ULCER & SKIN GRAFT

ULCER EXAMINATION
ULCER

Definition Break in continuity of epithelium, skin, mucous membrane, endothelium characterized by

progressive destruction of surface tissue cell-by-cell (molecular death)
Parts of ulcer
1. Base: The one which ulcer rest (bone/soft tissue)
2. Floor: Exposed surface of ulcer (discharge, granulation
tissue, slough)
3. Edge: Connect floor to margin
4. Margin: regular/irregular | round/oval

Sloping edge In healing ulcer

-inner (red) → healthy granulation tissue
-outer (white) → scar/fibrous tissue
-middle (blue) → epithelial proliferation
Undermined edge In TB ulcer (painless)
-Ulcer spread in & destroy subcutaneous
tissue faster than skin
=Meleney’s ulcer

Everted edge (rolled out) In squamous cell carcinoma (SCC)

-Develops when the tissue in the edge is
growing faster and spills over normal skin

Punched out edge Gummatous (syphilis) / trophic ulcer (DM)

Raised & pearly white beaded edge Rodent ulcer (Basal cell carcinoma)

Classification
1. Clinical
Spreading ulcer -Acute painful ulcer
-Edge – inflamed, irregular, edematous
-Floor – has profuse purulent discharge & slough, no granulation
tissue
 -Surrounding area – red & edematous
-LN – enlarged & tender

Healing ulcer -Edge - Sloping edge

-Floor- Scanty discharge, healthy granulation tissue
-surrounding area → no sign of inflammation
-LN – may/not enlarged, non-tender
-3 zones:
• Innermost red – healthy granulation tissue
• Middle bluish zone – growing epithelium
• Outer whitish zone – fibrosis & scar formation
-granulation tissue = proliferation of new capillaries & fibroblasts
intermingled with RBC & WBC with thin fibrin cover over it
-Signs of healthy granulation tissue—Pink, Punctate haemorrhages,
Pulseful, Painless, Pin head granulation
Non-healing ulcer -Chronic ulcer
-edge → punched out (diabetic ulcer), undermined (TB), rolled out
(SCC), beaded (BCC)
-Floor: unhealthy granulation tissue & slough, purulent/bloody
discharge
*greenish discharge d/t pseudocyanin → pseudomonas infection
-sign of unhealthy granulation tissue – pale, purulent discharge,
slough,
Callous ulcer Chronic non-healing ulcer
-Floor: pale, unhealthy, whitish yellow granulation tissue
-indurated base & edge
*ulcer does not show any tendency to heal
2. Based on duration
Acute ulcer <2weeks
Chronic ulcer >2weeks
3. Pathological
Specific ulcer TB ulcer, syphilitic ulcer, meleney’s ulcer
Malignant ulcer SCC, Rodent ulcer, Melanotic ulcer
Non-specific ulcer Traumatic ulcer (painful), arterial/venous ulcer, trophic/pressure
ulcer, infective ulcer, tropical (Vincent’s ulcer), Martorell’s
hypertensive ulcer (painful), cryopathic ulcer (ulcer d/t frostbite),
bazin’s ulcer, cortisol ulcer
DIFFERENCES

Investigation • Study of discharge – C&S, AFB, cytology

• Wedge biopsy – biopsy taken from edge
• X ray – TB /OM
• FNAC of LN
Treatment • Control pain, infection
• Rest, immobilization, elevation
• Debridement → removal of devitalized, necrotic, dead tissue
• Cleaning & dressing – use NS/EUSOL (Edinburgh University Solution)
• Desloughing - separate slough adequately before debridement
• Maggot debridement therapy → dissolve & engulf dead necrotic tissue, inhibit bacterial
growth, promotes granulation tissue formation
• After ulcer granulates → closed with 2nd suture, skin graft or flaps
Traumatic ulcer Painful
Trophic ulcer -Pressure sore/decubitus ulcer, painless
-Tissue necrosis & ulceration d/t prolonged pressure
++ presence of neurological deficit → aka neurogenic ulcer/neuropathic ulcer

Martorell’s ulcer In HTN, atherosclerosis patient, seen in calf, B/L and painful.
Arterial/ischemic ulcer Causes → Atherosclerosis & TAO (upper limb) | Raynaud’s phenomenon (UL)
Painful
Carcinomatous ulcer -Epithelioma, squamous cell carcinoma
-Hard, discrete regional LN palpable
Marjolin’s ulcer (SCC) -It is well differentiated SCC occurs in chronic scars (curable malignancy)
-seen in chronic venous ulcer
-in scar, no lymphatic tissue → does not spread into LN , painless
-Rx → wide excision, amputation (large), radiotherapy not given

