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Examination of an Ulcer
https://t.me/med1917
Floor of the Ulcer
Floor is the one what is seen. It rests on the base.
(Base is not seen; it is only felt). Floor may contain
red granulation tissue in healing ulcer; pale, unhealthy
granulation tissue in non-healing ulcer; thick slough
without any granulation tissue in callous chronic
ulcer; pigmented tissue in melanoma or pigmented
BCC or pigmented SCC (rare). Wash leather slough/
wet chamois leather slough is seen in gummatous
ulcer. Wash leather slough often also seen in postirradiated necrotic slough in the floor of malignant
ulcer. Often moving maggots may be present in the
floor. They eat necrotic dead tissue only. Cultivated
maggots are used as therapeutic desloughing agent.
Slough is dead soft tissue in situ (Figs 2.17 to 2.19).
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Fig. 2.17: Ulcer leg with exposed bone. Patient underwent
local rotation flap to cover. Area from where the flap is
rotated is covered with split skin graft. Skin grafting is not
possible over the exposed bone.
Fig. 2.16: Squamous cell carcinoma scalp. Note the
ulceroproliferative lesion with everted edge.
Discharge from Ulcer Bed
It can be serous (healing ulcer), serosanguinous,
bloody (malignant ulcer), purulent (infective ulcer);
colour of discharge has to be noted—greenish in
pseudomonas infection (Fig. 2.20). Quantity , quality ,
colour and smell of discharge should be assessed.
Dried up discharge looks like scab in the ulcer floor.
Fig. 2.18: Ulcer in the foot initially with slough, and later
after slough excision and regular dressings. Area requires
skin grafting later. Slough is dead soft tissue in situ.
Surrounding area has to be examined for inflammation, oedema, eczema, scars. Inspection of the
entire part/limb should be done for deep vein thrombosis, arterial disease, and neurological causes.
Always inspect opposite limb also.
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SRB’s Clinical Surgery
Fig. 2.19: Maggots in an ulcer.
Fig. 2.20: Non-healing ulcer foot in a diabetic patient with
pseudomonas infection. Note the greenish discharge in the
wound. Pseudomonas infection is commonly hospital
acquired.
Palpation
T enderness should be elicited over the edge, base and
surrounding area. Acute ulcers are tender. Chronic
ulcer is usually non-tender but can be tender if there
is secondary infection, involvement of deeper structures like periostitis in venous ulcer. Malignant ulcer
is non-tender to begin with. It may only become
tender in later period when it infiltrates into deeper
plane (Figs 2.21A and B).
Warmness over surrounding area signifies acute
inflammation.
Palpation of Edge for Tenderness and Induration
Induration is feeling of hardness. It often suggests
carcinoma. In chronic ulcer hardness can be felt
because of thick fibrosis (Fig. 2.22).
A
B
Figs. 2.21A and B: Checking the temperature in sur-
rounding area and comparing opposite/normal area.
Examination of an Ulcer
https://t.me/med1917
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Fig. 2.22: Palpating the edge for tenderness and
induration.
Palpation of Base for Induration/Fixity
Base is the one on which ulcer lies. Base may be fascia,
soft tissues or bone. If base is formed by bone then
ulcer is fixed and non-mobile. Mobility should be
checked in two planes. Induration of base is important
in carcinoma. Hunterian chancre also shows induration.
Depth of Ulcer
Trophic ulcer is deep with bone as its base. Depth
is measured in mm.
Bleeding on Palpation and Touching
Floor and edge should be palpated for this sign after
wearing a sterile glove. Malignant ulcer is vascular
and friable hence bleeds on touch. Healthy and
exuberant granulation tissues in the floor can bleed
on touch (Figs 2.23A and B).
Palpation of Deeper Structures and
its Relation to Ulcer
Bone and soft tissues should be palpated. Bone
thickening signifies periostitis or osteomyelitis due
to ulcer penetration. It is felt by running thumb firmly
over the surface of the bone. It is commonly elicited
in lower tibia and malleoli in case of venous ulcer;
in calcaneum in trophic ulcer. Mobility also of an ulcer
should be checked by wearing a glove. Ulcer is held
firmly at two opposite points over the margin and tried
A
B
Figs 2.23A and B: Palpation may cause bleeding on touch
in healthy granulation tissue or carcinoma. Base of an ulcer
also should be palpated for tenderness and induration.
to move over the base. It should be checked in two
perpendicular directions (Figs 2.24A to 2.25B).
Surrounding skin should be looked for oedema,
inflammation, pigmentation, pallor (Fig. 2.26).
