Ulcers of the Lower Extremity

 

Description:

This book focuses on the clinical evaluation and management of ulcers of the lower limbs. There are numerous causes for ulceration in the lower limbs and each variety requires careful clinical evaluation and management approach. In 29 chapters, written by highly experienced surgeons, the book covers prevalence, types, healing mechanisms, clinical evaluation and microbiology of the ulcers, followed by detailed review of each ulcer variety. Chapters on pyoderma gangrenosum, diabetic foot, grafts and flaps, amputation, pain control strategy and documentation of these cases provide a complete coverage from management stand-point. The book is essential reading not only for general surgeons and vascular surgeons, but also has relevance for orthopedic surgeons, podiatrists, dermatologists and oncologists who manage such cases. Also serves as reference guide for post-graduate examination. 

 

Table of Contents:

 

1: Epidemiology of Leg Ulcer

1.1 Introduction

1.1.1 Global Burden of Leg Ulcer

1.1.1.1 Indian Scenario

1.1.2 Socioeconomic Impact of Chronic Leg Ulcer Diseases

1.1.3 Importance of Prevalence Data

1.1.4 Definitions of Incidence and the Various Forms of Prevalence Estimates [32]

1.1.5 Methodological Pitfalls in Prevalence-Based Study

1.2 Risk Factors Associated with Leg Ulcers

Conclusion

References

2: Impact of Ulceration

2.1 Introduction

2.2 Prevalence

2.3 Quality-of-Life Issues

2.4 Cost of Ulcer Prevalence

2.5 Risk of Amputation

2.6 Venous Ulceration and Cost

2.7 Loss of Work

2.8 Psychological Impact

Conclusion

References

3: Types of Ulcers of Lower Extremity

3.1 Introduction

3.2 Venous Ulcer (Fig. 3.1)

3.3 Arterial Ulcer (Figs. 3.3, 3.4, and 3.5)

3.4 Mixed Arterial and Venous Ulcers

3.5 Diabetic/Neuropathic/Neuroischemic (Figs. 3.6, 3.7, 3.8, 3.9, and 3.10)

3.6 Hematological Ulcers

3.7 Rheumatoid Arthritis Ulcers

3.8 Vasculitis-Associated Ulcers

3.9 Connective Tissue Disease: Ehlers-Danlos with Ulceration

3.10 Traumatic (Figs. 3.11, 3.12, 3.13, and 3.14)

3.11 Infective Ulcers

3.12 Malignancy

3.13 Marjolin’s Ulcer

3.14 Calciphylaxis

3.15 Bazin’s Ulcer

3.16 Martorell’s Ulcer

Conclusion

References

4: Healing of Leg Ulcers

4.1 Introduction

4.1.1 Hemostatic Phase

4.1.2 Inflammatory Phase

4.1.2.1 Vasoconstriction and Vasodilatation

4.1.2.2 Polymorphonuclear Neutrophils

4.1.2.3 Macrophages

4.1.3 Proliferative Phase

4.1.3.1 Fibroplasia and Granulation Tissue Formation

4.1.3.2 Collagen Deposition

4.1.3.3 Epithelialization

4.1.3.4 Contraction

4.1.4 Remodeling Phase

4.2 Basic Concept of Treatment of Chronic Ulcer

4.2.1 Cleaning the Ulcer

4.2.2 Treatment of Infection

4.2.3 Dressings

4.2.4 Surgical Management of Ulcer

4.2.4.1 Vacuum-Assisted Closure (V.A.C.) Device

4.2.4.2 Compression Therapy

References

5: Clinical Anatomy of Lower Extremity

5.1 Introduction

5.2 Regions of Lower Limb [1]

5.2.1 Gluteal Region and Hip Joint (Figs. 5.1 and 5.2)

5.2.2 Anterior Compartment of the Thigh [2]

5.2.2.1 Superficial Nerves

5.2.3 Superficial Arteries

5.2.4 Superficial Veins (Fig. 5.3)

5.2.5 Femoral Artery (Figs. 5.5, 5.6, and 5.7)

5.2.6 Femoral Vein

5.2.7 Femoral Nerve

5.2.8 Medial Compartment of the Thigh

5.2.9 Posterior Compartment of the Thigh

5.3 Popliteal Fossa (Figs. 5.9 and 5.10)

5.3.1 Popliteal Artery

