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46
A. Farag
• Aneurysm of the Popliteal artery: may be traumatic “False aneurysm”
after penetrating trauma or rarely blunt trauma with fracture of the Lower
end femur or upper end tibia in the popliteal fossa with fractured bone
causing a side tear in the artery “DD.Traumatic AV stula with its associated distal edema, Pulsating VVs and Branham’s bradycardia sign”. Or due
to atherosclerosis or arteritis. A Cystic Pulsating swelling “Expansile pulsations as explained in the Chapter on swellings or chapter on vascular
examination” which is in the line of the popliteal artery. Proximal pressure
on the artery over the lower end of the femur, decreases or stops pulsations
which is regained on removal of the pressure in one heartbeat. It shows
thrill on palpation and bruit on auscultation. If thrombosed and totally
occluded it may be difcult to diagnose except with its associated Acute or
Chronic Ischemia, based on the speed of its thrombosis.
• A Bony tumor from The Lower end of femur or upper end of Tibia: Hard
in consistency and xed to the bone at the base of the swelling and usually
extends outside the limits of the Popliteal fossa.
• Skin Papillomas, Sebaceous cysts, Haemangioma, Hematomas,
Subcutaneous Lipoma and subcutaneous abscess as in the Chapter on
examination of swellings.
Limb distal: for:
• Pressure effects on veins, nerves, or associated Ischemia.
• For a primary malignant Lesion “Carcinoma or Melanoma” or for a primary
inammatory lesion.
Limb Proximal: For:
• Other Similar masses.
• Arteries, Veins and Nerves.
• Associated affected inammatory or Malignant Lymph node in the Inguinoiliac Group of LNs “The Vertical croup of the supercial inguinal LNs and the
Internal iliac group are draining the LL, While the transverse group are draining the Perineum, Anal canal and Vagina into the medial half and the buttocks
and back below a line at the Level of the Umbilicus is draining into its
Lateral Half”.
• In transit metastases “Black in color” in the medial aspect or the thigh incases
of Melanoma due to metastases in the Lymph vessels in its way to the
inguinal LNs.
Other Lower Limb: for:
• Comparison.
• A similar “Bilateral condition”.
Abdominal examination:
For:
• Lymphadenopathy.
6 Swelling inthePopliteal Fossa
• Hepatosplenomegaly in cases of Lymphoma/Leukemia or Liver mets in cases
of Melanoma, Osteosarcoma or other malignant tumors in the LL or in the
popliteal fossa.
• Abdominal Aortic or Iliac artery aneurysms.
• Other masses such as retroperitoneal Sarcoma.
47
Chapter 7
Examination ofanUlcer
MohamedYehiaElbarmelgi andMahmoudMostafa
Abstract Personal History It is important for the Pathology―epidemiology‖ of
the ulcer. E.g. Smoking, alcoholism, Spicy food in tongue ulcer.
Complaint: Loss of continuity of surface epithelium. The site of the Ulcer is of
paramount importance to suggest its pathology “Etiology”. At this point it is important to ask for number in the same area or in other body areas e.g. Genito-oral ulcers
in Behcit’s disease.
Keywords History · Personal · Ulcer · Pathology · Etiology · Number · Anatomy ·
Examination
Personal History (Table7.1): It is important for the Pathology “epidemiology” of
the ulcer. E.g. Smoking, alcoholism, Spicy food in tongue ulcer.
Complaint: Loss of continuity of surface epithelium. The site of the Ulcer is of
paramount importance to suggest its pathology “Etiology”, “Table” At this point it
is important to ask for number in the same area or in other body areas e.g. Genitooral ulcers in Behcit’s disease. Also in the oral cavity malignant ulcers are usually
single while multiple ulcers may suggest aphthous ulcers. Pain is also of paramount
importance since Neuropathic ulcers are painless while aphthous ulcers and ulcers
of Behcit’s disease are very painful.
Present History
Onset: Mode of onset may be diagnostic from the pathologic point of view e.g.
acute ulcers are mostly benign. While chronic ulcers may be malignant like Marjolin
ulcer on top of an old unstable scar “e.g. an old burn”.
