Here is a structured summary of Chapter 4: Examination of an Ulcer from A Manual on Clinical Surgery, covering all 8 pages you've shared.
Chapter 4: Examination of an Ulcer
Definition
An ulcer is a break in the continuity of the covering epithelium (skin or mucous membrane), following either molecular death of the surface epithelium or its traumatic removal.
HISTORY
| Point | Key Details |
|---|---|
| 1. Mode of Onset | Traumatic (heals if agent removed) vs. Spontaneous (may follow swelling - TB nodes, gumma, or malignant melanoma). Varicose ulcer from vascular insufficiency. Marjolin's ulcer on burn scar. |
| 2. Duration | Acute = shorter; Chronic = longer. Incubation period: Hunterian chancre (syphilis) = 3-4 weeks; Chancroid (soft sore) = 3-4 days. |
| 3. Pain | Acute inflamed ulcers = very painful. Syphilitic & trophic ulcers = painless. TB ulcers = slightly painful. Malignant ulcers = absolutely painless (no pain nerve endings). |
| 4. Discharge | Note nature: serum, pus, or blood. |
| 5. Associated Disease | Nerve diseases (tabes dorsalis, syringomyelia) → trophic/perforating ulcer. Syphilis → chancre (primary) or gummatous ulcer (tertiary). TB, nephritis, diabetes → ulcer formation. |
PHYSICAL EXAMINATION
General Survey
Give attention to the whole patient - ulcer may be a sequel of malnutrition, general atherosclerosis, syphilis, tuberculosis.
LOCAL EXAMINATION
A. INSPECTION
| Feature | Details |
|---|---|
| 1. Size & Shape | TB = oval, may coalesce → crescentic border. Syphilitic = circular/semilunar → serpiginous. Varicose = vertically oval. Carcinomatous = irregular. |
| 2. Number | TB, gummatous, varicose, soft chancres may be multiple. |
| 3. Position | Medial malleolus + varicose veins = varicose ulcer. Upper face (above angle of mouth to lobule of ear, near inner canthus) = rodent ulcer. Neck/axilla/groin adenopathy = TB ulcer. |
| 4. Edge (5 types) | (i) Undermined - TB (disease spreads faster in subcutaneous tissue than skin). (ii) Punched out - Gummatous or deep trophic ulcer (drops at right angle). (iii) Sloping - Healing traumatic/venous ulcers (reddish-purple, new epithelium). (iv) Raised & pearly-white beaded - Rodent ulcer (invasive, necrotic centre). (v) Rolled out/Everted - Squamous-cell carcinoma or ulcerated adenocarcinoma (growing portion heaps up over normal skin). |
| 5. Floor | Red granulation = healthy/healing. Pale/smooth = slowly healing. Wash-leather slough = pathognomonic of gummatous ulcer. Black mass = malignant melanoma. Trophic ulcer may go down to bone. |
| 6. Discharge | Healing = scanty serous. TB/malignant = purulent. Sero-sanguineous = TB or malignant. Pseudomonas infection = greenish. |
| 7. Surrounding Area | Glossy, red, oedematous = varicose (eczematous). Acutely inflamed = inflammatory. Scar + wrinkled = old TB. |
| 8. Whole Limb | Check for varicose veins (varicose ulcer) or neurological insufficiency/deep vein thrombosis (trophic ulcer). |
B. PALPATION
| Feature | Details |
|---|---|
| 1. Tenderness | Acute inflamed = exquisitely tender. Varicose/syphilitic = slightly tender. TB = slightly tender. Neoplastic = never tender. |
| 2. Edge & Margin | Margin = junction of normal epithelium and ulcer (boundary). Edge = area between margin and floor. Marked induration = squamous-cell carcinoma or adenocarcinoma. Some induration = gummatous or syphilitic chancre or trophic ulcer. |
| 3. Base | The structure on which the ulcer rests (felt between thumb and index finger). Slight induration = chronic ulcer. Marked induration = squamous-cell carcinoma or Hunterian chancre. |
| 4. Depth | Recorded in millimetres. Trophic ulcers may reach bone. |
| 5. Bleeding | Bleeds to touch = common in malignant ulcer. |
| 6. Relations with Deeper Structures | Malignant ulcer = fixed to deeper structures. Gummatous ulcer over bone = fixed to it. |
| 7. Surrounding Skin | Check temperature, tenderness, mobility, thickening (malignant). Test peripheral nerves for nerve lesion. Feel main arteries; check veins. |
C. EXAMINATION OF LYMPH NODES
| Ulcer Type | Lymph Node Findings |
|---|---|
| Acutely inflamed | Enlarged, tender, acute lymphadenitis; may later form abscess |
| Tuberculous | Become enlarged, matted, slightly tender |
| Hunterian chancre (Syphilis) | Pathognomonic hard (Hunterian), discrete, firm, shotty nodes |
| Rodent ulcer | Lymphatics obliterated early; nodes NOT usually involved |
| Gummatous | Lymph nodes not affected |
| Malignant | Stony hard = secondary involvement (NOT just enlargement) |
D. Examination for Vascular Insufficiency
- Search for varicose veins (lower leg ulcer)
- If no varicose vein found, examine arteries proximal to ulcer (atherosclerosis, Buerger's, Raynaud's)
E. Examination for Nerve Lesion
- Trophic ulcers develop from repeated trauma to insensitive (weight-bearing) areas
- Presence of trophic ulcer = neurological disturbance (tabes dorsalis, transverse myelitis, peripheral neuritis)
GENERAL EXAMINATION (based on suspected type)
- Syphilitic - Search for all syphilitic stigmas (Fig. 4.15): interstitial keratitis, otitis interna, alopecia, bossing of skull, saddle nose, Hutchinson's teeth, sabre tibia, Clutton's joints, gummatous orchitis, condylomata, etc.