5.3.2 Popliteal Vein

5.3.3 Anterior Compartment of the Leg

5.3.4 Dorsum of the Foot

5.3.5 Lateral Compartment of the Leg

5.3.6 Posterior Compartment of the Leg

5.3.7 Sole of the Foot

5.4 Applied Aspect

5.4.1 Applied Anatomy of Venous System of Lower Limb

5.4.2 Applied Anatomy of Arteries of Lower Limb

5.4.3 Applied Anatomy of Nerves of Lower Limb

Conclusion

References

6: Approach to a Case of Ulcer of Lower Extremity

6.1 Introduction

6.2 Thorough History

6.2.1 Examination

6.2.2 Limb Examination

6.2.3 Skin Examination

6.2.4 Ulcer Examination

6.3 Noninvasive Diagnosis

6.3.1 Ankle Brachial Pressure Index (ABPI)

6.3.2 Duplex Ultrasound

6.3.3 Plethysmography

6.3.4 Computer Tomography

6.3.5 Magnetic Resonance Imaging

6.3.6 Phlebography

6.3.7 Arteriography

6.3.8 Intravascular Ultrasound (IVUS)

6.3.9 Bacterial Culture

6.3.10 Skin Biopsy

6.3.11 Documentation

Conclusion

References

7: Investigations for Ulcer of the Lower Extremity

7.1 Introduction

7.2 Epidemiology

7.3 Investigations

7.4 Diagnostic and Prognostic Investigations

7.5 Noninvasive and Invasive Investigations

7.5.1 Leg Ulcer Measurement Tools (LUMT)

7.5.2 Doppler Duplex Scanning

7.5.3 Plethysmography

7.5.4 Computed Tomography (CT Arteriography and CT Venography) (Figs. 7.4 and 7.5)

7.5.4.1 Magnetic Resonance Imaging (MR Arteriography and MR Venography)

7.5.4.2 Phlebography/Venography

7.5.4.3 Percutaneous Arteriography

7.5.4.4 Intravascular Ultrasound (IVUS)

7.5.4.5 Skin Biopsy/Ulcer Biopsy

7.6 Microbial Isolation

7.7 Gene Variant Analysis

Conclusion

References

8: Microbiology of Ulcer

8.1 Introduction

8.2 Microbiology

8.2.1 The Normal Microbiota

8.3 Role of Host and Environment

8.4 Role of Microbes in Infection

8.5 The Role of Biofilm in Infected Ulcer

8.6 Bioload of Ulcer Wound

8.7 Vicious Cycle of Wound Healing

8.8 Infective Causes of Ulcer

8.8.1 Infectious Causes of Limb Ulcers

8.9 Infected Ulcers

8.9.1 Other Infective Causes of Ulcer

8.10 Infected Diabetic Foot Ulcers

8.10.1 Infection Status of Chronic Wounds

8.10.2 Microbial Load and Healing of Wound

8.10.3 Microbiology, Antibiotic Usage, and Resistance in Leg Ulcers

8.11 Lab Diagnosis of Infected Ulcers

8.11.1 The Role of Microbiology in Diagnosis

8.12 Culture

8.12.1 Picture of Common Isolates (Figs. 8.3–8.5)

8.13 Gram Stain

8.13.1 Which Culture Technique Should Be Used?

8.13.2 Procedure for Taking a Swab

References

9: Role of Bacteria in Pathogenesis of Lower Leg Ulcers

9.1 Introduction

9.2 Hypothesis

9.3 Lower Limb Skin Bacteria

9.4 Venous Ulcers

9.4.1 Do Bacteria Colonizing Ulcers Originate From Foot, Calf, and Perineal Skin?

9.4.2 Bacterial Isolates in Varicose Veins

9.4.3 Bacterial Isolates on Ulcers

9.5 Can Bacterial Flora Be Eradicated or at Least Attenuated?

9.5.1 Systemic Antibiotics

9.5.2 Topical Antibiotics and Antiseptics

9.6 Arterial Ischemic Ulcer

9.6.1 Bacterial Isolates in Arterial Walls

9.6.2 Microbial DNA in Arterial Wall

9.7 Diabetic Foot Ulcer

9.8 Lower Limb Lymphedema Ulcer

References

10: Venous Ulcer

10.1 Introduction

10.2 Pathophysiology of Venous Ulceration

10.3 Clinical Assessment (Figs. 10.2 and 10.3)

10.4 Investigations

10.4.1 Noninvasive Investigations

10.4.2 Invasive Investigations

10.4.2.1 Noninvasive Tests

Venous Duplex Imaging

Photoplethysmography (PPG)

