Examination of an ulcer
History
• Mode of onset: Traumatic, spontaneous
• Duration
• Pain: nature, site, time of onset
• Site, size..,
• Discharge
Nature of discharge: colour/ character/ quantity
• Associated disease
Physical examination
General survey
• Cachexia, Syphilis, TB
Inspection
• Size and shape of the ulcer
• Number: single or multiple
• Location of the ulcer
- Varicose ulcer: medial aspect of the
lower third of the leg
- Rodent ulcer in the face above a
line extending from the angle of the
mouth to the ear lobule
- Ulcer over weight baring area is
usually trophic or neuropathic ulcer,
over the heel or sacrum
- Ischaemic ulcers located distally
&over the dorsum of the foot &toes
Margin & edge of the ulcer
• Margin is the skin border or transitional zone of
skin around the ulcer
• 3types of margin:
I- The healing ulcer shows bluish line of growing
epithelium (squamous epithelium without
cornification hence looks bluish
Inside this line is the red granulation tissue
covered by one layer of epithelium which is
transparent and shows the red color of the
underlying granulations
& outside is the white zone of newly cornified
epithelium
• II- inflamed margin
Irregular margin with
inflamed surrounding skin
• III- Chronic non healing ulcer
Shows marked fibrosis with
thickened white skin margins
without the blue line of
growing epithelium
Edge
• It is the mode of union between the floor and the margin of the
ulcer
• Can be inspected and palpated
• There r 5 types of edges:
• Sloping edge: healing ulcer (Traumatic, venous)
• Punched out (Deep trophic U, gammatous U)
• Undermined edge (TB)
• Raised beaded edge (Rodent U)
• Everted edge (S.c.ca, ulcerated adenocarcinoma)
Floor of the Ulcer
• Floor is the exposed surface of the ulcer
• Note the type of:
- Granulation tissue
- Amount of Slough
- Nature of the discharge
Healthy granulation tissue
In addition to previously
mentioned criteria
- No slough
- A small amount of serous
discharge
Infected ulcer or spreading
• Unhealthy granulation tissue &
areas of slough
• Slough: necrotic soft tissue not
yet separated from living tissue
Discharge
• Character
• Amount
• Smell
Surrounding skin
Surrounding scars and puckering
Marjolin ulcer
Whole limb
Varicose veins, neurological insufficiency…
Palpation
• Surrounding skin for temperature &tenderness
• Edge
• Base: The tissue on which the ulcer rests
• Depth
• Bleeding
• Relation to deeper structure
Focal Examination
• Regional LN
• State of arteries and venous circulation and nerves
• Movements of neighboring joints
LN
• Hard, discrete, non tender?
Malignant
• Soft, tender
Infective
• Non tender, Matted
Tuberculous
A&V
• Lower half of the leg
• Varricose veins: long & short saphenous, scattered varicosities,
If varicose U is suspected test for DVT
• Ischaemic ulcer: pulse of all related arteries bilat
• Test sensation of the skin surrounding the ulcer
Trophic Ulcer
• Map Anaethetic arreas
• Features of leprosy
• Detailed neurological exam
Movements of neighboring joints
Restriction of mvt in the joints indicates:
muscle or tendon involvement
Painful inflammation
Systemic examination
• CVS for evidence of congestive heart failure that delays ulcer healing
• Respiratory system for TB and metastasis
• Abdomen: splenomegaly in hemolytic anemias in leg ulcers