M. Y. Elbarmelgi (*)
Cairo University, Cairo, Egypt
M. Mostafa
Arab Contractors Medical Centre ACMC, Cairo, Egypt
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_7
49© The Author(s), under exclusive license to Springer Nature
50
SQ CC and
melanoma
middle or
old age in
male or
female
A mass or as
an ulcer
Rapidly
increasing in
size
M. Y. Elbarmelgi and M. Mostafa
Melanoma
may present
under the toe
nail
At any age or sex Usually
Old age if due to
atherosclerosis or
middle or young age if
due to arteritis. Males
are more affected in
Burger’s disease with
Usually after a
secondary varicose
veins
Over an acute abscess like
carbuncle
A Painless Ulcer at
the pressure points
of the LL including
the heel or the sole
of the foot over the
metatarsal heads
smoking
Ulcer over the most
distal part of the Limb
“Toes” associated with
rest pain
An Ulcer over the
medial aspect of the
lower Leg
Signs of swelling which
ulcerates accompanied by
signs suggestive of local and
systemic sepsis
Painless and
associated with loss
of sensations in the
surrounding skin
Preceded by
manifestations of
Chronic ischemia or
neglected acute
ischemia
History of DVT some
months or years ago
without wearing a
protective Elastic
stocking
Short history usually in
immune-compromised
patient or diabetic patient
with multiple septic foci on
the top before ulceration or
Of loss of sensation
Of DVT Similar condition in the
surgical drainage
Similar condition or DM or
due to congenital
“Spina Bida”,
traumatic,
Inammatory or
Neoplastic causes
other LL or other
ischemias
immunosuppressive
treatment
Traumatic Inammatory Venous arterial Trophic
Any age, sex but
Table 7.1 D.D. of a lower limb ulcer
Personal
may be a hard work
or a sports injury
history
usually over the
shin of the tibia
Complaint Painful Ulcer
may suggest an
underlying
Periosteitis
Present history Long history which
the shin bone
Past history Of direct trauma to
7 Examination ofanUlcer
SQ CC and
melanoma
For
metastases
including the
Inguinal
LNs and in
transit mets
Melona is
usually
black or dark
in color
Squamous
cell
carcinoma
has a raised
everted edge
51
Similar condition
Venous disease Similar condition in the
Similar condition in the
Specially nerves for
stigmata of Syphilis,
leprosy, DM and
Back examination
family
family
ischemia
NAD Other manifestations of
Signs of sepsis “Fever,
rigors and malaise
Punched out edges,
the skin around it is
hyper-keratotic and
elevated over the
pressure areas and
characteristic-cally
painless with loss of
Gangrenous oor or
edges, trophic changes
in the surrounding skin
such as loss of hair
tapered toes, and dusky
red skin, Loss of distal
pulsations and level of
Secondary varicose
veins with incompetent
valves. The surrounding
skin is edematous,
eczematous and
pigmentation it is
painful and covered
Slough containing base over
an elevated infected tissue
of the carbuncle and angry
margin. When treated by
removal of the slough
medically or surgically the
base becomes Red clean
sensation
Coldness in the distal
part of the Limb
scanty granulation even
in the absence of
Varicose veins
“Gravitational ulcer
granulation tissue
Traumatic Inammatory Venous arterial Trophic
of Medical
importance
Family history Of DM or diseases
G.Examination For DM or diseases
of Medical
importance
Over the shin of the
tibia, irregular,
infected “Yellowish
red oor, oozing
serum or pus. Floor
usually xed to the
Local
examination
underlying
Periosteum.
Sloping edge, with
hyperemic margin
so they are staged higher than tumors without ulceration
N.B. Tuberculous ulcers are ulcers which are usually formed by breakdown of tubercles and usually has an undermined edge
N.B. Bed Sores develop when blood supply to the skin is cut off for more than 2 to 3hours. As the skin dies, the bedsore rst starts as a red, painful area, which
N.B. A Marjolin ulcer is a cutaneous malignancy usually Squamous Cell Carcinoma that arises in the setting of previously injured skin, longstanding unstable
scars, and chronic wounds. It does not spread to the draining LNs due to lack of Lymphatics in the scar tissue
N.B. Rodent ulcers are a type of skin cancer. Also known as basal cell carcinoma, rodent ulcers occur in the lower most layer of your skin. They usually develop
in skin areas exposed to the sun. Rodent ulcers are a very slow growing cancer that usually does not spread to other parts of your body
N.B. Ulceration is a breakdown of the skin on top of the melanoma. Melanomas with ulceration are more serious because they have a greater risk of spreading,
eventually turns purple. Left untreated, the skin can break open and the area can become infected. A bedsore can become deep
52
At this point we have to ask about history of trauma and/or inammation. If we
fail or forget to ask about them at this point we may miss 2 important categories in
the Etiology namely traumatic ulcers or ulcers following an inammation such as
ulcers after treatment of a Carbuncle.