Air Plethysmography

CT Venogram

MR Venogram

10.4.2.2 Invasive Tests

Ascending Venography

Descending Venography

Intravascular Ultrasonography (IVUS)

10.5 Treatment

10.5.1 Lifestyle Modification

10.5.2 Compression Therapy

10.5.3 Pharmacological Therapy

10.5.4 Wound and Skin Care

10.6 Treatment of Superficial Venous Reflux

10.6.1 Open Surgery

10.6.1.1 High Ligation of the Saphenous Vein

10.6.1.2 Great Saphenous Vein Stripping

10.6.1.3 Ambulatory Phlebectomy

10.6.1.4 Endovenous Thermal Ablation

10.6.1.5 Foam Sclerotherapy

10.7 Treatment of SSV Reflux

10.7.1 Treatment of Deep Venous Obstruction

10.7.2 Treatment of Deep Venous Reflux

10.8 Recurrent Venous Ulcer

Conclusion

References

11: Arterial Ulcer

11.1 Introduction

11.2 Epidemiology

11.3 Etiology

11.4 Clinical Features

11.4.1 History and Assessment

11.5 Diagnosis

11.6 Blood Investigations

11.7 Vascular Investigations [7]

11.7.1 Ankle–Brachial Index (ABI)

11.7.2 Toe Systolic Pressure Index (TSPI)

11.7.3 Transcutaneous Oxygen Tension (TcPO2)

11.7.4 Duplex Ultrasound Scan

11.7.5 Contrast Tomography (CTA) and Magnetic Resonance (MRA) Angiography

11.7.6 Digital Subtraction Angiography

11.8 Algorithm of Arterial Ulcer Management

11.9 Treatment

11.9.1 Risk Factor Reduction

11.9.2 Antiplatelet and Vasodilator Medication

11.9.3 Lipid-Lowering Agents

11.9.4 Pain Control

11.9.5 Pressure Area Management

11.9.6 Conservative Debridement and Antibiotics

11.9.7 Improvement of Circulation

11.9.8 Endovascular Intervention

11.9.9 Open Surgical Intervention

11.9.10 Vasculitis Ulcer Treatment [23]

11.9.11 Adjuvant Therapies [13]

11.9.12 Amputation

Conclusion

References

12: Diabetic Foot Ulcers

12.1 Introduction and Magnitude of the Problem

12.2 Definition

12.3 Clinical Features of Diabetic Foot

12.4 Neuropathic Diabetic Foot Ulcers

12.4.1 Sensory Neuropathy

12.4.2 Motor Neuropathy

12.4.3 Autonomic Neuropathy

12.5 Management of Neuropathic Foot Ulcers

12.6 Charcot Foot (Neuro-osteoarthropathy)

12.6.1 Definition

12.6.2 Epidemiology

12.6.3 Etiopathogenesis

12.7 Diagnosis and Treatment of Charcot Foot

12.7.1 Acute Charcot Foot

12.7.2 Chronic Charcot Foot

12.8 Ischemic Diabetic Foot Ulcers

12.8.1 Epidemiology

12.8.2 Diagnosis and Management of Ischemic Ulcer (Critical Limb Ischemia)

12.8.3 Treatment of Ischemic Foot Ulcer After Revascularization

Conclusions

References

13: Neuropathic Ulcers

13.1 Introduction

13.2 Epidemiology

13.3 Pathophysiology

13.4 Assessment of Patients with Neuropathic Ulcers

13.5 Multidisciplinary Foot Teams

13.6 Identification and Treatment of Infection

13.7 Identification of Deformities

13.8 Management of Neuropathic Ulcers

13.8.1 Debridement

13.8.2 Infection Control

13.8.3 Ensuring Adequate Blood Supply

13.8.4 Vacuum-Assisted Closure (VAC) Therapy

13.8.5 Adjunctive Therapies

13.8.6 Pressure Offloading

13.8.7 Treating Underlying Factors

13.8.8 Patient Education

13.8.9 Temperature Self-Assessment

13.8.10 Fat Pad Augmentation

13.8.11 Specialist Shoes

13.8.12 Amputation

Conclusion

References

14: Vasculitis and Ulceration

14.1 Introduction

14.2 Pathophysiology

14.3 Types of Vasculitis

14.4 Predisposing Factors

