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Examination of an Ulcer
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tender with large quantity of foul smelling serosanguinous discharge, showing undermined deep edge
having immediate deep purple zone and outer red
zone. Floor is covered with abundant unhealthy
granulation tissue. Infection is severe with endarteritis
of the skin leading to ulcer and destruction. It needs
an emergency critical care therapy. Condition has got
high mortality (Fig. 2.41).
41
Fig. 2.39: Foot is the commonest area for diabetic infective
problems. It can cause abscess, ulcer, osteomyelitis,
gangrene, septicaemia. Initially patient undergoes toe
amputation but later eventually may require with below knee
or above knee amputation.
Fig. 2.40:Infective ulcer in the foot. Note the quantity of
slough, exposed tendon and gangrenous great toe. Patient
might require below knee/above knee amputation.
It can occur in other areas of skin also. Very rarely
it can occur in leg or back of hand when patient is
suffering from ulcerative colitis. Clinically, patient is
toxic. Ulcer is rapidly spreading which is painful and
Fig. 2.41: Meleney’s postoperative synergistic gangrene.
Tuberculous Ulcer
It is due to breaking of the underlying cold abscess
and collar stud abscess into the surface skin. It is
common in neck, axilla and groin. But it can occur
anywhere in the skin. Primary cutaneous tuberculosis
with single or multiple ulcers also can occur.
Tuberculous ulcer presents with thin, bluish and
undermined edge. Disease spreads more in the deeper
subcutaneous plane than in the skin. Hence skin
overhangs directing towards centre. It is rounded in
shape. Yellowish discharge which is caseating
material is common. Regional lymph nodes may get
enlarged which are matted, firm and nontender . S tudy
of discharge; AFB staining; edge biopsy; ESR; chest
X-ray reveals the diagnosis. Epithelioid cells
(modified histiocytes) are typical of tuberculosis
(Figs 2.42A to C).
Lupus Vulgaris
Lupus means ‘wolf’. It is cutaneous tuberculosis which
occurs in young age group. Commonly it is seen in
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B
SRB’s Clinical Surgery
A
Fig. 2.43: Lupus vulgaris in forearm and thumb. Biopsy
confirmed tuberculosis. Patient needs antituberculous drugs
(Courtesy: Dr Ashfaque DNB, Surgeon, KMC, Mangalore).
face, hands and forearm (Fig. 2.43); starts as typical
apple-jelly nodule with congestion of face around.
It begins as superficial multiple nodules in skin which
eventually forms multiple superficial ulcers with
scarring, necrosis and undermined edge. Centre area
gradually heals apparently; periphery shows active
spreading disease. Often lesion extends into nose and
oral cavity involving mucosa. Due to lymphatic
obstruction oedema of face can occur . Long standing
lupus vulgaris can turn into squamous cell carcinoma.
C
Figs 2.42A to C: Tuberculous ulcer over chest wall and
neck. Neck is the common site and is from tuberculous
lymphadenitis. Note the undermined edge. Discharge study,
biopsy and later antituberculous drugs are the treatment.
Bazin’s Disease
It is also called as Erythema induratum/Erythrocyanosis frigida. It is localised area of fat necrosis
affecting adolescent girls. Symmetrical purple nodules
develop in the ankles and calves which eventually break
down forming small, multiple, indolent ulcers with
pigmented scars. It may be due to tuberculosis. Earlier
it is thought to be due to poor blood supply of the
skin around ankle, due to absence or poorly functioning
ankle perforators causing low form of persistent
ischaemia around ankle skin. In cold season, ankle
becomes cold, bluish and tender; in warm season ankle
becomes warmer, red, oedematous, painful and tender
due to hyperaemia.
Examination of an Ulcer
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Traumatic Ulcer
Such ulcer occurs after trauma. It may be mechanical—dental ulcer in the margin of the tongue due
to tooth injury; physical like electrical burn; chemical
like by alkali injury. Such ulcer is acute, superficial,
painful and tender. Secondary infection or poor blood
supply of the area make it chronic and deep.