N.B.Venous ulcers and Ischemic ulcers may start after a minor trauma such as
itching in venous ulcer or minor trauma to the big toe in Ischemic ulcers.
Course: A regressive ulcer is not usually a malignant ulcer.
Duration: A long history for years usually excludes malignant ulcers except for
Marjolin ulcer.
Screening of the Body Systems: It is important from the pathology point of view
such as History of Neurologic disorder can suggest Neuropathic ulcer, History of
arterial disease such as Lower Limb ischemia can suggest an Ischemic ulcer. History
of severe and uncontrolled Hypertension can suggest Martorell’s ulcer is an uncommon ischemic and extremely painful lesion located in the distal portion of the lower
limb, resulting from severe systemic and poorly controlled hypertension. It is common in women between 50 and 70years of age. The diagnosis is clinical and mostly
belated, following exclusion of other causes.
Past History of:
Medical past History: can suggest TB ulcer, Syphilis ulcer, Martorell’s
ulcer …etc.
Surgical Past History: Spine surgery may suggest Neuropathic ulcer and history
of Burn may suggest Marjolin ulcer.
Family History:
M. Y. Elbarmelgi and M. Mostafa
General Examination
May suggest the Etiology such as Neurologic examination, stigmata of Syphilis,
Leprosy or TB.
Local Examination
Inspection of the Ulcer
• Floor of the ulcer: the part of the ulcer which is seen by the eye without touch.
• Discharge:
• Edge: it is the Junction of the intact skin though abnormal and the oor of the
ulcer. It’s the most diagnostic of the pathology of the ulcer.
• Margin: the abnormal but intact skin between the edge of the ulcer and nor-
mal skin.
• Limb distal: for evidence of arterial, Venous, Nerve, or lymphatic pathology as
well as deformity and musculoskeletal and/or Joint abnormality.
7 Examination ofanUlcer
53
• Limb proximally: For draining Lymph nodes and/or other swellings or for LNs
in other areas.
Palpation of the Ulcer
• Base of the ulcer: It is the tissue upon which the ulcer rests. Indurated or soft.
Fixity to underlying structures special bone.
• Limb distal: for evidence of arterial, Venous, Nerve, or lymphatic pathology as
well as deformity and musculoskeletal and/or Joint abnormality.
• Limb proximally: For draining Lymph nodes and/or other swellings or for LNs
in other areas.
Chapter 8
Lymphadenopathy Sheet andD.D.
ofMultiple Swellings
AhmedFarag
Abstract A Simple revision of the Pathology and Anatomy of the Lymphadenopathy
is essential before proceeding to Clinical Sheet in order to ask relevant questions.
Lymph nodes amenable for Clinical examination have known Sites in the human
Body such as the Neck and face, Axillae, Groins, Intra-abdominally around the
aorta―Para-Aortic and Peri-aortic‖ and Iliac Lymph nodes around the Common
and External iliac arteries.
Keywords Lymph · Node · Pathology · Anatomy · Examination · Sheet ·
Diagnosis · General
A Simple revision of the Pathology and Anatomy of the Lymphadenopathy is essential before proceeding to Clinical Sheet in order to ask relevant questions:
Box 8.1 Causes of Lymphadenopathy
• Inammatory: Acute or Chronic. Specic or Non-specic.
Acute Non-Specic: LNs draining an abscess or acute inammation.
Chronic Non-specic: draining a Chronic septic focus like Carious tooth.
• Acute or Chronic Specic: includes
• Bacterial infections: lyme disease, tuberculosis, and cat scratch disease.
• Viral infections: Examples include measles, infectious mononucleosis,
HIV/AIDS, and cytomegalovirus (CMV).
• Parasitic infections: Examples include toxoplasmosis and Chagas
disease.
