Wounds, Ulcers, Fistula, and Sinuses

The Dr started the lecture with: "Congrats that you are now 4th year medical students,
because beginning the clinical life means that you are a part of medicine as a career , you
start seeing patients and practice this career with them, as you were always looking
forward to reaching this stage ."
When you start dealing with patients you have to be professional; to use your knowledge
and experience in the service of your patients, at the same time you have to be honest,
when you deal with your patient you have to be honest, you have to tell him everything,
build a good relationship between you and your patient. Communication skills are very
important to make the picture clear for the patient and the family"
Today, we are talking about a simple but very very common subject, especially in surgical
practice; wounds, ulcers, fistula and sinuses, all of them related to one another.

WOUNDS
1. Definition:
Epithelial discontinuity whether in the skin or mucus membrane (gastrointestinal tract,
respiratory tract )
Ulcer is a wound (its epithelial discontinuity) but it takes usually a chronic course.
Now you are doctors and you should speak using medical terms, so the words (tear) or (break) are
not appropriate.
-You have to use the language of the trade, the jargon of the trade
, ))((

2. Types of wounds:
There are different types, any type of trauma can cause epithelial discontinuity of
certain size and depth
A- Abrasion: if it's very superficial, it just removed part of the epidermis we call it
abrasion.
>> It looks like a burn, superficial burn
Abrasion ()
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This is a type of hematoma, it is

an abrasion, it is just a superficial
removal of small parts of
epidermis and dermis, and it looks
like a burn. It's in the leg, called
abrasion

B- Contusion: the response of the body as a result of a blunt

trauma (blow) to the skin (any part of body).

C-Hematoma: it's a part of contusion but there is collection of blood beneath the
skin.
This is a hematoma, as a result
of blow to the lip, with
collection of blood beneath the
mucus membrane of the lip.

D Incised wounds, tidy clean: the clean cut wounds, surgical wounds, or a knife
wound.
If the skin is exposed to a blow (blunt trauma), and this
skin is very close to the bone, the wound looks like an
incised clean wound (it is not incised with a knife but it
looks like incised wound like in this case).
It is very important if you look to see it (the pic), the area
of redness around the wound, this is an area of
erythema, and the area of erythema here (in the pic) is
wide, it's 2-3 cm, if it is bigger it may indicates an area of
infection in the wound.
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E- Lacerated wound, untidy contaminated to dirty: deep wound, cutting the edges
in an irregular way, weaving some parts as dead tissues or dirty tissues. Usually as a
result of road traffic accidents (RTA), for example car accident and part of a metal
may hit the neck, the abdomen, the lower limb, leading to a lacerated wound,
irregular wound and usually it is dirty wound contaminated with soil in RTA .
Lacerated wound ))

This is a lacerated wound, the picture is not clear enough, there are clips. The
lacerated wound may involve very deep structures inside the wound (bone,
nerves, arteries, veins, muscles, tendons...). If it is in the abdomen, it may
involve the abdominal viscera. If in the neck, it may involve the main
structures there: the esophagus, trachea, main blood vessels.

Some books divide wounds into:

1- TIDY wound: ( clean cut wound )
2- UNTIDY wound: (like lacerated wounds and usually contaminated with the
gastrointestinal contents, or pus from an abscess, or from earth like road traffic
accidents).
Other books divide wounds into CLEAN and CONTAMINATED.

Clean and Contaminated Wounds

This is the most used classification of wounds.
1- Clean wounds: this is the operative wound, no GIT, UG or resp. tract entered.
In surgeries, for example, operation of thyroid gland in the neck, it is a clean wound
and it remains clean. And usually this type of wounds heals by primary intention.
(Closed primarily).

2- Clean contaminated: operative wound with GIT UGT or resp. tract are entered, closed
primarily after cleaning or delayed 1ry.
For example operation for gall bladder, the wound is a clean wound, but when we
remove the gall bladder, it will be opened, and it will contaminate the clean wound
so called CLEAN CONTAMINATED WOUNDS. These operative wounds are usually with
communication with gastrointestinal tract, urogenital, respiratory tract. The wound
could be cleaned and it can be closed primarily (with primary intention), otherwise if
we think that the wound is not cleaned properly, we can close it after (3 -5) days and
we call this DELAYED PRIMARY.