Arterial/Ischaemic Ulcer
It is common in toes, feet or legs; often can occur
in upper limb digits. It is due to poor blood supply
following blockage of the digital or medium sized
arteries. Atherosclerosis and T AO (Thrombo Angiitis
Obliterans) are common causes in lower limb.
Cervical rib, Raynaud’s phenomenon and vasculitis
are common causes in upper limb. Ulcer initially
occurs after trauma, soon becomes nonhealing,
spreading with scanty granulation tissue. Ulcer is very
painful, tender and often hyperaesthetic. Digits may
often be gangrenous. Intermittent claudication, rest
pains are common. Other features of ischaemia are
obvious in the adjacent area. They are—pallor, dry
skin, brittle nail, patchy ulcerations, and loss of hair.
Ulcer is usually deep, destructs the deep fascia,
exposing tendons, muscles and underlying bone.
Dead tendons look pale/greenish with pus over it
(Figs 2.44 and 2.45).
Fig. 2.44: Diabetic ulcer foot with ischaemia.
43
Fig. 2.45: Ischaemic ulcer foot. Middle three toes are
already amputated because of gangrene.
Venous Ulcer (Gravitational Ulcer)
It is common around ankle (gaiter’s zone) due to
chronic venous hypertension. It is due to varicose veins
(long saphenous vein/short saphenous vein/
perforators) or post-phlebitic limb. Post-phlebitic limb
is partially recanalised deep venous thrombosis which
causes increased venous pressure around ankle through
perforators. Varicose veins are common in females.
50% of venous ulcer is due to varicose veins; 50%
is due to post-phlebitic limb (previous DVT). Pain,
discomfort, pigmentation, dermatitis, lipodermatosclerosis, ulceration, periostitis, ankle joint ankylosis,
talipes equinovarus deformity and Marjolin’s ulcer
are the problems of varicose veins and later venous
ulcer. Ulcer is initially painful; but once chronicity
develops it becomes painless. Ulcer is often vertically
oval; commonly located on the medial side;
occasionally on lateral side; often on both sides of
the ankle; but never above the middle third of
the leg. Floor is covered with pale or often without
any granulation tissue when well granulated edge is
sloping. Induration and tenderness is seen often in
the base of an ulcer. Ulcer heals on rest and treatment;
but reforms again. Scarring is common due to repeated
healing and recurrent ulcer formation (Fig. 2.46). This
unstable scar of long duration may lead into squamous
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SRB’s Clinical Surgery
Fig. 2.46: Venous ulcers in both feet. Site is around ankle
(gaiter’s zone). There are healthy granulation tissues. It
needs skin grafting and definitive procedure for varicose
veins after evaluation.
cell carcinoma (Marjolin’ s ulcer) (Fig. 2.47). Inguinal
lymph nodes (vertical group) are often enlarged. Ulcer
often attains very large size which is nonhealing,
indolent and callous.
Fig. 2.48: Proliferative squamous cell carcinoma heel.
Note the rolled out (everted) edge.
lesion with rolled out/everted edge (Fig. 2.48). Floor
contains necrotic content, unhealthy (tumour) granulation tissue and blood. Ulcer bleeds on touch and is
vascular and friable. Induration is felt in the base and
edge. It is usually circular or irregular in shape. Initially
ulcer is mobile but becomes nonmobile once it
infiltrates into deeper tissues. Hard, discrete, initially
mobile but later fixed regional lymph nodes are often
palpable (Fig. 2.49). Lymph nodes can fungate
eventually . Ulcer and lymph nodes are initially painless;
but becomes painful and tender once there is deeper
infiltration or secondary infection. Systemic spread is
rare. It is a loco-regional malignant disease. Verrucous
carcinoma is exophytic, locally malignant well differentiated squamous cell carcinoma without lymphatic
spread. For details refer Chapter 3: Examination of
Swelling.
Fig. 2.47: Marjolin’s ulcer can develop in a chronic
longstanding venous ulcer.