Inspection
Examination of Adjacent Joint
Joints are examined for both active and passive movements. Active movements are done by the patient.
Passive movements are elicited by the clinician (Figs
2.27A and B).
Examination of Regional Lymph Nodes
Examination of regional lymph nodes is essential —
Tender, palpable regional lymph nodes are found in
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A
B
Figs 2.24A and B: Bone thickening should be felt by
palpation over proximal and distal part of the ulcer. Here
ulcer is in ankle region and so thickening of tibia and
calcaneum should be checked.
SRB’s Clinical Surgery
A
acute infective conditions. Shotty, firm, discrete
lymph nodes are felt in Hunterian chancre. Lymph
nodes are not enlarged in BCC/rodent ulcer as
malignant cells block the lymphatics early. Stony
hard, initially discrete and mobile lymph nodes, but
later when advanced fixed to deeper structures are
features of secondaries from carcinoma. Initially
regional lymph nodes may get enlarged due to
infection as such, and not due to primary existing
carcinoma. Such nodes are usually firm, not hard and
may regress by trial antibiotic therapy. Lymph nodes
enlarged due to sepsis may get suppurated and may
form an abscess as soft, tender swelling. Lymph nodes
involved by tuberculosis are matted, firm, often may
lead to cold abscess or collar stud abscess.
Examination of Arterial Pulse
Examination of arterial pulse peripherally in relation
to ulcer should be done (Figs 2.28A and B).
B
Figs. 2.25A and B: Mobility of an ulcer should be checked.
If there is free mobility it means it is not fixed to bone. If
mobility is absent then it could be fixed to bone.
Fig. 2.26: Surrounding area should be
palpated for relevant findings.
Examination of an Ulcer
https://t.me/med1917
A
35
B
Figs 2.27A and B: Joint proximal to the ulcer area should be checked for any change in movement. Fibrous ankylosis
and total loss of joint movement can occur. Ankle joint should be examined by holding lower leg flexed with left hand
and right hand placed just distal to ankle joint (with heel off the ground) to check for dorsiflexion (normal is 25°) and
plantar flexion (normal 35°). Inversion (20°) and eversion (20°) is checked by holding the calcaneum with one hand
and foot distally with other hand.
Examination for Varicose Veins
Varicose veins are examined in standing position and
all relevant tests should be done in case of venous
ulcers.
Examination of Peripheral Pulses
Examination of peripheral pulses should be done to
confirm if there is any ischaemia (Fig. 2.29).
Examination of Spine and Neurological System
Examination of spine and neurological system like
sensation and muscle power in the region and specific
segments (Fig. 2.30).
Gait of the Patient
Gait of the patient should be checked to find out the
severity of loss of function due to ulcer (Fig. 2.31).
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A
B
Figs 2.28A and B: Regional lymph nodes should be palpa-
ted for enlargement. In lower limb ulcer, vertical superficial
group of inguinal nodes are palpated. External iliac nodes
are also checked above and on medial aspect of the
inguinal ligament. Its enlargement signifies severity of the
disease.
SRB’s Clinical Surgery
A
Fig. 2.29: Palpation pf peripheral pulses to find out
Systemic Examinations
Systemic examinations like of abdomen, respiratory
and cardiovascular system should be done properly
(Figs 2.32A and B).
Induration of an Ulcer
Induration is a clinical palpatory sign which means a
specific type of hardness seen in the diseased tissue.
It is obvious in well differentiated carcinomas
(squamous cell or adenocarcinomas). It is better felt in
ischemia.
B
Fig. 2.30: Examination of neurological system is a must.
Touch sensation and sense of positions are commonly
tested. Checking the muscle power and grading should also
be done. Spine should be examined for tenderness/
deformity.
Examination of an Ulcer
https://t.me/med1917
A
37
Fig. 2.31: Checking the gait in an ulcer patient.
squamous cell carcinoma. It is also observed in longstanding ulcer with fibrosis. It is absent or less in poorly
differentiated carcinomas and malignant melanoma.
Less indurated carcinoma is more aggressive. Specific
types of indurations are observed in venous diseases
and chronic deep venous thrombosis. Brawny indura-
tion is a feature of an abscess. Induration is felt at edge,
base and surrounding area of an ulcer. Induration at
surrounding area signifies extent of disease (tumor).
Outermost part of the indurated area is taken as the point
from where clearance for wide excision is planned.
Hunterian chancre shows induration.
Granulation Tissue
It is seen on the floor of an ulcer consisting of proliferating new capillaries and fibroblasts intermingled
with RBCs and WBCs with thin fibrin cover over it.
