APPROACH TO

FOOT ULCER

DEFINITION
An ulcer is a break in the continuity of the

covering epithelium skin or mucous membrane

due t0 molecular death of the cells associated
with either acute or chronic inflammation.
Legs & feet are susceptible to ulcer formation.

ETIOLOGY
TRAUMATIC
DIABETIC
ARTERIAL
VENOUS
MALIGNANCY

OTHER CAUSES
ERYTHROCYANOID ULCER (BAZINS DISEASE)
GUMMATOUS ULCER
MARTORELLS ULCER
INFECTIVE ULCERS TB, SYPHILIS, STAPHYLOCOCCUS,
etc.
ULCERS COMPLICATING VARIOUS DISEASES

GROSS ANEMIA, POLYCYTHEMIA, LEUKEMIA, RA, PAGETS,

etc.

TROPICAL ULCER
YAWS
ULCER FROM CONGENITAL AV FISTULA

WAGNERS CLASSIFICATION

GRADE 0 : NO OPEN LESION, INTACT SKIN-

IMPENDING ULCER (Callus may be present)

WAGNERS CLASSIFICATION
GRADE 1 : SUPERFICIAL ULCER

WAGNERS CLASSIFICATION
GRADE 2 : DEEP ULCER TO TENDON , CAPSULE OR

BONE

WAGNERS CLASSIFICATION
GRADE 3 : DEEP ULCER WITH ABSCESS ,

OSTEOMYELITIS & JOINT SEPSIS

WAGNERS CLASSIFICATION
GRADE 4 : LOCALISED GANGRENE

WAGNERS CLASSIFICATION
GRADE 5 : GANGRENE OF ENTIRE FOOT

PEDIS CLASSIFICATION

HISTORY - APPROACH
DESCRIBING ABOUT THE ULCER

TO ASSESS THE ETIOLOGY OF THE ULCER

HISTORY OF
PAIN
FEVER
DISCHARGE
COLOUR, AMOUNT, TYPE OF DISCHARGE

TO ASSESS ETIOLOGY
HISTORY OF
TRAUMA
SENSATION OF FOOT
INTERMITTENT CLAUDICATION
DILATATION OF VEINS/ PROLONGED STANDING
LOSS OF APPETITE/ WEIGHT
SWELLING IN GROIN
DIABETES, HYPERTENSION, TUBERCULOSIS,
VENEREAL DISEASE
MEDICATION INTAKE
SURGERY DONE

ARTERIAL ULCER

VENOUS ULCER

MALIGNANT ULCER

EXAMINATION OF ULCER
INSPECTION
6 S
SITE
SIZE
SHAPE
SURGACE
SKIN
SCAR
NUMBER
FLOOR
EDGE
MARGIN

PALPATION
LOCAL TEMPERATURE
TENDERNESS OF THE EDGE OR BASE OF

ULCER
BASE OF ULCER
MOBILITY OF ULCER

TO CHECK
PERIPHERAL PULSATION
PERIPHERAL SENSATION
ANY VENOUS DISEASE
DRAINING LYMPHNODES
MONOFILAMENT TEST
ANKLE BRACHIAL INDEX

DIAGNOSIS
SIDE, CONDITION OF THE ULCER, ETIOLOGY
Eg. Right foot chronic non healing ulcer due to

diabetes.

CAUSES OF NON HEALING ULCER

LOCAL FACTORS
LACK OF ADEQUATE REST
LACK OF ADEQUATE
IMMOBILISATION
REPEATED TRAUMA
REPEATED INFECTION
PRESENCE OF FOREIGN BODY
PRESENCE OF SEQUESTRUM
PRESENCE OF ARTERIAL
DISEASE
PRESENCE OF VENOUS
DEISEASE
PRESENCE OF LYMPHATIC
DISEASE
PRESENCE OF NERVE
DISEASE

GENERAL FACTORS
ANEMIA
HYPOPROTENEMIA
DIABETES MELLITUS
TUBERCULOSIS
HYPERTENSION
CHRONIC LIVER DISEASE
CHRONIC RENAL DISEASE
PATIENT ON STEROIDS
MALIGNANCY
RADIATION
CYTOTOXIC DRUGS

INVESTIGATIONS
LAB INVESTIGATIONS
Complete Blood Count
ESR
Fasting/ Post prandial blood sugar
Pus swab for Culture Sensitivity
Tissue for culture sensitivity
Edge Biopsy

RECOMMENDATION FOR COLLECTING

SPECIMENS FOR CULTURE
Obtain culture only if there is clinical evidence of infection,
Debride & cleanse the wound before collecting specimen,
Obtain tissue specimen from ulcer by currettage,
Biopsy of deep tissue or infected bone c/s,
Avoid sending just wound swab,
Obtain blood culture, if pt. is systemically ill,
Request for gram stained smear of specimen.

Imaging
Chest X ray
Local foot X ray
Arterial and Venous Doppler Study
CT Angiography

THANK YOU
PROF. DR. BARANI RAJKUMAR