SRB’s Surgery for Dental Students Sriram Bhat M
Page numbers followed by “f” or “t” indicate figure or table respectively
Abdominal compartment syndrome 226
Abdominal esophagus 392
Abdominal trauma 223224
Achalasia cardia
clinical features 395
etiology 394
investigations 395
treatment 395
Achondroplasia 416
Acid-base balance 191192
metabolic 192
respiratory 192
metabolic 191192
respiratory 192
metabolic 192
respiratory 192
Acinic cell tumor
Acrocyanosis 84
Actinomyces israelii 4546
Actinomycosis 4546
clinical features 4546
clinical types 45
differential diagnosis 46
investigation of 46
pathogenesis 45
sulfur granules in 45
treatment 46
Acute arterial occlusion 99100
Acute osteomyelitis 412
Acute pharyngitis 371
Acute pyomyositis 52
Acute suppurative tenosynovitis
complications 213214
surgical anatomy 213
treatment 213
Adenoid cystic carcinoma 319
Adenolymphoma 317, 317f
Adrenal glands 302304
Adventitious bursa 74
Aggressive fibromatosis 72
Ainhum 111, 111f
metabolic 191192
respiratory 192
Allis tissue holding forceps 466
Allograft 177. See also Grafts
Alveolar abscess 382
Ameloblastoma 379380
Anaphylactic shock 150, 152153
Anaplastic carcinoma 291, 291f
intracranial 452
needle 476
Ankylosing spondylitis 419
caudal 497
complications in 494
instruments in 493
preoperative assessment 491492
regional 495
spinal 496497
steps in 494
volatile 492
Aneurysms 103107
abdominal 104106
classification 105
complications of 106f
infrarenal, repairing of 105f
management of 105
carotid artery 107108, 108f
cirsoid 114
clinical features of 104
differential diagnosis of 104
dissecting 106107, 107f
clinical features of 107
complications of 107
DeBakey's classification 107
features of 107
hypertension and 106
investigation of 107
treatment of 107
false 103f, 104
fusiform 104f
investigations of 104
peripheral 106
popliteal 106
radial artery 106f
saccular 104f
sites of 104
treatment of 104
true 103, 103f
Anion gap 193
Ankle-brachial pressure index 91
Anthrax 4950
diagnosis 49
treatment 50
types 49
Anticoagulants 131133
heparin 131132
complications of 132
dosage of 132
indications for 131
low molecular weight 132
vs. oral anticoagulants 133t
oral 132133
indication of 132
side effects of 132133
types of 132
vs. heparin 133t
Antimalignancy drugs 461
Antisepsis 479
‘Apoplectic cyst’ 65
ARS. See Horse antirabies serum (ARS)
Arterial diseases 8793. See also Specific arterial diseases
arterial/venous grafts in 97, 97f
atherectomy in 96
atherosclerosis 9394
evaluation of 94
features of 94
management of 94
pathogenesis of 9394
risk factors 93
bypass graft 97f
aortofemoral 97f
femoropopliteal 98f
chemical sympathectomy in 98
critical limb ischemia 8891
Adson's test (scalene maneuver) in 90
Allen's test 90
Buerger's postural test for 90
costoclavicular compression maneuver 90
delayed capillary filling 89
delayed venous refilling 89
disappearing pulse syndrome 90
dry gangrene 88
elevated arm stress test for 90
features of 8990, 89f
gangrene 88
hyperabduction maneuver (Halsted test) 90
line of demarcation in 89, 89f
palpation of blood vessels in 9091
paresthesia 89
pregangrene 88
sensation in 89
systolic bruit 90
wet gangrene 89
endarterectomy in 96
intermittent claudication 8788
Boyd's classification of 88
Leriche's syndrome 88
site of pain 8788
intraluminal stent for 96
investigations for 9193
abdomen ultrasound 93
angiography 9192, 92f
ankle-brachial pressure index 91
lumbar sympathectomy in 9798
omentoplasty 9899
complications of 99
indications for 9899
for lower limb 99f
procedure of 99
profundaplasty in 96, 96f
rest pain 88, 88f
saphenous vein graft in
reverse 96
in situ 96
thrombectomy in 96
thromboangiitis obliterans 9495, 9496
with large ischemic ulcers 94f
pathogenesis 95
treatment of 9596
transluminal balloon angioplasty in 96
treatment of 9699
medical 96
surgical 9699
upper limb ischemia. See Upper limb ischemia
Arterial/ischemic ulcers 15f, 22, 22f
of lower limb 87
of upper limb 7677
Arteriovenous fistula (AVF) 114117, 116f
acquired 115f, 116117
investigation of 116
pathophysiology of 116
therapeutic 116
traumatic 116
treatment of 116117
congenital 114115, 115f
clinical features of 114115
complications of 115
investigation of 115
sites of 114
treatment of 115
in cranial cavity 115f
grafting of 116f
hypertrophic changes in 115f
quadruple ligation of 117f
Artery forceps (Hemostat) 466
Arthritis 417
Arthrodesis 410
Arthroplasty, types 411412
Artificial blood 166
Atherosclerosis 9394
evaluation of 94
features of 94
management of 94
pathogenesis of 9394
risk factors 93
Autograft 177
AVF. See Arteriovenous fistula (AVF)
Axial pattern flaps 180
Axillary nerve injury 205
Axonotmesis 197
Babcock's forceps 467
Bacillus anthracis 49
Bacteremia 38
Bake's dilator 470
Basal cell carcinoma 24f, 246247, 246f247f
Basal cell papilloma 63
Basedow's disease 281
Bazin's ulcer 15
Bilateral cleft lip 373
Blood clotting factors 159160
Blood coagulation, mechanism of 158160
blood clotting factors 159160
coagulation cascade system 159
hemophilia A and 160
hemophilia B and 160
platelet adhesion 158
platelet aggregation 158
von Willebrand's disease and 160
Blood fractions 164165
Blood substitutes 165166
Blood transfusion 163164
autologous 166
blood collection 164
complications of 164165
donor criteria 164
indications for 163
massive 165
Boerhaave's syndrome 400
Boil 3536
complications of 36
of hair follicle with perifolliculitis 36f
treatment of 35
anatomy of 404
Paget's disease 414
tumors 420
types 404405
Bone marrow transplantation 187
Bowen's disease 243
Brachial plexus injuries
investigation of 200
treatment of 200
types of 199200
Brachytherapy 236, 459
Branchial cyst 255, 255f
Branchial fistula 255
Bulbar tetanus 40
Burkitt's lymphoma 146147
investigation of 146147
sites of 146
treatment of 147
types of 146t
Burns 167176
biobrane for 172
burns contracture 173174
complications of 173
in elbow 173f
hypertrophic burn scar with 173f
management of, problems in 173174
Marjolin's ulcer and 173
prevention of development of 173
treatment for 173
chemical 175176
acid burns 175
alkali burns 175
external 176
treatment of 176
classification of 167169
percentage of burns, based on 167168, 168f
thickness of skin involved, based on 68169
clinical features of 169, 169f
death in 171
effects of 170
electrical 174175
fractures and dislocations in 174
gas gangrene in 174
mafenide acetate for 175
mannitol for 175
wound of entry in 174f, 175f
eschar 172173
first degree 168, 168f
inhalation 175
integra for 172
major 167
management of 171172
definitive treatment 171
dressing of wounds 172
first aid 171
fluid resuscitation 171
local 171172
mild 167
moderate 167
opsite for 172
pathophysiology of 169170
rule of nine 167, 168f
second degree 168169, 169f
sepsis in 170
third degree 169
transcyte for 172
treatment of 172
types of 167
Burns contracture 173174
complications of 173
in elbow 173f
hypertrophic burn scar with 173f
management of, problems in 173174
Marjolin's ulcer and 173
prevention of development of 173
treatment for 173
Bursa anserina 74
Bursae 7374
adventitious 74, 74f
anatomical 7374, 73f
bursa anserina 74
infrapatellar 73f
near elbow joint 73f
prepatellar 73f
psoas bursa 73
retrocalcaneum bursitis 74
semimembranosus 74
Café au lait spots 71f
Caisson's disease 103
Calcinosis cutis 75, 75f
Callous ulcer 14, 14f15f
Capillary hemangioma 112113
associated syndromes 112113
port-wine stain 112
salmon patch 112
in infant 112f
strawberry hemangioma 112
treatment of 112
types 112
Carbuncle 3637, 36f
complications of 36
investigation of 36
treatment of 3637
Carcinomatous ulcers 2223
Cardiac arrest 156158
cardiac massage
external 157, 157f
internal open 158, 158f
critical period 157158
defibrillation technique in 158, 158f
features of 157
immediate measures in 157
mouth-to-mouth respiration 157f
sequelae of 158
Cardiogenic shock 149150, 154
Carotid artery aneurysm 107108, 108f
Carpal tunnel 201
Carpal tunnel syndrome 201
Cat scratch fever 142
Causalgia 200
Cavernous hemangioma 113114
clinical features of 113
complications of 113
investigations of 113
of knee 113f
sites of 113
of tongue 113f
treatment of 114
Cellulitis 2729
causative agents of 27
clinical features 28
complications 29
of face 28f
investigation of 28
Ludwig's angina 28, 29f
management of 28
orbital 28
sequelae 27
treatment of 29
vs. pyogenic abscess 31t
Central venous pressure (CVP) 154155
angle of Louis and 154
complications of 154
for monitoring patient 155f
vs. pulmonary capillary wedge pressure 156t
Cephalic tetanus 40
Cervical lymphadenopathy 141f
acute suppurative lymphadenitis 141
cat scratch fever 142
chronic nonspecific lymphadenitis 141
differential diagnosis for 140142
infectious mononucleosis 141
lymphomas 142
secondaries in lymph nodes in 142
toxoplasmosis 141
tuberculous lymphadenitis 141
Cervical rib 8183
anatomy of 82f
clinical features of 8182
definition of 81
differential diagnosis of 82
investigations of 82
pathology of 81, 82f
treatment of 8283
types of 81
Cervicoaxillary canal 76
Chemical burns 175176
acid burns 175
alkali burns 175
external 176
treatment of 176
Chordoma 75
Cimino fistula 187
Cirsoid aneurysm 114
Claudication, intermittent 8788
Boyd's classification of 88
Leriche's syndrome 88
site of pain 8788
Claw hand 202203
clinical features of 203
investigation of 203
MCP joint 202
median 203
treatment of 203
ulnar 203, 203f
Clean contaminated wound 4, 4f
Clean wound 34, 4f
Cleft lip and cleft palate