- Tuberculous - Examine all lymph nodes (neck, chest, abdomen)
- Ischaemic - Examine whole body for atherosclerosis; examine both limbs (Buerger's = bilateral)
- Trophic - Determine type of nervous disease
SPECIAL INVESTIGATIONS
| Investigation | Purpose |
|---|---|
| Blood (CBC, ESR, Hb, RBC, sugar) | Rule out diabetes, anaemia; TB = high lymphocytes + ESR; Syphilis = WR/Kahn test |
| Urine (sugar) | Exclude diabetes |
| Bacteriological exam of discharge | Identify organism + antibiotic sensitivity. Dark ground illumination = Treponema pallidum from hard chancre. |
| Mantoux test | Diagnose TB ulcer |
| Chest X-ray | Primary focus in TB; metastatic deposits in malignancy |
| Biopsy | Malignant ulcer - edge biopsy to determine type, invasiveness, differentiation |
| X-ray bone & joint | Ulcer near bone; gummatous ulcer (new bone formation, 'sabre tibia') |
| Contrast radiography | Arteriography (arterial/ischaemic ulcer); ascending phlebography (deep vein thrombosis) |
| Radioactive fibrinogen test | Deep vein thrombosis (90% accurate) |
| Technetium clearance | Blood flow in calf muscle; arterial imaging with gamma camera |
CLASSIFICATION OF ULCERS
Clinical Classification (3 types):
- (a) Spreading ulcer - Inflamed skin, profuse offensive slough, no granulation, oedematous ragged edge, painful, lymph nodes inflamed
- (b) Healing ulcer - Pinkish/red granulation, reddish edge, bluish margin (growing epithelium), scanty serous discharge
- (c) Callous/Chronic ulcer - No tendency to heal, pale granulation, wash-leather slough (gummatous), scanty/absent discharge, considerably indurated base and edge
Pathological Classification:
(A) Non-specific ulcers:
- Traumatic (mechanical, physical, chemical)
- Arterial (atherosclerosis, Buerger's, Raynaud's)
- Venous (varicose, postphlebitic)
- Neurogenic/Trophic (bed sore, perforating ulcer)
- Associated with malnutrition (tropical ulcers - Vincent's organisms)
- Associated with other diseases (gout, diabetes, anaemia, avitaminosis, rheumatoid arthritis)
- Special types: Bazin's ulcer (fatty adolescent girls, calves), Martorell's ulcer (hypertension)
(B) Specific ulcers: TB, syphilitic, soft sore, actinomycosis, Meleney's ulcer
(C) Malignant ulcers: Epithelioma, Marjolin's ulcer, rodent ulcer, malignant melanoma
DIFFERENTIAL DIAGNOSIS
| Ulcer Type | Key Features |
|---|---|
| Traumatic | Heals quickly unless infected or ischaemic; mechanical/physical/chemical cause |
| Ischaemic/Arterial | Rare vs. venous. Peripheral arterial disease (atherosclerosis > Buerger's > Raynaud's). Older people. Anterior/outer leg, toes, heel, dorsum of foot. Painful. History of intermittent claudication. Leg elevation → pain worsens. Punched out, minimal granulation, tendons/bone exposed. Dorsalis pedis pulse feeble/absent. |
| Venous | Medial aspect lower 1/3 of leg. Associated with varicose veins. Deep fascia intact (unlike arterial). |
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