Case 41 Ischial Pressure Sores

Elizabeth Kiwanuka, Albert S. Woo, and Paul Y. Liu

Stage IV pressure ulcer over the right ischium with possible bone exposure
No evidence of gross contamination
Image reveals signs of wound contracture, demonstrating chronicity and evidence of healing

Risk factor assessment: Age, mental status, nutritional status, comorbid conditions (diabetes, vascular disease), mobility, spinal cord injury, spasm, and urinary and fecal continence
History of current wound: Duration, infections, and progression
Current wound management
Previous wound management and interventions
Prior offloading interventions
Social history: Tobacco and substance abuse, support network, and home environment
Etiology of the wound: Paraplegia in wheelchair, bed sore, neglect, and severe contracture
Nutritional status

Pressure ulcer staging (see Table 41.1)

Table 41.1 Pressure ulcer staging
Stage	Findings
I	Intact skin with non blanching erythema, usually over a bony prominence
II	Partial-thickness dermal loss; appears as a shallow open ulcer with a red–pink wound bed without slough, or as a serum-filled bullous lesion (intact or ruptured)
III	Full-thickness tissue loss; subcutaneous fat may be visible Bone, tendon, or muscle is not exposed; these are prefascial wounds; may have undermining
IV	Full-thickness tissue loss through the fascia with exposed bone, tendon, or muscle; often includes undermining and tunneling

Laboratory tests: Complete blood count (CBC), complete electrolyte panel, albumin/prealbumin, hemoglobin A1C, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)
Magnetic resonance imaging (MRI): Osteomyelitis is suggested by the presence of T2 hyperintensity and low intensity on T1 images
- Osteomyelitis: May show abnormal bone marrow signals
- May not accurately distinguish osteomyelitis from bone remodeling
The extent of radiographic involvement cannot be used in isolation to guide bony resection
- Resection is determined by the amount of unhealthy bone identified
Bone biopsy: May be useful to rule out osteomyelitis
Long-standing wounds should raise concern for Marjolin’s ulcer
- Tissue biopsy: Sent for culture and pathology in chronic wounds