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Examination of an Ulcer Patient

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Definition

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I. HISTORY

1. Mode of Onset

• Did it follow trauma or arise spontaneously?
• Traumatic ulcers heal if the agent is removed; chronicity implies a persisting cause (e.g., dental ulcer of the tongue, ulcer over a joint)
• Spontaneous ulcers may follow a swelling (matted tuberculous lymph nodes, gummata, or a rapidly growing malignant tumour)
• Ulcers may arise in a leg with varicose veins or vascular insufficiency
• A malignant ulcer (Marjolin's) may develop on the scar of a burn

2. Duration

• Acute ulcer: present for a short duration
• Chronic ulcer: persists for a long period
• Note the incubation period: Hunterian chancre (syphilis) = 3-4 weeks; chancroid (soft sore) = 3-4 days

3. Pain

• Painful: acutely inflamed ulcers
• Painless: syphilitic ulcers, trophic/neurogenic ulcers (tabes dorsalis, transverse myelitis, peripheral neuritis)
• Slightly painful: tuberculous ulcers
• Initially painless (later painful if deep invasion): malignant ulcers (epithelioma, basal cell carcinoma)
• Venous ulcer: relatively painless
• Arterial ulcer: pain is the main complaint, worsened by elevation

4. Discharge

• Nature: serum, pus, or blood?
• Serosanguineous discharge suggests tuberculosis or carcinoma
• Scant discharge with pale granulation: tuberculous ulcer

5. Associated Disease

• Nervous diseases (tabes dorsalis, syringomyelia, transverse myelitis, peripheral neuritis) → trophic/perforating ulcer
• Generalised tuberculosis, nephritis, or diabetes → ulcer formation
• Syphilis: primary stage (chancre), tertiary stage (gummatous ulcer)

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II. PHYSICAL EXAMINATION

General Survey

• Do not focus only on the ulcer - give due attention to the general examination
• Ulcer may be a sequel of malnutrition, generalised atherosclerosis, syphilis, or tuberculosis

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III. LOCAL EXAMINATION

A. INSPECTION

Types of Ulcer Edge (Key Feature for Diagnosis)

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B. PALPATION

1. Tenderness - Acutely inflamed ulcers are tender; malignant ulcers usually not tender
2. Edge - Feel the edge: indurated edge = malignant; soft/undermined = TB; punched-out = arterial/trophic
3. Floor/Base - Probe for depth; presence of slough, granulation tissue, bone, or tendon exposure
4. Induration at base - Slight induration in TB; marked/hard induration in malignancy
5. Discharge - Milk the ulcer gently; note nature and amount
6. Relations with deeper structures - Move the ulcer over deeper structures; fixity to underlying bone/fascia = gummatous or malignant; mobility = benign
7. Surrounding skin - Increased temperature + tenderness = acute inflammation; fixity of surrounding skin to deeper structures = malignant; test for loss of sensation (nerve involvement); feel for thickened peripheral nerves (leprosy, neurofibromatosis)

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C. EXAMINATION OF LYMPH NODES (Often Forgotten!)

Note: Simple lymph node enlargement in malignancy does NOT always mean metastasis - may be due to secondary infection. Stony hard consistency confirms metastatic involvement.

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D. EXAMINATION FOR VASCULAR INSUFFICIENCY

• Search for varicose veins in the upper leg/thigh when ulcer is on the lower leg
• If no varicose veins, examine peripheral arteries proximal to the ulcer (atherosclerosis, Buerger's disease, Raynaud's disease)
• Check: dorsalis pedis pulse (often feeble/absent in arterial ulcer)
• Look for ischaemic changes: pallor, dry skin, loss of hair, nail fissuring
• Elevation test: In arterial ulcer, elevation above heart level - no healing + pain worsened

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E. EXAMINATION FOR NERVE LESION

• Trophic ulcers result from repeated trauma to insensitive areas
• Test sensation around the ulcer (light touch, pin-prick, temperature)
• Check for motor deficits
• Palpate peripheral nerves for thickening (leprosy, neurofibromatosis)

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IV. DIFFERENTIAL FEATURES SUMMARY: Common Ulcer Types

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Trendelenburg Test

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1. TRENDELENBURG TEST - Varicose Veins (Brodie-Trendelenburg Test)

Purpose

• Superficial venous incompetence (saphenofemoral junction failure), or
• Deep venous insufficiency with incompetent perforating veins

Procedure

• Patient lies supine
• Elevate the leg above body level to drain the varicose veins completely

• Apply a tourniquet (or digital compression) to the proximal thigh over the suspected incompetent feeding vein (saphenofemoral junction)

• Patient stands erect with tourniquet in place
• Observe whether the veins remain empty or fill rapidly

• Release the compression and observe again

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Interpretation

Key rule: If the varices remain empty under tourniquet compression but fill promptly on release, the tourniquet site marks the level of incompetence. The compression site is marked before surgical ligation. - Pye's Surgical Handicraft, 22nd Ed.

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Perthes Test (Companion test)

• Tourniquet placed on midthigh after patient stands (veins filled)
• Patient walks for 5 minutes
• Patent deep system + competent perforators → superficial veins below tourniquet collapse
• Deep venous obstruction → superficial veins distend further with walking
• Harrison's Internal Medicine, 22nd Ed.

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2. TRENDELENBURG SIGN - Hip Abductor Weakness (Orthopaedic)

Purpose

Procedure

1. Examiner stands behind the patient
2. Ask the patient to stand on one leg (the suspected affected side)
3. Observe the level of the pelvis/iliac crests

Interpretation

Mechanism

• Normally, when standing on one leg, the ipsilateral gluteus medius and minimus contract to hold the pelvis level
• If these muscles are weak, the pelvis drops toward the unsupported side
• The patient compensates by leaning the trunk over the affected hip (Trendelenburg lurch)
• If bilateral: produces a waddling gait (duck gait)

Causes of Positive Trendelenburg Sign

Positive signs are typically found with damage to the superior gluteal nerve. Bilateral positive signs (as in CDH) produce waddling gait. - Gray's Anatomy for Students

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Quick Comparison Summary

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