ULCERS

1. Arterial Ulcers

 Cause: Result from poor blood supply to the affected area, usually due to
peripheral arterial disease (PAD).
 Location: Commonly occur on the toes, feet, heels, and other pressure
points.
 Appearance:
o Well-defined edges with a "punched-out" look.
o Base may appear dry, pale, or necrotic (black).
o Surrounding skin is often shiny, cold, and hairless due to poor
circulation.
 Symptoms:
o Severe pain, especially at night or when the leg is elevated.
o Pain improves when the leg is lowered (dependent position).
 Risk Factors:
o Atherosclerosis, smoking, diabetes, high cholesterol, and
hypertension.
 Management:

Goals of Treatment:

 Restore blood flow.

 Prevent infection.
 Promote wound healing.

A. Improve Circulation

1. Lifestyle Modifications:
o Smoking cessation (essential to improve blood flow).
o Exercise (e.g., supervised walking programs to promote collateral circulation in
PAD).
2. Pharmacological Management:
o Antiplatelet agents (e.g., aspirin or clopidogrel) to reduce the risk of thrombosis.
o Statins to manage hyperlipidemia.
3. Surgical/Revascularization Procedures:
o Angioplasty: Widening of narrowed arteries using a balloon catheter, often with
stent placement.
o Bypass Surgery: Creating a graft to bypass blocked arteries.

B. Wound Care
  Debridement: Remove necrotic tissue cautiously (avoid aggressive debridement if blood
flow is severely compromised).
 Dressings: Use non-occlusive, moisture-retaining dressings (e.g., hydrogel for dry
ulcers).
 Topical Agents: Consider antimicrobial dressings if signs of infection.

C. Pain Management

 Pain relief with analgesics (e.g., NSAIDs, opioids for severe cases).

D. Prevent Complications

 Avoid compression therapy as it worsens ischemia.

 Regular monitoring for signs of infection (e.g., cellulitis, osteomyelitis).

2. Venous Ulcers
 Cause: Result from chronic venous insufficiency (CVI), where blood pools
in the veins due to valve dysfunction.
 Location: Typically found in the medial lower leg, especially above the
medial malleolus (ankle).
 Appearance:
o Irregularly shaped with shallow depth.
o Often surrounded by hyperpigmentation or lipodermatosclerosis.
o Exudative (wet) with granulating tissue in the base.
 Symptoms:
o Aching or heaviness in the legs, which worsens with prolonged
standing or sitting.
o Pain is usually mild compared to arterial ulcers.
 Risk Factors:
o Obesity, prolonged immobility, deep vein thrombosis (DVT), and
varicose veins.

Venous Ulcers management;

Goals of Treatment:

 Improve venous return.

 Manage inflammation and exudation.
 Heal the ulcer and prevent recurrence.

A. Compression Therapy
  The cornerstone of venous ulcer management.

1. Elastic Compression Stockings/Bandages: Apply graduated pressure to reduce venous

pooling and promote blood flow.
o Pressure ranges:
 Mild: 20-30 mmHg for mild venous insufficiency.
 Moderate: 30-40 mmHg for more severe cases.
2. Contraindications: Avoid in patients with significant arterial disease (check ABPI first;
avoid compression if ABPI < 0.5).

B. Wound Care

 Debridement: Remove slough and necrotic tissue to promote healing.

 Dressings: Use absorbent dressings (e.g., foam, hydrocolloid) to manage high exudate
levels.
 Skin Care:
o Keep surrounding skin moisturized to prevent dryness.
o Use barrier creams to protect against maceration.

C. Improve Venous Circulation

 Leg Elevation: Elevate the legs above heart level for 30 minutes, 3-4 times daily.
 Exercise: Ankle pumps and calf strengthening exercises to improve venous return.

D. Address Underlying Causes

 Treat varicose veins or venous reflux with procedures like endovenous laser therapy,
sclerotherapy, or vein stripping if indicated.

