DECUBITUS AND VARICOSUS

ULCER OF CHRONIC WOUNDS

OLEH:
DAHNIAR RIZKI F G99152044
DARMA AULIA H G99152037
KATHERINE G S G99152032
YASYFIE ASYKARI G99161104
NURUL FADILAH G99162083

PEMBIMBING ;
DR. AMRU SUNGKAR, SP.B, SP.BP-RE

KEPANITERAAN KLINIK ILMU BEDAH

FAKULTAS KEDOKTERAN UNS/RSUD DR. MOEWARDI SURAKARTA
2017
CHRONIC WOUND ULCER

Ulcer is a
Chronic wound is a wound that does not heal in a set of stages and predictable of
the time the way most wounds do
Wounds that do not heal within 3 months are often considered as chronic wound
CHRONIC WOUND CLASSIFICATION

Venous ulcer / Stasis ulcer

Pressure ulcer / Decubitus Ulcer
Diabetic ulcer
Arterial ulcer
VARICOSUS ULCER
DEFINITION
An area of discontinuity of epidermis, persisting for 4 weeks or more,
occurring as a result of venous hypertension and calf muscle pump
insufficiency
Varicosus ulcer often considered as a sequel from Chronic Venous
Insufficiency Disease
Varicosus ulcer must exclude with :

arterial disease

neuropathy, diabetes

rheumatoid arthritis

carcinoma

haemoglobinopathies
Varicose Veins

Definition:
Varicose veins are veins that have become distended over time.
Long, tortuous and dilated veins of the superficial varicose
system due to the pooling of blood in the lower extremities.
PRIMARY RISK FACTOR

Older age 30-40 years

Woman
Obesity
Pregnancy
Previous Leg Injury (Fractures)
Phlebitis
Deep Vein Thrombosis History
PATHOPHISIOLOGY
Pathophysiology of Varicose Veins:
Veins are thin-walled vessels that are easily distended by the
chronic pooling of blood in the lower extremities.
Chronic distention of veins can reduce effectiveness of one-way
venous valves that are present in the lumen to prevent the back
flow of blood and lead to a condition termed valvular
incompetence.
These venous valves work in conjunction with skeletal muscle
pumps in the legs to move blood back to the heart from the
extremities.
 Valve (open)

Skeletal
muscle

Valve (closed)

Venous valves Vei

n

Direction
of
blood flow

(From Marieb, E.N.,Human Anatomy and Physiology, 3rd ed., Benjamin Cummings, Glenview, IL, 1995.
MECHANISM

Venous Hyprtension

Insufficiency Calf Muscle :

Deep vein thrombosis, perforator insufficiency, suerficial and deep vein

insufficiencies, arteriovenous fistulas and calf muscle pump insufficiencies lead to
increased pressure in the distal veins of the leg
 Fibrin cuff theory

Fibrin gets excessively deposited around capillary beds leading to elevated

intravascular pressure. This cause enlargement of endhoteliar ores resulting in
further increased fibrinogen deposition in the interstitium. The fibrin cuff which
surrounds the capillaries in the dermis decreases oxygen permeability 20 fold. This
permeability barrier inhibits diffusion of oxygen and other nutrients, leading to tissue
hoxia causing impaired wound healing
 Inflammatory trap theory
Various growth factors and inflammatory cells, which get trapped in the fibrin cuff
promote severe uncontrolled inflammation in surrounding tissue preventing proper
regenarion of wounds. Leukocytes get trapped in capillaries, releasing proteolytic
enzymes and reactive oxygen metabolites, which cause endothelial damage. These
injured capillaries become increasingly permeable to various macromolecules,
accentuating fibrin deposition. Occlusion by leukocytes also causes local ischemia
thereby increasing tissue hypoxia and reperfusion damage.
CLINICAL MANIFESTATIONS
The most common manifestations are :
1. Aching and edema
2. Their appearance through the skin is unsightly.
3. May be associated with varicocele or inguinal hernia.

Treatment often involves:

1. The use of support stockings to prevent venous pooling.
2. Surgical interventions may also be used to improve appearance and
reduce discomfort.
DIAGNOSIS

Doppler
Duplex USG
Imaging X-Ray
Phlebography
Dermatopathology
DIFFERENTIAL DIAGNOSIS
TREATMENT

Conservative
Elastic compression
In-elastic compression
Pneumatic intermiten compression
Leg elevation
Dressing
Mechanic therapy

Medical agents
Pentoxyfilline
Aspirine
Iloprost
Zinc oral
Antibiotic/antiseptic
Other
Hyperbaric oxygen therapy
Surgical management
Debridement
Skin grafting
Surgery for venous insufficiency
Prophylaxis for Deep Vein Thrombosis
COMPLICATION
PROGNOSIS

Sebagian besar penerita umumnya baik jika ditangani dengan pengobatan dan
tindakan yang benar.
PRESSURE ULCER