Examination checklist

    Examination of an ulcer

    A 22-step mark sheet for examining an ulcer — site, size, edge, floor, base, discharge and surroundings, then the regional nodes, pulses and sensation — with the edge types and the causes of a chronic leg ulcer.

    Surgery
    Lumps and ulcers
    All colleges

    Mark sheet

    22 steps · 22 marks

    #StepWellPartlyNot
    1. 1Greets the examiner and the patient, introduces self and obtains consent1½0
    2. 2Washes hands, puts on gloves, and asks about pain before removing the dressing1½0
    3. 3Exposes both limbs fully (or the whole region) and compares sides1½0
    4. 4States the site with reference to anatomical landmarks1½0
    5. 5States the number of ulcers1½0
    6. 6Measures the size in two dimensions and describes the shape1½0
    7. 7Describes the edge — sloping, punched out, undermined, rolled or everted1½0
    8. 8Describes the floor — granulation tissue (healthy or unhealthy), slough, necrotic tissue, exposed tendon or bone1½0
    9. 9Describes the discharge — serous, purulent, bloody; its amount and smell1½0
    10. 10Inspects the surrounding skin — pigmentation, lipodermatosclerosis, eczema, scars, oedema, cellulitis1½0
    11. 11Palpates the surrounding skin for temperature and tenderness1½0
    12. 12Palpates the edge and base for induration and bleeding on touch1½0
    13. 13Assesses the depth and tests whether the base is fixed to deeper structures (bone, tendon)1½0
    14. 14Probes gently (or asks to) for bone at the base1½0
    15. 15Examines the regional lymph nodes1½0
    16. 16Palpates the peripheral pulses — femoral, popliteal, posterior tibial, dorsalis pedis1½0
    17. 17Checks capillary refill and Buerger's test where ischaemia is suspected1½0
    18. 18Tests sensation — light touch and 10 g monofilament, vibration, proprioception1½0
    19. 19Examines for varicose veins and signs of venous hypertension1½0
    20. 20Examines the joints for mobility (ankle joint) and deformity (Charcot foot)1½0
    21. 21Asks to measure the ankle–brachial pressure index1½0
    22. 22Offers a general examination — anaemia, diabetes, sickle cell disease, rheumatoid arthritis, nutrition1½0

    Summary of findings

    I examined a 58-year-old man with an ulcer on his left leg. There is a single ulcer, 6 × 4 cm, on the medial aspect of the lower third of the left leg, 5 cm above the medial malleolus. It is oval with a gently sloping edge. The floor has pink granulation tissue with patches of slough and a small amount of serous discharge. The surrounding skin is pigmented and indurated, with eczema and pitting oedema, and there are varicose veins along the course of the great saphenous vein. The ulcer is not fixed to the tibia. The inguinal lymph nodes are not enlarged. All peripheral pulses are palpable, and sensation is intact. These findings suggest a venous ulcer. I would like to measure his ankle–brachial pressure index.

    Differential diagnoses

    The edge tells you the cause

    EdgeTypical cause
    Sloping, shelvingHealing ulcer, venous ulcer
    Punched outArterial, neuropathic (diabetic, leprosy), gummatous syphilis
    UnderminedTuberculosis, pressure sore, Buruli ulcer (Mycobacterium ulcerans)
    Rolled, pearlyBasal cell carcinoma
    Raised, everted, induratedSquamous cell carcinoma (including Marjolin's ulcer)

    Chronic leg ulcer — where it is and what goes with it

    TypeSiteFeatures
    VenousGaiter area, above the medial malleolusShallow, sloping edge, painless or aching, pigmentation, lipodermatosclerosis, varicose veins, normal pulses
    ArterialToes, heel, dorsum of foot, shinPunched out, painful (worse on elevation), pale floor, absent pulses, cold foot
    NeuropathicPressure points — plantar metatarsal heads, heelPunched out with callus, painless, warm foot, absent sensation
    Sickle cellAround the malleoliPainful, recurrent, in young adults with sickle cell disease
    Tropical phagedenicLower leg in the malnourished, after minor traumaRapid, painful, foul slough
    BuruliLimbs, in people near slow-flowing waterPainless nodule becoming a large ulcer with undermined edges
    Malignant (Marjolin)In a chronic scar, burn or long-standing ulcerEverted, indurated edge, bleeds easily, growing, may involve nodes
    Vasculitic or pyoderma gangrenosumAnywherePurple undermined edge, rheumatoid arthritis or inflammatory bowel disease

    Investigations

    • Swab only if the ulcer looks infected; take tissue for culture including acid-fast bacilli and M. ulcerans PCR when suspected
    • Wedge biopsy of the edge (including normal skin) for any ulcer that is atypical, not healing after 12 weeks of good care, or has a raised edge
    • Full blood count, glucose or HbA1c, ESR or CRP, haemoglobin electrophoresis, albumin, HIV serology and syphilis serology when indicated
    • Ankle–brachial pressure index — below 0.8 means arterial disease; above 1.3 means incompressible, calcified vessels (diabetes, kidney disease)
    • Venous duplex — superficial and deep reflux or obstruction
    • X-ray or MRI of the underlying bone — osteomyelitis

    Treatment

    • Treat the cause — compression and venous ablation, revascularisation, off-loading and glucose control, antibiotics
    • Wound bed preparation: debride slough, control infection and exudate, keep moist
    • Nutrition, mobility and pain relief
    • Skin grafting once the bed is healthy
    • Wide excision for malignancy; see Marjolin's ulcer

    Examiner questions

    References

    • O'Connell PR, McCaskie AW, Sayers RD, eds. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023.

    Updated September 18, 2026