[0:00]A case of non-healing ulcer. This case presentation is the third in the series of Cassette Clinics of General Surgery prepared by Dr. Ghanashyam Vaidya from Karnatak Health Institute Ghataprabha, an ex-student of Seth GS Medical College and KEM Hospital Mumbai. A 65 years old male Hindu patient, Shamlal, staying in Parel, a retired factory worker, comes with complaints of an ulcer on the sole of left foot since 2 months. The patient was apparently alright 2 months back, when he first noticed the ulcer on the sole, with slight pain. It increased in size for 10 days, and is constant in size since then. Regarding complications, there was mild purulent discharge but no history of pain and fever. No history of bleeding, no history of discharge of bony fragments or sulfur granules, no history of difficulty in walking, no history of inguinal pain and swelling. Regarding etiology of the ulcer, at the onset, there was no history of any apparent trauma. Why? Sir, trauma may be the initiating factor and it also brings to the mind the possibility of an underlying foreign body or bone damage. So there is no history of any apparent trauma, no history of swelling preceding the ulcer. When will there be a swelling preceding an ulcer? Sir, in an ulcer produced by the rupture of a subcutaneous abscess or fungation of a malignant swelling. There is history of numbness in the distal part of both the feet, but he can feel the chappals and the ground while walking. No history of loss of sensations anywhere else on the body. No history of varicosities, edema or dragging pain in the legs. No history of fever with calf pain and swelling. No history of intermittent claudications or rest pain. No history of polyuria, polydipsia. Patient is not a known diabetic or hypertensive. No history of evening rise of temperature, night sweats, loss of appetite and weight, cough with expectoration and hemoptysis, or contact with a known case of tuberculosis. No history of recent weight loss, growth or bleeding in the ulcer. No history of repeated trauma to the site of the ulcer. Regarding treatment taken, there is no history of taking rest, immobilization, or regular dressings. Family history is not contributory. What family history did you ask for? I asked for family history of diabetes. I also asked for history of tuberculosis or leprosy in any family member with close contact. Personal history: Sleep, bladder and bowel habits are normal. Non-alcoholic, but chronic smoker, smokes 20 bidis per day for last 40 years. On examination, what would you like to do first, general examination or local examination? Sir, general examination first, because it will give an idea about the general condition and nutritional status of the patient. And of associated pathologies which may point to the etiology of the ulcer or its chronicity. Now what would you look for in the general examination of a case of an ulcer? Sir, firstly, the state of nutrition, that is, pallor in the mucus membranes, amount of subcutaneous fat and signs of vitamin deficiency in the eyes, lips and skin. Secondly, for the stigmata of tuberculosis, leprosy and syphilis. What are they? Sir, the stigmata of tuberculosis are phlyctenular conjunctivitis, matted lymphadenopathy, scars and sinuses in the neck. The stigmata of leprosy are hypopigmented, anesthetic patches, thickened ulnar, greater auricular and posterior tibial nerves, trophic ulcers, destruction of distal phalanges and typical leonine facies due to collapse of the bridge of the nose with loss of lateral third of the eyebrows. Right. Proceed. On general examination, the patient is averagely built, averagely nourished. Pulse is 84 per minute, regular, good volume. Blood pressure is 130/80 millimeters of mercury, respiratory rate is 20 per minute, regular. There is mild pallor of the mucus membranes, no icterus or cyanosis, no signs of vitamin deficiency, no significant lymphadenopathy. No stigmata of tuberculosis, leprosy or syphilis. On local examination, on inspection, there is a single oval ulcer, 3 by 2 centimeters in size, situated on the sole of left foot, over the heads of 2nd and 3rd metatarsals. In which conditions do you get multiple ulcers? Sir, in neuropathic ulcers, bedsores, tuberculous ulcers and venerial ulcers. What do you mean by an ulcer? Sir, ulcer is a breach in the surface continuity of the skin or mucous membrane due to molecular death of the cells. A breach in the surface continuity of the skin or mucous membrane due to molecular death of the cells. What do you mean by saying molecular death of cells? Sir, that is a process of slow chemical destruction of the cells, that excludes forcible or traumatic disruption of continuity of skin which will be termed separately as a wound. How will you define a wound? Sir, wound is defined as a forcible solution of the continuity of any of the soft tissues of the body. Continue. A single oval ulcer, 3 by 2 centimeters in size, situated on the sole of left foot, over the heads of 2nd and 3rd metatarsals. What does the site of this ulcer suggest? Being situated over a pressure-bearing area, the ulcer is likely to be neuropathic or traumatic. Also, it is unlikely to be arterial or