Definition of ulcer
● A breach in the continuity of a covering
epithelium.
skin External ulcer
mucosa Internal ulcer
Causes of leg ulcers
Venous ulcer
Arterial ulcer
Trophic ( neuropathic )
Pressure ulcers (pressure sores)
Neoplastic ulcer
Signs and Symptoms of Leg Ulcers
● Skin Changes
● Pain and Discomfort
● Swelling
● Wound Appearance
● Odor and Discharge
Venous ulcers
● Venous ulcers are found
in the lower medial third
of the lower limb ( gaiter
area). This site is a
diagnostic feature.
● Irregular, sloping edges
● They are commonly
caused by primary
varicose veins or deep
venous thrombosis (DVT).
Venous ulcers
● Clinical presentations
o Ankle oedema
o Aching pain
o Skin discoloration (Venous
eczema )
o Dry scaly skin
o Lipodermatosclerosis
(inverted champagne bottle)
o Discharge
Arterial ulcers
● Ischemic ulcers are
usually located on the
lateral surface of the
ankle or the distal digits.
● The ulcer has punched-
out appearance
● They are commonly
caused by peripheral
artery disease (PAD)
Arterial ulcer
● C/P
o intensely painful.
o Thin shiny skin.
o Absence of hair.
o Non palpable
pulses.
Neuropathic ulcers
● Resulted from nerve damage, often
due to conditions such as diabetes,
as well as injuries, infections, and
exposure to toxins.
● Nerve damage can lead to a lack of
sensation in the feet in a condition
called peripheral neuropathy, which
makes it easier for injuries to occur
and go unnoticed.
● Minor wounds left untreated can
progress into ulcers over time.
Neuropathic ulcers
● C/P:
o Usually found on the bottom
of the feet.
o The ulcers are painless.
o surrounded by callused or
thickened skin.
o 3- The surrounding tissues
may have a normal blood
supply.
Pressure ulcers (pressure sores)
● Pressure ulcers are also
know as a decubitus ulcers
or a bedsores, is an
ulcerated area of skin
caused by irritation and
continuous pressure on a
part of the body.
● Pressure ulcers often occur
in bedridden, elderly
patients, especially those
who are unconscious.
Reduced blood supply
makes healing difficult.
Pressure ulcers (pressure sores)
C/P:
● Patches of fixed skin
colour change.
● The patches are usually
red on white skin, or purple
or blue on black or brown
skin.
● The skin patches feel warm,
spongy or hard.
● pain or itchiness in the
affected area of skin.
Neoplastic ulcers
● Basal and squamous cell
carcinomata;
Commonly affecting old edge people
Faired skinned people
Affecting sun exposed areas (face, scalp,
lips, ears, arms, hands, etc)
History Taking
A – Personal history;
Name
Age
Sex
Occupation
Marital status
Menstrual history
Number of children
Special habits ( smoking, alcohol, drug intake)
B- Chief complaint; (on the patient his words)
History Taking
C- Present History; ( analysis of the complaint)
Onset ( spontaneous, post-traumatic, incidentally discovered).
Course ( progressive, regressive, stationary, intermittent).
Duration ( short, long).
Discharge ;
What is aggravating? (Serous, serosanguineous, sanguineous,
purulent)
What is relieving?
Associated symptoms ( pain, swelling, discharge, discoloration).
Associated diseases ( D.M, hypertension, syphilis, HIV, etc.).
Effect on the patient’s daily activity.
Past History
● Medical: were
hospitalized for a
long time ? Medical is important because bed-
ridden patients
develop pressure ulcers commonly
● Surgical found over
bony prominences e.g. occipital,
● Medications scapula , heel ,
and sacral bones.
● Allergy
Family History
Social History
Smoking If answer is yes ,For each one ask :
• When did they start
Alcohol • What type of smoke/alcohol
• For how long
• How many per day
• Did they stop and when
• Did they developed any complications
Physical Examination
● Washing your hands.
● Introducing yourself/confirm the patients ID
● Explaining your procedure.
● Taking the consent.
● Privacy.
● Positioning *there is no specific place for an ulcer depends on the site.
● Exposing the ulcer (*any organ that comes in 2s expose them both e.g.
both legs).
Inspection
● 6Ss:
● 1. Site
● 2. Size “ 2dimentional , but describe the depth to make it 3D)”,
● 3. Shape of the margin (regular or irregular)
● 4. Surrounding skin
● 5. Single or multiple
● 6. Surface: in lump no need to mention it here in Ulcer!
● Margins: color changes , necrosis , pigmentation
● Edge: sloping, punched out, undermined, rolled, everted.
● Floor/Base: color, granulation tissue (important) , dead tissue, blood , bone ,
tendon.
● Discharge (color, amount, and smell): serous, sanguineous, sero-sanguineous, or
purulent.
Palpation :*wear sterile gloves and ask patient if there is tenderness
● 1. Temperature of the surrounding tissue (by the dorsum of the hand).
● 2. Tenderness of the surrounding tissue.
● 3. Margins of the ulcer
a. if a small ulcer then hold with index and thumb and
move it horizontally
b. if huge then stick your fingers inside . you are
looking for consistency(soft, firm, or hard)
● 4. Edge of the ulcer.
● 5. Base of the ulcer.
● 6. Discharge (as above).
Relations:
Surrounding tissue: important in the deep ulcers (e.g. venous
ulcers surrounded y hard and black skin) .
Assess whether the ulcer is adherent or invading deep
structures such as the tendons, periosteum , and bones .
End your examination with;
● Local lymph nodes: in an ulcer at the sole the nearest lymph drainage is at
the popliteal area.
● Blood supply of the local tissue if arterial assess the ones above/below the
ulcer for pulses and in veins you assess them only by inspection.
● Innervation of the local tissue in the aid of a cotton or tongue depressor and
then compare to opposite limb or start from the point where they feel and
finish with where they lost sensation.
● Assess the Range of motion of the surrounding 2 joints by assess both
passively (you do it) and actively (the patient does it).
● General examination.
● Thank the patient.
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