Ulcer Foot By Dr R.N.M. Francis M.S Prof of surgery SBMC

1. Ulcer Foot By Dr R.N.M. Francis M.S Prof of surgery SBMC

2. Defenition A breach in continuity of skin or epithelium, due to molecular death of tissue. Parts of an ulcer Margin Edge Floor Discharge Base

3. Margin of the ulcer denotes the junction between the normal and the ulcerated area. It gives the shape of the ulcer: Round Oval Irregular

4. 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 .

5. 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

6. 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.

7. Discharge in an ulcer Serous ------- healing Purulant ------ infected Bloody --------- neoplastic Serosanguinous ----- infected Greenish ------- Pseudomonas infected

8. Examination of an ulcer • 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

9. Types of ulcers • Ulcers can be grouped depending upon • 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.

10. b) Nature of pathology Nonspecific ulcers Specific ulcers Malignant ulcers

11. 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

12. Specific ulcers Caused by specific aetiological factors Produces typical features for that aetiology Types: Tuberculous Syphilis Actinomycosis Meleney’s ulcer Hemolytic strepococcal gangrene Meleney’s ulcer

13. Malignant ulcers Epithelioma Rodent ulcer Melanoma

14. Non specific ulcers • Ischaemic ulcers • Due to poor blood supply • Develop over limbs • Over pressure areas • Superficial, later become deep • Painful • Can be multiple

15. 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.

16. 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

17. 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.

18. Tuberculous ulcer • The edge of the ulcer is undermined. • Pale granulation tissue in the floor. • Serous discharge. • It results secondary to caseous lymph nodes.

19. 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

20. 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.

21. 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

22. Treatment Conservative Rest to the part Avoid local irritation Improve the nutrition: Protein supplementation Vitamin supplementation Blood transfusion Appropriate antibiotics Treat the cause

23. 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

24. 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

25. 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

26. 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

27. Diabetic ulcer Control the sugar Perform culture/ sensitivity Desloughing Antibiotics Local amputation/ disarticulation

28. Venous ulcers Elevation Compression stockings Treat varicose veins

29. 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.