diseases of 375
treatment for 375
Clergyman's knee 73f
Clostridium histolyticus 41
Clostridium oedematiens 41
Clostridium septicum 41
Clostridium tetani 39, 40
Clostridium welchii 41
Coagulation cascade system 159
Cock‘s peculiar tumor 68
Cold abscess 3335
differential diagnosis 35
features of 34
in HIV patient 54f
investigation of 3435
in neck 147f
sequelae of 35
sites of origin 34
treatment 35
tuberculous 35f
vs. pyogenic abscess 35t
Common peroneal nerve 204205
Compartment syndrome 7, 100
fasciotomy done for 7f
Compound palmar ganglion
clinical features 215
investigations 215
pathology 215
treatment 215
Contaminated wound 4, 4f
Cortisol ulcers 15
Costoclavicular space 76
Covert compensated hypovolemia 152
Creatine phosphokinase 52
Critical limb ischemia 8891
Adson's test (scalene maneuver) in 90
Allen's test 90
Buerger's postural test for 90
costoclavicular compression maneuver 90
delayed capillary filling 89
delayed venous refilling 89
disappearing pulse syndrome 90
dry gangrene 88
elevated arm stress test for 90
features of 8990, 89f
gangrene 88
hyperabduction maneuver (Halsted test) 90
line of demarcation in 89, 89f
palpation of blood vessels in 9091
paresthesia 89
pregangrene 88
sensation in 89
systolic bruit 90
wet gangrene 89
Cross leg flap 184, 184f
Crush syndrome
effects of 7
of finger 8f
treatment of 8
Cryoprecipitate 164
Cutaneous flap 180
CVP. See Central venous pressure (CVP)
Cyclosporin-A 186
advantages 485
disadvantages 485
indications 485
mode of action 485
Cysts 6465
apoplectic 65
classification of 65t
clinical features of 65
effects of 65
false 6465
sebaceous 6768
true 64
Day care surgery
advantages 485
precautions 485
Decompensated hypovolemia 152
Decompression disease 103
Decubitus ulcers 1920, 19f
predisposing factors in 20
sites of 19
treatment of 20
Deep vein thrombosis (DVT) 119121. See also Embolism
axillary vein thrombosis and 120
clinical features of 120
effects of 121t
etiology of 119
investigation of 120
phlegmasia alba dolens 120
phlegmasia cerulea dolens 120
postoperative thrombosis and 120
prevention of 121
sequelae of 121t
sites of 120
spontaneous thrombosis and 120
treatment of 121
Deep palmar space infection
causes 212213
surgical anatomy 212
treatment 213
Degloving injury, of thigh and leg 6f
Deltopectoral flaps 182, 182f
Demodex folliculorum 67
Dercum‘s disease 61
Dermatofibroma 241, 241f
Dermatofibrosarcoma protuberance 241242
Dermoids 6567
angular 66, 66f
implantation 6667
clinical features of 66
differential diagnosis of 66
of foot 67f
of hand 67f
postauricular 66f
sequestration 6566
clinical features of 66
common sites for 65
differential diagnosis of 66
investigation of 66
treatment of 66
teratomatous 67
tubulodermoids 66
Desmoid tumor 72
DEV. See Duck embryo vaccine (DEV)
Dextrans 165166
Diabetic foot 110111, 110f
clinical features of 111
investigation of 111
Meggitt's classification of 110t
pathogenesis of 110
problems in 110
treatment of 111
Diabetic ulcers 2021, 20f
investigation of 21
sites of 2021
treatment of 21, 21f
types 483
uses 483484, 483f
Differentiated thyroid carcinoma (DTC) 288
Dirty infected wound 4, 4f
Disappearing pulse syndrome 90
advantages of 472
classification of 472
types 471
Duck embryo vaccine (DEV) 48
Dupuytren's contracture
complications 216
etiology 215216
treatment 216, 216f
Dyshormonogenesis 276
Dysplasia 228
Electrical burns 174175
fractures and dislocations in 174
gas gangrene in 174
mafenide acetate for 175
mannitol for 175
wound of entry in 174f, 175f
Elephantiasis 137f, 138f
Embolism 101103. See also Deep vein thrombosis (DVT)
and acute upper limb ischemia 7778
air 103
arterial 101102
effects of 101
embolectomy for 101, 101f
investigations for 101
treatment of 101102
fat 102103
clinical features of 102
treatment of 102103
saddle embolus 102, 102f
therapeutic embolization 103
types of 101
Epignathus 75, 75f
Erysipelas 30
Erythrocyanosis frigida 15
Erythromelalgia/erythralgia 86
Eschar 172173
circumferential 172173
third degree burn with 172f
Esmarch rubber tourniquet 166, 166f
anatomy 391, 391f
nerve supply
stricture of 398399
types 391392
indications 393
types 394
Exotoxins 41
Face, dangerous area of 30, 30f
Facial nerve palsy 323324
Faciocutaneous flap 180
Fibrinogen 164
Fibroma 7172
hard 72
soft 71
treatment of 72
Fine Needle Aspiration Cytology (FNAC) 231
Fistula 1012, 11f
clinical features 11
discharges in 12
of abdominal wound 11f
with discharging fecal matter 12f
investigation of 12, 12f
treatment of 12
types of 11t
Flaps 177, 180185
advantages of 181
anatomy of skin 180f
axial pattern 180
blood supply of skin 180f
cross leg 184, 184f
cutaneous 180
deltopectoral 182, 182f
disadvantages of 181
faciocutaneous 180
forehead 181182, 182f
free 181, 184185
groin 183, 183f
indications for 180
muscle 180
myocutaneous 180, 180f
pectoralis major myocutaneous 183184, 184f
radial forearm 185
raising 180f
random pattern 180
saltatory 181
types of 180181
Fluids, electrolyte
acid-base balance 191192
metabolic 192
respiratory 192
metabolic 191192
respiratory 192
anion gap 193
hyperkalemia 191
hypernatremia 190
hypokalemia 190191
clinical features 191
gradual 191
sudden 190
treatment 191
hyponatremia 189190
clinical features of 189
hypervolemic 189190
hypovolemic 190
investigation of 190
normovolemic 190
pseudohyponatremia 190
treatment of 190
physiology of 188
water intoxication 188189
water loss 188
Foot drop, with claw toes 204f
Forehead flaps 181182, 182f
causes of 405
complications of 407410
types of 405407
Free flaps 184185
Fresh frozen plasma 164
Frey's syndrome 323
Furuncle. See Boil
Ganglion 7273
clinical features of 72
common sites of 72
differential diagnosis of 72
pathogenesis 72
transilluminant 72f
treatment of 7273
on wrist 72f
Ganglioneuroma 6970
Gangrene 108110
clinical features 108109
absence of pulse 109
change in color 108
line of demarcation 109
proximal ischemic features 109
definition of 108
diabetic foot and 110111, 110f
clinical features of 111
investigation of 111
Meggitt's classification of 110t
pathogenesis of 110
problems in 110
treatment of 111
dry 109, 109f
gas. See Gas gangrene
investigations of 109
knee amputation in 109110
of toes 89f
treatment of 109110
life-saving procedures 109110
limb-saving methods 109
wet 109
Gas gangrene 4142
clinical features of 42
clinical types of 42
effects of 41
exotoxins in 41
of forearm and hand 42f
investigation of 42
organisms in 41
polyvalent antiserum for 42
treatment of 42
Gastrostomy 194, 194f
Gelatin 166
Gel foam 163f
Glomus tumor 68
classification of 277, 278f
diffuse hyperplastic 278
nodular 278
retrosternal 280
Gonorrhea 56
Grafts 177
contracture of 179
mesh 179f
rejection 187
split skin 177179
tendon 207
Wolfe 179180
Granuloma pyogenicum. See Pyogenic granuloma
Gravitational ulcer. See Venous ulcers
Groin glap 183, 183f
Hamartomata 111112
definition of 111
pathogenesis of 111
problems with 112
treatment of 112
Hand 208218
infections 209210
injuries 214215
surgical anatomy of 208209
Hand held Doppler 91f
Hansen's disease. See Leprosy
Harvey's sign 89
Hashimoto's thyroiditis 293
HDCV. See Human diploid cell vaccine (HDCV)
Head and Neck
anatomy of lymphatics of 253255
levels of 264f
types of 266267
Head injuries
extradural 447449
mechanism 443445
subdural 449450
Healing ulcers 14, 14f
Heberden's nodes 216
Hemangiosarcoma 238
Hemangioma 112114
capillary 112113
associated syndromes 112113
port-wine stain 112
salmon patch 112, 112f
strawberry hemangioma 112
treatment of 112
types 112
cavernous 113114
clinical features of 113
complications of 113
investigations of 113
of knee 113f
sites of 113
of tongue 113f
treatment of 114
of cheek 114f
classification of 112
of face 113f
strawberry 112
on leg post-trauma 2f
subungual 3f
Hemolysin 41
Hemophilia A 160
Hemophilia B 160
Hemorrhage 160163
acute 161
acute on chronic 161
arterial 160
blood loss, measurement of 161
capillary 160
chronic 161
clinical features of 161
effects of 161
hemorrhagic shock, classification of 161
pathophysiology of 162
primary 160
reactionary 160
secondary 160
treatment of 162163
venous 160
Hibernoma 61
HIV infection/AIDS 5256
anti-HIV antibody 53
antiviral therapy for 55
clinical classification of 53t
cold abscess with discharging sinus in 54f
general features in 54t
GI problems in 54
history of 52
hospital and surgeon in, measures for 5556, 56f
immunotherapy for 55
management of 55
mode of transmission 53
neurological problems in 5455
pathogenesis 5354
prevention of 55
psychotherapy for 55
pulmonary problems in 54
tests for 53
tumors in 54t
universal precautions against 55t
Hodgkin's lymphoma (HL) 142145, 142f
Ann-Arbor clinical staging in 143
clinical features of 143
differential diagnosis of 143
investigation of 144145, 145f
Reed-Sternberg cells in 142143
Rye's classification 142
sites of 143
treatment for 144145
vs. non-Hodgkin's lymphoma 145t
in young boy 143f
Horner's syndrome, ptosis right eye in 83
Horse antirabies serum (ARS) 4849
Hospital acquired infection. See Nosocomial infection
Housemaid's knee 73f
HRIG. See Human rabies immunoglobulin (HRIG)
Human albumin 164
Human diploid cell vaccine (HDCV) 48
Human rabies immunoglobulin (HRIG) 49
Humby's knife 178f
Hunterian chancre 44
Hutchinson's triad 45t
Hyaluronidase 41
Hydrophobia. See Rabies
Hyperbaric oxygen 156
Hyperkalemia 191
Hypernatremia 190
Hyperparathyroidism 300
clinical features 300
investigations 300301
treatment 301
clinical features 281
