examination of wound and ulcers

8/10/2019 Examination of Wound and Ulcers

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Wounds, Ulcers, Fistula, and Sinuses

The Dr started the lecture with: "Congrats that you are now 4th year medical students,because beginning the clinical life means that you are a part of medicine as a career , youstart seeing patients and practice this career with them, as you were always looking

forward to reaching this stage ."

When you start dealing with patients you have to be professional; to use your knowledgeand experience in the service of your patients, at the same time you have to be honest,when you deal with your patient you have to be honest, you have to tell him everything,build a good relationship between you and your patient. Communication skills are very

important to make the picture clear for the patient and the family"

Today, we are talking about a simple but very very common subject, especially in surgicalpractice; wounds, ulcers, fistula and sinuses, all of them related to one another.

WOUNDS

1. Definition:

Epithelial discontinuity whether in the skin or mucus membrane (gastrointestinal tract,respiratory tract )

Ulcer is a wound (its epithelial discontinuity) but it takes usually a chronic course.

Now you are doctors and you should speak using medical terms, so the words (tear) or (break) arenot appropriate.

-You have to use the language of the trade, the jargon of the trade

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2. Types of wounds:

There are different types, any type of trauma can cause epithelial discontinuity of

certain size and depth

A- Abrasion: if it's very superficial, it just removed part of the epidermis we call it

abrasion.

>> It looks like a burn, superficial burn

Abrasion ( (


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B- Contusion: the response of the body as a result of a blunt

trauma (blow) to the skin (any part of body).

C-Hematoma: it's a part of contusion but there is collection of blood beneath the

skin.

D Incised wounds, tidy clean : the clean cut wounds, surgical wounds, or a knife

wound.

This is a type of hematoma, it isan abrasion, it is just a superficialremoval of small parts ofepidermis and dermis, and it lookslike a burn. It's in the leg, calledabrasion

This is a hematoma, as a result

of blow to the lip, withcollection of blood beneath themucus membrane of the lip.

If the skin is exposed to a blow (blunt trauma), and thisskin is very close to the bone, the wound looks like anincised clean wound (it is not incised with a knife but itlooks like incised wound like in this case).

It is very important if you look to see it (the pic), the areaof redness around the wound, this is an area oferythema, and the area of erythema here (in the pic) iswide, it's 2-3 cm, if it is bigger it may indicates an area of

infection in the wound.


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E- Lacerated wound , untidy contaminated to dirty : deep wound, cutting the edgesin an irregular way, weaving some parts as dead tissues or dirty tissues. Usually as a

result of road traffic accidents (RTA), for example car accident and part of a metalmay hit the neck, the abdomen, the lower limb, leading to a lacerated wound,

irregular wound and usually it is dirty wound contaminated with soil in RTA .

Lacerated wound ( (

Some books divide wounds into:1- TIDY wound: ( clean cut wound )2- UNTIDY wound: (like lacerated wounds and usually contaminated with the

gastrointestinal contents, or pus from an abscess, or from earth like road trafficaccidents).

Other books divide wounds into CLEAN and CONTAMINATED.

This is a lacerated wound, the picture is not clear enough, there are clips. The

lacerated wound may involve very deep structures inside the wound (bone,nerves, arteries, veins, muscles, tendons...). If it is in the abdomen, it mayinvolve the abdominal viscera. If in the neck, it may involve the mainstructures there: the esophagus, trachea, main blood vessels.


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Clean and Contaminated WoundsThis is the most used classification of wounds.

1- Clean wounds : this is the operative wound, no GIT, UG or resp. tract entered.In surgeries, for example, operation of thyroid gland in the neck, it is a clean woundand it remains clean. And usually this type of wounds heals by primary intention.(Closed primarily).

2- Clean contaminated : operative wound with GIT UGT or resp. tract are entered, closedprimarily after cleaning or delayed 1ry.

