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Canadian Medical Alliance for the Preservation of the Lower Extremity

Pressure Ulcers / Decubitus Ulcers / Bed Sores

A decubitus ulcer is an ulcer caused by excessive pressure. 
They are also known as pressure sores and bed sores. 

Pressure sores are seen in people who spend long periods
of time in a bed, in a wheelchair, or in a recliner.  They're
more common in neuropathic patients who cannot feel the
abnormal pressure, those with poor circulation or slow
healing from conditions like diabetes, smoking, steroid use
and aging, and those with fragile skin.

Remarkably, something between 60% and 80% of pressure
ulcers are acquired in the hospital.*  In other words, they're
caused by spending time in the very place where we're
supposed to go to get better.  

*Bales I, 2009.  Reaching for the moon: achieving zero pressure ulcer
  prevalence.  J Wound Care. 2009 Apr;18(4):137-144

If one wishes to find some good news in that depressing
statistic, it would probably be that most pressure wounds
are preventable if we took some effort to avoid them.

 

Location
 

Pressure sores for those in a hospital or are otherwise bed-ridden are common in the low back and hips and heels.  As this site is devoted to wounds of the lower extremity, we'll confine our discussions to lesions there. 

For patients spending a lot of time in bed or a recliner, pressure sores are usually on the back of the heel (black arrow, left) or the outside corner of the back of the heel (red arrow, left), because the feet tend to rotate to the outside.

Occasionally you'll see pressure ulcers on the back
of the calf.  And
when the patient spends a lot of
time on their side, pressure sores are seen on the outside of the foot (yellow arrows) at the fifth metatarsal head or fifth metatarsal base or ankle.  

Those who spend a lot of time in wheel chairs tend
to get  pressure ulcers on the bottom of the heel (blue arrow, left).


Sometimes, when the foot rest has a back for the
heel bone, or if
the leg rest is elevated, pressure ulcers are seen on the back of the heel (green arrow. left), or, depending upon the angle of the foot, somewhere in between (orange arrow, left).

 

 

 

 

 

 

 

 

Depending upon factors like age, health, circulation, the age of the wound and the time per day the patient is positioned in a way to create the pathological pressure, decubitus ulcers may present as a wound with a red base, as with this bed-ridden patient who spends a lot of time on his side pictured below left; or they may present with yellow-white areas of necrosis, as seen on the back of the heel, below center.  

If the pressure is not identified quickly, the issue progresses, and the area degenerates into a brown to black in color, called eschar.  This represents widespread tissue death--a form of localized gangrene, as seen in the wheel-chair patient below right.  This is one form of necrotic tissue that should not be removed in most cases.  

 

 

 

 

 

 

 

 

Treatment for decubitus ulcers may include infection control where
infection is present, and control of discomfort. 

And when the wounds are covered by the white to yellow necrotic
tissue known as slough (seen above centre), they may be debrided. 
Wounds covered with black eschar are generally not debrided.

But the main thrust of treating these ulcers is removing the

deforming pressure, something known as offloading.  Offloading
can be achieved by placing the injured area off the bed or chair
with pillows or another ad hoc material. 

 

For the weight-bearing surface of the foot, an over-the-counter

offloading shoe or a custom shoe could be employed.

 

For bed-bound patients, there are several manufacturers who

make offloading boots (right) and similar appliances that will
offload the foot nicely.

Below we see a wound in a patient largely bed bound.  Pressure

developed on the outside (lateral) portion of the heel because of 
how he positions himself in bed. 

 

Treatment consisted of very moderate debridement with strict
offloading through both padding and an accommodative boot (right).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Here is a wound where debridement to a vascular base was employed along with offloading to achieve closure.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In the examples to the right and
below, closure achieved by

offloading.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Below is a typical pressure sore.  The patient was told he had gangrene and would need an amputation, but responded with offloading.

 

 

Below is another patient who was told he had gangrene and needed an amputation.  There is certainly dead tissue present, but it's not a circulatory issue so much as a pressure issue.  And pressure wounds are all about relieving pressure.

"Pressure
 Pushing down on me
 Pressing down on you 
 No man ask for
 Under pressure
 That brings a building down
 Splits a family in two
 Puts people on streets "

--David Bowie, Queen
  Under Pressure
  

This page written by Dr. S A Schumacher
Podiatric Surgeon
Surrey, British Columbia  Canada

All clinical photographs owned and provided
by Dr. S A Schumacher.  They may be reproduced
for educational purposes with attribution to: 
Dr. S A Schumacher, Surrey, BC Canada
and a link to this website, www.CanadianMAPLE.org

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