It contains fine capillary loops, fibroblasts with thin
fibrin and plasma covering.
B
Figs 2.32A and B: Systemic examination like of abdomen,
respiratory, cardiovascular system, spine, neurological examination is a must.
Types:
Healthy granulation tissue: It is seen in a healing
ulcer. It has got sloping edge. It bleeds on touch. It
has got serous discharge. Skin grafting takes up well
in an ulcer with healthy granulation tissue (Fig. 2.33).
Streptococci growth in culture should be less than
5
/gram of tissue before skin grafting.
10
Unhealthy granulation tissue: It is pale with puru-
lent discharge. Its floor is covered with slough. Its
edge is inflamed and oedematous. It is seen in spreading ulcer.
Unhealthy, pale, flat granulation tissue: It is seen
in chronic nonhealing ulcer (callous ulcer).
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Fig. 2.33: Ulcer with healthy granulation
tissue ready for split skin grafting.
SRB’s Clinical Surgery
Exuberant granulation tissue (Proud flesh): It
occurs in a sinus wherein granulation tissue protrudes
out of the sinus orifice like a proliferating mass. It
is commonly associated with a retained foreign body
in the sinus cavity (Fig. 2.34).
Pyogenic granuloma: It is a type of exuberant
granulation tissue. Here granulation tissue protrudes
out from an infected wound or ulcer bed presenting
as well localised, red swelling which bleeds on
touching.
FNAC of the regional lymph node. Other tests like
Chest X-ray, Mantoux test in suspected case of
tuberculous ulcer. Haemoglobin and albumin levels
in blood are important. Granulation tissue will not
develop if Hb% is below 10 gm%; and if albumin
is less than 3 gm%.
Fig. 2.34: Exuberant granulation (proud flesh) in an ulcer.
It should be scooped out using Volkmann’s scoop prior to
skin grafting.
Investigations for an Ulcer
Study of discharge: Culture and sensitivity, AFB
study, cytology.
Edge biopsy: Biopsy is taken from edge because edge
contains multiplying cells. Usually two biopsies are
taken. Because of central necrosis, biopsy may be
inadequate if taken from the centre. But in recurrent
post radiation malignant ulcer biopsy is taken from
centre, as active proliferating cells are present in the
centre not in periphery due to vascular fibrosis in the
edge by radiotherapy. X-ray of the part to see
periostitis or osteomyelitis (Fig. 2.35).
Fig. 2.35: X-ray showing osteomyelitis with sequestrum
inside. Osteomyelitis prevents ulcer healing. Bone thickening on clinical examination is typical.
Assessment of an Ulcer
Cause of an ulcer should be found—diabetes/venous/
arterial/infective. Clinical type should be assessed.
Assessment of wound is important—anatomical site;
size and depth of the wound; edge of the wound;
mobility; fixity; induration; surrounding area; local
blood supply (Fig. 2.36). Wound perimeter may be
useful in assessing this. Wound imaging is done by
tracing it on a transparent acetate sheet at regular
intervals. Presence of systemic features; regional
nodal status; function of the limb/part; joint movements; distal pulses; sensations should be assessed.
Severity of infection should be assessed—culture of
discharge. Specific investigations like edge biopsy;
X-ray of part; blood sugar; arterial/venous Doppler;
angiogram are done.
Trophic Ulcer
It occurs due to impaired nutrition, defective blood
supply, and neurological deficit. It usually occurs in
Examination of an Ulcer
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Fig. 2.36: Ulcer after wound debridement. Adequate wound
excision is done whenever there is slough and necrosis to
allow granulation tissue to develop.
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Fig. 2.37: Bedsore (decubitus ulcer) in sacral region—it
is a trophic ulcer. It is usually with punched out edge.
Stage 4—Full thickness skin loss with fascia and
underlying structures like muscle/tendon/bone, etc.—
late deep ulcer (Fig. 2.38). Pressure sore is tissue
necrosis and ulceration due to prolonged pressure.
Blood flow to the skin stops once external pressure
becomes more than 30 mm Hg (more than capillary
the heel, in relation to heads of metatarsals, buttocks,
over the ischial tuberosity, sacrum, over the shoulder,
occiput. Because there is neurological deficit trophic
ulcer is called as neurogenic ulcer/neuropathic ulcer.
Initially it begins as callosity due to repeated trauma
and pressure which then suppurates and gives way
through a central hole which extends into the deeper
plane as perforating ulcer (penetrating ulcer).