-Verrucous carcinoma is exophytic, locally malignant well differentiated SCC

without LN spread, good prognosis, curable malignancy
Rodent ulcer (BCC) -ulcerative form of basal cell carcinoma (BCC), common in face
-only locally malignant, not spread to regional LN/blood. But it erodes deeply
into local tissues (cartilages, bones) causing extensive tissue destruction →
hence name rodent ulcer
-Types → Geographical or field fire or forest fire BCC = wide area involve
central scabbing & peripheral active proliferating edge
 Rx → Radiosensitive, surgery (if erode cartilage/bone, close to eye, recurrent)
Melanotic ulcer -Ulcerative form of melanoma
-spread rapidly to regional lymph node
Maleney’s ulcer -post op wound
-spreading ulcer, painful
TB ulcer Painless, LN – enlarged, matted, firm, nontender
Venous ulcer -around ankle (gaiter’s zone)
-common medial side
Syphilitic ulcer -Genital chancre (hard chancre/Hunterian chancre) = painless, hard, non-
bleeding ulcer
WOUNDS

Definition of wound A break in integrity of skin or tissue

Type of wound Primary healing (1st intention)
healing -occurs in clean incised wound/surgical wound

Secondary healing (2nd intention)

-occurs in wound with extensive soft tissue lose (major trauma, burn, wound
with sepsis)

Tertiary wound healing (Delayed Primary closure/ Healing by 3rd intention)

-after wound debridement & control of local infection, wound is closed
Factors affecting • Age: Younger age → faster
wound healing • Adequate nutrition
• Infection → prevent wound healing
• Anemia → poor oxygenation
• DM, cardiac, renal disease
• Steroid, NSAID, alcohol
Stages of wound
healing

Types of scars

-occurs anywhere in body

-common over sternum
-not genetically predisposed
-genetically predisposed
-growth limit up to 6 months
-continue gwow after 6m
-limited to scar tissue only. Not
-extend to adjacent normal skin
extend to normal skin
 SINUS FISTULA
It is a blind track lined by granulation tissue Abnormal communication between lumen of
leading from an epithelial surface into the one viscus to another
surrounding tissues.
Fistula = flute/pipe/tube

Causes Causes
• Congenital → Preauricular sinus • Congenital → Branchial fistula, Tracheo-
• Acquired → actinomycosis, osteomyelitis osephageal fistula
• Acquired → Post op, malignancy
ULCER
• Ulcer examination
• Do sensory examination of lower foot
• How to check for base of ulcer
• How to check tenderness of ulcer
• What is ulcer
• Describe the ulcer
• Give anatomy of ulcer, define each
• Types of edge and give example for each one
• Causes of ulcer
• Which cases causes painful ulcer - Martorell’s hypertensive ulcer, traumatic, arterial ulcer
• Type of ulcer in varicose vein – venous ulcer
• How to classify ulcer
• Different venous/arterial/neuropathy
• How to differentiate venous ulcer and arterial ulcer
• Healthy vs unhealthy granulation tissue
• How you describe non healing ulcer. 5 points.
• Beza healing and spreading ulcer
• Definition of slough
• Why palpate lymph node
• Why do neurovascular exam
• Rodent ulcer- what is it, location and the name of the line, why it located there → common above
onghren’s line, carcinoma arise from basal layer of skin or mucocutaneous junction
• What is trophic ulcer
• Different between hypertrophic ulcer and keloid
• What is marjolin ulcer : is that a good or bad prognosis - good
• Basal cell carcinoma and squamous cell carcinoma- what is it, difference and prognosis. Which one is
better
• Where basal cell carcinoma is normally seen? – Face
• Rx of cancerous ulcer
• Site of rodent ulcer. What is the name of the line?
• What is rodent ulcer, field fire ulcer
• Between BCC and SCC, which one involve lymph node? – both does not spread to LN
• Between BCC and SCC, which one is better respond to chemotherapy and which one is better
respond to radiotherapy?
-BCC highly radiosensitive and does not produce any disfigurement, but if underlying bone is
involved, than it is not suitable for radiation
• Hypertension related to venous ulcer
• Hypertensive related ulcer → Martorell’s hypertensive ulcer (painful)
• What is atherosclerotic ulcer?
• What you want to do to this pt now apart from debridement
• How to treat TB ulcer → Discharge study, biopsy and later anti tuberculous drugs
• Check peripheral pulses? Where you find it? Against what bone?
• Organism causing green discharge → Pseudomonas
• Antibiotic specific for that
• If patient wound is not healing, what will you do? - skin graft
• After dressing and ulcer still not healing, what to do? (do swab and give antibiotic)
• Definition ulcer, sinus, fistula and how they differ