Carcinomatous Ulcer (Epithelioma,
Squamous Cell Carcinoma)
It arises from prickle cell layer of skin. It may initially
begin as a nodule or ulcer; but later forms an ulcerative
Fig. 2.49: Squamous cell carcinoma in the arm with
secondaries in the axillary lymph node. Friable tumor
tissues in the floor causing bleeding after trauma.
Secondaries are fixed with ulceration. It is advanced
disease.
Examination of an Ulcer
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Marjolin’s Ulcer (1828)
It is slow growing locally malignant lesion—a very
well differentiated squamous cell carcinoma occurring
in unstable scar of long duration. It is commonly seen
in chronic venous ulcer scar. Often it is observed in
burns scar and scar of previous snake bite. Lesion
is ulcerative/proliferative. Edge may be everted or may
not be. It is painless as scar does not contain nerve
fibrils. It does not spread into lymphatics as scar is
devoid of lymphatics. Induration is felt at edge and
base. There is marked fibrosis also. Once lesion spreads
into adjacent normal skin, it can spread into regional
lymph nodes (Fig. 2.50).
45
external genitalia, mucocutaneous junction. It does
not occur in mucosa. For details refer Chapter 3:
Examination of Swelling (Fig. 2.51).
A
B
Figs 2.50A and B: Marjolin’s ulcer in the leg. It occurs in
an unstable scar of long duration. It does not spread
through lymphatics.
Rodent Ulcer
It is ulcerative form of basal cell carcinoma which
is common in face. Ulcer shows central area of dry
scab with peripheral active raised and beaded (pearly
white) edge. Often floor is pigmented. It erodes into
deeper plane like soft tissues, cartilages and bones
hence the name—rodent ulcer. As lymphatics are
blocked early in the disease by large tumour cells,
it does not spread to regional lymph nodes. Blood
spread is absent. It is only locally malignant. It is
common in face; rarely it can occur over tibia,
Fig. 2.51: Nodular BCC in the nose which eventually
may ulcerate to form rodent ulcer.
Melanotic Ulcer
It is ulcerative form of melanoma. It can occur in skin
as de novo or in a pre-existing mole. Ulcer is pigmented often with a halo around. Ulcer is rapidly growing,
often with satellite nodules and ‘in-transit’ lesions.
It is very aggressive skin tumour arising from
melanocytes. It spreads rapidly to regional lymph
nodes which are pigmented. Blood spread is common
to liver, lungs, brain, and bones. It can occur in mucosa,
genitalia, and eye. It is a systemic malignant disease.
For details refer Chapter 3: Examination of Swelling.
Syphilitic Ulcer
Nowadays it is a rare entity. It is caused by Treponema
pallidum bacterium. It is a sexually transmitted
disease. It is named as ’Syphilis’ after a Shepherd
named Syphilus who acquired the disease as was
written in a poem by Francastorius of Verona. Many
clinical lesions are observed in different stages of
syphilis. John Hunter inoculated syphilis organism to
himself to study the clinical features and effects. After
24 years of inoculation, he died at the age of 65 from
rupture of syphilitic aortic aneurysm. Genital chancre
(Hard chancre, Hunterian chanre) is painless, hard,
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button like, indurated, nonbleeding ulcer; usually seen
in corona or frenum of penis, often on lips, breasts
and anal region; appears 4 weeks after initial infection
in first stage of the disease (primary syphilis). Shotty,
painless, firm, discrete groin lymph nodes may get
enlarged along with genital chancre. Suppuration in
these nodes will not occur. Extragenital chancres in
lips and breasts show enlarged neck/axillary nodes
which are inflamed, painful and often may be matted
also. During second stage (secondary syphilis) white,
thickened mucous patches appears commonly in the
mouth like small, circular, superficial snail track
ulcers. Also there appears raised, flat, hypertrophied,
and warty like epithelium at mucocutaneous junctions
(mouth, genitalia) called as condyloma lata.