signs of 282284
symptoms of 281
types 281
Hypertrophic scar 7, 9
complication of 9
diagrammatic representation of 9f
over thigh 9f
vs. keloid 10
Hypokalemia 190191
clinical features 191
gradual 191
sudden 190
treatment 191
Hyponatremia 189190
clinical features of 189
hypervolemic 189190
hypovolemic 190
investigation of 190
normovolemic 190
pseudohyponatremia 190
treatment of 190
Hypothyroidism 297
Hypovolemic shock 149, 152
Incised wound 2
in leg 2f
over eyebrow 2f
Infectious mononucleosis 141
Inhalation burns 175
blast 223
bullet 222223
colonic 225
duodenal 224
liver 225
neck 222
pancreatic 225
penetrating 223
renal 226
small bowel 225
spinal 222
splenic 226
Internal organs, injury to 3, 3f
Isograft 177
Isotope lymphoscintigraphy 134135
fibrous dysplasia of 384385
osteomyelitis of 382
tumors 377
Jejunostomy 194195
needle 194f, 195
Witzel 195
Kaposi's sarcoma 238239
Kasabach-Merritt syndrome 112
Keloid 7, 89
diagrammatic representation of 9f
in ear 8f
over sternum 9f
in shoulder and arm area 8f
sites of 8f9f, 9
treatment of 9
vs. hypertrophic scar 10
Keratoacanthoma 241
Klebsiella 50
Klippel-Trenauny-Weber syndrome 112
Kuntz nerve 84
Lacerated wound 2
in leg 2f
on scalp 2f
disadvantage 484
precautions 484
uses 484
Laryngectomy 365f, 366
Laryngocele 257258
anatomy of 362f
benign lesions of 360362
carcinoma 365f
surgical anatomy of 358360
view of 363f
Latent tetanus 40
Lecithinase 41
Leiomyosarcoma 238
Lepromatous leprosy 43
Leprosy 4344
investigation of 43
lepromatous 43
Mycobacterium leprae 43
surgical complications in 44
treatment of 43
tuberculoid 43
types 43
Leriche's syndrome 88
Leukoplakia 329
histology 330
incidence 330
types 329
Lipoma 6163
clinical features 62
complications in 62
differential diagnosis 62
over nape of neck 62f
over shoulder region 63f
pedunculated 62f
sites of 6162
treatment of 62, 63f
types of 61
Liposarcoma 63t, 237
Lips 325
carcinoma of 340341, 341f
neoplasm of 340
Livedo reticularis 86
Liver transplantation 186187
Long thoracic nerve 205
Ludwig's angina 28, 29f, 259f
Lupus vulgaris 26
Lymphangiography 134
Lymphangitis 2930, 135, 135f
chronic 30
features of 2930
of leg 30f
management of 30
Lymph cyst 6869
common sites of 69
transilluminant 69f
Lymphedema 30, 135140
Brunner's grading of 138
classification of
Kinmoth 135
lymphangiographic 134
clinical features of 137
complication of 138
differential diagnosis of 138
elephantiasis 137f, 138f
investigation of 138
pathology of 136137
primary 135136
Ram's horn penis 137f
of right leg 137f
secondary 136
sites of 137t
surgery for 139140, 139f
bypass procedure 139
Charle's operation 140, 140f
combined 139
excisional 139
Homan's operation 139
Kondolean's operation 140
nodovenous and lymphovenous shunt in 139f
physiological 139
Sistrunk operation 139
Thompson's operation 139140, 140f
treatment of 138139
Lymphomas 142
Burkitt's 146147
death in 145
Hodgkin's 142145, 142f
mediastinal 144f
non-Hodgkin's 145146
prognostic factors in 145
Lysol 480
Madura foot 10, 4647, 46f
clinical features 47
differential diagnosis 47
organisms in 46
pathogenesis 4647
treatment of 47
Maffucci syndrome 113
Malignant edema. See Gas gangrene
Malignant lymphoma of Africa. See Burkitt's lymphoma (NHL)
Malignant mixed tumor (MMT) 319
Malignant salivary tumors, management of 320321
Malignant tumors
etiology 362
spread of 229230
staging 364
treatment 364
types 362364
Mallet finger (Base ballfinger) 216
Marjolin's ulcers 23, 23f
Martorell‘s hypertensive ulcer 15
Median mental sinus 10, 1213, 13f
Median nerve injuries 200201
clinical features of 200201
investigation of 201
treatment of 201
Melanotic ulcers 24, 24f
Meleney's ulcer 2122
MEN syndrome (MEA syndrome) 302
Mercurochrome (Merbromin) 178f
Merkel cell carcinoma 241
Mesh graft 179f
Metabolic acidosis 192
Metabolic alkalosis 191192
Milian's ear sign 30
MODS. See Multiorgan dysfunction syndrome (MODS)
Mononucleosis, infectious 141
Morrant Baker cyst 7475
clinical features 7475
management of 75
treatment of 75
Mucoepidermoid tumor 318, 318f
clinical features 318
types 318
Multiorgan dysfunction syndrome (MODS) 38
Multiple endocrine neoplasia syndrome 61
Muscle flap 180
Muscle necrosis 7
Mycetoma pedis. See Madura foot
Mycobacterium bovis 42
Mycobacterium fortuitum 42
Mycobacterium kansasii 42
Mycobacterium leprae 43
Mycobacterium marinum 42
Mycobacterium tuberculosis 42, 147
Mycobacterium ulcerans 42
Myelinic neuroma 70
Myer's stripper 128f
Myocutaneous flap 180, 180f
Necrotizing fasciitis 5152
on chest wall and over sternum 51f
clinical features 52
of leg 51f
management of 52
types of 52
classification 227
components 227
investigations for 230232
Nerve injuries
axillary 205
median 200201
peripheral 197199
ulnar 202
Neurilemmomas 71
Neurofibromas 7071
complications of 71
elephantiatic neurofibromatosis 71
generalized neurofibromatosis 71
multiple 71f
nodular 70
plexiform 7071, 70f
sites of 70
treatment of 71
Neurogenic shock 150
Neuromas 6970
end 69, 69f
false 69, 69f
lateral 69, 69f
myelinic 70
true 6970
Neuropraxia 197
Neurotmesis 197
Nevus flammeus 112
Nocardia asteroides 46
Nocardia brasiliensis 46
Nocardia madurae 46
Non-Hodgkin's lymphoma (NHL) 145146, 146f
treatment of 146
types of 145
vs. Hodgkin's lymphoma 145t
Nosocomial infection 50
Nutrition 193194
assessment 193
caloric requirement 193
feeding methods 193194
gastrostomy for 194, 194f
jejunostomy for 194195, 194f
nutritional support, indications for 193
obesity 195196
classification of 196
complications of 196
definition of 195196
surgery and 196
treatment for 196
total parenteral 195
Obesity 195196
classification of 196
complications of 196
definition of 195196
surgery and 196
treatment for 196
causes 217
clinical features 217218, 218f
treatment 218, 218f
Opportunistic infections 5051
investigation of 51
organisms in 5051
treatment of 51
Orbital cellulitis 28
Osteomyocutaneous flaps 181
Overt compensated hypovolemia 152
Oxidized regenerated cellulose 163f
Oxygen therapy 156
Pachydermatocele 7071
Packed cells 164
Papilloma 6364
complications of 64t
differential diagnosis 64
infective 63
pedunculated 64f
on right waist 64f
skin 63
of tongue 64f
treatment of 64
true 6364, 64f
Parathyroid, anatomy of 299
acute 210
chronic 210211
Parotid fistula 312
causes 312
clinical features 312
diagnosis 312
treatment 312
PCWP. See Pulmonary capillary wedge pressure (PCWP)
Pectoralis major myocutaneous flap (PMMF) 183184, 184f
Perfluorocarbon 166
Peripheral nerve injuries
clinical features of 198
management of 198
nerve suturing, types of 198199, 198f199f
Seddon's classification 197198
Tinel's sign 199
Phlegmasia alba dolens 120
Phlegmasia cerulea dolens 120
Phenol 480
Pheochromocytoma 305
Pilonidial sinus 10
Plantar fasciitis (Policeman's Heel) treatment 217
Plasma 164
Platelet concentrate 164
Platelet rich plasma 164
Plummer disease 281
PMMF. See Pectoralis major myocutaneous flap (PMMF)
Pneumatic tourniquet 166
Polyarteritis nodosa 8485
Port-wine stain 112
Postphlebitic limb 131
Pott's puffy tumor 37, 37f
Proteinase 41
Pseudohyponatremia 190
Psoas bursa 73
Ptosis right eye, in Horner's syndrome 84f
Pulmonary capillary wedge pressure (PCWP) 155156, 155f
complications of 155
vs. central venous pressure 156t
Pyemia 38
Pyogenic abscess 3033, 31f
bacterial 31
clinical features of 31
complications of 32
differential diagnosis for 33
in forehead region and face 32f
Hilton's method of draining 33f
investigation of 3132
modes of infection 30
sites of 31
in suboccipital region 32f
treatment of 3233
vs. cellulitis 31t
vs. cold abscess 35t
Pyogenic granuloma 17, 17f, 3738
clinical features 37
differential diagnosis 38
in nose 38f
sites of 38
treatment of 38
Rabies 4749
clinical features 47
in dogs 49
immunization 4849
in animals 49
horse antirabies serum 4849
human rabies immunoglobulin 49
Negri bodies in 47
passive immunity 4849
pathogenesis 47
postexposure prophylaxis 4748
vaccines for 48
wounds in 48
Radial forearm flap 185
Radial nerve lesions 203204
in arm 203
brachial plexus 203
clinical features of 204
deep branch 204
investigation of 204
superficial branch 203204
treatment of 204
wrist drop 204, 204f
Ram's horn penis 137f
Random pattern flaps 180
Ray fungus 45
Raynaud's disease 78, 83
Raynaud's phenomenon 8384
cervical sympathectomy for 84
collagen vascular diseases and 83
investigations of 83
Raynaud's disease 83
Raynaud's syndrome 83
treatment of 8384
types of 83
and upper limb ischemia 78
Raynaud's syndrome 78, 83
Recurrent fibroid of Paget's 72
Recycled blood 166
Red rubber catheter 473
Red-rubber tracheostomy tube 386
Reflux esophagitis 398
Reidel's thyroiditis 293294
Reinke's edema 361
Renal transplantation 186
Reperfusion injury 100101
Respiratory acidosis 192
Respiratory alkalosis 192
Rest pain 88, 88f
Retrocalcaneum bursitis 74
Risus sardonicus 39
Rodent ulcers 2324, 24f
Rubber tourniquet 166
Ryle's tube 473
Saddle embolus 102, 102f
SAG-M blood 164
Salivary calculus
presentation 309
investigations 310
Salivary glands
adenocarcinoma of 319
anatomy 306307
facial nerve 307308
minor 322
squamous cell carcinoma of 319
submandibular 308
Salivary neoplasms 313
classification 314
etiology 313314
incidence 314315
investigations 316
treatment 316317, 316f
Salmon patch 112, 112f
Saltatory flap 181
Scalene triangle 76
Scalenus anticus muscle 76
Schwannoma 71
Scleroderma 85
Sebaceous cyst 6768
clinical features of 6768
complications of 68
in face 67f
infected 67f
on scalp 67f
treatment of 68, 68f
