MARKING SCHEME

QUESTION: Discuss the management of chronic leg ulcers

DEFINITION:
A chronic leg ulcer is a loss of epithelial cover in the anatomic region between the knee and
ankle joint that has persisted for over six weeks (1/2 marks)

INTRODUCTION:
Candidate should know that after the hands the legs are next in incidence of trauma
Reasons for this should be stated i.e. organ for locomotion, poor blood flow because it is an
extremity. Also poor venous drainage because of dependency due to bipedal status of man.
Constant contact with micro-organism all combine to increase incidence and chronicity of leg
ulcers. (1/2 marks)

AETIOPATHOLOGY
Infective Acute Bacterial e.g. Staph aureus, Strept pyogenes e.t.c.
Sub- acute Bacterial e.g. Staph. Epidermidis mixed bacterial infections.
(Tropical ulcer) Klebsiella, Pseudomonas e.t.c.
Chronic Bacterial Mycobacterial Myco tuberculosis, Buruli Myco ulcerans
Leprosy,
Syphilis (Treponema pallidum) Yaws (Treponema pertenue)
Fungal infections (subcutaneous mycosis e.g Sporotrichosis
Infestations Dracuncunlosis
Myasis
Trauma (most common with mixed bacterial infections result in Tropical ulcer)
Hemoglobinopathic Membranopathy (Hereditary spherocytosis, Hereditary Elliptocytosis)
Hemoglobinopathy (Sickle cell Disease, Hemoglobin C disease)
Beta-Thallassaemia
Vascular Venous
Arterial
Lymphatic
Neoplastic Primary Tumour (melanoma, basal cell, squamous cell )
Secondary Tumours (rare)
Neuropathic Pressure sore, Syphilitic leprosy
Metabolic Diabetes
Candidates should contrast the pathogenesis of each condition (2 Marks)

D) CLINICAL CLASSIFICATION Non Specific Ulcer

(according to edge) Specific Ulcer
(Sloping, Punched out, Rolled, Undermined)
significance of the edge in diagnosis should be stated by patient (2 Marks)

E) HISTORY
Onset whether caused by trauma or spontaneous.
The progression (increasing rapidly, slowly, heals and breakdown) candidate state significance
Number of ulcers (state significance): Presence of pain (state significance):
Duration (state significance): Pedal swelling (state significance):
Other Symptoms: Calf Pain, Claudication, Impotence, Paresthesia
(candidate should correlate each symptom with the differential diagnosis) (4 Marks)

F) PHYSICAL EXAM
Site of ulcer: Number of ulcers: The Edge: The Flour: The Base: The Margin: The state of
surrounding Skin: Presence of Pedal Oedema: Ankle Blood Pressure: Palpate all Peripheral
Pulses: Lymph node Enlargement: Senation to Pain and Touch: Vibratory Sensation (Syphilis):
Trendelenburg Test and Perthes Test Varicose veins: Trophic Changes in the Extremity.
(candidate should correlate each sign with the differential diagnosis) (4 Marks)

G) INVESTIGATIONS
FBC
FBS
Urinalysis
Electrolyte Urea Creatinine
Wound Swab For MCS and AAFB
Wound Biopsy
Venogram
Arteriogram
Doppler/Duplex
Angiogram
Plain Xrays
(candidate should not list each investigation with the differential diagnosis stating also their
limitation) (3 Marks)

H TREATMENT
NON SURGICAL (State indications Acute/size <5cm/ non fibrotic) itemize different types of
dressing solution (state types of solution and their advantages EUSOL, HIBITANE, HONEY
BIOLOGIC MEMBRANES etc)
SURGICAL debridement, Wound Closure SSG, FLAPS, FASCIOCUTANEOUS, MUSCLE
FLAPS e.t.c.
(candidate should not list each treatment option but indicate when they are likely to be used)
(4 Marks)

TOTAL MARKS=20