Non healing venous ulcer

38 years old female with ℅ pain and wound at right ankle

Prick Wound since 3 months. Size from 0.5x0.5cm to 7x5cm. Went to 4 hospital for debridement and
TT injection and medication was taken but wound non healed. Other history is not significant. Single
ulcer, 7x5cm, with granulation tissue, non-tender, not bleed on touch at middle malleolus of right
ankle. Pigmentation around the ulcer. Mobile and not attached to underlying structure

• Zone of ulcer
- Innermost red – healthy granulation tissue
- Middle bluish zone – growing epithelium
- Outer whitish zone – fibrosis & scar formation

• How to check for malignancy? → Lymph node

• Type of malignant ulcer
• Which is bad prognosis?
• How they metastasis?
• Treatment? → Surgery
• Type of skin grafting
• Advantages and disadvantages of each
• How do we do flap?
Venous ulcer

1. Why you say it venous ulcer

2. Lower limb examination
3. Describe the ulcer on inspection and palpation.
4. Where is this ulcer situated?

5. What is this type of ulcer?

6. What is mx of ulcer (medical and surgery)
-Investigation → Discharge study (C&S), Xray (periostitis), Ulcer edge biopsy (rule out marjolin
ulcer), RBS, Hb%, doppler
-Treatment
• Bisgaard method – elevate, massage, passive & active exercise
• Care of ulcer – cleaning & dressing
• 4 layers bandage technique
• Antibiotic
• Once ulcer bed granulates well → do split skin graft
• Specific rx for varicose vein → Trendelenburg operation,
perforator ligation, stripping of vein

7. How to do Trendelenburg surgery? What vein do we ligate?

8. Do you know the steps?
9. What disease cause venous ulcer
10. Why important to check vein (rule out DVT and varicose vein)
11. What is the contraindication for venous ligation? → DVT
12. Why? - can develop venous gangrene
13. What are the surgery for venous ulcer? → Trendelenburg operation, stripping of veins, perforator
ligation.

Healing ulcer
1. Perform complete ulcer examination
2. Why do you check inguinal lymph nodes?
3. What is the diagnosis
4. Peripheral pulses and its location
5. Characteristics of healing ulcer
6. Management
7. Where is gaiter’s area. → Located circumferentially around the lower leg from approximately mid
calf to just below the medial and lateral malleoli.
8. Sign of healing ulcer
9. 5 criteria healthy granulation tissue
10. Signs of ischemic changes.
11. Stages of wound healing
12. Factors affecting wound healing
13. Classification of ulcer
14. What are different examples of malignant ulcer → → SCC, Rodent ulcer, Melanotic ulcer
15. Which type of malignant ulcer spread through lymphatics and which one not
-BCC, SCC → not spread
- malignant melanoma → spread to LN
16. Why BCC does not spread through lymphatics
17. Why SCC spread through lymphatics

18. Give classification of malignant melanoma (Ada 4 to 5)

19. Malignant melanoma clinical features (ABCDE)

20. Which part of body does malignant melanoma is common?

-Malignant melanoma = most aggressive cutaneous malignant tumor
-neural crest (ectodermal) origin
-sites → head, neck, trunk, lower limb (25%)

21. How malignant melanoma occur?

22. Types of malignant melanoma

1. Superficial spreading (most common)

2. Nodular melanoma (more aggressive) – in young age
3. Lentigo maligna melanoma (least malignant) – old age, common in face
4. Acral lentiginous melanoma
5. Amelanotic melanoma (worst type)
6. Desmoplastic melanoma

23. How to differentiate a mole growing or is it malignant melanoma – ABCDE features of

melanoma
24. Which malignant melanoma is the most dangerous? – Nodular melanoma (more aggressive)
25. What is Martorell ulcer? Describe
26. Verrucous ulcer

37y/o, male, working as kulli, non-DM/HTN c/o swelling and pain over left LL since 2 months
developed after getting injury while working. generalized swelling up to knee, gradual and
progressive, redness of skin, associated with severe pain and high-grade fever. went to the hospital
after 4 days, I&D done

Local examination:
Single ulcer at left dorsum of foot extend to lateral aspect of leg, size 17×10×5cm, irregular shape
(mcm bntuk L), edge sloping, margin well define, floor red granulation tissue, tender on touch, no
discharge, not bleed on touch, surrounding area slight edema

1. Present case blh tgk kertas. Hx then summary. PE then summary dri awal
2. Provisional diagnosis
3. What is ulcer and cellulitis
4. Define edge
5. Type of edge with example
6. Causes of ulcer (cellulitis, DM, PVD)
7. Investigation to rule out each cause
8. Tell all peripheral pulses and anatomical site, how to palpate popliteal artery, in which position
9. How you test for neuro examination, component, how to check proprioception
10. How to manage this patient, principle mx (kena clean dlu...)

