Ulcer Examination
Dr. Mahdi Aljamal, MD
General and Laparoscopic Surgeon
Ulcer definition:
• a localized defect in the continuity of an epithelial surface.
• It is usually associated with an inflamed base of granulation tissue
with or without necrotic slough.
• The majority are chronically inflamed; the slough at their base
represents inadequate drainage.
• Acutely inflamed ulcers may have an outer rim of cellulitis.
Ulcer causes:
• Venous disease e.g. varicose veins \ chronic venous HTN
• Arterial disease
- large vesseles = atheroscelrosis
- small vessesls = DM
• Autoimmune = arteritis = SLE, RA
• Trauma
• Chronic infection
• Malignancies = BCC, SCC
• Neuropathic
Wagner’s
classification of
ulcers:
Ulcer Parts:
Ulcers have different parts:
• the floor (uncovered ulcer surface),
• the base (ulcer rest seat),
• the margin (interface between the wall of ulcer and normal
epithelium)
• the edge (the part of the margin and floor)
Ulcer Examination- insepction
• Ask the patient what he/she thinks caused the ulcer.
• Location, size
• Examine remembering BEDDS:
• Base:
- look for granulation tissue, necrotic tissue, or possible malignancies.
- The base may be the same or deeper than the floor.
Ulcer Examination:
insepction
• Edges: there are 5 types:
- Undermined
(pressure\trophic, TB)
- Punched Out: ischemic
(arterial) or neuropathic,
gummatous ulcer
(syphilis)
- Sloping (indicates
healing, so usually
traumatic /venous)
- Everted (SCC)
- Rolled (BCC) = rodent
ulcer
Ulcer Examination - insepction:
• Describe what structure is visualized at the base (ex: fascia, muscle,
bone)
• Discharge and what type:
- serous (clear) e.g. healing ulcer,
- sanguineous (bloody) e.g. malignant ulcer
- serosanguinous (mixed, orange)
- purulent (infected) e.g. spreading ulcer
- greenish discharge – pseudomonas infection
- discharge with bony spicules = osteomyelitis
• Surrounding Skin
Ulcer Examination - palpation:
• Tenderness
• fixation
• Local rise of temprature
• Bleeding on touch
• Consistency of ulcer, edges, surroundings – dry, wet, soft, edematous
• Regional LNs
• Surrounding sensation
• Surrounding pulsation
• Function of surrounding joints
• Systemic examination
Ulcer Examination – palpation- regional
LNs
• Tender and enlarged = acute secondary infection
• Non-tender and enlarged = chronic infection
• Non-tender and hard = SCC
• Non-tender, large, firm, and multiple = can be Malignant melanoma
Venous Ischemic\areterial Neuropathic
Site Gaiter region over medial malleolusu of ankle Tipe of toes and pressure Heel, underneath metatarsal
(e.g. long saphenous varicosity with ulcer) areas heads (pressure bearing areas)
Short saphenous varicosity ucler (lateral side of
leg) – perforating ulcers (over the sole at
pressure points)
Shape Variable, usually irregular Regular outline Regular outline
Size Can be very large Varying size from mm to Several cm
several cm
Edge Usually sloping pale purple\ brown Punched out, clean Clean
Can be tender on palpation
Base Pink granulation tissue or white fibrous tissue Bone may be exposed, no Often exposing bone
characteristics granulation tissue
Surrounding Chornic venous sings e.g. lipodermatosclerosis Grey\blue (thick and dark) Normal (can be red and
skin (thick and pigmented) Shiny hairless pale cool skin edematous)
Hemosidrein pigmentation, varicose eczema,
atrophie blanche
Skin May be warmter Cold Normal
temprature
Pulses Present Absent present
Recommneded videos to be watched:
• https://www.youtube.com/watch?app=desktop&v=QeViOIyNtA0
Thank you ☺