For example operation for gall bladder, the wound is a clean wound, but when we

remove the gall bladder, it will be opened, and it will contaminate the clean woundso called CLEAN CONTAMINATED WOUNDS. These operative wounds are usually withcommunication with gastrointestinal tract, urogenital, respiratory tract. The woundcould be cleaned and it can be closed primarily (with primary intention), otherwise ifwe think that the wound is not cleaned properly, we can close it after (3 -5) days andwe call this DELAYED PRIMARY.

3- Contaminated wounds : open fresh wounds with gross spillage from GIT, for delayedprimary closure. As appendectomy wound.

So we have:

A- Primary intention: when we can bring the two edges of thewound together.

B- Secondary intention: when there is a loss of skin, we can'tbring the two edges together.

C- Delayed primary: means we close the wound after a period

of time (3-5 days).D- Other wounds are closed by using skin grafts.


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4- Dirty wounds: Old traumatic and purulent wounds and perforated viscous. Fordebridement and delayed primary or graft :

A- Road traffic accident wound with contamination with soil. It may contain soil,mug, glass or grass particles...etc. Soil and mug contain many microorganisms, theworst is the clostridia that can make tetanus and gas gangrene, the presence ofclostridia is more significant and more dangerous than staphylococci andstreptococci (as their presence in the wound is not a problem as much it is in caseof clostridia).

B- Perforated viscous: like perforated peptic ulcer or duodenal ulcer, usually the

wound here needs debridement, proper cleaning, delayed primary, or it mightneed a skin graft.

Management of Wounds - (Wound assessment and primary care)

1) Patient history and physical examination.

2) Compression dressing to stop bleeding.

3) Anti-TT.

4) Antibiotics check sensitivity .

5) Anesthesia local or GA.

6) Washout with sterile isotonic saline.

7) Brushing to remove sand and glass.

8) X-ray for FBs and fractures.

9) Debridement excise dead tissue .

10) Explore for injuries to different structures.

11) Dressing & suturing.


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5. Anesthesia local or GA

6. Explore the wound: Washout with sterile isotonic saline

7. Brushing to remove sand and glass

Do this with a brush to remove sand, pieces of glass, stones, and pieces of metal.

8. X-ray for Foreign Bodies and fractures

This point MUST be considered, as leaving the tiniest foreign bodies in the patientwithout removal will leave the patient unsatisfied with you, and possibly exaggerate

when telling people what happened. For example, you might break the small tip of aneedle in the patients wound, and the next day the patient will tell people you left awhole pair of scissors in his body. So dont miss any foreign bodies in patientsbodies.

9. Debridement excise dead tissue

You should inspect the viability of the tissue, if there is any dead tissue, excise it.EXCEPT in the face. We cannot sacrifice the skin of the face. Usually the viability ofthe skin of the face is good, due to rich blood supply, good venous drainage, it heals

well and the infection rate is less. 10. Explore for injuries to different structures (nerves, muscles, tendons, arteries,

veins...etc.)

Usually arteries need primary repair. Some of the veins -like the long saphenousvein- might be ligated, while the femoral vein should be repaired. The nerves shouldalso be repaired, but it might be delayed. Tendons can also be repaired later on

after the wound is cleaned to ensure there is no infection in the area.

11. Dressing & suturing

If we think that the wound is contaminated or dirty, we can close it primarily after

3-5 days. If we lost skin, we can do a skin graft later on. If we think it is clean, we

can close it primarily on the same day.


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Closure

- This is a tidy clean wound. Usually for the face we makean immediate primary closure in the same day.

- Tidy dirty wounds for delayed primary closure

Healing

Healing by primary intention

Healing by secondary intention for wounds with loss of skin

Physiological stages of wound healing

These stages are very important, never forget them!

1) Inflammatory Phase Day 1-4

Initial response, with rubor (redness), tumor(swelling), dolor(pain), calor

Platelet aggregation and adhesiveness to the area, and activation, Leukocytemigration, phagocytosis and mediator release

Venule dilation, Lymphatic blockade, Exudation

Primary intention, lasts 4 days

Secondary intention, continues until epithelialization is complete

2) Proliferative Phase Day 4-42 Fibroblast proliferation stimulated by macrophage-released growth factors

Increased production of collagen by fibroblasts, Granulation tissue and neo-vascularization (the formation of capillaries).