A. Farag (*)
Kasr Alainy Hospital, Cairo University, Cairo, Egypt
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_8
55© The Author(s), under exclusive license to Springer Nature
56
A. Farag
• Fungal infections: Examples include histoplasmosis and
coccidioidomycosis.
• Neoplastic: Primary such as Lymphoma or Leukemia or secondary
from a primary focus such as breast cancer.
• Autoimmune diseases: For Examples rheumatoid arthritis, lupus,
and Sjögren’s syndrome.
• Other causes: These include drug reactions, sarcoidosis, Castleman
disease and allergies.
Lymph nodes amenable for Clinical examination have known Sites in the human
Body such as the Neck and face, Axillae, Groins, Intra-abdominally around the
aorta “Para-Aortic and Peri-aortic” and Iliac Lymph nodes around the Common and
External iliac arteries. Other Lymph nodes like Epitrochlear Lymph nodes and
Popliteal Lymph nodes are amenable to clinical examination.
Personal History (Box 8.1 andBox 8.2)
The most specic to the Pathologic diagnosis is:
Age: T.B., Lymphoma and Leukemia are more common in young age. Metastatic
Lymph nodes from cancer are common in old age and metastatic axillary Lymph
nodes from breast cancer is more common in the middle age.
Residence: Past and Present such as T.B or Filariasis from endemic areas.
Pet animals: Such as Cats for the cat scratch disease or Toxoplasmosis and Birds
for Psittacosis.
Complaint: Single or Multiple Swellings at the anatomical site of the Lymph
nodes is Lymphadenopathy till prove otherwise. “DD: Multiple lipomas, multiple
neurobromatosis, Multiple Pyaemic abscesses, multiple malignant metastases,
multiple exostosis. All are not at the anatomical site of Lymph nodes”.
Box 8.2 Causes of Localized and Generalized Lymphadenopathy
• Localized:
Inammatory:
Non Specic: Acute or chronic
Specic: Acute “e.g. measles” or Chronic “e.g. T.B.”
Neoplastic:
Primary “e.g. Lymphoma” Secondary “from e.g.
carcinoma of the oral cavity”
• Generalized:
Inammatory:
Infectious Mononucleosis or
HIV
Neoplastic:
Lymphoma or Leukemia
8 Lymphadenopathy Sheet andD.D. ofMultiple Swellings
Site: Hodgkin’s disease and tuberculosis usually starts in the cervical Lymph
nodes while Filariasis and Syphilis usually starts in the inguinal Lymph nodes.
Epitrochlear LNs are enlarged in the second stage of Syphilis “Rare nowadays”.
Fever, Loss of weight and Loss of appetite: Low grade night sweat and night
fever with loss of weight and loss of appetite is more common with TB, an
intermittent fever with Filariasis and fever and Pruritis may be associated with
Lymphomas “in Hodgkin’s disease, intermittent bouts of remittent fever (PelEbstain fever). Acute High grade fever can be due to an Acute Non-Specic
inammation or due to Acute Specic inammation like Infectious Mononucleosis.
Primary Focus: is important for localized Lymph node enlargement, Breast and
chest wall in axillary LN enlargement while Anal, Vaginal or Perineal or LL lesion
“Inammatory or Neoplastic” is asked for in Inguinal LN enlargement.
N.B. Axillary LN enlargement “Posterior group” and Inguinal L.N. enlargement
“Lateral half of the transverse supercial inguinal LNs” can be due to a lesion in the
back of the patient above and below the level of the Umbilicus respectively.
N.B.Don’t forget to examine the 4 backs:
• Back of the Breast.
• Back of the scrotum.
• Back of the knee.
• Back of the patient.
57
Painful or Painless
N.B.Authors prefer to include this in the complaint so as not to be missed and will
help to suggest a possible pathology at this early phase of the clinical sheet.
Pain in the involvement of the lymph nodes painful? The nodes are painful in
both acute and chronic inamed LNs, but are painless in lymphomas and secondary
carcinoma.
Present History
Onset: including mode of Onset was it associated with Local or Systemic
Symptoms of Inammation and the First Group of Lymph node affected if there
is a generalized lymphadenopathy.
Course: Regressive or stationary are suggestive of benign nature of the disease.
Duration: The Longer the duration “Years” suggests the benign nature of the
disease.