Secondaries in lymph nodes in 142, 144f
SEPS. See Subfascial endoscopic perforator ligation surgery (SEPS)
Septicemia 38
Septic shock 150, 152153
hyperdynamic 152
hypodynamic hypovolemic 152
stages of 152153
Shock 149153
anaphylactic 150, 152153
cardiogenic 149150, 154
clinical features of 153
effects of 151152
hypovolemic 149, 152
investigation of 153
neurogenic 150
pathophysiology of 150151
respiratory 150
septic 150, 152153
stages of 151
treatment of 153
Trendelenburg position in 153f
Sialectasis 311
Sialography, indications 308309
Sialosis 311
Sick cell syndrome 151
Sinus 10, 10f
discharges in 12
persistence of 11
pilonidal 10
tuberculous 10
types of 11t
clinical examination of 509510
forceps 471
median mental 10, 1213, 13f
SIRS. See Systemic inflammatory response syndrome (SIRS)
Sjögren's syndrome
clinical features 313
investigations 313
types 313
Skin grafting 177180
harvesting 178f
Mesher in 179f
split skin graft 177179
advantages of 179
contraindications of 178
disadvantages of 179
Humby's knife in 178f
indications for 177178
pre-requisite for 178
stages of 178
Wolfe graft 179180
advantages of 179
disadvantages of 180
Skin tumors
adnexal tumors 240, 240f
classification of 240
Spina ventosa 217
Spreading ulcers 14
Squamous cell carcinoma 243, 243f244f
Squamous cell papilloma 63
SSI. See Surgical site infection (SSI)
Staphylococcus aureus 50, 52, 57
Strawberry hemangioma 112
Streptococcus epidermidis 50
Streptococcus pneumoniae 50
Streptococcus pyogenes 27, 30, 51, 52
Student's elbow 73f
Sturge-Weber syndrome 113
Subclavian steal syndrome 8687, 87f
Subfascial endoscopic perforator ligation surgery (SEPS) 128129, 129f
Surgical site infection (SSI) 5760
classification of 5859, 59f
common sources of 57
factors related to 57
identification system in 58
management of 60
NNIS system as risk index 58t
organisms in 57
physical status classification 58
prevention of 5960
risk classification in 58
sequence of events in 57
surgical wounds, classification of 58
variable influences 58t
Suture materials
classification 476478
types of 478
causes 216
treatment 216
types 216, 216f
Syphilis 4445
congenital 45
early 44
investigation of 44
late (tertiary) 44
latent 44
primary 44
secondary 44
treatment of 4445
Systemic inflammatory response syndrome (SIRS) 156
Systemic sclerosis 85
Systolic bruit 90
Temporal arteritis 86
Tendon 205206
grafts for 207
healing of 206
repairing of 206
suturing of 206, 206f
transfer of 206
Terminal pulp space infection (FELON)
complications 212
investigation 211
surgical anatomy 211, 211f
treatment 211, 211f
Tetanus 3841
ascending 40
clinical features of 39
Clostridium tetani 39
descending 40
differential diagnosis of 40
early 40
late 40
pathogenesis 3940
incubation period 39
period of onset 3940
respiratory system, effects on 40
postures in 40t
staging of 40t
treatment of 4041
antitetanus globulin in 40
antitetanus serum in 40
crystalline penicillin in 41
nursing care 41
tetanus toxoid in 40
types of 40
Tetanus neonatorum 40
Thakayasu's pulseless arteritis 8586
Thoracic outlet, surgical anatomy of 76
Thoracic outlet syndrome (TOS) 8081
clinical features of 8081
differential diagnosis of 80t
investigations of 81
scalene triangle 80
treatment of 81
Thromboangiitis obliterans (TAO) 9496
investigations of 9495
with large ischemic ulcers 94f
pathogensis 95
treatment of 9596
Thrombophlebitis 131
Thyrocardiac 287
Thyroid function tests 276277
Thyrotoxicosis 280281
Thyroid 270
anatomy 272274
development 272
ectopic 274, 274f
FNAC of 277
lingual 274275, 275f
medullary carcinoma of 292293
solitary nodule 279280
Thyroglossal cyst 275276
Thyroglossal fistula 276
complications of 295296
procedure 294
types 294
Tinel's sign 199
Tongue 326, 343, 344f
benign tumors of 345346
fissure, 346
tie 347, 347f
indications 370
procedure 370, 370f
acute 368
anatomy of 367368
Torticollis (Wry neck) 262, 262f
TOS. See Thoracic outlet syndrome (TOS)
Total parenteral nutrition (TPN) 195
Torticollis (Wry neck) 262, 262f
Toxic nodule 284
Tourniquets 166
Toxoplasma gondii 141
Toxoplasmosis 141
TPN. See Total parenteral nutrition (TPN)
Tracheoesophageal fistula 400
approaches for 389
complications of 390
functions of 389
indications for 387388
technique of 388
tubes 386, 386f, 471
types 386
Transplantation 185186
bone marrow 187
donor criteria 185186
cadaver donor 185
living donor 185
requirements for 185186
liver 186187
renal 186
Traumatic acute arterial occlusion 99100
clinical features 99
investigation of 99
treatment of 100
Traumatic ulcers 15, 22
Treponema pallidum 44
Triage 219
algorithm 219
definitive care 221
investigations 221
management 220221
Trigeminal neuralgia 205
Trismus 39
Trophic ulcers 19
Tropical ulcers 15, 2425
Tuberculoid leprosy 43
Tuberculosis 4243
features of 43
investigation of 43
organisms in 42
pathogenesis of 4243
treatment of 43
with tuberculous ulcer 42f
Tuberculous lymphadenitis 141, 147148
clinical features of 148
differential diagnosis of 148
investigation of 148
mode of infection of 147148
sites of 147
stages of 147, 147f
treatment of 148
Tuberculous sinus 10
Tuberculous ulcers 14f, 2526, 26f
Ulcerated plaque 93
Ulcers 1318, 511514
arterial/ischemic 15f, 22, 22f
Bazin's 15
callous 14, 14f15f
carcinomatous 2223
chilblains and 26
classification of
clinical 14
pathological 1416
cortisol 15
debridement of 18
decubitus 1920, 19f
definition of 13
diabetic 2021, 20f
discharges in 16
dressing of 18
frostbite and 26
granulation tissue in 1618
exuberant 17
healthy 14f, 16, 16f
pyogenic granuloma 17, 17f
unhealthy 16, 16f
unhealthy, pale, flat 16
healing 14, 14f
in leg and shoulder 18f
induration in 17
investigations for 17
maggots in 16f
malignant 15
management of 18
Marjolin's 23, 23f
Martorell‘s hypertensive 15
melanotic 24, 24f
Meleney's 2122
nonspecific 15
parts of 1314, 13f
with Pseudomonas infection 18f
rodent 2324, 24f
spreading 14
traumatic 15, 22
treatment of 1718
trophic 19
tropical 15, 2425
tuberculous 14f, 2526, 26f
venous 25, 25f
Ulnar nerve injuries 202
Ulnar paradox 202
advantages 486
disadvantages 486
thyroid 486
uses 486
Upper limb ischemia 7783
cervical rib 8183
anatomy of 82f
clinical features of 8182
definition of 81
differential diagnosis of 82
investigations of 82
pathology of 81, 82f
treatment of 8283
types of 81
gangrene of finger in 77f
investigations in 7879, 79f
management of 7980
bypass surgery 80
chronic ischemia, treatment of 7980
embolus, treatment of 79
Raynaud'sphenomenon, treatment of 80
trauma, treatment in 79
Raynaud's phenomenon and 78
thoracic outlet syndrome and 8081
clinical features of 8081
differential diagnosis of 80t
investigations of 81
scalene triangle 80
treatment of 81
types of 7778
acute 7778
chronic 78
Urban tetanus 40
Urinary bladder injury 226
Varicose veins 121130
clinical features of 123124
clinical tests for 123124, 124t
Brodie-Trendelenburg test 123, 123f124f
Fegan's test 124
Morrissey's cough impulse test 124
Perthe's test 124
Pratt's test 124
Schwartz test 124
three-tourniquet test 124
complications of 129t130t
etiology of 122123
investigation of 124126
arm-foot venous pressure for 126
duplex scan for 125, 125f
venography for 125
venous Doppler for 124, 125f
of lower limb 121f
CEAP classification of 123t
pathogenesis of 122
sites of 123t
thermoablation of 129
treatment of 126130
Cockett and Dodd subfascial ligation 128, 128f
conservative 126
crepe bandages for 126f
foam sclerotherapy by Tessari 127, 127f
injection-sclerotherapy (Fegan's technique) 126127
microsclerotherapy 127
sclerosants for 126t
stripping of vein 128, 128f
subfascial endoscopic perforator ligation 128129, 129f
surgery 127129
trendelenburg operation 127128, 128f
types of 122, 122f
white cell trapping theory in 122
Veins of lower limb, anatomy of 118119, 118f
blood flow in, physiology of 119
deep veins 118
long saphenous vein 118, 119f
perforator veins 118119, 119f
short saphenous vein 118, 119f
superficial veins 118, 118f
Venous ulcers 25, 25f, 130131
complications of 131t
Gaiter's zone and 130
investigation of 130
of lower limb 130f
pathogenesis of 130
periostitis and 130
treatment of 130131
Vocal (Singer's/Screamer's) nodule 360361
Vocal polyp 361
Volkmann's retractor 467
Volkmann's scoop 475
von Recklinghausen's disease 71
von Willebrand's disease 160
Waldeyer's ring 253
Warthin's tumor 317, 317f
Water intoxication 188189
clinical features of 189
ECF excess 189
ECF loss 189
investigation of 189
transurethral resection of prostate 188189
treatment of 189
Water loss 188
Wayne's diagnostic indices 282t
Webspaces, infection of
bacteria 212
clinical features 212
treatment 212
Woolsorter's disease 49
Wound 17
abrasion 2, 3f
clean incised 2, 2f
crush injury 3
definition 1
healing 47
factors affecting 5t
phases of 5
problems with 67
stages of 5
types of 5
hematoma 2f, 3f
lacerated 2, 2f
management of 56
Rank and Wakefield classification 12
tidy wounds 1
untidy wounds 12
surgical classification 34
clean contaminated wound 4, 4f
clean wound 34, 4f
contaminated wound 4, 4f
dirty infected wound 4, 4f
Wound debridement 6
Wound dehiscence 6
Wound infection 6
Wrist drop 204, 204f
Xenograft 177
Xeroderma pigmentosa 243
Zadik's/Fowler's operation 218f
Zygomatic complex fracture 429432
management of 432434
mandible 434
Chapter Notes

Save Clear

Wound, Sinus, Fistula and UlcerCHAPTER 1

Wound is a break or discontinuity in the integrity of skin or tissues. It can be a simple wound or a complex wound.
