round
Oval
Irregular
Floor of the ulcer
The exposed part of the ulcer is called the floor
The floor may be covered by:
Red granulation tissue --------- healing ulcer
Unhealthy granulation tissue
Slough ---------- Infected
Wash leather ---------- syphilis
GRANULATION TISSUE
Proliferation of new capillaries and fibroblasts intermingled with RBC
and WBC with thin fibrin cover over it .
Edge of an ulcer
It is the part of the ulcer between the floor and the margin.
It denotes the nature of the ulcer:
Sloping --------- healing
Everted ---------- malignancy
Undermined ------tuberculosis
Punched out ------ penetrating
Base of an ulcer
Base is the structure on which the ulcer lies.
It is a palpatory finding.
Marked induration is a feature of malignancy.
Discharge in an ulcer
Serous ------- healing
Purulant ------ infected
Bloody --------- neoplastic
Serosanguinous ----- infected
Greenish ------- Pseudomonas infected
Examination of an ulcer
1)General survey:
Build of the patient
Evidence of any systemic disorder
2) Local examination :
Inspection
Palpation
3)Regional examination:
a) Examination of lymph nodes
b) Examination for vascular insuffiency ---- peripheral pulses
c) Examination for varicose veins
d) Examination for nerve lesion
Types of ulcers
Ulcers can be grouped depending upon
a)Nature of progress
Healing ulcer
Spreading or active ulcer
Callous ulcer
Zones in the margin of healing ulcer
Red zone : Healing zone and reflects granulation tissue.
White zone: Denotes area of fibrous tissue reaction on the skin side
Blue zone: Junction between the two.
b) Nature of pathology
Nonspecific ulcers
Specific ulcers
Malignant ulcers
Nonspecific ulcers
No specific aetiological cause
Traumatic: mechanical, physical, chemical, radiation.
Arterial
Venous
Trophic
Tropical ulcer
With associated diseases: anaemia, nephritis, diabetes, rhematoid
arthritis.
Miscellaneous:
Bazin’s ulcer
Mortorell’s ulcer
Meleney’s ulcer
Specific ulcers
Caused by specific aetiological factors
Produces typical features for that aetiology
Types: Tuberculous
Syphilis
Actinomycosis
Meleney’s ulcer
Hemolytic strepococcal gangreneMeleney’s ulcer
Malignant ulcers
Epithelioma
Rodent ulcer
Melanoma
Non specific ulcers
Ischaemic ulcers
Due to poor blood supply
Develop over limbs
Over pressure areas
Superficial, later become deep
Painful
Can be multiple
Venous ulcers
•Complication of varicose veins and DVT
•Due to ambulatory venous hypertension
•Seen in the lower third of medial aspect of leg because of the presence
of direct perforating veins which transmit the pressure changes directly
to the superficial system.
Trophic ulcers (Penetrating ulcers)
Seen in: Neurological cases
Hansen’s disease
Diabetes
Common sites: Heel
Ball of foot
Sacrococcygeal region
Features:
Deep ulcers
Base may be formed by underlying bone
Punched out edges
Foul smelling slough
Surrounding insensitivity
Tropical ulcers
These ulcers are sometimes seen in tropical countries.
They are also called as Delhi boil, Baghdad sore.
They are thought to be due to Vincent’s organism.
It starts as an indurated papule on exposed surface.
Leads to formation of an indolent ulcer.
Leaves back an ugly and pigmented scar.
Tuberculous ulcer
The edge of the ulcer is undermined.
Pale granulation tissue in the floor.
Serous discharge.
It results secondary to caseous lymph nodes.
Marjolins ulcer
Squamous cell carcinoma developing in a scar tissue or chronic ulcer.
Everted edges
Indurated base
Bleeding on touch
Regional lymph nodes are not involved.
Poor response to radiotherapy
Footballer’s ulcer
Also called as traumatic ulcer.
Occurs on shin of tibia.
If not treated can become indolent and adherent to bone.
Usually acquired during game of football.
Investigations
1) Lab investigatios
Urine routine
Blood urea
Blood sugar
2) Discharge for culture and sensitivity.
3) Staining of the discharge for AFB.
4) Wedge biopsy.
5) X-ray
Treatment
Conservative
Rest to the part
Avoid local irritation
Improve the nutrition: Protein supplementation
Vitamin supplementation
Blood transfusion
Appropriate antibiotics
Treat the cause
Local methods of taking care of the ulcer
1) Separation of slough
Hypochlorite solution
0.5% silver nitrate
Normal saline soaks
2) Local coverage of the ulcer
Amnion
Gauze impregnated with antibiotics --- Sofra tulle
3) Excessive granulation
Excision
Curettage
Application of copper sulphate crystals
Surgical methods that may be employed
Excision of the ulcer and grafting
Covering the area with SSG
Requisites for an ideal dressing
Should maintain high humidity between wound and the dressing.
Remove excess exudates.
Permit gaseous exchange.
Impermeable to microorganisms
Allow easy removal
Cost effective
Some of the local wound care modalities
Agent Composition Function Commercial names
Polymer films Polyurethane Allows water vapour Opsite, tagaderm
permeation
Hydrocolloids Hydrophilic colloid Impermeable to fluids Intrasite
particles & bacteria
Alginates Seaweed polymer Absorbs exudates Algisorb
non-adherent
Medicated Soframycin Topical antibiotic Sofratulle
Gauze Bacitracin
RhPDGF Acts through Stimulates angiogenesis Plermin
RhEGF tyrosinekinase Stimulates Regen- D
receptor epithelialisation
Diabetic ulcer
Control the sugar
Perform culture/ sensitivity
Desloughing
Antibiotics
Local amputation/ disarticulation
Venous ulcers
Elevation
Compression stockings
Treat varicose veins
Trophic ulcers
Protection and soft padding. MCR shoes to redistribute the pressure
points.
Desloughing and debridement are carried out.
Amputation or disarticulation of bone involved.