14.5 Clinical Presentation

14.6 Differential Diagnosis

14.7 Laboratory Studies

14.8 Treatment

Conclusion

References

15: Lymphatic Ulcer of Lower Limb

15.1 Introduction

15.2 Pathology

15.3 Role of the Lymphatic System in Ulcer Healing

15.4 Treatment of Lymphatic Ulcers

15.4.1 Conservative Procedures in Lymphedema

15.4.2 Surgical Procedures in Lymphedema (Figs. 15.5 and 15.6)

15.4.3 Treatment of Ulcer

References

16: Infective Leg Ulcers

16.1 Introduction

16.1.1 Mixed Etiology

16.1.2 Pyoderma Gangrenosum

16.1.3 Mycobacteria-Associated Leg Ulcers

16.2 Leprosy Ulcer

16.2.1 Buruli Ulcer

16.3 Leg Ulcer Infection

16.4 Acute Soft Tissue Infections of the Leg

16.5 Diabetic Foot Infections

16.6 Venous and Pressure Ulcer Infections

16.7 Targeted Antibiotic Therapy

16.8 Factors Promoting Microbial Proliferation in Leg Ulcers

Conclusion

References

17: Necrotizing Soft Tissue Infection

17.1 Introduction

17.2 History

17.2.1 Types

17.2.1.1 Type I NF (Polymicrobial/Synergistic)

17.2.1.2 Type II NF

17.2.1.3 Type III NF

17.2.1.4 Type IV NF: Fungal

17.3 Pathophysiology

17.4 Clinical Features

17.4.1 Investigations

17.4.1.1 Hematology

17.4.1.2 Biochemistry

17.4.1.3 Culture

17.4.1.4 Radiological

17.4.1.5 Histology

17.5 Scoring Systems for Prediction of NF

17.6 Treatment of NF

17.6.1 Antibiotic Therapy

17.7 Surgical Treatment of NF (Figs. 17.4, 17.5, and 17.6)

17.8 Hyperbaric Oxygen

17.9 Outcome

Conclusion

References

18: Pyoderma Gangrenosum

18.1 Introduction

18.2 History and Nomenclature

18.3 Epidemiology

18.4 Etiology and Pathogenesis

18.5 Clinical Features (Figs. 18.1 and 18.2)

18.6 Clinical Variants

18.6.1 Classic or Ulcerative PG

18.6.2 Pustular PG

18.6.3 Bullous PG

18.6.4 Superficial Vegetative PG or Superficial Granulomatous Pyoderma

18.6.5 Peristomal PG

18.6.6 Pyostomatitis Vegetans

18.7 Histopathology

18.8 Evaluation of a Patient with PG

18.9 Diagnosis

18.10 Differential Diagnosis

18.10.1 Early Inflammatory Non-ulcerative Stage (Papules, Pustules, Plaques, or Nodules)

18.10.2 Later Ulcerative or Vegetative Stage

18.11 Treatment

18.11.1 General Measures

18.11.2 Wound Care

18.11.3 Specific Therapy (Table 18.3)

References

19: Self-Inflicted Ulceration

19.1 Introduction

19.2 Dermatitis Artefacta

19.3 Neurotic Excoriations

19.4 Münchausen Syndrome

Conclusion

References

20: Pressure Ulcers of the Lower Limb

20.1 Introduction

20.2 Etiology (Mechanism of Ulcer Formation)

20.2.1 Direct Causes

20.2.1.1 Pressure

20.2.1.2 Shear

20.2.1.3 Friction

20.2.1.4 Immobility

20.2.1.5 Loss of Sensation

20.2.1.6 Combined Pathology

20.2.1.7 Failure of Reactive Hyperemia Cycle

20.2.2 Indirect Causes (Associated Factors)

20.2.2.1 Mobility Problems

20.2.2.2 Poor Nutrition

20.2.2.3 Health Conditions

20.2.2.4 Aging Skin

20.2.2.5 Incontinence

20.2.2.6 Mental Health Conditions

20.3 Diagnosis

20.3.1 Severity of Pressure Ulcers

20.3.1.1 Grade 1

20.3.1.2 Grade 2

20.3.1.3 Grade 3

20.3.1.4 Grade 4

20.4 Treatment

20.4.1 Cleaning and Debridement

20.4.2 Wound Dressings

20.4.3 Antibiotics

20.4.4 Newer Research

20.4.5 Surgical Management of the Pressure Ulcer

20.4.5.1 Reconstructive Surgery