venous. Why? Because varicose ulcers are typically situated over the lower third of the leg, usually on the medial aspect, and arterial ulcers are usually found over the dorsum of the toes or in between the toes or on the dorsum of the foot. And where are diabetic ulcers characteristically situated? Sir, no particular site, because any ulcer whose healing is delayed due to diabetes is termed as a diabetic ulcer. The carbuncles which lead to ulcer formation in diabetics commonly are seen on the nape of the neck and back. Why does diabetes delay the healing of ulcers? Firstly, diabetes promotes the growth of bacteria in the tissues due to hyperglycemia and hyperlipidemia. Secondly, there is diminished peripheral blood supply due to arteriosclerotic changes and microangiopathy. Thirdly, diabetic neuropathy with consequent loss of sensations make the foot prone to repeated unrecognized trauma. And lastly, the healing process in the diabetics is poor due to deficient fibroblastic reaction. To repeat, bacterial growth due to hyperglycemia in the tissues, diminished peripheral blood supply, diabetic neuropathy and deficient fibroblastic reaction. Good. Continue the presentation. It has a well-defined, regular, white margin, with absence of the blue line of growing epithelium. The edge is punched out all along the circumference. Wait, what is a margin? Sir, margin is the line of junction between the ulcerated and intact skin. That is, essentially a two-dimensional structure with no depth. While edge is three-dimensional. Margin represents the line or strip of skin bordering the ulcer and is a sign of inspection.
[8:20]While edge is the block of tissue between the margin and the floor which is to be inspected and palpated. That is, one can palpate the edge but not the margin. Yes, this distinction between margin and edge should be clear in your minds. Margin is a line or strip of skin bordering the ulcer.
[8:52]While edge is the block of tissue between the margin and the floor of the ulcer. Now, what are the types of margins that you have seen? Sir, ill-defined and irregular margin in a growing or spreading ulcer. Well-defined, regular, white margin of a non-healing ulcer.
[9:15]And typical margin of a healing ulcer which is well-defined, regular, and shows three zones, white, blue and red from without inwards. The outermost white zone due to fibrosis in the subcutaneous tissues as the ulcer heals. The next zone of thin epithelium growing over the granulation tissue from the periphery, which appears blue as it is multilayered but not cornified. And the innermost layer of single layer of epithelial cells which is transparent and appears red due to underlying granulation tissue. And where do you get nodules on the margin? In a rodent ulcer, that is basal cell carcinoma. Yes, and usually the ulcers kept in the examination are chronic non-healing ones. So you should always be ready with description of such ulcers. Now tell me the types of edges that you have seen. A sloping edge, an undermined edge, a punched out edge, a raised and everted edge and a raised but not everted edge. In which conditions do you get them and why? Firstly, the sloping edge of a healing ulcer. Because the healthy granulations or the floor is just below the skin surface and thin epithelium grows over it as a sloping surface from all the sides. Secondly, undermined edge of a tuberculous ulcer which is usually secondary to a cold abscess in the subcutaneous tissues, raising the skin up and then rupturing at a point producing a much smaller ulcer than the area of destruction in the subcutaneous plane. It is also seen in amoebic ulcers of large intestines, because the growth and the lytic processes of the amoebae occur in the submucosa with breakdown of mucosa only in the center. Then the punched out edge of gummatous ulcers and trophic ulcers is due to equal destruction of tissues in all the planes. For example, beneath a bony point in a trophic ulcer, the tissues will undergo pressure necrosis equally in all layers from skin to bone. Fourthly, raised and everted or rolled out edge of a malignant ulcer, which is because of overgrowth of the tissues in excess of the central destruction which is producing the ulcer. And lastly, raised slightly but not everted in basal cell carcinoma, where the growth of the tissue is very slow so the edge does not roll out. Proceed. The floor shows scanty serous discharge, no slough, and is covered by pale, flat granulation tissue. Yes, what does the floor of an ulcer mean? Floor is the exposed surface of the ulcer which can be seen. How do you describe it? It is described with reference to discharge, slough and granulation tissue. The discharge may be either scanty and serous in healthy granulation tissue or serosanguinous to purulent in presence of infection. Slough when present indicates that the infection is not yet controlled and granulation tissue is yet to form. What is slough? Sir, slough is a dead piece of soft tissue not yet separated from the living tissues. A dead piece of soft tissue not yet separated from the living tissues. Have you heard of wash leather slough? Sir, wash leather slough is characteristic of gummatous ulcer, also