Ulcers & wounds

1. Wounds & Ulcers Dr. Ranjeet Patil

2. Definition Wound Breach in the continuity of skin or mucous membrane Ulcer Persistent breach in the continuity of skin or mucous membrane associated with cell death

3. Anatomy

4. Classification Wounds Simple Skin Complex Deeper

5. Classification Wounds Rank & Wakefield Tidy Surgical incisions Untidy Crushing, tearing

6. Classification Wounds Open Incised Abrasion Lacerated Crush Penetrating Closed Contusion Hematoma

7. Classification Wounds Surgical Wounds Clean Clean Contaminated Contaminated Dirty

8. Management of Wounds Resuscitation of patient Cleaning, Dressing Hemostasis Splint Fluids Inj TT

9. Management of Wounds Incised Primary Suturing Lacerated Excision & Primary Suturing Crushed Debridement, excision Delayed Primary Suturing Deep devitalised Debridement Secondary Suturing/ Grafting

10. Compartment Syndrome Calf, Forearm Closed injury>Hematoma>Increased Pressure/Fracture Compression of vessels Pallor, Paraesthesia , Pulselesness , Pain, Swelling, Coldness Rx- Fasciotomy

11. Crush Syndrome Crushing of Muscles>Extravasation of blood>Myoglobin release Earthquakes, Industrial accidents, Air crashes Renal failure, Toxemia, Septicemia, Gas gangrene Rx- Multiple deep incisions, Mannitol , NaHCO3, Hemodialysis

12. Degloving injury Shearing force between tissue planes as traction-avulsion One or multiple planes Machine, RTAs Debridement, Excisions, Dressing, Grafts, Flaps

13. Classification Ulcers Clinical Spreading Healing Callous

14. Classification Ulcers Pathological Specific Malignant Non-Specific

15. Specific Ulcers Tuberculosis Syphilis Actinomycosis Meleney’s

16. Malignant Ulcers Carcinomatous Rodent Melanotic

17. Non-Specific Ulcers Traumatic Arterial Venous Trophic Infective Tropical Cryopathic Martorells Bazin’s Diabetic Cortisol Miscellaneous

18. Wagner’s Classification Grade 0- Preulcerative /Healed Grade 1- Superficial Grade 2- Deeper to subcutaneous Grade 3- Abscess formation Grade 4- Gangrene of part of tissue Grade 5- Gangrene of entire limb

19. Parts of Ulcer Margin Edge Floor Base

20. Edge

21. Edge

22. Margin Regular Irregular Rounded, Oval

23. Floor Granulation Red Pale & Smooth Wash-Leather Pink, Punctate, Pulseful , Painless, Pin head Exuberent Discharge Serous Purulent Sero -purulent Bloody Sero-sanguinous Sulpher granules

24. Base On which the ulcer rests Palpated Indurated in malignancy

25. Traumatic Ulcers Anywhere on body Limbs-Shin, Malleoli, Joints Chronic- Staph Eg Plaster Sores, Dental Ulcers, Footballer’s Ulcer, Skin burns, Caustic ulcers

26. Arterial Ulcers Inadequate skin circulation Limbs- Repeated pressure/trauma Causees Atherosclerosis- Ant & lat legs, Dorsum, Heels Buerger’s disease- Painf , Claudication, Punched out ulcers Raynaud’s disease

27. Venous Ulcers Commonest on leg Medial lower 3 rd leg Pigmentation, Oedema Causes Varicose veins-Perforator incompetence, Stasis DVT- Valveless Recanalisation

28. Trophic Ulcers Neurologic deficit, Impaired blood supply & nutrition Sites Sacrum, Heel, Buttocks, Occiput Bedsores, Perforating Ulcers Causes Diabetic Neuropathy, Paraplegia, Leprosy, Spinal injury, Peripheral injury, Peripheral neuritis

29. Tropical Ulcers Tropical Countries Cause unknown Callous ulcer

30. Diabetic Ulcer Diabetic Neuropathy-Trophic Atherosclerosis-Arterial Glucose laden tissues-Infective

31. Tuberculous Bursting of Caseous LN Slightly painful Neck, Axilla, Groin Undermined thin reddish-blue edge, Sero-sanguinous discharge & induration Enlarged LN Lupus Vulgaris- Cutaneous TB- Face & Hands

32. Syphilitic Treponema Pallidum Hard Chancre- Ext Genitals Painless, indurated base(button Like) Nipple, lip, tongue, anal canal Secondary- Mucus patches, Condylomas Tertiary – Gummatous ( Subcut bones)

33. Malignant Marjolin’s ulcer SCC from chronic scar Malignant Lips, cheeks, penis, vulva, mouth, oesophagus 40 yrs + SCC, BCC, Melanoma

34. Others Soft Chancre- Ducreys Painful, Ext genitals, with Bubo Meleney’s Ulcer Post-op- Perforated viscus , Empyema Thoracis Strepto & Staph, Abdomen Martorell Hypertensive, Old age Post calf Bazin’s Women

35. History Mode of onset Duration Pain Discharge Treatment taken

36. Examination Inspection Size & Shape Number Position Edge, Margin, Floor Discharge Surrounding area Palpation Tenderness Edge & margin Base Depth Bleeding Surrounding skin

37. Examination Lymph Nodes Peripheral pulsations Nerves Joints for mobilty Systemic examination

38. Investigations Routine Specific Study of discharge Edge biopsy X-ray of part FNAC of LN CXR Colour Doppler

39. Treatment Treatment of cause Correction of Deficiencies Blood transfusions Pain Mangement Debridement, Cleaning, Dressing Antibiotics Suturing, Grafts, Flaps

40. Thank you