Generalised, shotty, hard, discrete, painless lymph
nodes, epitrochlear and suboccipital lymph nodes in
particular, are enlarged. Epitrochlear nodes are felt
1-2 cm above the medial epicondyle (It is also enlarged
in Non-Hodgkin’s lymphoma/NHL). Iritis, arthritis,
hepatitis (massive liver in syphilis is called as hepar
lobatum), meninigitis, syphilitic osteitis with ‘ivory’
sequestrum, coppery red skin rash, motheaten alopecia
are other features of second stage. In tertiary/late stage
syphilis gummatous ulcer develops. It is deep,
punched out, painless, nontender ulcer with wash
leather slough in the floor, with ’silvery tissue paper’
like scar around and occurs over the subcutaneous
bones like tibia, sternum, skull, palate or other area.
It also can occur in the tongue, anterior aspect of the
scrotum. It is due to delayed hypersensitivity reaction
with endarteritis obliterans and vasculitis. Perforation
of nasal septum/palate can occur. Clutton’s joint and
Sabre tibia are often seen. Lymph nodes are not
affected in tertiary syphilis. Neurosyphilis (tabes
dorsalis), aneurysm of arch of aorta are other features
of tertiary syphilis. Tabes dorsalis presenting as
generalised paralysis of insane is often called as late
tertiary or quaternary syphilis. Long quiescent
asymptomatic period from secondary to tertiary is
called as latent syphilis. Secondary syphilis stage
shows plenty of circulating Tr eponema spir ochaetes
in blood whereas in tertiary stage spirochaetes are
less or absent in circulation.
SRB’s Clinical Surgery
Soft Chancre/Soft Sore/Ducrey’s Ulcer/
Chancroid/Bubo
These multiple irregular genital ulcers that appear
3 days after infection with Haemophilus ducreyi as
a venereal disease. They are acute painful, tender, non
indurated ulcers. Floor shows yellowish slough with
purulent discharge. Edge is oedematous and inflamed.
Acute regional lymphadenitis with suppuration
presenting as tender, soft or firm swelling is common.
Such soft fluctuant inguinal swelling is termed as
bubo. It differs from climatic bubo/tropical bubo
which is due to lymphogranuloma inguinale, a
venereal spreading organism (LGV, Chlamydia type
L1, 2, 3). In LGV, primary genital stage lesion is
small and painless and commonly unnoticed.
Secondary stage lesion develops in 2 weeks. In males
inguinal lymph nodes; in females intrapelvic and
pararectal nodes are involved. Suppuration of
inguinal nodes occurs eventually leading into
discharging sinuses. Frei intradermal test becomes
positive in 6 weeks and remains positive for life time.
In tertiary stage, eye, joint, meninges may involve
after many years. Repeated chronic inflammation,
lymphatic blockage, scarring can cause rectal stricture
and vulval elephantiasis (esthiomene) in females.
Other Ulcers
Ulcers can occur in various parts like over shin, legs,
feet, face, chest wall in various diseases like anaemia,
polycythaemia, sickle cell disease, hereditary spherocytosis, lukaemia, vasculitis, autoimmune diseases like
rheumatoid arthritis, Paget’s disease of bone (deep,
nonmobile, fixed to bone; common in tibia), ulcerative
colitis, etc. Treponema pertenue causing Yaws can have
multiple painless ulcers in leg and feet due to bare
foot walking (organism enters through abrasion) which
heals spontaneously with a tissue paper like scar. Poor
hygiene and dressings can cause multiple, small, red
often scabbed Staphylococcus aureus ulcers in the
skin of the leg and feet which is often recurrent and
disturbing. Traumatic staphylococcal ulcer is often
seen in the shin which may become chronic and deep,
and is seen in footballers—‘Footballer’s ulcer ’.
Examination of a Swelling/Lump
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Examination of a
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3
Swelling/lump denotes enlargement or protuberance
in any part of the body, due to congenital/inflammatory/
traumatic or neoplastic causes. Often in areas like
abdomen, word ‘mass’ is used to denote a swelling. The
word ‘mass’ is usually used in a large swelling where
its extent is difficult to estimate. In breast,word ‘lump’
is commonly used. There is no clear cut difference in
each of these terminologies (as by meaning all are
same), but purely on clinical grounds it is used in
different places like for example ‘swelling’ in the skin
(swelling means an eminence or elevation); ‘lump’ in
the breast (lump means something hard or solid); ‘mass’
in the abdomen. Any of these can be often visible and
palpable or may be only palpable but not visible.