Gain in tensile strength


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3) Remodeling Phase 6wks-1 year,

Intermolecular cross-linking of collagen via vitamin C-dependent hydroxylation

Increase in tensile strength, Type III collagen replaced with type I

Scar flattens

Wound infection

It becomes apparent

Between 2-4 days from operative day (these days are the days when we suspect

that the wound might be infected). This is also applied on operational wounds. Theoperation day is considered day zero, on day one they dont suspect having a woundinfection, on day 2 they do (after 48 hours).

Area of erythema redness' of more than 5cm (here the patient starts to complainof throbbing pain)

Indurations

After a few days fluctuations will occur (abscesses).

Ulcers

Definition: An ulcer is an epithelial discontinuity. It is considered a wound due to achronic cause.

Ulcer is a chronic wound due to:

Physical or chemical injury (Something you should always remember: you shouldNEVER apply disinfectants or an anti-septic solution to a living tissue)

Ischemia (inadequate blood supply)

Neoplastic changes (squamous cell, basal cell carcinoma...)

Systemic diseases (renal failure, liver failure, diabetes, a patient receivinghydrocortisone can all reduce the possibility of wound healing)


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History

When first noticed?

(The onset of the ulcer and its duration). Sometimes the people around the patient

are the ones who will notice the ulcer, not the patient himself. (For example thepatient's wife might find blood on his socks, or smell a bad odor from his shoes).

What brought it to attention?

(The symptoms associated with the ulcer: pain, discharge, bleeding, and smell)

The progress of ulcer (size, shape, depth, discharge and response to any treatment)

Previous similar lesions, systemic symptoms and what the patient thinks.

(It's very important to ask the patient what he thinks and take his opinion).

"It's important to take his opinion because the patient is the universe

around which the medical profession rotates"

Examination of an ulcer

1. Site :sometimes its characteristic because certain ulcers occur in certain sites, forexample:- Venous is sited in the leg above the medial Malleolus.- Arterial in the toes.- Diabetic in the foot as neuropathic, arterial or infective traumatic.

2. Size3. Shape4. The base and the floor5. The edge of the ulcer6. The margins7. The draining lymph nodes


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1-Site:This is an ulcer that occurred with varicose vein.

This is the same leg after healing. This type of ulcer occurs when there is inadequatevenous drainage that causes venous ischemia.

Normally, the superficial venous system drains into the deep system, but if the deep

system is not functioning properly, it will cause stagnation of blood and fluid in thesubcutaneous tissue and skin will be ruptured. Especially those who stand for a long period

of time without exercising their legs.

This is a venous ulcer.


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Arterial ulcers usually occur in the toes, the inadequate arterial blood supply to the toescan lead to ulceration in the bulb of the toe. The patient may present with an in growing

toe nail (he will come with pain in his nail, you should make sure that the blood supply isadequate before removing the nail. if you remove the nail in the presence of ischemia , theulcer will never heal and result in ischemic ulcer ).

This is a diabetic foot in which the patient has only the heel, the big toe and part of thesole. The other toes and the rest of the foot are amputated because the blood supply wasinadequate. The result is ischemia and infection (ischemia occurs because the veins andthe arteries become thrombosed).

We see another ischemic ulcer over the heel on the left of the figure.

Neuropathic UlcerUsually there is hypertrophied skin, it's an attempt for healing all the time .the patient willhave an area which is cleaned, covered with healthy granulation tissue but there is nohealing.The patient doesnt feel his foot , and keeps using his limb all the time and this prevents

epithelialization of this area.


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This is a traumatic ulcer in the left limb on a paraplegic patient due to repeated traumafrom the edge of the table and the wheelchair. So this ulceration is due to loss of sensation

(he doesnt feel his limbs).