E. Treat Infections

 Antibiotics: Only if there is a clear sign of infection (e.g., cellulitis, increased exudate
with odor, redness).

3. Neuropathic Ulcers
 Cause: Occur due to peripheral neuropathy, commonly in diabetic patients,
where there is loss of protective sensation and pressure-related injury.
 Location: Commonly on weight-bearing areas like the soles, metatarsal
heads, and heels.
 Appearance:
o Painless and surrounded by callus.
o Well-defined edges with a deep wound bed.
 o Often associated with underlying bone deformities (e.g., Charcot
foot).
 Symptoms:
o Painless due to sensory nerve damage.
o May become infected without obvious signs due to impaired immune
response.
 Risk Factors:
o Diabetes mellitus, peripheral neuropathy, poor footwear.
 Management:

Goals of Treatment:

 Relieve pressure on the ulcer.

 Prevent infection.
 Promote healing.

A. Offloading Pressure

1. Special Footwear: Custom orthotic shoes or padded footwear to reduce pressure on

weight-bearing areas.
2. Total Contact Casting (TCC): A cast that redistributes pressure from the ulcerated area
to healthier parts of the foot.
3. Assistive Devices: Crutches or wheelchairs for severe cases.

B. Glycemic Control

 Tight blood sugar control is essential in diabetic patients to promote wound healing.
 Target HbA1c: Generally < 7% (individualized based on comorbidities).

C. Wound Care

1. Debridement:
o Remove necrotic tissue or callus (use sharp, enzymatic, or autolytic debridement
methods).
2. Dressings:
o Moisture-retaining dressings (e.g., hydrogel, hydrocolloid) for dry ulcers.
o Absorbent dressings for exudative wounds.
3. Infection Management:
o Topical antibiotics for localized infections.
o Systemic antibiotics for deeper infections (osteomyelitis or sepsis).

D. Address Peripheral Neuropathy

 Medications for Neuropathic Pain (if present): Pregabalin, gabapentin, or duloxetine.

E. Regular Monitoring

 Daily foot inspection by the patient.

 Routine follow-ups with a podiatrist for ulcer evaluation and foot care.

Varicose Veins

Varicose veins are dilated, tortuous, and elongated superficial veins, most commonly affecting
the lower limbs. They result from venous valve incompetence, leading to chronic venous
insufficiency.

Pathophysiology

1. The venous system in the legs has valves that prevent blood from flowing backward.
2. Valve dysfunction or damage leads to retrograde blood flow, causing increased venous
pressure (venous hypertension).
3. This pressure distends the veins, causing them to become varicose.

Risk Factors

 Age: More common in older adults.

  Gender: Higher prevalence in women (due to hormonal influences like pregnancy or
menopause).
 Family History: Genetic predisposition.
 Occupation: Prolonged standing (e.g., teachers, hairdressers).
 Obesity: Increased intra-abdominal pressure.
 Pregnancy: Hormonal changes and increased venous pressure from the growing uterus.

Clinical Features

1. Visible Symptoms:
o Prominent, dilated, tortuous veins (blue or purple) on the legs.
o Often seen on the posterior calf or medial aspect of the leg.
2. Associated Symptoms:
o Aching, heaviness, or throbbing in the legs.
o Swelling (edema), especially after prolonged standing.
o Itching or burning sensations.
o Night cramps.
o Skin changes (e.g., pigmentation, eczema, or ulceration in advanced cases).
3. Complications (if untreated):
o Bleeding from superficial veins.
o Thrombophlebitis (inflammation and clotting in the vein).
o Venous ulcers (usually around the medial malleolus).

Management

A. Conservative Management

1. Compression Therapy:
o Use graduated compression stockings to improve venous return and reduce
swelling.
o Pressure ranges:
 Class 1 (15-20 mmHg) for mild cases.
 Class 2 (20-30 mmHg) for moderate-severe cases.
2. Lifestyle Modifications:
o Leg Elevation: Elevate legs above heart level for 20-30 minutes, 3-4 times daily.
o Exercise: Encourage activities like walking or swimming to enhance calf muscle
pump function.
o Avoid prolonged standing or sitting.
3. Weight Management: Maintain a healthy weight to reduce venous pressure.
B. Medical Management

 Topical Agents: For associated symptoms like eczema (e.g., emollients, corticosteroid
creams for inflammation).
 Analgesics: For pain or discomfort.