Wound is simply a disruption of any tissues—soft tissue or bone or internal organs. Ulcer is disruption or break in the continuity of any lining—may be skin, mucous membrane or others. Ulcer is one of the types of wounds. There may be disruption of the structure and function.
  1. Tidy wounds
    They are wounds of surgical incisions and caused by sharp objects.
    Usually primary suturing is done. Healing is by primary intention.
  2. Untidy wounds
    They are:
    • Crushed
    • Tear
    • Avulsion
    • Devitalized injury
    • Vascular injury
    • Multiple irregular wounds
    • Burns, etc.
Fracture may be present.
Wound dehiscence, infection, delayed healing are common.
Liberal excision of devitalized tissue and allowing to heal by secondary intention is the management.
  1. Clean incised wound
    It is a wound caused by sharp objects like knife, glass or blades. Primary suturing is done and it heals by first intention leaving a thin, linear scar (Figs 1.1 and 1.2).
  2. Lacerated wound
    Wound edge is devitalized, crushed and wide. It is treated by wound excision and delayed primary suturing. Scar formed is wide and prone for hypertrophic scar formation (Figs 1.3A and B)
  3. Bruising, contusion.
  4. Hematoma (Figs 1.4 and 1.5).
  5. Closed blunt injury.
  6. Puncture wounds and bites.
  7. Abrasion (Fig. 1.6)
    It is superficial, and is due to shearing of skin in which surface is rubbed off. It heals by epithelialization.
  8. Traction and avulsion and degloving injury (Fig. 1.7).
    zoom view
    Fig. 1.1: Incised and lacerated wounds in the leg
    zoom view
    Fig. 1.2: Incised wound over eyebrow
    zoom view
    Figs 1.3A and B: Lacerated wound on the scalp
    zoom view
    Fig. 1.4: Hematoma leg after trauma
    zoom view
    Fig. 1.5: Subungual hematoma
    zoom view
    Fig. 1.6: Abrasion over the face due to trauma
    zoom view
    Fig. 1.7: Degloving injury in leg
  9. Crush injury
    It is caused by war wounds, road traffic accidents, and tourniquet.
    It leads on to:
    • Compartment syndrome
    • Muscle ischemia
    • Gangrene, loss of tissue.
  10. War wounds and gunshot injuries.
  11. Injuries to bones and joints may be open or closed.
  12. Injuries to nerves, either clean cut or crush.
  13. Injuries to arteries and veins (major vessels).
  14. Injury to internal organs may be penetrating or non-penetrating (blunt) injuries (Figs 1.8A and B)
    zoom view
    Figs 1.8A and B: Stab wound in the abdomen using a sharp knife. It is a penetrating trauma
  1. Clean wound
    • Herniorrhaphy
    • Excisions
zoom view
Fig. 1.9: Clean thyroidectomy wound
zoom view
Fig. 1.10: Clean contaminated appendicectomy wound
zoom view
Fig. 1.11: Contaminated wound in suppurative appendicitis
zoom view
Fig. 1.12: Dirty wound of ileal perforation with peritonitis
    • Surgeries of the brain, joints, heart transplant.
    • Infective rate is less than 2% (Fig. 1.9).
  1. Clean contaminated wound
    • Appendicectomy (Fig. 1.10).
    • Bowel surgeries.
    • Gallbladder, biliary and pancreatic surgeries.
    • Infective rate is up to 30%—high.
  2. Contaminated wound (Fig. 1.11)
    • Acute abdominal conditions.
    • Open fresh accidental wounds.
  3. Dirty infected wound (Fig. 1.12)
    • Abscess drainage.
    • Pyocele.
    • Empyema gallbladder.
    • Fecal peritonitis.
Wound may be
  • ▸ Closed wound like contusion, abrasion or laceration.
  • ▸ Open wound like incised, lacerated, penetrating or crush injury.
Wound healing is complex method to achieve anatomical and functional integrity of disrupted tissue by various components like neutrophils, macrophages, lymphocytes, fibroblasts, collagen; in an organized staged pathways—hemostasis → inflammation → proliferation → matrix synthesis (collagen and proteoglycan ground substance) → maturation → remodeling → epithelialization → wound contraction (by myofibroblasts).5
  • ▸ Stage of inflammation.
  • ▸ Stage of granulation tissue formation and organization. Here as the result of fibroblastic activity, synthesis of collagen and ground substance occurs.
  • ▸ Stage of epithelialization—it occurs in 48 hours.
  • ▸ Stage of wound contraction and connective tissue formation.
  • ▸ Stage of scar formation and resorption.
  • ▸ Stage of maturation.
Phases of Wound Healing
Inflammatory Phase (Lag/Substrate/Exudative)
It begins immediately after wound formation lasting for 4-6 days (Rubor, calor, tumour, door and loss of function—features of inflammation will develop). Macrophages secrete fibroblastic growth factor, which enhances angiogenesis. Polymorphonuclear leukocytes appear after 48 hours, which secrete inflammatory mediators and bacterial oxygen derived free radicals. Factors involved are—platelet derived growth factor (PDGF), epidermal growth factor (EGF), transforming growth factor (TGF), interleukins, tumor necrosis factor (TNF), prostaglandins, collagenase and elastase.
Proliferative Phase
It begins within 7 days and lasts for 6 weeks. Here, collagen and glycosamines are produced by fibroblasts. Hydroxyproline and hydroxylysine are synthesized by enzymes using iron, alpha ketoglutarate and vitamin C. About 50% of strength is achieved in 30 days.
Remodeling Phase (Maturation phase)
It begins within 6 weeks and lasts for 2 years. There is maturation of collagen by cross-linking which is responsible for tensile strength of the scar.
Management of Wounds
  • ▸ Wound is inspected and classified as per the type of wound.
  • ▸ If it is in the vital area, then:
    • The airway should be maintained.
    • The bleeding if present should be controlled.
    • Intravenous fluids are started.
    • Oxygen, if required may be given.
    • Deeper communicating injuries and fractures, etc. should be looked for.
  • ▸ If it is an incised wound, then primary suturing is done after thorough cleaning.
  • ▸ If it is a lacerated wound then the wound is excised and primary suturing is done.
  • ▸ If it is a crushed or devitalized wound, there will be edema and tension in the wound. Wound debridement is done by excising all the devitalized tissues and the edema is allowed to subside in 5–6 days. Then, delayed primary suturing is done.
  • ▸ If it is a deep devitalized wound, after wound debridement, it is allowed to granulate completely. Later, if the wound is small, secondary suturing is done. If the wound is large, a split skin graft (Thiersch graft) is used to cover the defect (Fig. 1.13).
  • ▸ In a wound with tension, fasciotomy is done so as to prevent the development of compartment syndrome.
  • ▸ Vascular or nerve injuries are dealt with accordingly. Vessels are sutured with 6-zero polypropylene nonabsorbable suture material. If the nerves are having clean-cut wounds it can be sutured primarily with polypropylene 6-zero or 7-zero suture material. If there is difficulty in identifying cut ends of nerves or if the cut ends of nerves are crushed then a marker stitch using silk is placed at the site and later secondary repair of the nerves are done.
  • ▸ Internal injuries have to be dealt accordingly (intracranial by craniotomy, intrathoracic by intercostal tube drainage, intra-abdominal by laparotomy). Fractured bones also should be identified and properly dealt with.
  • ▸ Antibiotics, fluid and electrolyte balance, blood transfusion, tetanus toxoid or antitetanus globulin injection (ATG).
zoom view
Fig. 1.13: Degloving injury, thigh and leg. It is extensive and needs regular dressing, debridement and later skin grafting
Wound Debridement (Wound toilet, or wound excision) is liberal excision of all devitalized tissues at regular intervals (of 48–72 hours) until healthy, bleeding, vascular tidy wound is created.
  • Wound infection is common in devitalized deep difficult wounds. Diabetes, immunosuppression, cytotoxic drugs, anemia, malnutrition, malignancy increases the chances of wound infection.
  • Wound dehiscence is common in all above said adverse factors. Wound suddenly gives away with pain causing copious serosanguineous discharge. After laparotomy when done especially as an emergency procedure as in trauma, acute abdomen and also in malignancy, 7abdominal closed wound may burst in 5–7 days. Usually, all layers of abdomen give away causing discharge, occasionally bowel will extrude out. It needs emergency closure of the abdominal wound using specialized sutures or retention sutures.
  • Hypertrophic scar or keloid formation due to altered collagen synthesis in the wound-healing process. Collagen synthesis is increased three times in hypertrophic scar and 20 times in keloid.
  • ▸ Deeper wound will cause specified problems like paresthesia, ischemia, paralysis, etc.
  • ▸ It is common in calf and forearm.
  • ▸ Closed injury causes hematoma leading to increased pressure.
  • ▸ It is often associated with fracture, which compresses the major vessel further aggravating the ischemia causing pallor, pulseless, pain, paresthesia, diffuse swelling and cold limb.
  • ▸ If allowed to progress, it may eventually lead on to gangrene or chronic ischemic contracture with deformed, disabled limb.
  • Muscle necrosis releases myoglobulin, which is excreted in the urine damaging kidneys leading into renal failure.