Bed sore is a healing ulcer, it was black and gangrenous. The figure in the slide not clear atall. O n the right its the o ne that is black and gangrenous.

Sometimes ulcers can occur inside the body , this is an example of peptic ulcer disease

inside the stomach and it may occur in the duodenum but it will be smaller.

It becomes apparent in upper GI endoscopy


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2. The shape of the ulcer could be irregular or regular.3. Size :

In cm. If it's irregular we can describe it as: it's an irregular ulcer with a maximum

length of 10cm and a maximum breadth of 5cm.

4. The base and the floor :

This is the floor, it's the upper part where it may show the covering of an ulcer .It'sabout secretions which can become dry especially in burns. We call it scar.

The other part is called the base, which is the part that is beneath the ulcer.

5. The edge of the ulcer

Which is part of the ulcer where it communicatewith normal skin and it can be:

1. Sloping: this is a good sign, the ulcer hereis a healing ulcer.

2. Punched out: which can occur in syphilisor in ischemic ulcers.

3. Undermined ulcers occurs in TB4. Rolled ulcers in basal cell carcinoma5. Everted ulcer in squamous cell carcinoma

Usually malignant ulcers are added to the surfaceof the skin (higher than the surface) while benignulcers take from the normal skin.


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6. The margins

It's a medical term that describe the surrounding tissue of an ulcer. Which could be

segmented, red and erythematous, swollen and edematous.

The skin around venous ulcer is pigmented (deeper in color).

7. The draining lymph nodes

The draining lymph nodes of the lower limbs are the superficial group of inguinal lymphnodes. The superficial group lies transverse in the inguinal area. The deep group lies along

the common femoral and external iliac arteries (longitudinal).

SinusesA sinus is a tract which is lined with a granulation tissue connecting a n abnormal cavity an

abscess to an epithelial surface.

The most common sinus that we deal with is the pilonidal sinus ( .(

It's communicating the abscess cavity with the skin, usually the granulation tissue will

protrude through the opening to the outside so it's called exuberant.

The main symptoms are recurrent infection and discharge, if the sinus is closed the patientstart complaining of throbbing pain until we open it. When it's open, he will complain of

infection and discharge.

The factors that lead to sinus formation

1. Inadequate drainage of an abscess.

for example : drained a pilonidal abscess by small incision , a sinus after that will be

formed .but if we open it widely and clean it , abscess start to heal from the bottomto the upward .


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2. Chronic inflammationSome sinuses in the neck due to tuberculous lymph nodes, or syphilis or fungal

infection (actinoycosis) in the mandible, or crohn's disease in the anal canal.3. The presence of foreign bodies :

Like the hair that is present in a pilonidal sinus will leave it open. Sometimes thesutures materials which we use might be considered foreign bodies.

4. Congenital sinuses lined with epithelial tissues like: dermoid cyst, branchial cyst andpreauricular sinus.

5. Malignant diseases may spread to present as a sinus,Like: paget disease of the nipple, and sister-Joseph nodule in the umbilicus from a

carcinoma of the stomach with the spread into the peritoneum and invasion of the

umbilical scar .so it will open into the umbilicus.

This is the preauricular sinus, and there is the auricular sinus. Both of them are

congenital. The sinus is from an abnormal cavity to the skin.

Fistulae

Fistula is an abnormal communication (tract) between 2 epithelial surfaces. For example:the anal canal and the bowel to the skin (2 epithelial surfaces: anal canal and the skin)

It occurs when an abscess breaks into two adjacent epithelial surfaces, and then it opensto the inside and outside and sometimes we interfere to open it to the outside. It will lead

to fistula formation. So fistula in the anal canal is common.

Etiological factors as in sinuses in addition to continuous flow of feces in perianal fistula

and Crohns disease

Congenital In tracheo-bronchial fistula.


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This is a figure of Crohns disease

Done by : Haya Al Rawabdeh

Bara Zubi

Rawan Hammoudeh

Collected and checked by : Khawla Momani

examination of wound and ulcers

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