So we have:
A- Primary intention: when we can bring the two edges of the
wound together.
B- Secondary intention: when there is a loss of skin, we can't
bring the two edges together.
C- Delayed primary: means we close the wound after a period
of time (3-5 days).
D- Other wounds are closed by using skin grafts.

3- Contaminated wounds: open fresh wounds with gross spillage from GIT, for delayed
primary closure. As appendectomy wound.

4- Dirty wounds: Old traumatic and purulent wounds and perforated viscous. For
debridement and delayed primary or graft :
A- Road traffic accident wound with contamination with soil. It may contain soil,
mug, glass or grass particles...etc. Soil and mug contain many microorganisms, the
worst is the clostridia that can make tetanus and gas gangrene, the presence of
clostridia is more significant and more dangerous than staphylococci and
streptococci (as their presence in the wound is not a problem as much it is in case
of clostridia).
B- Perforated viscous: like perforated peptic ulcer or duodenal ulcer, usually the
wound here needs debridement, proper cleaning, delayed primary, or it might
need a skin graft.

Management of Wounds - (Wound assessment and primary care)

1) Patient history and physical examination.

2) Compression dressing to stop bleeding.
3) Anti-TT.
4) Antibiotics check sensitivity.
5) Anesthesia local or GA.
6) Washout with sterile isotonic saline.
7) Brushing to remove sand and glass.
8) X-ray for FBs and fractures.
9) Debridement excise dead tissue.
10) Explore for injuries to different structures.
11) Dressing & suturing.

It is very important for all of you from now on to try to explore and see how we can deal
with wounds, you can go to the accident and emergency unit and see wounds of different
types, and see how they can deal with the coming patients from the beginning to the end.

We should receive the patient, if he is talking, by directly communicating with him. You
should clean your hands and wear gloves and put a mask. If you are present at the scene
of the accident, the most important thing to do is to stop the bleeding. How we can stop
bleeding? by direct pressure dressing, if we have sterile gauze, majority of cars nowadays
they carry a first aid kit, so you can use the gauze and the bandages in the kit in the car, or
in your house, if there is no sterile gauze, you can use clean clothes, you can put a towel,
wrap it with pressure to prevent bleeding.
The difference between sterile and clean, is that the sterile contains the minimal amount
of organisms, however the clean contains a higher amount of microorganisms but it is not
heavily contaminated.
How can we deal with a wound?

Management
Wound assessment and primary care
1. Patient history and physical examination
Always talk to the patients and take the history of the problem. He will tell you if he
was hit by a car, or if he fell from a high area, or hit by a bullet, or a stab wound, a
direct blowetc. Then you do a very quick physical examination and examine the
wound. You should make a sketch for the wound (dimensions of the wound, site of
the woundetc.)
2. Compression dressing to stop bleeding
3. Anti-TT
Then you ask the patient if he is covered for anti-tetanus or not. We give the patient
anti-tetanus immunoglobulin and anti-tetanus toxoid plus an anti-biotic.
4. Antibiotics check sensitivity
The most appropriate anti-biotic for clostridium is penicillin. REMEMBER penicillin is
given AFTER the sensitivity test. Give them long acting penicillin for two weeks.
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5. Anesthesia local or GA
6. Explore the wound: Washout with sterile isotonic saline
7. Brushing to remove sand and glass
Do this with a brush to remove sand, pieces of glass, stones, and pieces of metal.
8. X-ray for Foreign Bodies and fractures
This point MUST be considered, as leaving the tiniest foreign bodies in the patient
without removal will leave the patient unsatisfied with you, and possibly exaggerate
when telling people what happened. For example, you might break the small tip of a
needle in the patients wound, and the next day the patient will tell people you left a
whole pair of scissors in his body. So dont miss any foreign bodies in patients
bodies.
9. Debridement excise dead tissue
You should inspect the viability of the tissue, if there is any dead tissue, excise it.
EXCEPT in the face. We cannot sacrifice the skin of the face. Usually the viability of
the skin of the face is good, due to rich blood supply, good venous drainage, it heals
well and the infection rate is less.
10. Explore for injuries to different structures (nerves, muscles, tendons, arteries,
veins...etc.)
Usually arteries need primary repair. Some of the veins -like the long saphenous
vein- might be ligated, while the femoral vein should be repaired. The nerves should
also be repaired, but it might be delayed. Tendons can also be repaired later on
after the wound is cleaned to ensure there is no infection in the area.
11.Dressing & suturing
If we think that the wound is contaminated or dirty, we can close it primarily after
3-5 days. If we lost skin, we can do a skin graft later on. If we think it is clean, we
can close it primarily on the same day.