  • ▸ These patients require longitudinal lengthy, deep incisions i.e. fasciotomies to relieve the pressure and prevent compression (Fig. 1.14).
  • ▸ Antibiotics.
  • ▸ Bladder catheterization.
  • ▸ Mannitol or diuretics to create diuresis so as to flush the kidney.
  • ▸ Fresh blood transfusion.
  • ▸ Hyperbaric oxygen.
zoom view
Fig. 1.14: Fasciotomy done for compartment syndrome
It is due to crushing of muscles causing extravasation of blood and release of myohemoglobin into the circulation, leading to acute tubular necrosis and acute renal failure.
  • ▸ Earthquakes
  • ▸ Mining and industrial accidents
  • ▸ Air crash
  • ▸ Tourniquet.
Initially tension increases in the muscle compartment commonly in the limb, which itself impedes the circulation and increases the ischemic damage. In 3 days, urine gets discolored and scanty. Patient becomes restless, apathy and delirious with onset of uremia. Crush syndrome is often life-threatening.
Note: Crush injury of small area my not cause crush syndrome (Fig. 1.15).
zoom view
Fig. 1.15: Crush injury of finger
  • ▸ Tension in the muscle compartment is relieved by placing multiple, parallel, deep incisions in the limb so as to prevent further damage.
  • ▸ Rheomacrodex, or Mannitol is given to improve the urine output by improving the renal function.
  • ▸ Alkalization of the urine is done using sodium citrate or sodium bicarbonate.
  • ▸ Hemodialysis is done sometimes as a life saving procedure.
  • ▸ Other measures:
    • Bladder catheterization
    • Oxygen therapy
    • Antibiotics
    • Blood transfusion.
  • ▸ Keloid is common in blacks. Common in females. Common in Negroes.
  • ▸ Genetically predisposed. Often familial.
  • ▸ There is defect in maturation and stabilization of collagen fibrils.
  • ▸ Keloid continues to grow even after 6 months, may be for many years.
  • ▸ It extends into adjacent normal skin.
  • ▸ It is brownish black in color, painful, tender and sometimes hyperesthetic.
zoom view
Figs 1.16A to C: Keloid in shoulder and arm area; keloid in ear. Note the keloid at sternum, which is commonest site
Common over sternum. Other sites are upper arm, chest wall, and lower neck in front (Figs 1.16A to C and 1.17A).
Differential diagnosis: Hypertrophic scar.
Modes of treatment
  • ▸ Steroid injection—Triamcinolone is given intrakeloidally, at regular intervals, may be once in 7–10 days, of 6–8 injections.
  • ▸ Steroid injection → Excision → Steroid injection.
  • ▸ Methotrexate and vitamin A therapy into the keloid.
  • Intralesional excision retaining the scar margin which may prevent recurrence. It is ideal and better than just excision.
Recurrence rate is very high
Note: Excision and primary suturing has got high recurrence rate; hence it is not usually practiced.
  • ▸ Occurs anywhere in the body (Fig. 1.17B).
  • ▸ Not genetically predisposed. Not familial.
  • ▸ Growth usually limits up to 6 months.
  • ▸ It is limited to scar tissue only. It will not extend to the normal skin.
  • ▸ It is pale brown in color, not painful, non-tender.
  • ▸ Often, self-limiting also. It responds very well for steroid injection.
  • ▸ Recurrence is uncommon.
  • ▸ Repeated breakdown of the scar often occurs causing infection and pain.
  • ▸ After repeated breakdown it may turn into Marjolin's ulcer.
It is controlled by pressure garments or often revision excision of scar and closure, if required with skin graft.
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Figs 1.17A and B: Keloid over sternum and hypertrophic scar over thigh
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Fig. 1.18: Diagrammatic representation of linear scar, hypertrophic scar and keloid
SINUS (FIG. 1.19)
  • ▸ “Sinus” means “hollow” or “a bay” (Latin).
  • ▸ It is a blind track lined by granulation tissue leading from an epithelial surface into the surrounding tissues.
  • ▸ Sinus sprouts outside and it does not have a floor clinically.
  • ▸ Discharge can be seen on the mouth of the sinus.
Causes of Sinus
  • Congenital: Preauricular sinus.
  • Acquired: Chronic osteomyelitis of bone causing bone spicules and discharge to come out of the sinus opening. Median mental sinus in the mentum in lower jaw is due to tooth infection. Pilonidal sinus is due to entering of hairs in the interbuttock cleft over the sacrum. Madura foot in the foot and leg is due to Nocardia Madurai fungal infection causing multiple discharging sinuses. Tuberculous sinus is eventual outcome of cold abscess in neck, groin, etc. discharging cheesy, caseating, yellowish material.
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Fig. 1.19: Sinus
  • ▸ It is an abnormal communication between the lumen of one viscus to another or the body surface or between the vessels.
  • ▸ Fistula means “flute” or “a pipe or tube”.
Causes of Fistula
  • ▸ Branchial fistula in neck.
  • ▸ Thyroglossal fistula.11
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Fig. 1.20: Fistula
  • ▸ Orocutaneous fistula in advanced carcinoma cheek.
  • ▸ Tracheo-esophageal fistula.
  • ▸ Postoperative gastrointestinal fistula (Fig. 1.21).
  • ▸ Rectovesical fistula.
  • ▸ Fistula-in-ano.
Fistula can be
  • External: Here fistula communicates from skin to hollow viscus inside. Examples – parotid fistula, thyroglossal fistula, branchial fistula.
  • Internal: Here fistula develops between two hollow viscera. Colovesical fistula, aortoenteric fistula.
Fistula also can be
  • Congenital—Branchial/tracheoesophageal fistula.
  • Acquired—Thyroglossal fistula, fistula-in-ano, etc.
Types of Sinus/Fistula
Preauricular sinus
Ruptured abscess
Branchial fistula
Tracheoesophageal fistula
Congenital AV fistula
Chronic osteomyelitis
Acquired AV fistula
Median mental sinus
Clinical Features
  • ▸ Discharge from the opening of sinus. No floor.
  • ▸ Raised indurated edge, indurated base, non-mobile.
  • ▸ Often sprouting granulation tissue is seen over the sinus opening.
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Fig. 1.21: Fecal fistula of abdominal wound
Investigations (Fig. 1.22)
  • ▸ Fistulogram/sinusogram using ultrafluid lipidol or water-soluble iodine dye.
  • ▸ Discharge for culture and sensitivity, AFB, cytology, staining.
  • ▸ Biopsy from the edge, chest X-ray, ESR.
  • ▸ The cause is treated—sequestrectomy, foreign body removal, control of tuberculosis.
  • Excision of sinus or fistulas. Always specimen should be sent for histology.
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Fig. 1.22: X-ray of femur showing osteomyelitis of the femur with sequestrum and sinus
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Figs 1.23A and B: Fecal fistula with discharging fecal matter through the fistulous wound. Note the tension sutures in one of the pictures
It is a chronic infective condition, wherein there is infection of roots of one or both lower incisor teeth forming root abscess, which eventually tracks down between two halves of the lower jaw in midline, presenting as discharging sinus on the point of chin in midline (Fig. 1.24).13
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Fig. 1.24: Median mental sinus. Note the origin of the sinus from the root/roots of the lower incisor/incisors
Clinical Features
  • ▸ Usually painless discharging sinus in the midline on the point of chin.
  • ▸ Often infection in incisor may be revealed (in many patients clinically tooth looks normal, even though root is infected invariably).
  • ▸ It is often mistaken for infected sebaceous cyst.
  • ▸ Osteomyelitis of the mandible is the possible complication.
Differential Diagnosis
  • ▸ Infected sebaceous cyst.
  • ▸ Tuberculous sinus.
  • ▸ Osteomyelitis.
  • ▸ Dental X-ray is diagnostic (Plain X-ray mandible may not reveal the disease).
  • ▸ Discharge study—culture and sensitivity, cytology, AFB.
  • ▸ Antibiotics after doing discharge study (culture and sensitivity).
  • ▸ Lay opening and excision of the sinus track with extraction of incisor tooth/teeth.
An ulcer is a break in the continuity of the covering epithelium, either skin or mucous membrane due to molecular/cell death.
Parts of an Ulcer (Fig. 1.25)
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Fig. 1.25: Parts of an ulcer
It may be regular or irregular. It may be rounded or oval.
Edge is the one, which connects floor of the ulcer to the margin.
Different edges are (Fig. 1.26):
Sloping edge. It is seen in healing ulcer. Its inner part is red because of red, healthy granulation tissue.
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Fig. 1.26: Ulcer edges
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Fig. 1.27: Tuberculous ulcer over the foot. Note the undermined edge
Undermined edge is seen in tuberculous ulcer (Fig. 1.27).
Punched out edge is seen in gummatous (syphilitic) ulcer, trophic ulcer and pressure sores. It is due to endarteritis.
Raised and beaded edge (pearly white) is seen in rodent ulcer (BCC).
Everted edge (rolled out edge): It is seen in carcinomatous ulcer.
It is the one, which is seen. Floor may contain discharge, granulation tissue, or slough.
Base is the one where ulcer rests. It may be bone or soft tissues.
Spreading ulcer: Here edge is inflamed and edematous.
Healing ulcer (Fig. 1.28): Edge is sloping with healthy pink/red granulation tissue with serous discharge.
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Fig. 1.28: Healing ulcer with healthy granulation tissue
Callous ulcer: Floor contains pale unhealthy granulation tissue with indurated edge/base (Fig. 1.29). Ulcer has no tendency to heal. It lasts for many months to years. It is due to callous attitude of the patient (Figs 1.30 and 1.31).
Specific Ulcers
  • ▸ Tuberculous ulcer (See Fig. 1.26).
  • ▸ Syphilitic ulcer: It is punched out, deep ulcer, with ‘wash-leather’ slough in the floor and with indurated base.
  • ▸ Actinomycosis.
  • ▸ Meleney's ulcer.
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Fig. 1.29: Nonhealing ulcer foot with unhealthy/pale granulation tissue
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Fig. 1.30: Callous ulcer in the leg. Note the slough on the surface of ulcer with no signs of healing
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Fig. 1.31: Callous ulcer leg. Note ulcer floor without any granulation tissue. It is due to callous attitude of the patient
Malignant Ulcers
  • ▸ Carcinomatous ulcer.
  • ▸ Rodent ulcer.
  • ▸ Melanotic ulcer.
Nonspecific Ulcers
  • Traumatic ulcer: It may be due to mechanical, physical, chemical injury.
