TYPES OF ULCER, EXAMINATION

AND MGT OF ULCERS

DR M OZINKO
CONSULTANT BURNS AND PLASTIC
SURGEON
 INTRODUCTION
• An ulcer is the persistent loss or break
in the continuity of the surface
epithelium .
• The underlying tissue may be similarly
affected .
• A wound is the disruption of a tissue .
• MGT involves a multidisciplinary approach
• A detailed hx is key to diagnosis.
 TYPES OF SKIN ULCERS
• A] SPECIFIC ULCERS
• 1] Tropical ulcers- borrelia vincenti and bacteriodes
fusiformis
• 2]Tuberculous ulcers-M. tuberculosis
• 3]Buruli ulcers- M. ULCERANS
• 4]syphilic ulcers –treponema pallidium
• 5]Yaws ulcers- treponema pertenue
 B] NON SPECIFIC ULCERS
• 1]Traumatic ulcer
• 2] pyogenic ulcer
• 3] ulcers of neurotrophic origin
– i] Leprosy
– II] Diabetic neuropathy
– Iii]Cord lesion
– Iv] peripheral neuropathy
– V] syringomyelia
 4)Ulcers of vascular origin
• Venous ulcer
• Arterial ulcer
• Decubitus ulcer
• Pressure ulcer
 5] ulcers associated with metabolic or
systemic diseases
• i] Diabetic ulcers
• Ii]Haemoglobinopathic ulcers
• Iii] Ulcers of spherocytosis
• Iv] Ulcers of ulcerative colitis
 C] Neoplastic ulcers
• i] Squamous cell carcinoma
• Ii] Rodent [basal cell ] ca
• Iii] malignant melanoma
• Iv] Kaposi sarcoma
• V] penetrating malignant tumours
 HISTORY TAKING
• BIODATA
• Presenting complaint
• Course or progression
• Cause or aetiology
• Complications
• local- bone pain , evidence of osteomyelitis ,
joint deformity
• General complications – weight loss , nausea vomitin
g , malaise
• Systemic complications –
• Mss –bone and spinal pain ,swelling
• RESP –cough , sputum ,haemoptysis ,pain
• Digest –jaundice
• CNS –headache , sleeplessness , paralysis
 HX CONT’D
• Hx of Care
• PMHX – previous admission ,HEADS
• Drghx –anticancer ,steroid
• FSHX – types of family illness , habits –alcohol ,
tobacco
• ROS
• General physical exam
 EXAMINATION OF ULCERS
• SITE ,
• Size
• Shape –round .ovoid , irregular , serpentine
• Edge
• 1]a flat, sloping edge –venous, healing non specific
ulcers
• 2] punched out ulcer –syphilitic ulcer
• 3] undermined edge-pressure sores , TB ulcers ,
Buruli ulcer, necrotising fasciitis
 EXAM OF ULCER CONT’D
4] Raised and rolled edge –Basal cell ca[Rodent ulcer]
5]Raised and everted edge – squamous cell ca
DEPTH –
Measure in millimeters ,or anatomically by describing
the structures it has penetrated or reached .
FLOOR- It is what you see .
Healthy granulation tissue with pink colour
Sloughs
Tendon , bone , cartilage , blood vessels , necrotic
tissues , eschar
Nodular floor
Discharge –serous , sanguinous , serosanguinous,
purulent , try to estimate the quantity. Take a
bacteriological swab for m/c/s . A dried discharge is
called scab
 EXAM CONT’D
• BASE- It is what you palpate
• It may be soft in healing ulcer, may be hard or
indurated suggesting malignant or long standing
callous ulcers
• SURROUNDING SKIN
• Temperatue, tenderness, scars, dilated veins ,
varicose veins, warts ,edema , fissure ,colour change
 EXAM CONT’D
• Examination of arteries
• Examine for sensation
• Examine the joints
• Examine regional lymph nodes
• Examine patient standing and lying down for leg
ulcers
 PRINCIPLES OF MANAGEMENT
Detailed history taking
General physical examination
Investigations;
Full blood count r/o anaemia
Urinalysis - r/o dm
VDRL for syphilis
Genotype r/o SCD
Serum protein for malnutrition
MANTOUX TEST for TB
 Investigations cont’d
• Bacteriology of the ulcer e.g Mycobacterium ,
Fusobacterium ,Borrelia vincenti, etc.
• RADIOLOGY;
• I]Plain film for bony changes or calcification
• Ii] Duplex Doppler Scanning arteriography or
venography for vascular disorders .
• III] Plain X - ray of the chest for pulmonary TB
or metastasis of malignant ulcer
• BIOPSY for definitive tissue diagnosis
 TREATMENT
• Admit , bed rest and elevation of the limb
• Parenteral antibiotics , then oral
• Adequate analgesia
• Tetanus prophylaxis
• Wound debridement - autolytic , enzymatic , surgica
l , mechanical , chemical and biological
• Wound dressing .
• Haematinics
 TREATMENT CONT’D
• Wound cover –skin graft
• Prevention of contractures by splinting
• GENERAL MEASURES;
• Correct anaemia
• Adequate nutrition
• Nursing care to prevent pressure sores
• Use of medical stockings to enhance blood and
lymphatic drainage .
• Obese and elderly patient should have subcut
clexane
• Physiotherapy where necessary .
 conclusion
• Ulcers are common conditions that are frequently
admitted by the plastic surgeon .
• A thorough understanding of their aetiology ,
presentation is necessary for their proper treatmen
t.
• It involves a multidisciplinary approach .