Closure
- This is a tidy clean wound. Usually for the face we make
an immediate primary closure in the same day.
- Tidy dirty wounds for delayed primary closure

Healing
Healing by primary intention
Healing by secondary intention for wounds with loss of skin

Physiological stages of wound healing

These stages are very important, never forget them!
1) Inflammatory Phase Day 1-4
Initial response, with rubor (redness), tumor(swelling), dolor(pain), calor
Platelet aggregation and adhesiveness to the area, and activation, Leukocyte
migration, phagocytosis and mediator release
Venule dilation, Lymphatic blockade, Exudation
Primary intention, lasts 4 days
Secondary intention, continues until epithelialization is complete
2) Proliferative Phase Day 4-42
Fibroblast proliferation stimulated by macrophage-released growth factors
Increased production of collagen by fibroblasts, Granulation tissue and neovascularization (the formation of capillaries).
Gain in tensile strength

3) Remodeling Phase 6wks-1 year,

Intermolecular cross-linking of collagen via vitamin C-dependent hydroxylation
Increase in tensile strength, Type III collagen replaced with type I
Scar flattens

Wound infection
It becomes apparent
Between 2-4 days from operative day (these days are the days when we suspect
that the wound might be infected). This is also applied on operational wounds. The
operation day is considered day zero, on day one they dont suspect having a wound
infection, on day 2 they do (after 48 hours).
Area of erythema redness' of more than 5cm (here the patient starts to complain
of throbbing pain)
Indurations
After a few days fluctuations will occur (abscesses).

Ulcers
Definition: An ulcer is an epithelial discontinuity. It is considered a wound due to a
chronic cause.
Ulcer is a chronic wound due to:
Physical or chemical injury (Something you should always remember: you should
NEVER apply disinfectants or an anti-septic solution to a living tissue)
Ischemia (inadequate blood supply)
Neoplastic changes (squamous cell, basal cell carcinoma...)
Systemic diseases (renal failure, liver failure, diabetes, a patient receiving
hydrocortisone can all reduce the possibility of wound healing)
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History
When first noticed?
(The onset of the ulcer and its duration). Sometimes the people around the patient
are the ones who will notice the ulcer, not the patient himself. (For example the
patient's wife might find blood on his socks, or smell a bad odor from his shoes).
What brought it to attention?
(The symptoms associated with the ulcer: pain, discharge, bleeding, and smell)
The progress of ulcer (size, shape, depth, discharge and response to any treatment)
Previous similar lesions, systemic symptoms and what the patient thinks.
(It's very important to ask the patient what he thinks and take his opinion).

"It's important to take his opinion because the patient is the universe
around which the medical profession rotates"

Examination of an ulcer
1. Site :sometimes its characteristic because certain ulcers occur in certain sites, for
example:
- Venous is sited in the leg above the medial Malleolus.
- Arterial in the toes.
- Diabetic in the foot as neuropathic, arterial or infective traumatic.
2. Size
3. Shape
4. The base and the floor
5. The edge of the ulcer
6. The margins
7. The draining lymph nodes

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1-Site:
This is an ulcer that occurred with varicose vein.

This is the same leg after healing. This type of ulcer occurs when there is inadequate
venous drainage that causes venous ischemia.

Normally, the superficial venous system drains into the deep system, but if the deep
system is not functioning properly, it will cause stagnation of blood and fluid in the
subcutaneous tissue and skin will be ruptured. Especially those who stand for a long period
of time without exercising their legs.

This is a venous ulcer.

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Arterial ulcers usually occur in the toes, the inadequate arterial blood supply to the toes
can lead to ulceration in the bulb of the toe. The patient may present with an in growing
toe nail (he will come with pain in his nail, you should make sure that the blood supply is
adequate before removing the nail. if you remove the nail in the presence of ischemia , the
ulcer will never heal and result in ischemic ulcer ).
This is a diabetic foot in which the patient has only the heel, the big toe and part of the
sole. The other toes and the rest of the foot are amputated because the blood supply was
inadequate. The result is ischemia and infection (ischemia occurs because the veins and
the arteries become thrombosed).
We see another ischemic ulcer over the heel on the left of the figure.