20.4.6 Prevention: Mattresses and Cushions

20.5 Summary

References

21: Atypical Leg Ulceration

21.1 Introduction

21.2 Unusual Causes of Leg Ulceration

21.2.1 Microcirculatory Disorders

21.2.2 Physical or Chemical Injury

21.2.3 Infectious Diseases

21.2.4 Neuropathic Diseases

21.2.5 Vasculitis

21.2.6 Hematological Disorders

21.2.7 Clotting Disorders

21.2.8 Metabolic Diseases

21.2.9 Ulcerating Tumors

21.2.10 Ulcerating Skin Diseases

21.2.11 Drug Reactions

21.2.12 Miscellaneous

21.3 Microcirculatory or Vascular Disorders

21.3.1 Raynaud’s Phenomenon

21.3.2 Martorell Ulcer

21.3.3 Cutaneous Vasculitis

21.4 Hematological Disorders

21.4.1 Sickle Cell Anemia

21.4.2 Antiphospholipid Syndrome

21.4.3 Symmetrical Peripheral Gangrene

21.5 Metabolic Disorders

21.5.1 Necrobiosis Lipoidica

21.5.2 Porphyria Cutanea Tarda

21.5.3 Gout

21.5.4 Calciphylaxis

21.5.5 Calcinosis Cutis

21.6 Neuropathic Disorders

21.6.1 Hansen’s Disease (Leprosy)

21.6.2 Pyoderma Gangrenosum (PG)

21.6.3 Kaposi’s Sarcoma

21.7 Allergic Ulceration

21.8 Factitious Ulceration

21.9 Necrotizing Fasciitis

21.10 Chemotherapy Extravasation Ulceration (Fig. 21.5)

Conclusion

References

22: Squamous Cell Carcinoma

22.1 Introduction

22.2 Epidemiology

22.2.1 Risk Factors

22.2.2 Pathogenesis

22.2.3 Genetics of SCC

22.2.4 Chemical Carcinogenesis

22.2.5 Photocarcinogenesis

22.2.6 Precancerous Lesions: Actinic Keratosis

22.2.7 Bowen’s Disease

22.3 Clinical Presentation and Diagnosis

22.3.1 Clinical Presentation

22.3.2 Staging

22.4 Treatment

22.4.1 Treatment of Premalignant Lesions

22.4.2 Treatment of Malignant Lesions

22.4.3 Mohs Microscopically Controlled Surgery (MMCS)

22.4.4 Surgical Excision

22.4.5 Chemoradiation

22.5 Follow-Up

Conclusion

References

23: Melanoma of the Extremity

23.1 Introduction

23.2 Cellular Classification of Melanoma

23.3 Molecular Classification of Melanoma

23.4 Growth Pattern in Melanoma

23.5 Diagnostic Hallmark

23.6 Characteristic Clinical Presentations [7]

23.7 Staging of Melanoma

23.8 Prognostic Factors

23.9 Management

23.9.1 Diagnosis

23.10 Treatment

23.11 Systemic Therapy in Melanoma

23.11.1 Immunotherapy

23.11.2 Signal Transduction Inhibitors

23.11.3 Chemotherapy

23.11.4 Radiotherapy

23.11.5 Isolated Limb Perfusion

References

24: Basal Cell Carcinoma

24.1 Introduction

24.1.1 BCC: Presentation as a Chronic Leg Ulcer (CLU)

24.2 Primary BCC

24.2.1 Pathogenesis of Primary BCC

24.3 Genetic Events

24.3.1 PTCH

24.3.2 p53

24.4 Cellular Events

24.4.1 Clinical Behavior of Basal Cell Cancer

24.4.2 Factors Responsible for the Biological Behavior of BCC

24.5 Clinical Subtypes of Basal Cell Carcinoma

24.6 Histologic Subtypes of BCC

24.7 Characteristics Related to Anatomic Site

24.8 Basal Cell Carcinoma Developing in a Chronic Leg Ulcer (Secondary BCC)

24.9 Diagnosis

24.9.1 Shave Biopsy

24.9.2 Punch Biopsy

24.9.3 Excisional Biopsy

24.10 Treatment

24.10.1 Surgical

24.10.2 History and Evolution of Technique

24.10.3 Indications for Mohs Micrographic Surgery

24.10.4 Curettage and Electrodessication

24.11 Cryosurgery

24.12 Nonsurgical

24.12.1 Topical Treatment

24.13 Radiation Therapy