C. Interventional/Surgical Management

1. Sclerotherapy:
o Injection of a sclerosant (chemical agent) into the vein, causing it to collapse and
close.
o Best for small varicose or spider veins.
2. Endovenous Ablation Techniques:
o Radiofrequency Ablation (RFA): Heat generated by radiofrequency energy
closes the vein.
o Endovenous Laser Therapy (EVLT): Uses laser energy to obliterate the vein.
3. Surgical Options:
o Ligation and Stripping: The affected vein is tied off and removed.
o Indicated for severe or recurrent cases.
4. Foam Sclerotherapy: A foam sclerosant is injected into larger veins for more effective
closure.
5. Phlebectomy: Removal of smaller varicose veins through tiny skin incisions.

D. Advanced Management for Complications

 Venous Ulcers: Compression therapy combined with appropriate wound care.

 Thrombophlebitis: Anti-inflammatory medications and compression.

Perforators in the Lower Limb:

1. Cockett's Perforators:
o Found in the medial aspect of the lower leg.
o Connect the posterior tibial veins (deep system) to the great saphenous vein
(superficial system).
o Located around the ankle and lower calf.
2. Boyd's Perforator:
o Found in the upper part of the calf.
o Connects the great saphenous vein to the deep veins of the calf.
3. Dodd's Perforator:
o Found in the medial aspect of the thigh.
o Links the great saphenous vein to the femoral vein.
4. Hunterian Perforator:
o Found in the upper thigh.
o Connects the great saphenous vein to the femoral vein.
A graft refers to a tissue or organ that is transplanted from one part of the body to another or
from one individual to another. Grafting is commonly used in surgical and medical practices to
replace or repair damaged tissues or organs. There are several types of grafts based on the source
of the tissue:

1. Autograft:

 Tissue is taken from one part of the body and transplanted to another part of the same
individual's body.
 Example: Skin grafts used to cover burns.

2. Allograft (Homograft):

 Tissue is taken from one individual and transplanted into a genetically different
individual of the same species.
 Example: Kidney transplants between humans.
 Requires immunosuppressive medication to prevent rejection.

3. Xenograft (Heterograft):

 Tissue is transplanted from one species to another.

 Example: Porcine (pig) heart valves used in humans.

4. Isograft:

 Tissue is transplanted between genetically identical individuals, such as identical twins.

 Low risk of rejection since there is no genetic difference.

Common Uses of Grafts:

 Skin Grafts: For burn victims or large wounds.

 Bone Grafts: To repair fractures or support bone healing in orthopedic surgery.
 Corneal Grafts: For restoring vision in cases of corneal damage.
 Organ Transplants: Kidney, liver, heart, and other organ replacements.

Key Challenges in Grafting:

 Rejection: The recipient's immune system may attack the graft if it's not from the same
individual or an identical match.
 Infection: Graft sites are prone to infections if not cared for properly.
 Failure: Sometimes, grafts do not integrate well with the recipient's body.
Skin Grafting:

Skin grafting is a common surgical procedure where healthy skin is transplanted to cover
wounds, burns, or damaged areas. Skin grafts are classified into two types based on the thickness
of the skin taken:

1. Split-Thickness Skin Graft (STSG):

 Definition: Includes the epidermis and a portion of the dermis.

 Source Areas: Common donor sites include the thighs, buttocks, or abdomen.
 Advantages:
o Heals faster at the donor site due to the dermis remaining intact.
o Can cover larger areas, making it suitable for extensive burns or wounds.
 Disadvantages:
o May contract during healing, leading to reduced elasticity.
o Often lacks natural pigmentation and hair follicles, so it may not blend
aesthetically.
 Uses: Burn injuries, chronic ulcers, and large wounds.

