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.