seen in post-irradiation necrosis ulcer. Proceed. The granulation tissue may be healthy or unhealthy. What is granulation tissue? It is a highly cellular and vascular tissue formed as a result of body's response to control infection and promote healing. On account of its marked cellularity, it has a remarkable power of resisting infection. Microscopically, it is made of macrophages, fibroblasts and neovasculature with thin-walled capillaries. How does it look on inspection? When healthy, it is pink, covered with tiny red granulations and scanty serosanguinous discharge. When unhealthy, it may show pale and flat granulations or hypertrophic exuberant granulations and it may be covered with slough. Any other findings on inspection? The surrounding skin shows no redness, edema, dilated veins, scars or sinuses. There is a zone of hypopigmentation. Why hypopigmentation? Probably due to fibrosis in the subcutaneous tissues surrounding the chronic ulcer. And where do you get hyperpigmentation? In varicose ulcer. Right. So on inspection, first describe the number, size and shape of the ulcer, then the margin, then the floor, and lastly the surrounding skin. Now proceed with palpation. On palpation, the surrounding skin shows no local rise of temperature, no tenderness, edema or induration. The edge is firm, non-tender, with no undermining. What is the difference between edema and induration? Sir, edema is a soft swelling of the subcutaneous tissues, while induration has a firm feel. Because edema is due to fluid retention in the tissues, while induration is the result of cellular infiltration of the tissues. What else did you look for? Warmth and tenderness for evidence of acute inflammation, indicating a spreading ulcer, and edema, which may be due to acute inflammation or due to impaired lymphatic and venous return which may be the cause of the ulcer. Induration if present, suggests a malignancy or a developing abscess. The edge is firm, non-tender, with no undermining. How did you look for undermining? Firstly, by trying to insert a sterile pin underneath the margin and secondly, by pulling the margin away from the ulcer, looking for a gap underneath. Why do you think that the edge is firm? Due to fibrosis in the tissues in the periphery of the ulcer. In which ulcers do you get such a firm edge? Any chronic ulcer. What is an edge? Edge is the mode of union between the margin and the floor of the ulcer. And what is the base of the ulcer? Base is the tissue on which the ulcer rests. Its visible surface exposed by the ulcer is the floor of the ulcer. How do you examine the base of the ulcer? If the ulcer is large, palpate it with a gloved finger through the floor, and if the ulcer is very small, try to pinch and lift the ulcer and feel for the tissues underneath. And what do you feel? Firstly, whether the base is indurated or not, as seen in squamous cell carcinoma, and secondly, for the structures to which the ulcer is fixed, that is, the structures forming the base of the ulcer. Is this ulcer fixed to the bone? No sir, it can be moved over the bone. Is it fixed to the underlying muscles? Sir, there are no underlying muscles here. But it is fixed to the flexor tendons of the toes as its mobility gets restricted in longitudinal direction when the toes are flexed. Right. Always make a note of the muscles underlying. Because you will always be asked about the anatomical structures in the base. For example, if an ulcer is over the cheek, is it fixed to the buccinator and masseter? Okay. How is the granulation tissue to palpate? Sir, it is non-tender and does not bleed on touch. Should it be tender or non-tender? Sir, healthy granulation tissue is non-tender and bleeds on touch. Why does it bleed on touch? Due to large number of newly formed fragile capillaries which break on slightest pressure. So bleeding on touch is a good sign? Not necessarily, because malignant tissues in the base of a carcinomatous ulcer are also friable and bleed on touch. Yes. Now can you give me a complete description of healthy granulation tissue? Sir, healthy granulation tissue is pink, covered with tiny red granulations and scanty serosanguinous discharge.
[18:11]On palpation, it is non-tender and bleeds on touch. Good. After local examination, we will move on to focal examination. Will you enumerate what you want to examine? Sir, lymph nodes, arteries, veins, nerves and movements of the neighboring joints. Right. But these five points should be narrated in a definite order. Immediately after local examination, first examine the lymph nodes. So lymph nodes first, movements of the neighboring joints last, and in between is the examination of arteries, veins and nerves. Their order will depend on the site of the ulcer. For example, if the ulcer is on the medial malleolus of the leg, then examine the veins first. If it is on the dorsum of the foot, examine the arteries first. And so on.
[19:05]On focal examination, the left deep inguinal lymph nodes of the vertical chain are enlarged, half to 3 centimeters in size, non-tender, discrete and mobile. There is loss of touch and pain sensations surrounding the ulcer and over the anterior half of the soles of both legs.