  • Arterial ulcer: Atherosclerosis, TAO.
  • Venous ulcer (gravitational ulcer, post-phlebitic ulcer).
  • Trophic ulcer.
  • Infective ulcers: Pyogenic ulcer.
  • Tropical ulcers: It occurs in tropical countries. It is callous type of ulcer, e.g. Vincent‘s ulcer.
  • Ulcers due to chilblains and frostbite (cryopathic ulcer).
  • Martorell‘s hypertensive ulcer: It occurs due to obliteration of end arteries. It is observed in skin over the back of calf region. Ulcer is severely painful with deep, non-healing ischemic look.
  • Bazin's ulcer: It is seen exclusively in the legs and ankles of young females, as erythematous purplish nodules and non-healing ulcers. It may be due to ischemic (Fig. 1.32)/hypersensitive/tuberculous etiology. It is treated with antituberculous drugs, dressings, vasodilators and often by sympathectomy. It is also called as Erythrocyanosis frigida.
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Fig. 1.32: Ischemic ulcer foot is due to poor blood supply due to either, atherosclerosis, TAO, diabetes mellitus
  • Diabetic ulcer.
  • Ulcers due to leukemia, polycythemia, jaundice, collagen diseases, lymphedema.
  • Cortisol ulcers are due to long time application of cortisol (steroid) creams to certain skin diseases. These ulcers are callous ulcers, last for long time and requires excision with skin grafting.
Note: Maggots may form in ulcer and they eat only dead tissues (Fig. 1.33).
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Fig. 1.33: Ulcer showing maggots. Maggots eat only dead tissue
It is proliferation of new capillaries and fibroblasts intermingled with RBC‘s and WBC‘s with thin fibrin cover over it.
Healthy Granulation Tissue
It occurs in a healing ulcer. It has a sloping edge with serous discharge. It bleeds on touch. Skin grafting takes up well with healthy granulation tissue. Streptococci growth in culture should be less than 105/gram of tissue before skin grafting (Figs 1.34A and B)
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Figs 1.34A and B: Healthy granulation tissue seen in ulcer bed; it is coverd with split skin graft (SSG)
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Fig. 1.35: Nonhealing ulcer. Note the unhealthy granulation tissue
Unhealthy Granulation Tissue
It is pale with purulent discharge. Its floor is covered with slough. Its edge is inflamed and edematous. It is a spreading ulcer (Fig. 1.35).
Unhealthy, Pale, Flat Granulation Tissue
It is seen in chronic nonhealing ulcer (callous ulcer).17
Exuberant Granulation Tissue (Proud Flesh)
It occurs in a sinus wherein granulation tissue protrudes out of the orifice of the sinus like a proliferating mass. It is commonly associated with a retained foreign body in the sinus cavity.
Pyogenic Granuloma
It is a type of exuberant granulation tissue. Here granulation tissue protrudes out from an infected wound or ulcer bed, presenting as well localized, red swelling, which bleeds on touch (Figs 1.36A and B)
Treatment: Antibiotics, excision and biopsy.
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Figs 1.36A and B: Pyogenic granuloma on the face and finger. They present with pain, bleeding and swelling. It needs excision under local anesthesia
Induration in an ulcer is due to carcinoma or due to fibrosis in a long-standing ulcer.
Investigations for an Ulcer
  • Study of discharge: Culture and sensitivity, AFB study, cytology.
  • Edge biopsy: Biopsy is taken from the edge because edge contains multiplying cells. Usually two biopsies are taken. Biopsy from the center may be inadequate because of necrosis.
  • ▸ X-ray of the part.
  • ▸ FNAC of the lymph node.
  • ▸ Chest X-ray, Mantoux test is done in suspected case of tuberculous ulcer (Figs 1.37A and B)
Treatment of an Ulcer
  • ▸ Treat the cause like diabetes, anemia, and malnutrition. Often needs blood transfusion.
  • ▸ Antibiotics are given depending on the culture and sensitivity.
  • ▸ Regular dressings using EUSOL (Edinburgh University Solution containing calcium hydroxide, boric acid, sodium hypochlorite), H2O2, povidone iodine.
  • ▸ Wound excision/slough excision/debridement of the wound at regular intervals.
  • ▸ Once wound granulates well, split skin grafting is done to cover the defect (Figs 1.38A and B)
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Figs 1.37A and B: Ulcer with Pseudomonas infection. Note the greenish floor
  • ▸ If there is no adequate blood supply, or if bone is exposed then flap is needed depending on the location of ulcer, either groin flap, pectoralis major flap, etc.
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Figs 1.38A and B: Healing ulcers in leg and shoulder area in different patients. Note the healthy granulation tissue with sloping edge
It is due to:
  • ▸ Impaired nutrition.
  • ▸ Defective blood supply.
  • ▸ Neurological deficit.
It usually occurs:
  • ▸ Over the heel.
  • ▸ In relation to heads of metatarsals.
  • ▸ Buttocks.
  • ▸ Over the ischial tuberosity.
  • ▸ Sacrum.
  • ▸ Over the shoulder.
  • ▸ Occiput.
Because, there is neurological deficit, trophic ulcer is also called as neurogenic ulcer/neuropathic ulcer.
Due to repeated trauma and pressure, it initially begins as callosity which suppurates and gives way through a central hole extending into the deeper plane as perforating ulcer (penetrating ulcer).
Clinical Features
  • ▸ Painless ulcer, which is punched out.
  • ▸ Ulcer is non-mobile with base formed by underlying bone.
Study of discharge, biopsy from the edge, X-ray of the part, X-ray spine, blood sugar.
  • ▸ Cause should be treated.
  • ▸ Nutritional supplements.
  • ▸ Rest, antibiotics, slough excision, regular dressings.
  • ▸ Once ulcer granulates well, flap cover or skin grafting is done.
  • ▸ Excision of the ulcer and skin grafting.
Bedsore/pressure sore is a trophic ulcer with underlying bone as the base.
It is nonmobile, deep, punched out ulcer.
It is common in:
  • ▸ Old age.
  • ▸ Bedridden individuals.
  • ▸ Tetanus.
  • ▸ Patients with orthopedic and head injuries.
  • ▸ Diabetic.
  • ▸ Paraplegic.
  • ▸ Comatose.
  • ▸ Emaciated patient.
  • ▸ Anemia.
  • ▸ Prolonged immobilization.
Sites of bedsore are occiput, heel, sacrum (Fig. 1.39), ischium, scapula, greater trochanter, spinous process, elbows, and buttocks.
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Fig. 1.39: Bedsore over sacral region. It is a trophic ulcer
Predisposing Factors
  • ▸ Malnutrition, anemia, sensory loss, pressure, moisture.
  • ▸ Incontinence makes skin moist and septic, so five times more prone for pressure sore.
  • ▸ Excessive sweating, edema body.
  • ▸ Friction due to foreign body, thick bed sheets, hard rough cot.
Superficial bedsores are common (75%). They are painful and heal slowly by itself.
Deep bedsores are painless but covered with slough. It requires antibiotics, grafting or flaps to cover it later.
  • ▸ Change of positions should always be encouraged.
  • ▸ Use of waterbed, ripple bed is advised. Bed should be smooth and free from wrinkles and unevenness. Air rings or air cushions are also useful.
  • ▸ Moisture has to be avoided. Skin must be kept clean and dry. It should be washed with soap and water and dried properly. A soothening powder may be beneficial.
  • ▸ Ripple bed has an alternate pressure point pad under the bottom sheet of ordinary mattress. It provides regular automatic frequent redistribution of pressure areas. The pad consists of vinyl plastic pad with alternating sets of air cells. To control the air, an air pump is also present.
  • ▸ In a patient with urinary incontinence, special silicone bedclothes are used to attain waterproof covering to skin. Indwelling Foley‘s catheter is placed to drain urine. Thorough washing of the back and drying twice daily is essential. Disposable soft inco-pads are used repeatedly as required.
  • ▸ Bowker-Davidson special pressure cushions contain foamed cushion with a waterproof polyvinyl chloride bag containing 5 liters of the thixotropic gel.
  • ▸ Soaking by urine, sweat, pus, and feces has to be taken care off.
  • ▸ Good nursing, regular dressing, good nutrition are necessary.
  • ▸ Antibiotics, blood transfusions are very essential.
  • ▸ Excision of dead tissue followed by skin grafting or local rotation flaps may have to be done.
Patients with diabetes are more prone for foot problems like cellulitis, abscess formation, gangrene, osteomyelitis of foot. It is due to neuropathy, more susceptibility for infection, clawing of toes, loss of functioning of foot arch, microangiopathy, bacterial resistance, and decreased body immunity.
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Fig. 1.40: Ulcer foot in diabetic patient
  • ▸ Foot-plantar aspect—is the commonest site.
  • ▸ Leg.21
  • ▸ Upper limb, back, scrotum, perineum.
Diabetic ulcer may be associated with ischemia. Ulcer is spreading and deep.
  • ▸ Blood sugar both random and fasting.
  • ▸ Urine ketone bodies.
  • ▸ Discharge for culture and sensitivity.
  • ▸ X-ray of the part.
  • ▸ Arterial Doppler of the limb.
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Fig. 1.41: Microcellular rubber (MCR) chappal used in neuropathic diabetic foot
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Figs 1.42A and B: Below knee amputation is done for diabetic gangrene foot
  • ▸ Control of diabetes using insulin. Sliding scale insulin is used depending on the color seen in urine test. Human insulin is the preferred type of insulin. When there is ketosis, intravenous insulin is used in normal saline.
  • ▸ Antibiotics.
  • ▸ Nutritional supplements.
  • ▸ Regular cleaning, debridement, dressing.
  • Microcellular (MCR) chappals are used to avoid ulcer formation (Fig. 1.41)
  • ▸ Abscess drainage, toe amputation (Ray amputation), below-knee/above-knee amputations (Fig. 1.42).
  • ▸ Once granulates, the ulcer is covered with skin graft or flap.
  • ▸ Suitable prosthesis to the limb helps the patient to achieve ambulation (Fig. 1.43).
  • ▸ Patient is prone for septicemia, ketosis, electrolyte imbalance, silent myocardial infarction and often all these can be fatal.
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Fig. 1.43: Leg prosthesis used after lower limb amputation for diabetic gangrene
  • ▸ It is commonly seen in postoperative wounds in abdomen and chest wall like empyema drainage or after surgery for peritonitis.
  • ▸ It is common over abdomen and thorax. It begins in wound margin and spreads rapidly. It can also occur in other areas of skin.