2. Full-Thickness Skin Graft (FTSG):

 Definition: Includes the entire epidermis and dermis.

 Source Areas: Common donor sites include the groin, behind the ears, or the inner upper
arm.
 Advantages:
o Provides better cosmetic results with natural pigmentation and hair growth.
o More resistant to contracture, offering better flexibility and elasticity.
 Disadvantages:
o The donor site may require closure with sutures or a separate skin graft.
o Limited in size due to the need for primary closure at the donor site.
 Uses: Small but visible areas such as the face, hands, or neck, where aesthetics and
functionality are critical.
A flap in surgery refers to a piece of tissue that maintain its own blood supply while being
transferred from donor to a recipient site. It is used to cover wounds, reconstruct defects, or
repair damaged areas. Flaps differ from grafts in that they have their vascular supply intact.

Types of Flaps

Flaps are classified based on several factors:

1. Based on Blood Supply:

 Random Pattern Flap:

o Relies on blood supply from the surrounding tissue without a defined blood
vessel.
o Used for small defects in areas with good vascularity.
 Axial Pattern Flap:
o Contains a defined artery and vein, ensuring a better blood supply.
o Example: Radial forearm flap.

2. Based on Composition:

 Cutaneous Flap:
o Composed of skin and subcutaneous tissue.
o Used for surface reconstruction.
 Fasciocutaneous Flap:
o Includes skin, subcutaneous tissue, and fascia.
o Provides strength and coverage, often used for extremities.
 Muscle Flap:
o Composed of muscle tissue, with or without skin.
o Used for deeper defects or to fill dead space.
 Osteocutaneous Flap:
o Contains bone, skin, and soft tissue.
o Used for reconstruction requiring bone support, e.g., jaw reconstruction.

3. Based on Movement:

 Local Flap:
o Tissue is adjacent to the defect and remains connected by its base.
o Types:
 Advancement Flap: Moved directly forward into the defect.
 Rotation Flap: Rotated around a pivot point into the defect.
 Transposition Flap: Moved across an area of healthy tissue to cover the
defect.
 Regional Flap:
o Tissue is harvested from a nearby area and retains its blood supply.
 Free Flap:
 o Tissue is completely detached and transferred to a distant site. Blood vessels are
reconnected using microsurgery.
o Used for complex reconstructions, such as after cancer surgery.

4. Based on Function:

 Functional Flap:
o Retains functionality, such as a muscle flap that still contracts.
 Non-functional Flap:
o Provides coverage or volume without preserving original functionality.

Common Uses of Flaps:

 Trauma: To cover open fractures, especially when bones or tendons are exposed.
 Cancer Reconstruction: For defects after tumor excision, such as breast reconstruction
post-mastectomy.
 Burns and Scars: For severe burns or contractures where grafting is insufficient.
 Congenital Defects: To reconstruct areas like cleft palate.

Advantages of Flaps over Grafts:

 Better Blood Supply: Ensures faster healing and increased survival rate of the tissue.
 Thicker Tissue Coverage: Provides more volume and strength compared to grafts.
 Functional Reconstruction: Muscle flaps can restore some degree of movement or
function.
 Versatility: Can include skin, muscle, fat, or bone as needed.

Disadvantages of flaps:

1. Surgical Complexity: Requires advanced skills and equipment, especially for free flaps.
2. Complications: Risk of flap necrosis, infection, hematoma, seroma, or venous
congestion.
3. Donor Site Morbidity: Scarring, pain, and possible functional impairment at the donor
site.
4. Prolonged Recovery: Longer hospital stay, delayed mobility, and potential need for
rehabilitation.
5. Aesthetic Issues: Mismatch in color, texture, or bulkiness requiring additional
procedures.
6. Cost: Expensive due to the resources, equipment, and expertise required.
7. Limited Indications: Not ideal for patients with poor vascular status or large defects.