Neurological causes: Diabetic neuropathy, peripheral neuritis, tabes dorsalis, spina bifida, leprosy,
spinal injury, paraplegia, peripheral nerve injury,
syringomyelia. Bedsores are trophic ulcers.
Clinical features: It occurs in 5% of all hospitalised
patients. It is painless ulcer which is punched out;
nonmobile with base formed by bone (Fig. 2.37).
Staging of pressur e sore—Stage 1—Non-blanching
erythema—early superficial ulcer; Stage 2—Partial
thickness skin loss—late superficial ulcer; Stage 3—
Full thickness skin loss extending into subcutaneous
tissue but not through fascia—early deep ulcer;
Fig. 2.38: Trophic ulcers in the heel in two different patients.
It often requires rotation flap/transposition flap to cover.
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SRB’s Clinical Surgery
occlusive pressure) and this causes tissue hypoxia,
necrosis and ulceration. It is more prominent between
bony prominence and an external surface.
Factors causing pressure sore : Normal stimulus to
relieve the pressure is absent in anesthetised patient;
nutritional deficiencies worsens the necrosis; inadequate padding over the bony prominences in malnourished patients; urinary incontinence in paraplegic
patient causes skin soiling—maceration—infection—
necrosis.
anaemia, and malnutrition and vitamin deficiency . It
is commonly caused by Fusobacterium fusiformis
(vincent’s organisms) and Borrelia vincenti. There are
abrasions, redness, papule and pustule formation, acute
regional lymphadenitis and severe pain. Serosanguinous discharge often undermined and raised edge is
common. Eventually it forms a chronic indolent large
ulcer. After long time when it heals, it forms a
pigmented, parchment like scar. Squamous cell
carcinoma may be a occasional late complication in
such disease.
Ulcer due to Chilblains
It is due to exposure to intense cold causing blisters,
ulceration in the feet. These ulcers are superficial.
It is due to excessive cutaneous arteriolar constriction. The condition is also called as perniosis.
Ulcer due to Frostbite
It is due to exposure of the part to wet cold below
the freezing point. There is arteriolar spasm,
denaturation of proteins and cell destruction. It leads
on gangrene of the part. These ulcers here are always
deep.
Martorelle’s Ulcer
It is seen in hypertensive patients often with
atherosclerosis. It is seen in calf. Often it is bilateral.
It is painful. Localised necrosis of calf skin occurring
suddenly with sloughing away and formation of deep,
punched out ulcer extending into the deep fascia is
the pathology. There is sudden obliteration of the
arterioles of the calf skin. All peripheral pulses are
present. It takes months to heal.
Bairnsdale Ulcer
It is a chronic, irregular, undermined ulcer due to
Mycobacterium ulcerans infection. Discharge study
will show acid-fast bacilli. Deep severe form with
extensive dermal necrosis is called as Buruli ulcer.
Tropical Ulcer
It is an acute ulcerative lesion of the skin observed
in tropical regions like Africa, India and South America.
It is associated with lower socioeconomic group,
Diabetic Ulcer
Causes: Increased glucose in the tissue precipitates
infection; diabetic microangiopathy affects microcirculation; increased glycosylated haemoglobin
decreases the oxygen dissociation; increased
glycosylated tissue protein decreases the oxygen
dissociation; diabetic neuropathy involves all sensory,
motor and autonomous components; associated
atherosclerosis affects the circulation.
Sites: Foot-plantar aspect—is the commonest site;
leg; upper limb; back; scrotum; perineum, etc.
Diabetic ulcer may be associated with ischaemia.
Ulcer is spreading and deep (Figs 2.39 and 2.40).
Problems with diabetic ulcer: Neuropathy, in foot
—clawing of toes, hammer toe (due to intrinsic
muscle paralysis); multiple deeper abscesses; osteomyelitis of deeper bones are common; reduced leucocyte function; resistant infection; spreading cellulitis;
arterial insufficiency; septicaemia; diabetic ketoacidosis; associated cardiac diseases like ischaemic heart
disease.
Meleney’s Ulcer (Postoperative Synergistic
Gangrene, Pyoderma Gangrenosum)
It is commonly seen in postoperative wounds in
abdomen and chest wall like in drainage of empyema
or surgery for peritonitis. It is an acute rapidly spreading ulcer with gangrene of skin and subcutaneous
tissues. It is common in old age, immunosuppressed
people and when surgery is done in infected conditions. It is caused by microaerophilic streptococci and
anaerobes. It begins in scrotum or perineum and
rapidly spreads to groin and lower abdominal wall.
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