  • ▸ Infection is severe, often with endarteritis of the skin leading to ulcer and destruction.
  • ▸ It causes severe toxicity and extensive necrosis of the skin and deeper plane, which often needs debridement, antibiotics and later skin grafting.
  • ▸ Such ulcer occurs after trauma. It may be mechanical—dental ulcer in the margin of the tongue due to tooth injury; physical like by electrical burn; chemical like by alkali injury.
  • ▸ Such ulcer is acute, superficial, painful and tender. Secondary infection or poor blood supply of the area makes it chronic and deep.
  • Footballer's ulcer is a traumatic ulcer occurring over the shin of males due to direct knocks on the shin. It is staphylococcal infection with a chronic and deep ulcer.
  • ▸ Traumatic ulcers can occur anywhere in the body due to trauma.
  • ▸ Trauma causes infection, necrosis, fasciitis, crush injury, endarteritis of the skin leading into formation of large/deep non-healing ulcer.
  • Treatment depends on size and extent of ulcer. Regular dressing, later skin grafting.
  • ▸ It is common in toes, feet or legs; often can occur in upper limb digits. It is due to poor blood supply following blockage of the digital or medium sized arteries.
  • ▸ Atherosclerosis and TAO (thromboangiitis obliterans) are common causes in lower limb.
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Fig. 1.44: Ischemic ulcer foot and gangrene of toe
  • ▸ Cervical rib, Raynaud's phenomenon and vasculitis are common causes in upper limb.
  • ▸ Ulcer initially occurs after trauma, soon becomes nonhealing, spreading with scanty granulation tissue.
  • ▸ Ulcer is very painful, tender and often hyperesthetic. Digits may often be gangrenous. Intermittent claudication, rest pains are common. Other features of ischemia are obvious in the adjacent areas. They are—pallor, dry skin, brittle nail, patchy ulcerations, and loss of hair.
  • ▸ Ulcer is usually deep, destructs the deep fascia, exposing tendons, muscles and underlying bone. Dead tendons look pale/greenish with pus over it.
  • Management: Specific investigations like arterial Doppler, angiogram, lipid profile, and blood sugar are done. Treatment is done accordingly—drugs like vasodilators; arterial surgeries may be needed.
  • ▸ It arises from prickle cell layer of skin. It may initially begin as a nodule or ulcer; but later forms an ulcerative lesion with rolled out/everted edge. Floor contains necrotic content, unhealthy (tumor) granulation tissue and blood (Fig. 1.45).
  • ▸ Ulcer bleeds on touch and is vascular and friable. Induration is felt at the base 23and edge. It is usually circular or irregular in shape. Initially ulcer is mobile but becomes nonmobile once it infiltrates into deeper tissues. The typical foul smell is due to necrotic material, infection and release of polyamides from the tumor cells.
  • ▸ Hard, discrete regional lymph nodes are often palpable, initially mobile but later become fixed. Lymph nodes can fungate eventually. Ulcer and lymph nodes are initially painless; but becomes painful and tender once there is deeper infiltration or secondary infection. Systemic spread is rare. It is a locoregional malignant disease.
  • Verrucous carcinoma is exophytic, locally malignant well differentiated squamous cell carcinoma without lymphatic spread.
  • Management: Edge biopsy; FNAC of regional lymph nodes are the investigations. Treated with wide local excision with skin grafting and regional lymph node block dissection.
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Fig. 1.45: Squamous cell carcinoma heel. It is proliferative ulcer. Note the raised and everted edge
  • ▸ It is slow growing locally malignant lesion—a very well differentiated squamous cell carcinoma occurring in an unstable scar of long duration.
  • ▸ It is commonly seen in chronic venous ulcer scar. Often it is observed in burns scar and scar of previous snake bite. Lesion is ulcerative/proliferative (Fig. 1.46).
  • ▸ Edge may be everted or may not be. It is painless as scar does not contain nerve fibrils. It does not spread into lymphatics as scar is devoid of lymphatics. Induration is felt at the edge and base. There is marked fibrosis also.
  • ▸ Once lesion spreads into adjacent normal skin, it can spread into regional lymph nodes behaving like squamous cell carcinoma.
  • Managed by edge biopsy and wide local excision and grafting. If large and deep, amputation is needed.
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Fig. 1.46: Marjolin's ulcer in a chronic unstable scar (of long duration) in the leg. It does not spread through lymphatics
  • ▸ It is ulcerative form of basal cell carcinoma, which is common in face.
  • ▸ Ulcer shows central area of dry scab with peripheral raised active and beaded (pearly white) edge. Often floor is pigmented. It erodes into deeper plane like soft tissues, cartilages and bones hence the name—rodent ulcer.
  • ▸ As lymphatics are blocked early in the disease by large tumor cells, it does not spread to regional lymph nodes.
    24Blood spread is absent. It is only locally malignant.
  • ▸ It is common in face; rarely can it occur over tibia, external genitalia, mucocutaneous junction. It does not occur in mucosa (Fig. 1.47).
  • Management: Edge biopsy, CT scan of the part to see the depth, wide excision.
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Fig. 1.47: Basal cell carcinoma (BCC/rodent ulcer) face
  • ▸ It is ulcerative form of melanoma. It can occur in skin as de novo or in a pre-existing mole. Ulcer is pigmented often with a halo around (Fig. 1.48).
  • ▸ Ulcer is rapidly growing, often with satellite nodules and ‘in–transit’ lesions. It is very aggressive skin tumor arising from melanocytes.
  • ▸ It spreads rapidly to regional lymph nodes which are pigmented. Blood spread to liver, lungs, brain, and bone is common. It can occur in mucosa, genitalia, and eye. It is a systemic malignant disease.
  • Investigations: Excision biopsy (usually incision biopsy is not done), FNAC lymph node, US abdomen.
  • Treatment is wide local excision, regional node block dissection and chemotherapy.
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Fig. 1.48: Melanotic ulcer in the foot
  • ▸ It is endemic in monsoon hit humid tropics with repeated epidemics but sporadic in subtropics. Trauma or insect bite leads into infection exclusively in the lower part of the leg and foot.
  • ▸ It is an acute ulcerative lesion of the skin observed in tropical regions like Africa, India and South America. It is associated with lower socioeconomic group, anemia, and malnutrition and vitamin deficiency.
  • ▸ It is commonly caused by Fusobacterium fusiformis (vincent's organisms) and Borrelia vincenti.
  • ▸ There are abrasions, redness, papule and pustule formation, acute regional lymphadenitis and severe pain.
  • ▸ Pustule bursts in 3 days along with necrobiosis and phagedena causing a spreading painful ulcer with an undermined edge, brownish floor and serosanguineous discharge. Spreading stops in few weeks with ulcer persisting for many months to years. Eventually a chronic, large nonhealing/callous ulcer forms with persistent pain, profuse serosanguineous discharge, extremely unpleasant odor, long existing firmly adherent slough in the floor without any obvious constitutional symptoms. During healing it causes a slight pigmented, parchment like round scar.25
  • ▸ Often destruction is progressive without cessation (phagedena) to extend into entire soft tissues of foot and leg inviting amputation. Phagedena (Greek—to eat) is also seen in chancroid and cancrum oris.
  • ▸ Occasionally squamous cell carcinoma can develop on it.
  • Treatment—improvement in nutrition, penicillin, metronidazole, Eusol dressing, skin grafting at a later date.
  • ▸ It is common around ankle (gaiter's zone) due to chronic venous hypertension. It is due to varicose veins (long saphenous vein/short saphenous vein/perforators) or post-phlebitic limb.
  • ▸ Postphlebitic limb consists of veins that is been partially recanalized following deep venous thrombosis, which causes increased venous pressure around ankle through perforators. It is called as post-thrombotic ulcer. DVT has to be treated in these patients.
  • ▸ Varicose veins are common in females. Fifty percent of venous ulcer is due to varicose veins; 50% are due to postphlebitic limb (previous DVT). Pain, discomfort, pigmentation, dermatitis, lipodermatosclerosis, ulceration, periostitis, ankle-joint ankylosis, talipes equinovarus deformity and Marjolin's ulcer are the problems of varicose veins and later of venous ulcer (Fig. 1.49).
  • ▸ Ulcer is initially painful; but once chronicity develops it becomes painless. Ulcer is often vertically oval; commonly located on the medial side; occasionally on lateral side; often on both sides of the ankle; but never above the middle-third of the leg. Floor is covered with pale or often without any granulation tissue. When well granulated, edge is sloping. Induration and tenderness is seen often at the base of an ulcer.
  • ▸ Inguinal lymph nodes (vertical group) are often enlarged. Ulcer often attains very large size which is nonhealing, indolent and callous.
  • ▸ Ulcer heals on rest and treatment; but reforms again. Scarring is common due to repeated healing and recurrent ulcer formation. This unstable scar of long duration may lead into squamous cell carcinoma (Marjolin's ulcer).
  • Management: Venous Doppler, regular dressing, skin grafting, specific treatment for varicose veins.
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Fig. 1.49: Venous ulcer around ankle with skin changes over surrounding area. It is the commonest site of venous ulcer
  • ▸ It is due to mycobacterium tuberculosis. It is usually due to cold abscess later forming ulcer in the neck, chest wall, axilla and groin.
26It can also be primary tuberculosis of the skin (commonly in face). Ulcer can be single or multiple; oval or rounded; with undermined edge (due to progression of disease outwards underneath and healing inwards by skin), painful and tender with caseating material on the floor. Ulcer is usually not deep. Regional lymph nodes may be enlarged matted, firm, and nontender.
  • Management: Discharge study for epithelioid cells (modified histiocytes), AFB; edge biopsy, antituberculous drugs.
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Fig. 1.50: Tuberculous ulcer in the neck. It is typically undermined
  • ▸ It is cutaneous tuberculosis, which occurs in young age group.
  • ▸ Commonly seen on face, starts as typical apple-gelly nodule with congestion of face around. Eventually ulceration occurs with scarring, necrosis and undermined edge.
  • ▸ Long standing lupus vulgaris can turn into squamous cell carcinoma.
ESR, discharge study, biopsy, chest X-ray.
  • ▸ Antituberculous drugs.
  • ▸ If complete healing does not occur, then excision and skin grafting is required.
It is due to exposure to intense cold causing blisters, ulceration in the feet. These ulcers are superficial. The condition is also called as perniosis.
  • ▸ It is due to exposure of the part to wet cold below the freezing point.
  • ▸ It leads to gangrene of the part. Ulcers, here are always deep.