Types of ulcer edges ■

▪︎Sloping edge : healing, traumatic and ischaemic venous ulcers.

▪︎Undermined edge : TB

▪︎Punched-out edge : ischaemic and syphilitic ulcers

▪︎Rolled edge : basal cell carcinoma

▪︎Everted edge : squamous cell carcinoma and the ulcerated adenocarcinoma.

#Ulcer
#Surgery_rotation
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🔴Diabetic Foot

▪︎It's Any Pathology Affect Lower Limbs (Specially Foot) That Results Directly From The Chronic Complications Of Diabetes Mellitus


▪︎Pathologies Affect Foot Could Be :
📍1. Infections
📍2. Ulcerations
📍3. Deep Tissue Destruction
📍4. Peripheral Vascular Disease
📍5. Neurological Abnormalities


▪︎Diabetic Foot Responsible For 40-60% Of Non-Traumatic Foot Amputation (Most Amputations Proceeded By Foot Ulcer)

▪︎Foot Ulcer is The Most Important Complications Of Diabetic Foot

▪︎15% Of Diabetic Patients Will Develop Foot Ulcers


🔷Pathophysiology For The Development Of Diabetic Foot
📍1. Peripheral Vascular Disease :
▪︎Chronic Elevation in Blood Sugar Levels Results in Arterial Atherosclerosis

▪︎This Will Results in Reduction Of The Blood Supply To The Foot


📍2. Neurological Dysfunction (Diabetic Neuropathy Most Common Long Term Diabetic Complication) :
🔻I. Sensory Neuropathy :
▪︎Decrease Superficial & Deep Sensations Of The Foot

▪︎Results in Recurrent Undiscovered Foot Trauma & Callus Formation


🔻II. Motor Neuropathy :
▪︎Alterations in The Biomechanics Of The Foot (Muscle Wasting/Ligaments Weakness/Bone Erosions)

▪︎Results in Foot Deformity & Unequal Pressure Distribution On The Foot That Contribute To More Foot Trauma (Metatarsal Head Exposure)


🔻III. Autonomic Neuropathy :
▪︎Decrease Skin Foot Sweating & Abnormal Blood Flow To The Foot (Veins Dilatation Due To AV Shunts)

▪︎Results in Skin Foot Fissuring/Warm Foot/OsteoPenia/Bone Collapse


📍3. Final Results On The Foot (Complications Of Diabetic Foot) :
🔻I. Symptomatic Foot :
▪︎Paraesthesia/Numbness
▪︎Claudication
▪︎Pain

🔻II. Decrease Healing Of Foot Wounds (Diabetic Or NeuroTrophic Or NeuroPathic Ulcers) نفس الاسم

🔻III. Recurrent Foot Infections & Abscess Formation

🔻IV. Progressive Foot Deformity & Joints Destruction (Charcot's Foot NeuroArthroPathy)

🔻V. Foot OsteoMyelitis & Cellulitis

🔻VI. Foot Or Toes Amputation Due To Gangrene (Necrosis)


🔷Risk Factors For Diabetic Foot Ulcers (High Risk Foot)
📍1. Poor Glycemic Control

📍2. Elderly & Blind People (Or Low Vision) & Uneducated

📍3. Obesity & High Alcohol Intake

📍4. Past Hx Of Foot Ulcers

📍5. Diabetic Neuropathy & Peripheral Vascular Disease

📍6. Foot Deformity (Callus/Claw Foot/Hallux Valgus/High Arched/Hammer Toes)


🔷Evaluation Of Diabetic Foot
📍1. Patient Hx To Detect :
▪︎Any Risk Factors Present For Diabetic Foot

▪︎General Medical Condition


📍2. Foot Examination :
🔻I. Ulcer Exam (Size/Shape/Number/Edge/Floor/Base/Temperature/Tenderness/Discharge/Surrounding Skin)

🔻II. Neurological Exam (Sensation/Motor/Autonomic)

🔻III. Vascular Exam (Peripheral Pulses/Skin Temperature & Color/Capillary Refill)

🔻IV. Identify Any Foot Deformity

🔻V. Special Tests (Imaging/Doppler/Angiography/Ankle Brachial Index/Electrophysiological Test)


📍3. Classification Of Diabetic Foot (Wagner Classification) :
▪︎Grade 0 ➡ Intact Skin (But Impending Ulcer Due To Presence Of Risk Factors)

▪︎Grade I ➡ Superficial Ulcer (Partial Or Full-Thickness & No Infection)

▪︎Grade II ➡ Deep Ulcer Extending To Underlying Tissue (But No Bone Involvement)

▪︎Grade III ➡ Deep Ulcer With Abscess & Bone Involvement (OsteoMyelitis)

▪︎Grade IV ➡ Limited Foot Gangrene (Only ForeFoot Or Heel Or Toes)

▪︎Grade V ➡ All Foot Gangrene

#Diabetic_Foot_ulcer
#Surgery_rotation
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🔷Mx Of Diabetic Foot
📍1. Patient Education (Grade 0) :
▪︎No Bare Walking لا تمشي حافي
▪︎No Corn Or Callus Removal
▪︎Attention To Hot Water
▪︎Use Creams For Foot Moisture
▪︎Wear Comfort Shoes
▪︎Stop Alcohol & Smoking
▪︎Glycemic Control

