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Wounds &

Ulcers

Dr. Ranjeet Patil


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
Anatomy
Classification
Wounds
•Simple
•Skin
•Complex
•Deeper
Classification
Wounds
• Rank & Wakefield
• Tidy
• Surgical incisions
• Untidy
• Crushing, tearing
Classification
Wounds
• Open
• Incised
• Abrasion
• Lacerated
• Crush
• Penetrating
• Closed
• Contusion
• Hematoma
Classification
Wounds
• Surgical Wounds
• Clean
• Clean Contaminated
• Contaminated
• Dirty
Management of
Wounds
• Resuscitation of patient
• Cleaning, Dressing
• Hemostasis
• Splint
• Fluids
• Inj TT
Management of Wounds
• Incised
• Primary Suturing
• Lacerated
• Excision & Primary Suturing
• Crushed
• Debridement, excision
• Delayed Primary Suturing
• Deep devitalised
• Debridement
• Secondary Suturing/ Grafting
Compartment
Syndrome
• Calf, Forearm
• Closed
injury>Hematoma>Increased
Pressure/Fracture
• Compression of vessels
• Pallor, Paraesthesia,
Pulselesness, Pain, Swelling,
Coldness
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
Degloving injury
• Shearing force
between tissue planes
as traction-avulsion
• One or multiple planes
• Machine, RTAs
• Debridement,
Excisions, Dressing,
Grafts, Flaps
Classification
Ulcers
• Clinical
• Spreading
• Healing
• Callous
Classification
Ulcers
• Pathological
• Specific
• Malignant
• Non-Specific
Specific Ulcers
• Tuberculosis
• Syphilis
• Actinomycosis
• Meleney’s
Malignant Ulcers
• Carcinomatous
• Rodent
• Melanotic
Non-Specific
Ulcers
• Traumatic • Martorells
• Arterial • Bazin’s
• Venous • Diabetic
• Trophic • Cortisol
• Infective • Miscellaneous
• Tropical
• Cryopathic
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
Parts of Ulcer
• Margin
• Edge
• Floor
• Base
Edge
Edge
Margin
•Regular
•Irregular
•Rounded, Oval
Floor
• Granulation • Discharge
• Red • Serous
• Pale & Smooth • Purulent
• Wash-Leather • Sero-
• Pink, Punctate, purulent
Pulseful,
Painless, Pin • Bloody
head • Sero-
• Exuberent sanguinous
• Sulpher
Base
• On which the ulcer rests
• Palpated
• Indurated in malignancy
Traumatic Ulcers
• Anywhere on body
• Limbs-Shin, Malleoli, Joints
• Chronic- Staph
• Eg
• Plaster Sores, Dental Ulcers,
Footballer’s Ulcer, Skin burns,
Caustic ulcers
Arterial Ulcers
• Inadequate skin circulation
• Limbs- Repeated
pressure/trauma
• Causees
• Atherosclerosis- Ant & lat legs,
Dorsum, Heels
• Buerger’s disease- Painf,
Claudication, Punched out
Venous Ulcers
• Commonest on leg
• Medial lower 3rd leg
• Pigmentation, Oedema
• Causes
• Varicose veins-Perforator
incompetence, Stasis
• DVT-Valveless Recanalisation
Trophic Ulcers
• Neurologic deficit, Impaired
blood supply & nutrition
• Sites
• Sacrum, Heel, Buttocks,
Occiput
• Bedsores, Perforating Ulcers
• Causes
• Diabetic Neuropathy,
Paraplegia, Leprosy, Spinal
Tropical Ulcers
• Tropical Countries
• Cause unknown
• Callous ulcer
Diabetic Ulcer
• Diabetic Neuropathy-Trophic
• Atherosclerosis-Arterial
• Glucose laden tissues-Infective
Tuberculous
• Bursting of Caseous LN
• Slightly painful
• Neck, Axilla, Groin
• Undermined thin reddish-blue
edge,
• Sero-sanguinous discharge &
induration
• Enlarged LN
Syphilitic
• Treponema Pallidum
• Hard Chancre- Ext
Genitals
• Painless, indurated
base(button Like)
• Nipple, lip, tongue, anal
canal
• Secondary- Mucus
Malignant
• Marjolin’s ulcer
• SCC from chronic scar
• Malignant
• Lips, cheeks, penis, vulva,
mouth, oesophagus
• 40 yrs+
• SCC, BCC, Melanoma
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
History
• Mode of onset
• Duration
• Pain
• Discharge
• Treatment taken
Examination
• Inspection • Palpation
• Size & Shape • Tenderness
• Number • Edge & margin
• Position • Base
• Edge, Margin, • Depth
Floor
• Bleeding
• Discharge
• Surrounding
• Surrounding
area skin
Examination
• Lymph Nodes
• Peripheral pulsations
• Nerves
• Joints for mobilty
• Systemic examination
Investigations
• Routine
• Specific
• Study of discharge
• Edge biopsy
• X-ray of part
• FNAC of LN
• CXR
• Colour Doppler
Treatment
• Treatment of cause
• Correction of Deficiencies
• Blood transfusions
• Pain Mangement
• Debridement, Cleaning, Dressing
• Antibiotics
• Suturing, Grafts, Flaps
Thank you