1
Third stage
Surgery
Lec-1
.د
اسامة
1/1/2016
Ulcer
Its discontinuity of the covering epithelium with progressive destruction of the epithelial
surface.
Classification
1- Nonspecific which could be due to
Traumatic, infective, neuropathic, iatrogenic, ischemic, physical, or chemical causes
2- Specific due to specific infection like TB, Syphilis.
3- Malignant.
Clinical evaluation of ulcer
1- Site: 95% of Bcc occur in the upper part of the face. Venous ulcer mostly affect the
medial malleuolus.
2- Size: its depend on the nature of the ulcer, inflammatory ulcer is rapidly progressing ,less
rapidly is malignant one.
3- Shape: rodent (BCC)ulcer tend to be circular.
4- Edge:
Sloping edge found in healing ulcer.
Undermined edge due to destruction of subcutaneous tissue more than the skin like
in TB or ulcer in a fatty area.
Punched out edge occur when there is a cut limit between pathological and normal
cells like in ischemic, neuropathic and syphilitic ulcer.
Everted edge due to excessive growth of cells that sheds on the margin of the ulcer
like in malignancy.
Rolled edge occur in less malignant ulcer like Bcc.
5- Floor: part of the ulcer that can be seen, it may show granulation, slough, exposed
tendon or bone.
6- Base: part of the ulcer that can be palpated which may be indurated or attached to deep
structure.
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7- Discharge: pus mean infection, watery discharge in TB, or blood discharge.
8- Pain: ischemic and inflammatory ulcers are painful while neuropathic ulcer is not.
9- Lymphatic drainage: painful lymph adenitis associated with inflammatory condition while
painless lymph node is due to secondary deposition.
10- Surrounding area: which may show sign of inflammation or invasion of malignancy.
Investigation
1- Culture and sensitivity in case of suspected infection.
2- Biopsy which could be
A- Incisional: where part of the ulcer is removed.
B- Excisional: where all the ulcer is removed
Management
1- General:
A- Control the causative factor like infection, ischemia, neuritis, malignancy.
B- Control the comorbed factor like DM, anemia, malnutrition.
C- antibiotic in infected ulcer
2- Local:
A- desloughing and pus drainage.
B- Excision of the ulcer with primary suture or graft.
C- Dressing by using non adhesive non allergic cost effective material like hydrocolloid gel
or micro porous polyurethane.
Gangrene
It is death and putrefaction of macroscopical portion of tissue.
Etiology
1- Vascular obstruction: by emboli, thrombus, arteritis, burger disease, raynoid disease.
2- Infection: like boil, carbuncle, gas gangrene.
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3- Traumatic: which could be
A- Direct by crushing or strangulation.
B- Indirect vascular injury proximal to the site of gangrene.
4- Physical cause like burn, frostbite
5-Chemical like phenol or drugs like ergot
6-Elecetrical shock.
The gangrenous part show
1-lack of vascular supply there are no pulse, venous return or capillary filling.
2-Lack of sensation
3-lack of temperature regulation
4- lack of function
5- change of color into black due to disintegration of HB to iron sulfate.
5 P ( painless, pulsless, parasthesia, progressive loss of tempreture, paralyses)
Clinical types of gangrene
1- Dry type: slow and gradual loss of blood supply without infection, the lesion is dry and
wrinkled, early appearance of line of demarcation.
2-Wet type (moist) : sudden obstruction of blood supply, always associated with infection,
the area show edema and there is no line of demarcation.
The line of demarcation: it is the line between the dead and viable tissue determined by a
zone of hyperemia and hyperesthesia, the separation achieved by a layer of granulation
tissue and ulceration.
In case of dry gangrene the line appear in few days without infection (separation with
aseptic ulceration)
while in moist gangrene the line of demarcation delay or fail to form (separation with septic
ulceration)
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Principle of management
1-Amputation:
which could be
A- Life saving amputation in case of gas gangrene or sever crushing injury or in moist type
with extensive infection.
B-Limb saving amputation in case of dry gangrene with adequate vascular supply proximal
to the pathology.
2- General treatment: include control of DM, anemia, malnutrition, ischemia and infection.
3- Local treatment: this achieved by keeping the limb cold and dry prevent local pressure or
massaging, drainage of pus if present.
The aim is to change the wet type to dry one and keep the dry type dry as possible.
Gas gangrene
Causes: clostridia perfringens
a gram positive anaerobic spore forming bacilli found in the soil and stool.
Wound in danger: Dirty, contaminated, with necrotic tissue, presence of foreign bodies.
Mostly involved wounds are: war injuries ,sever crush, trauma in industries or RTA, post
amputation for vascular reasons.
Predisposing factors: DM, malignancy, immune suppression.
Clinical picture:
Local: sever local pain with swelling, thin brownish discharge with sweet smell associated
with crebetus sensation on palpation due to subcutaneous gas formation
Systemic: fever and circulatory collapse
X ray show gas in the subcutaneous space.
Prophylaxes: Prophylactic penicillin to patient with high risk, Adequate wound toilet and
depredment.
Treatment:
Heavy dose of antibiotic in form of IV penicillin each 6 hours.
Aggressive wound excision
live saving amputation
Hyperbaric oxygen?