📍2. Reduce Mechanical Factors (Grade I) By Using :
▪︎Walking Aids
▪︎Medical Shoes
▪︎Walking Plaster Casts
▪︎Correction Of Foot Or Bony Deformities


📍3. Reduce Metabolic Factors (For All Grades Mx Of Hypertension/Hyperglycemia/HyperLipidemia/Anemia/Vitamins Deficiency)


📍4. Wound Control (Grade ≥2) :
🔻I. Culture & Sensitivity & Antibiotics (3w For Subcutaneous Infection & 12w For OsteoMyelitis)

🔻II. Foot Xray (To Detect Gas in Deep Tissue/Foreign Body/Bony Erosions/Joint Deformity)

🔻III. Wound Care :
▪︎Necrotic Tissue Debridement
▪︎Daily Dressing & Cleaning
▪︎Hyperbaric Oxygen Therapy
▪︎Platelet Derived Growth Factors
▪︎Skin Graft Or Flap To Close Defect
▪︎Infected Bone Excision (Grade III)


📍5. Amputation :

🔻I. Indications For Amputation :
▪︎Grade 4-5 Diabetic Foot

▪︎Severe Infection (Deep Tissue Necrotizing Infection/Deep Abscess/Uncontrolled Sepsis)

▪︎Tissue Gangrene

▪︎Non-Ambulatory Patient المريض اصلا مقعد

▪︎Inability To Obtain Planter Grade For Weight Bearing
يعني القدم منتهية صلاحيتها وماعاد يقدر يمشي عليها

🔻II. Types Of Amputation :
▪︎Partial Foot Amputation
▪︎Below Knee Amputation
▪︎Above Knee Amputation

#Diabetic_Foot_ulcer
#Surgery_rotation
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❇️ The stoma

▪︎is an artificial opening made in the colon or small intestine to divert faeces and flatus out-side the abdomen where they can be collected in an external Bag.

▪︎stoma may be temporary or permanent / End or loop

▪︎Colostomy: from the large bowel.
▪︎Ileostomy: from the small bowel.


🔹Indications of stoma (p1)

▪︎Permanent end-colostomy: abdominoperineal resection of large rectal cancers leading to the removal of the entire rectum.

▪︎Temporary end-colostomy: allow the distal bowel to rest in the Cases of acute diverticulitis or obstruction.

▪︎Temporary Loop colostomy: protect distal anastomoses after recent surgery.

#Stoma
#Surgery_rotation
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■❇️Stoma Types & Complications

🔹Indications of stoma (P2)

▪︎Permanent End ileostomy: after a panproctocolectomy (rectum & colon removal) for conditions such as ulcerative colitis or familial adenomatous polyposis.

▪︎Temporary End-ileostomy: during emergency bowel resection where it is considered unsafe to form an anastomosis with the remaining bowel at that time (e.g. intra-abdominal sepsis or bleeding).

▪︎Temporary loop ileostomy: protect distal anastomoses after recent surgery.


🔹Comparison

●Ileostomy:
•Spout Present (عنق)
•Fluid content
•In right iliac fossa
•Develop fluid & Electrolyte imbalance

●Colostomy:
•No Spout
•Solid content
•In left iliac fossa

#Stoma
#Surgery_rotation
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Stoma Examination ■

▪︎Begin by inspecting the stoma

noting :
●The site (Right/Left Iliac fossa)
●the number of lumens (1 End/2 Loop)
●the presence or absence of a spout (Neck)
●the contents of the effluent (Solid/Fluid)

▪︎Inspect the surrounding skin for erythema, tissue breakdown، Hernia, fistulation

▪︎Spout present: ileostomy
(مخرج الستومة مرتفع عن الجلد زي العنق )

▪︎Spout absent: colostomy
(مخرج الستومة مع الجلد مافيش عنق)
#Stoma
#Surgery_rotation
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🔴Scrotal swelling

🔹Painful
▪︎Testicular torsion
▪︎incarcerated Inguinal hernia
▪︎Epididym orchitis
▪︎Torsion of appendix testis (Blue Dots Sign)
▪︎Truma

🔹Painless
▪︎Hydrocele
▪︎Spermatocele
▪︎Varicocele
▪︎Reducible Inguinal hernia
▪︎Testicular tumor

🔹Emergent
▪︎testicular torsion
▪︎Necrotizing fasciitis (Fournier’s gangrene)
▪︎Trauma
▪︎Epididym orchitis


▪︎Mostly In Left Side ➡️ Varicocele
▪︎Mostly in Right Side ➡️ Undescended Testis/Testicular Tumor/Inguinal Hernia

▪︎+Ve Transillumination
•Hydrocele ➡️ Testis Not Palpable
•Spermatocele ➡️ Testis Are Palpable

▪︎Scrotal Elevation Relief The Pain (+Ve Prehn's Sign) ➡️ Epididmyitis/Orchitis

▪︎Scrotal Elevation Not Relief The Pain (-Ve Prehn's Sign) ➡️ Testicular Torsion

▪︎-Ve (Absent) Cremasteric Reflex ➡️ Testicular Torsion

#Surgery_rotation
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