References

25: Sarcoma of Extremities Presenting as Ulceration

25.1 Introduction

25.2 Epidemiology

25.3 Etiology

25.4 Differential Diagnosis

25.5 Pathophysiology and Methods of Dissemination

25.6 Symptoms and Signs

25.7 Diagnosis

25.7.1 History and Clinical Examination

25.7.2 Imaging

25.7.3 Radiographs

25.7.4 Computerized Tomography (CT)

25.7.5 Magnetic Resonance Imaging (MRI)

25.7.6 Positron Emission Tomography (PET)

25.7.7 Radionuclide Bone Scans

25.7.8 Angiography

25.7.9 Biopsy

25.8 Treatment

25.8.1 Treat the Primary Causes: Medical Options

25.8.2 Treat the Primary Causes: Surgery

25.8.3 Treat Patient/Family Concerns

25.8.4 Treat the Wound

25.8.5 Cleansing

25.8.6 Exudate Management

25.8.7 Bleeding Control

25.8.8 Infection and Odor Control

25.8.9 Perilesional Skin Care

25.8.10 Pain Control

References

26: Grafts and Flaps for the Lower Limb

26.1 Introduction

26.2 Split Skin Graft

26.3 Flaps

26.4 Vascular Basis of the Flaps

26.5 Hemodynamics of Flaps

26.6 Vascular Axis

26.7 Practical Techniques for Flaps

26.8 Few Common Flaps

26.8.1 Fasciocutaneous Flap

26.8.2 Adipofascial Flap

26.8.3 Propeller or Skeletonized Perforator Flap

26.8.4 Sural Neurocutaneous Flap

26.8.5 Fascial Flap

26.8.6 Muscle/Myocutaneous Flap

26.8.7 Flaps for Heel and Sole Defects

26.8.8 Combination of Different Techniques

26.8.9 Free Flaps

26.9 Postoperative Care

26.10 Complications

26.11 Instructions to the Patient During Follow-Up

Conclusion

References

27: Amputation of the Lower Extremity

27.1 Introduction

27.2 Indications

27.2.1 Ulcer with Gangrene Changes

27.2.2 Ulcer with Atherosclerosis

27.2.3 Ulcers in Infective Conditions

27.2.4 Ulcers in Traumatic Conditions

27.2.5 Miscellaneous

27.2.6 Diabetic Ulcers

27.3 Surgical Principles of Amputation

27.4 Types of Amputations in Ulcers of Foot (Fig. 27.5)

27.4.1 Toe Amputation

27.4.2 Amputation Through Metatarsals

27.4.3 Amputation Through Mid Foot

27.4.4 Amputation Through Hindfoot/Ankle

27.4.5 Syme’s Amputation

27.4.6 Leg Amputation (Fig. 27.8)

References

28: Pain Management

28.1 Introduction

28.2 Etiopathology and Pathophysiology of Leg Ulcer Pain

28.3 Characteristics of Pain in Different Types of Ulcers

28.4 Pain Intensity

28.5 Management of Pain in Chronic Leg Ulcer

28.5.1 Topical

28.5.2 Non-pharmacological Methods

28.5.3 Systemic Agents

28.6 Surgical Management

28.6.1 Split-Skin Grafting

28.6.2 Lumbar Sympathectomy

28.7 Chemical Lumbar Sympathectomy

28.8 RF (Radiofrequency) Lumbar Sympathectomy

28.9 Surgical Sympathectomy

28.9.1 Endoscopic Lumbar Sympathectomy

28.9.2 Other Surgical Interventions

Conclusion

References

29: Documentation of Ulcer

29.1 Introduction

29.2 Significance of Documentation

29.3 Describing an Ulcer (Table 29.1)

29.4 Classification of Ulcers

29.4.1 Wagner System [6]

29.4.2 University of Texas System

29.4.3 S(AD) SAD System (Area, Depth, Sepsis, Arteriopathy, and Denervation) [7]

29.5 Tools for Ulcer Measurement

Conclusion

References

 

An aparitie	08-07-17
Autor	Ajay K Khanna; Satyendra K Tiwary
Dimensiuni	15.88 x 2.54 x 23.5 cm
Editura	Springer
Format	Hardcover
ISBN	9788132226338
Limba	Engleza
Nr pag	479