A comprehensive clinical guide to diagnose leg ulcers

1. How to Examine Ulcers
Ali Sabbour
Prof. of General & Vascular Surgery, Ain Shams University

2. Definitions
An ulcer is a break in the continuity of an epithelium
Chronic ulcers are those that persist for more than 4 weeks
What prevents an ulcer to heal?
What are the causes of chronic ulcers?
Ch. Venous Ins. Ischemia
Infection Localized destructive Repeated /Persistent
D/s trauma
Non Specific
Specific •TB •Malignancy
•TB
•Gamma
Denervation
•Osteomyelitis
• Syphilis Peripheral nerve lesions
DM, Nerve injury, Leprosy
Spinal cord lesions

3. History
Duration More than 4 weeks is considered chronic
Cause e.g. Minor trauma
Main Pain, Discharge,….
symptom
Course •Increasing in size or depth
•Became painful (infected?)
•Discharging (infected?)
•Recurrent (healing & breaking down)
Similar ulcer (same site or elsewhere)

4. Examination
Site Shape Size
Floor Floor
Edge
Depth
Edge
Discharge
Skin (or tissues) around
Relations (adherent to deeper tissues)
Draining LNs

5. Examination
Site
Some ulcers have characteristic locations
e.g. Venous ulcer situated in the gaiter area of
the leg
Shape
Size
Are important in follow up of ulcer healing

6. Examination Solid brownish or blackish tissue indicates full thickness skin death
Site Shape Size
Floor
By inspection you may notice:
•Granulation tissue
Gamma 3ry syphilis. Sloughs (wash-leather)
•Sloughs
•Gangrenous tissue
•Deeper tissues as tendon or bone
Sloughs in ischemic foot ulcer
Healthy granulation tissue. The red colour reflects good vascularity
Gangrenous tissue & tendons in ischemic ulcer

7. Examination
Site Shape Size
Floor
Depth
Neuropathic ulcers are deep
Venous ulcers are superficial

8. Examination
1- Sloping
Site Shape Size
Floor
Depth
The ulcer is shallow & the epithelium is
growing in from the edge in an attempt to
Edge (5 types) heal

9. Examination 2- Punched-out
Edge (5 types)
1- Sloping or square cut: It results from rapid death
cut
& loss of the whole thickness of the skin
with minimal attempt of healing
Gamma of 3ry
Neuropathic ulcer in the
syphilis Leprosy sole of foot

10. Examination 3- Undermined edge
Edge (5 types)
1- Sloping
When infection is affecting the subcutaneous
2- Punched-out
tissue more than the skin, the edge becomes
undermined
Undermined edge in diabetic foot infection
Tuberculous ulcer
Pressure bed sore in
the buttock.
Subcutaneous fat is more
Undermined edge in susceptible to pressure
Pyoderma gangrenosa than the skin

11. Examination 4- Rolled
Edge (5 types)
1- Sloping
2- Punched-out
Develops when there is slow growth of
3- Undermined
tissue in the edge of the ulcer
Basal cell carcinoma (rodent ulcer):
Pale pink edge with clumps & clusters of cells visible through the
paper thin superficial covering of squamous cells

12. Examination
5- Everted edge
Edge (5 types)
1- Sloping
2- Punched-out
3- Undermined
Develops when the tissue in the edge of the
4- Rolled ulcer is growing quickly and spilling out of
the ulcer to overlap the normal skin.
This edge is typical of carcinoma at any site
Malignant transformation in
Malignant ulcer colon
a chronic venous ulcer
carcinoma
“Marjulin” ulcer

13. Examination
Site Shape Size
Floor
Depth
Edge
Purulent discharge from
Discharge infected bed sore
Serosanguinous discharge
May be: serous, sanginous,
from infected diabetic foot
serosanguinous or purululent
ulcer
A dry discharge forms a scab
that covers the ulcer
Dry scab covering the ulcer

14. Examination
Site Shape Size
Floor
Depth
Edge
Discharge
Cellulitis around the ulcer
Skin (or tissues) around
Pigmentation around
venous ulcer
Hyperpigmentation of ch. Recurrent infection

15. Examination
Site Shape Size
Floor
Depth
Edge
It is important to know if the
Discharge ulcer is adherent to the
Skin (or tissues) around
deep structures
Relations (adherent
to deeper tissues)

16. Examination
Site Shape Size
Floor The draining LNs may be
enlarged 2ry to infection or
Depth
2ry to tumour deposits.
Edge
Infected LNs may be
Discharge tender
Skin (or tissues) around
Relations (adherent to deeper tissues)
Draining LNs