Pressure ulcers: Back to the basics

Abstract

Pressure ulcer in an otherwise sick patient is a matter of concern for the care givers as well as the medical personnel. A lot has been done to understand the disease process. So much so that USA and European countries have established advisory panels in their respective continents. Since the establishment of these organizations, the understanding of the pressure ulcer has improved significantly. The authors feel that the well documented and well publicized definition of pressure ulcer is somewhat lacking in the correct description of the disease process. Hence, a modified definition has been presented. This disease is here to stay. In the process of managing these ulcers the basic pathology needs to be understood well. Pressure ischemia is the main reason behind the occurrence of ulceration. Different extrinsic and intrinsic factors have been described in detail with review of literature. There are a large number of risk factors causing ulceration. The risk assessment scales have eluded the surgical literature and mostly remained in nursing books and websites. These scales have been reproduced for completion of the basics on decubitus ulcer. The classification of the pressure sores has been given in a comparative form to elucidate that most of the classifications are the same except for minor variations. The management of these ulcers is ever evolving but the age old saying of "prevention is better than cure" suits this condition the most.

Keywords: Bed sore; decubitus ulcer; pressure ulcer; prevention; risk factors; ulcer.

Figure 1

(a) Left sided ischial pressure ulcer with multiple sinuses in a paraplegic patient. Sinuses are highlighted with arrows. Gluteus maximus muscle has been marked for raising as a muscle flap (b) Complete excision of the ulcer with excision of sinuses has been done. The gluteus maximus muscle flap has been used to cover the ischial tuberosity and for filling the cavity

Figure 2

(a) A large sacral ulcer(b) Sacral ulcer has been managed with transverse back flap

Figure 3

(a) Left trochanteric pressure ulcer with a small external wound (b) The ulcer after debridement of the ulcer edge and the underlying bursa. One can notice the large wound under a small and deceptive pressure ulcer (c) Bilateral Trochanteric pressure ulcers have been resurfaced with bilateral tensor fascia lata myocutaneous flaps

Figure 4

(a-d) Pressure points in sitting, supine, lateral and prone postures

Figure 5

Pressure ulcer over the lateral border of heal, lateral malleolus and lateral border of fibula due to pressure in lateral posture

Figure 6

Pressure ulcer over the knee and thigh because of the pressure in prone position

Figure 7

Sacral pressure ulcer in a patient with 60% total body surface burn