Chronic Leg Ulcers

Atef Abdel Hameed, MD

Professor of Vascular Surgery
Ain Shams University
The Origin of the word (ULCER)

• Old French : Ulcere ... Vulgar

• Latin : Ulcus .. Painful sore

• Greek : Elkes.. Wound sore

Definition of Ulcer

A break in the continuity of the covering epithelium,

either skin or mucous membrane due to molecular
death.
(Loss of surface tissue, disintegration and necrosis of epithelial tissue)

(Epidermis & at least part of dermis)

Chronic ulcer

• More than 4-6 weeks

• Results when sequel of repair is disturbed at one or more

stages of inflammation, proliferation, re-epithelization or
remodeling
How to examine an ulcer

• Shape (Regular/Irregular)
• Site
• Size (Extent)
• Number
How to examine an ulcer

• Edge
• Floor
• Base
• Margin
• Discharge
How to examine an ulcer

• Temperature of surrounding skin

• Regional lymphadenopathy
• Peripheral pulsations
• Peripheral sensation
Edge

• Slopping (Healing)
• Undermined (T.B)
• Punched out
(Trophic/syphilitic)
• Rolled out (Rodent)
• Everted (Malignant)
Floor

• Sloughed
• Granulating (healthy/poor)
• Necrotic
• Gangrenous
Base

• Hard / Soft
• Fixed / Mobile
• Underlying (Muscle / Bone)
Margin

• Regular / Irregular
• Hyperemic / pigmented
• Temperature
Causes of chronic leg ulcers
• Venous
• Arterial
• Mixed (Arterial & venous)
• Neuropathic (DM)
• Infective
• TB
• Traumatic
• Connective tissue disorders (Vasculitis)
• Pressure ulcers (Bed sores)
• Miscellaneous (Drugs / metabolic)
Venous ulcer

• Most common (45-60%)

• Main pathology is VENOUS HYPERTENTION
• Venous stasis
• Reflux (superficial / Deep)
• Obstruction
• Varicose veins (primary / secondary)
• Postphlebitic syndrome
• Pigmentation / eczema / lipodermatosclerosis
Venous ulcer

• At gaiter area
• Single or multiple
• Edge : slopping
• Floor : granulating or necrotic
• Base : subcutaneous tissue
• Margin : warm / pigmented
• Discharge : serous
• Peripheral pulsations : intact
• Lymph nodes : according to infection
Ischemic ulcer

• 10-15%
• Toes / feet / heel
• Edge : punched out (Endarteritis obliterans)
• Floor (sloughed / poor granulation/ gangrenous)
• Base (bone)
• Margin (atrophic / blackish)
• Peripheral pulsations (weak / absent)
• Lymph nodes
Neuropathic ulcer

• 15-25%
• Most commonly with DM
• Peripheral neuropathy (Sensory / motor)
• At pressure areas
• Edge : slopping / punched out
• Floor : granulating
• Base : tendons / deformed bones
• Discharge : mostly NO
• Pulsations : intact / absent
• Peripheral sensation : absent
Wegner classification of diabetic foot ulcer
WIFI Classification system
Malignant ulcer

• Uncommon
• DE NoVo / on top
• Edge : everted
• Floor : necrotic
• Base : fixed
• Discharge : serosanguinous
• Pulsations : intact
Management

• Local treatment
• Control of infection
• Pain management
• General condition
• Treatment of the cause
• Dramatic solutions
THANK YOU