[19:26]The sensations over the rest of the leg and body are normal. There is no palpable thickening of the posterior tibial, ulnar and greater auricular nerves. There are no hypopigmented, anesthetic patches over the body. The pulsations of dorsalis pedis, posterior tibial, popliteal and femoral arteries on both sides are well felt and equal. No changes of chronic ischemia in the leg. Radial and carotid pulsations are normal and no palpable thickening of the vessel walls. Then, on examination in standing position, there is no varicosity of short or long saphenous system, no ankle flare, no calf tenderness and Homan's sign is negative. Lastly, the active and passive flexion and extension movements of the second and third toe are restricted. Movements of the rest of the toes and ankle are normal. On systemic examination, per abdomen there is no lump, spleen is not palpable, chest is normal. Why spleen? Because chronic leg ulcers are sometimes a feature of hemolytic anemia in which spleen is enlarged. My diagnosis is chronic non-healing ulcer over the sole of left foot, probably neurogenic. Chronic non-healing ulcer over the sole of left foot, probably neurogenic. Why do you say that the ulcer is chronic and non-healing? Sir, it is chronic because it is present for a period longer than the normal healing period of an uncomplicated ulcer at that site, and it is non-healing because granulation tissue is pale with flat granulations, base is fixed to the underlying tendon, edge is firm and punched out, and does not show the blue line of growing epithelium. Good. What are the other clinical types of ulcers? Sir, ulcer may be acute or chronic depending on the duration, and it may be healing, non-healing or spreading depending on its characteristics. What are the causes of non-healing of an ulcer? Local, focal and systemic causes. Local causes are very large or very deep ulcer, fixity to underlying structures, exposure of bare bone or tendon in the floor, inadequate rest, that is, ulcer on a mobile area or over a joint or area of constant pressure. Then chronic type of infections like tuberculosis or fungal infection, and malignant change. The focal causes are impaired nerve supply, blood supply and impaired venous or lymphatic drainage. The general and systemic causes are anemia, malnutrition, vitamin deficiencies, diabetes, and cachexia due to tuberculosis or malignancy. How will you treat this case? Sir, I will do certain investigations first. Complete hemogram, ESR for evidence of anemia or chronic infections, blood sugar and HbA1c to rule out diabetes, blood urea and serum creatinine, VDRL, HIV, HBSAG and HCV, X-ray of the chest and ECG. Why ECG? As a part of routine investigatory profile and to rule out IHD if atherosclerosis is suspected. Locally, I will take a smear for smear culture and antibiotic sensitivity, X-ray of the local part to see the bone involvement, and if indicated, a four-quadrant edge biopsy. That is, if there is suspicion of malignancy or if there is no response to routine treatment. Describe the local treatment of an ulcer. Sir, I will describe the local treatment according to the three stages of healing of an ulcer. First is the stage of separation of slough. Second is the stage of formation of granulation tissue, and third is the stage of epithelialization. As a first step, I will examine the ulcer and decide in which stage of healing it is. And before any local treatment is commenced, I will send the discharge and slough for smear culture and antibiotic sensitivity. In the first stage when the floor is covered with slough, the slough is removed either by chemical debridement using antibiotic ointments, continuously wet eusol dressings and repeated hydrogen peroxide washes to wash away the loosened slough, or by surgical debridement using knife and scissors or scoop. Once the slough is removed, stop eusol dressings as eusol hampers granulation tissue formation. Now in the second stage, I will apply wet dressings with glycerin acriflavine or platelet-derived growth factor to stimulate the granulation tissue till the granulations almost reach the surface. At this stage, if the granulations become hypertrophic and rise above the skin surface, they should be scraped away with a scoop or cauterized by applying silver nitrate crystals or hypertonic saline. In the third stage of epithelialization, I will apply antibiotic ointment to the floor and scarlet red to the margin plus infrared light exposure to stimulate epithelialization. If the ulcer is more than 4 to 5 centimeters in size, complete epithelialization cannot occur without significant fibrosis and contracture. Hence, a partial thickness skin graft should be placed as soon as healthy granulations are formed. This helps quick healing with minimal fibrosis and better cosmetic and functional result. The general treatment will depend on the cause of the ulcer or its chronicity. That is, rest to the part with immobilization in a plaster slab if necessary, correction of anemia, systemic antibiotics if there is active infection, fever, pain or induration, strict control of diabetes, limb elevation and elastocrape bandage if varicose ulcer, and treatment of specific infection like tuberculosis or fungal infection if present. All right. That's enough. Thank you sir.