History
History of Present Illness
Duration
It is important to note the duration of all swellings.
Swelling/Lump
Swelling which has been present since birth could be
congenital like meningocele. Swelling of short duration associated with pain may be of inflammatory
origin. Acute inflammatory swelling will be of short
duration with severe pain. Chronic inflammatory
swellings often have long duration with mild pain.
Benign tumours are usually painless swelling of long
duration. Malignant tumours present as swellings of
short duration, rapidly enlarging, initially painless (but
can be painful later). Patient may not be aware of the
existence of a painless swelling for a long time. Often
patient will not give much importance to a painless
swelling (Figs 3.1A to C and 3.2).
Mode of Onset and Progress
It is very important to take the history regarding the
mode of onset of the swelling. Swelling whether
occurred after trauma (example—haematoma) or spontaneously . It is important to note the rate of progress,
A
B
Figs 3.1A to C: Sacrococ-
cygeal teratoma in newborn
C
infants and also X-ray of the
same condition.
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Fig. 3.2: Spina bifida—a congenital anomaly of spine
presenting as swelling. Failure of fusion of posterior part
of the spine is called as spinal dysraphism. It can be spina
bifida occulta or spina bifida aperta. Meningocele, meningomyelocele, syringomyelocele, myelocele are different types
of spina bifida aperta.
SRB’s Clinical Surgery
whether rapid or slow , malignant swellings progresses
rapidly whereas benign swellings progress slowly.
Sudden haemorrhage in a swelling can cause increase
in its size rapidly in minutes to hours. Sarcomas may
progress rapidly in weeks. Swelling that shows recent
rapid progress in size means probably benign lesion
is turning into malignancy. Swelling which eventually
shows reduction in size is probably of inflammatory
origin. Certain swellings may be stationary—status
quo, i.e. neither progressive nor regressive (Figs 3.3
and 3.4).
Fig. 3.3: Abscess on chest wall in a patient who has
undergone mastectomy earlier for carcinoma of breast.
Patient was on chemotherapy and presented with abscess
in the region of acute onset and short duration with pain,
fever, tenderness, redness and swelling.
Site of beginning of the swelling and its eventual
progression is also often an important history to find
out the anatomical origin of the swelling. Side and
exact site should be asked. Size and shape of the swelling at the time of initial observation should be asked.
Number of swellings patient has observed and which
swelling appeared first and next in order should be
asked. Progression of each should be clarified.
Pain
When pain started? Detail history of location of pain/
type of pain/severity/whether it interferes with work
or not is to be noted. Inflammatory conditions are
painful whereas malignant conditions are painless to
begin with but later becomes painful. Infiltration into
the nerves, soft tissues; ulceration; necrosis or
inflammation may be the cause of pain in malignancy
Fig. 3.4: Haematoma ear. It is subperichondrial haematoma,
which usually occurs in boxers, wrestlers and rugby players
can also occasionally occur spontaneously. Presents as
discoursed, doughy soft swelling with feeling of heaviness
and discomfort. Fluctuation may be absent as there may
be complete clotting of extravasated blood. It resolves very
slowly. Often there is oedema of adjacent part of the ear.
Pain is usually absent. Repeated multiple subperichondrial
haematomas of ear leads to cauliflower ear which is unsightly,
deforming and often may lead into cartilage necrosis and
destruction. Bleeding disorders should be thought of if
haematoma is of spontaneous onset.
Examination of a Swelling/Lump
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eventually. Rapid enlargement of malignant tumour
or haemorrhage also can cause pain in malignancy.
Pain is usually over the swelling but often it can be
deep seated pain or referred pain towards different
place away from the swelling. In a large swelling pain
may be only over certain part of the swelling.
