trophic ulcer.pptx

trophic ulcer ethology pathogenesis c/f , management

1. Trophic ulcer Moderator: Dr Puneet Bhargava Sir Presenter: Dr Gangadhar

2. Ulcer An ulcer is a break in the continuity of the covering epithelium - skin or mucous membrane. It may either follow molecular death of the surface epithelium or its traumatic removal.

3. Aetiology Venous Disease (Varicose Veins) Arterial Disease ; Large vessel (Atherosclerosis) or Small vessel (Diabetes) Arteritis: Autoimmune (Rheumatoid Arthritis, Lupus) Trauma Chronic Infection: TB/Syphilis Neoplastic: Squamous or BCC, Sarcoma Neurogenic cause

4. Wagner's Grading of ulcers Grade 0 - Preulcerative lesion/healed ulcer Grade 1 - Superficial ulcer Grade 2 - Ulcer deeper to Subcutaneous tissue exposing soft tissue or bone Grade 3 - Abscess formation or osteomyelitis Grade 4 - Gangrene of part of tissues/limb/foot Grade 5 - Gangrene of entire one area/foot

5. The word ‘Trophic’ is derived from the Greek word Trophe = nutrition. American Heritage Medical Dictionary 2007 defines trophic ulcers as ‘an ulcer due to impaired nutrition of the part’. Mosby's Medical Dictionary 2009 defines trophic ulcer as ‘a pressure ulcer caused by external trauma to a part of the body that is in poor condition because of disease, vascular insufficiency or loss of afferent nerve fibres’.

6. Classification of trophic ulcers

7. Trophic Ulcer Pressure Sore or Decubitus Ulcer Punched out edge with slough on the floor Ex: Bed Sores & Perforating ulcers Develop as a result of Prolonged Pressure Sites : Ischial Tuberosity > Greater Trochanter > Sacrum > Heel > Malleolus > Occiput

8. Diabetic Ulcer It may be caused due to Diabetic Neuropathy Diabetic Microangiopathy Increased Glucose : Increased Infection Foot ( Plantar ), Leg, Back, Scrotum, Perineum Ischemia, Septicemia , Osteomyelitis.

9. Venous Disease Pathogenesis: increase ambulatory venous hypertension with microcirculatory abnormalities. (a)Ulcer in a patient with PVD and venous disease showing skin changes, (b) skin changes persist after reconstruction with sural artery flap

10. NEUROGENIC ULCER These include all ulcers in insensate hands and feet in patients with neuropathy. Protective pain and pressure perception being absent, they do not relieve pressure and hence the repetitive trauma leads to skin breakdown and ulceration.

11. EXAMINATIONS  INSPECTION Location, size, shape, floor, edge, discharge, surrounding area. PALPATION Tenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area - oedema, mobility. REGIONAL LYMPH NODES SENSATIONS PULSATIONS FUNCTION OF THE JOINT SYSTEMIC EXAMINATION

12. Management The key to successful management of a chronic ulcer would be to correctly identify the etiology as well as the local and systemic factors that could be contributing to its non healing nature.

13. Investigations  Complete blood picture: Hb%, TLC, DLC, ESR, Urine and blood examination to rule out diabetes Chest X-ray - PA. Pus for culture/sensitivity Lower limb angiography in cases of arterial diseases X-ray of the part to see for Osteomyelitis Biopsy: Non-healing/malignant ulcers

14. Treatment Address cause Correct deficiencies Control pain, infection Debridement, dressing Closure of defect

15. Debridement Surgical debridement should be aggressive to include removal of all surrounding hard callus, hyperkeratotic skin, all dead necrotic tissue, infected soft tissue and bone. Activation of platelets for control of haemorrhage leads to release of growth factors which begins the process of healing.

16. (a) Neuropathic bone deep ulcer, (b) radiograph showing bone destruction Osteomyelitis

17. Wound bed preparation Moist woun d dressing : Hydroge l an d Alginate Dressing material selection : Silver HBOT(Hyperbaric oxygen therapy) NPWT (Negative pressure wound therapy ) Growth factors: local application of PDGF

18. Off Loading Measures Strict bed rest Use of crutches, Wheel chair , Walkers Pressure reducing measures like air cushion, waterbeds, Plaster boot Removable contact casting, half shoes or specialised footwear.

19. The best off loading device is a total contact cast(TCC). TCC should be applied only after debridement and removal of all dead tissue.

20. Surgical Rec onstruction Surgical options for reconstruction should be considered for ulcers which have exposed bone, tendons W hen the area of the ulcer has not decreased by more than 10% after sincere conservative management for 2 months.

21. Common flaps done for foot ulcers are local transposition flaps, medial plantar artery flap, fillet flaps, distally based sural neurocutaneous flaps, VY plantar flaps local muscle flaps.

22. Neuropathic ulcer reconstructed with local flap (a) pre-, (b) intra- and (c) postop views

23. Tendon imbalance correction, particularly Achilles or gastro-soleus tightness correction can help address foot problems and avoid ulcers. Flexor tenotomies have also been suggested to decrease metatarsal head ulcers in patients with claw toes.

24. Nerve decompression N erve de compression as an adjunct therapy to medical treatment should be used when there is clinical and / or electrodiagnostic evidence of compression neuropathy. Prevention of limb loss in chronic diabetes mellitus, for diminishment of pain and for restoration of sensory/ motor function.

25. Objective wound measurement Keeps the treating surgeon and the patient aware of progress. Record keeping should be done by two methods- photographic record of the ulcers document the length, breadth and depth measurements of the ulcer at weekly intervals. It helps to objectively analyse healing and motivates patients towards self-care.

26. Patient education and home care Explanation in simple terms about their specific pathology. Understanding that changing habits and making a few lifestyle changes could go a long way to keep progression of disease and its consequences in check, e.g. leg elevation whenever possible, changing position to keep pressure off one point. Cessation of smoking. Regular chiropodist care (foot and nail grooming).

27. 5. Strict glycaemia control for diabetics. 6.Compression for venous diseases. Daily end of day check of hands and feet for signs of breakdown. Self-monitoring of sole/fingertip temperature. 9.Specialized footwear for off-loading pressure. 10.Regular follow-up with physician even in periods of no ulcer stage.

28. THANK YOU

29. Conclusion Care of patients with trophic ulcers needs to be multidisciplinary involving a large team which includes Dermatologist . physician, general surgeon, plastic surgeon, endocrinologist, vascular surgeon, interventional radiologist, dietician, physiotherapist and chiropodist.