Venous ulcer with varicose vein

56 years old salesman andauto driver came with complaint of swelling at left inner thigh and wound
at left ankle for 3 months. Swelling is insidious not associated with pain. Progressively increased in
size. Bluish in color. No swelling at other part of body. Pt also complained of having wound at left
ankle that occurs insidiously without any discharge.

Past medical hx: First time having this complaint. Had chest pain last 9 years and (only) angiography
was done. K/C/O of HTN 10 years ago and is on tab amlodipine since then.
Fam hx: Father has same complaint

P/E: Generally normal. Hypertensive. L/E: Exposed both legs adequately for comparison
(For varicose vein) Inspection: Great saphenous vein involvement (medial thigh),
localized swelling. Bluish color. Skin of limb of limb is normal, with no ulcer on
that area. No scar noted.

Palpation:
BT test - Perforator incompetent noted Tourniquet test - Adductor canal incompetence
Modified Perthes test - Swelling shrinks
Fegan’s test - Button-like felt

1. What is ulcer
2. Classification of ulcer
3. Parts of ulcer
4. What is long standing ulcer that is malignant, called as? → SCC
5. Full diagnosis
6. Why this is venous ulcer?
7. How DM can cause ulcer?
8. Pathophysiology of diabetic ulcer
9. Which vein is involved here?
10. Arterial vs Venous ulcer

Non-healing ulcer secondary to cellulitis

37 years old man, saree maker, had h/x of rusty nail prick at left ankle 2 months back. 2 days later,
came to Yellur Hospital with huge blisters at dorsal of left leg, up to above ankle. Associated with pain,
redness, fever. According to him, upon pricking the blisters, there was clear discharge with scanty
bleeding. No pus. Admitted & received treatment for 13 days. After discharged, came to Yellur every
alternate day for ulcer dressing & debridement. No DM, HTN or any chronic disease. Right now, came
for follow up.
1. Hx and examination.
2. What is wound/ulcer.
3. Type of ulcer.
4. What type of ulcer in this patient?
5. What is margin//edge.
6. Type of edge.
7. Factors delayed wound healing.
8. What is slough//granulation tissue.
9. What is rodent ulcer, why called rodent, seen in?
10. Criteria of good wound dressing.
Graft Transfer of tissue from one area to other without its blood supply or nerve supply.
Autograft Transfer tissue from one location to another on the same patient. Eg: Skin graft
Isograft Transfer tissue between two genetically identical individuals (between two identical twins)
Allograft Transfer tissue between two genetically different members → kidney transplantation
(Human to human) (Homograft)
Xenograft Transfer tissue from a donor of one species to a recipient of another species (Heterograft) –
different species

SKIN GRAFT

Types
1. Partial thickness graft (Split thickness skin graft = SSG)
2. Full thickness graft
PARTIAL THICKNESS GRAFT (SSG) – removal of full epidermis + part of dermis

Stages of graft intake

Function of mesh

Advantages Disadvantages
- Easier, can cover wide area of recipient - Contracture of graft, hematoma formation, Infection
- Graft take up is better - Loss of hair growth, dry scaling skin
- Donor area heals on its own - Graft failure
FULL THICKNESS GRAFT -include both epidermis + full dermis
 FLAPS

Definition Transfer of donor tissue with its blood supply to the recipient area
Parts of flaps Base, pedicle, tip of flap

Indication

Types 1. Random pattern flaps

2. Axial pattern flaps

Areas
Skin grafting

• Type of skin graft

• Allograft, xenograft
• What is allograft/autograft/heterograft
• Partial vs full thickness skin graft
• Which has better cosmetic outcome
• Which graft heal faster and comestically better
• Site of graft taken
• Knife use to take graft
• Function of meshing graft
• The contraindication of skin grafting?
• Beza skin graft and flap
• Beza full thickness graft and partial thickness
• Apa nak check (inspect and palpate)
• Movement of wrist joint
• Features of donor tissue: healthy, no infection, blablabla
• When we do skin graft
• Steps of skin graft (cite both donor and recipient site kene buat apa, paling penting ckp lepas dh
amek donor tu kene letak dlm normal saline, jgn ckp iodine utk recipient site, jwb normal saline )
• Types of skin graft, which one is better
• Where you take graft
• Method for skin graft
• Which type of skin graft is better
• After skin graft what you want to do
• How long after skin grafting do we open the dressing.

• How you want to immobilize this pt

• When will you open the dressing
• Stages of graft uptake
• Types of flaps
• Indications and contraindications for skin grafting.