Nature of the pain is important to be noted. Pain
may be throbbing in acute inflammation or suppuration;
burning in inflammatory conditions or neurological
causes like Herpes Zoster infection; aching; stretching;
distending; deep seated; sharp; vague; stabbing, etc.
Presence of Fever
Fever may be present in inflammatory conditions.
Pyogenic abscess, acute lymphadenitis are associated
with fever, often of high grade. Certain malignancies
also can present with fever at later stage like in
Hodgkin’s lymphoma or renal cell carcinoma.
Presence of Other Lumps
Multiple neurofibromatosis, lipomatosis, multiple
abscesses in the body , generalised lymphadenopathy
of any cause (Lymphomas) are the examples of multiple
swellings in the body.
Secondary changes in the swelling like ulceration/
fungation/bleeding has to be noted.
Loss of function of part or as a whole. Patient with
cold abscess may show spinal pathology with alteration
in limb movements, sensation, etc. Swellings adjacent
or from the joint will show impaired joint function.
Loss of weight and decreased appetite may signify
that swelling is related to malignant condition and
also probably advanced.
Past History
History of previous surgery for similar swelling at
the same site or different site has to be asked for.
Neurofibroma even though once excised often may
occur at some other place in the body. Incompletely
removed earlier benign lesion, either cyst or tumour
or if the lesion is a malignant one then recurrence
can occur at the same site.
Personal History
Personal history of alcohol consumption/smoking/
tobacco chewing/history of sexual contact/dietary
49
habits are also important. Altered appetite or weight
loss can also be mentioned under personal history.
Family History
Family history suggestive of similar swellings is
important. Neurofibromatosis is often familial. History
of tuberculosis among the family members may be
relevant in cold abscess. Certain malignancies can run
in families.
General Examination
Detailed general examination is very essential.
Anaemia/oedema/jaundice/clubbing/lymphadenopathy/radial pulse/blood pressure/raise in temperature/
attitude of the patient/nutritional assessment by skin
texture, subcutaneous fat, weight, body mass index/any
other relevant findings should be mentioned. Cachexia
signifies advanced malignancy or tuberculosis. Bone
tumours, malignant tumour infiltrating nerves can alter
the attitude of the limb. Increased pulse rate and fever
suggests swelling with inflammatory pathology .
Local Examination
Inspection
Location, Size and Shape of the Swelling
Exact anatomical location of the swelling and its size
is noted. Its shape—globular or haemispherical or oval
or pear-shaped or irregular or kidney shaped/diffuse
or well localised is noted. As deeper part of the swelling
is not seen, it is not possible to say a swelling as
‘circular’ but can be told as spherical (Figs 3.5A to
C). Vertical and horizontal dimension should be
assessed and should be measured using a measuring
tape. Site of the swelling is mentioned from a fixed
bony prominence like tibial tubercle, sternal angle,
angle of the mandible, etc. (Fig. 3.6).
Dermoid cysts occur in midline/outer canthus of
eye/or any embryonic line of fusion. Lipoma can occur
anywhere in the body.
Colour of the Swelling
Blue colour of haemangioma/black colour of naevus
or melanoma/blue colour of ranula are often diagnostic.
Redness over the swelling suggests inflammation
(Fig. 3.7).
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SRB’s Clinical Surgery
A B
Figs 3.5A to C: Swelling should be inspected properly for its exact anatomical location, shape, size and extent.
Fig. 3.7: Sebaceous cyst face which is infected.
Fig. 3.6: In a parotid swelling, raise of ear lobule is an
important finding which should be observed during
inspection.
Surface over Swelling
C
Redness is well seen.
The surface may be smooth/irregular (papilloma)/
nodular/cauliflower like (squmous cell carcinoma)/
lobular.
Number of the Swellings
Neurofibromas and sebaceous cysts can be multiple.
Dermoid cyst is usually single (Figs 3.8 and 3.9A
to C).
Fig. 3.8: Postauricular dermoid. Dermoid is usually a
single swelling.
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