March 31, 2009

Approach to an ulcer

1) Explain the abnormalities seen in the picture (4m)

2) Give one most possible causes of the abnormality and the Pathophysiology for the condition (3m)

3) Name one complication of the abnormality (1m)

4) Outline the management for this patient. (2m)

Ok friends! First of all please try to answer the above questions first. I post the answer below. Approach to an ulcer also being posted below



a) Grade one single ulcer

b) Plantar surface of big toe

c) Healing margin

d) Punched edge

e) Floor filled with granulation tissue


a) Trophic ulcer due to uncontrolled diabetis mellitus

b) Uncontrolled DM --> peripheral neuropathy -->motor damage + sensory damage + autonomic damage --> ulcer formation without realizing it --> will extend and complicate the ulcer.

3) Osteomyelitis


a) Debridement

b) Relieve the pressure

c) Antibiotic if present with infection.

Approach to an ulcer

Basically it is divided into 3 steps. Inspection, palpation and focal examination.

1) Size and shape
2) Number
3) Location
4) Margin (Healing, Inflammed, Fibrosed)
5) Edge (Sloping, punched, everted, undermined, everted, raised)
6) Floor (Granulation tissue, slough, discharge)
7) surrounding skins (inflammation, pigmentation, scars&puckering, hypopigmentation)

1) Surrounding skins (Temperature, tenderness)
2) Edge of the ulcer (soft: healing ulcer, firm: non healing, hard:malignant)
3) Floor of ulcer (Consistency, underlying structure)
4) Test the fixity (skin, muscle, bone)

Focal examination
1) Lymph node
2) Arteries, venous circulation, nerves
3) Movement of neighboring joint

******Grading of ulcer (especially for ulcer foot)
Grade 0 — No ulcer in a high risk foot.
Grade 1 — Superficial ulcer involving the full skin thickness but not underlying tissues
• Grade 2 — Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation
• Grade 3 — Deep ulcer with cellulitis or abscess formation, often with osteomyelitis
• Grade 4 — Localized gangrene.
• Grade 5 — Extensive gangrene involving the whole foot.

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