Neuropathic Ulcer
Usually there is hypertrophied skin, it's an attempt for healing all the time .the patient will
have an area which is cleaned, covered with healthy granulation tissue but there is no
healing.
The patient doesnt feel his foot, and keeps using his limb all the time and this prevents
epithelialization of this area.

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This is a traumatic ulcer in the left limb on a paraplegic patient due to repeated trauma
from the edge of the table and the wheelchair. So this ulceration is due to loss of sensation
(he doesnt feel his limbs).

Bed sore is a healing ulcer, it was black and gangrenous. The figure in the slide not clear at
all. On the right its the one that is black and gangrenous.

Sometimes ulcers can occur inside the body, this is an example of peptic ulcer disease
inside the stomach and it may occur in the duodenum but it will be smaller.

It becomes apparent in upper GI endoscopy

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2. The shape of the ulcer could be irregular or regular.

3. Size:
In cm. If it's irregular we can describe it as: it's an irregular ulcer with a maximum
length of 10cm and a maximum breadth of 5cm.

4. The base and the floor :

This is the floor, it's the upper part where it may show the covering of an ulcer .It's
about secretions which can become dry especially in burns. We call it scar.
The other part is called the base, which is the part that is beneath the ulcer.

5.

The edge of the ulcer

Which is part of the ulcer where it communicate

with normal skin and it can be:
1. Sloping: this is a good sign, the ulcer here
is a healing ulcer.
2. Punched out: which can occur in syphilis
or in ischemic ulcers.
3. Undermined ulcers occurs in TB
4. Rolled ulcers in basal cell carcinoma
5. Everted ulcer in squamous cell carcinoma
Usually malignant ulcers are added to the surface
of the skin (higher than the surface) while benign
ulcers take from the normal skin.

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6. The margins
It's a medical term that describe the surrounding tissue of an ulcer. Which could be
segmented, red and erythematous, swollen and edematous.
The skin around venous ulcer is pigmented (deeper in color).

7. The draining lymph nodes

The draining lymph nodes of the lower limbs are the superficial group of inguinal lymph
nodes. The superficial group lies transverse in the inguinal area. The deep group lies along
the common femoral and external iliac arteries (longitudinal).

Sinuses
A sinus is a tract which is lined with a granulation tissue connecting an abnormal cavity an
abscess to an epithelial surface.
The most common sinus that we deal with is the pilonidal sinus () .
It's communicating the abscess cavity with the skin, usually the granulation tissue will
protrude through the opening to the outside so it's called exuberant.
The main symptoms are recurrent infection and discharge, if the sinus is closed the patient
start complaining of throbbing pain until we open it. When it's open, he will complain of
infection and discharge.

The factors that lead to sinus formation

1. Inadequate drainage of an abscess.
for example : drained a pilonidal abscess by small incision , a sinus after that will be
formed .but if we open it widely and clean it , abscess start to heal from the bottom
to the upward .
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2. Chronic inflammation
Some sinuses in the neck due to tuberculous lymph nodes, or syphilis or fungal
infection (actinoycosis) in the mandible, or crohn's disease in the anal canal.
3. The presence of foreign bodies :
Like the hair that is present in a pilonidal sinus will leave it open. Sometimes the
sutures materials which we use might be considered foreign bodies.
4. Congenital sinuses lined with epithelial tissues like: dermoid cyst, branchial cyst and
preauricular sinus.
5. Malignant diseases may spread to present as a sinus,
Like: paget disease of the nipple, and sister-Joseph nodule in the umbilicus from a
carcinoma of the stomach with the spread into the peritoneum and invasion of the
umbilical scar .so it will open into the umbilicus.
This is the preauricular sinus, and there is the auricular sinus. Both of them are
congenital. The sinus is from an abnormal cavity to the skin.

Fistulae
Fistula is an abnormal communication (tract) between 2 epithelial surfaces. For example:
the anal canal and the bowel to the skin (2 epithelial surfaces: anal canal and the skin)
It occurs when an abscess breaks into two adjacent epithelial surfaces, and then it opens
to the inside and outside and sometimes we interfere to open it to the outside. It will lead
to fistula formation. So fistula in the anal canal is common.
Etiological factors as in sinuses in addition to continuous flow of feces in perianal fistula
and Crohns disease
Congenital In tracheo-bronchial fistula.
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This is a figure of Crohns disease

Done by: Haya Al Rawabdeh

Bara Zubi
Rawan Hammoudeh

Collected and checked by: Khawla Momani

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