Pressure injury formation is a complex process that involves numerous factors.²

As muscle is more sensitive to pressure than is skin, areas with a significant amount of muscle may be susceptible to an inverted cone pattern of injury, in which most of the necrosis is deep to the skin.⁵

Particular risk factors in the pediatric population have been identified^1,6:

Nonblanchable erythema may be observed within 30 minutes of unrelieved pressure and typically disappears within 1 hour after pressure is eliminated.

Ischemia develops after pressure is present for 2 to 6 hours.

Necrosis may occur if pressure is not relieved within 6 hours.

Ulceration tends to occur over bony prominences within 2 weeks after development of necrosis.

Determine factors contributing to the pressure injury (extrinsic and intrinsic) and whether they can be eliminated postoperatively.

Ambulatory status

Previous pressure injuries

Compliance and motivation with treatment

Assess risk factors using Braden Scale, including mobility, activity, sensation, moisture, friction/shear, and nutrition.

Assess sensation and lower extremity motor function, including spasticity.

Palpate for any fluctuance or bony prominences.

Note any signs of infection such as warmth, erythema, tenderness, purulent drainage, and systemic signs of infection.

Assess ongoing factors that may be contributing to wound breakdown, such as items causing pressure, spasticity, and fecal or urinary incontinence.

Staging of pressure injuries based on the updated guidelines of National Pressure Ulcer Advisory Panel⁸:

Nutritional assessment (including albumin, prealbumin, electrolytes)

Wound cultures if concern for infection

WBC and ESR if concern for infection/osteomyelitis

MRI or CT scan may help in identification of osteomyelitis and communicating sinus tracts.

Bone biopsy and culture if concern for osteomyelitis prior to treatment with antibiotics

Generally indicated for stage 1 and 2 pressure injuries

Correct nutritional deficiencies and medical comorbidities.

Control spasticity.

Treat infection with local wound care and culture-directed antibiotics.

Cleaning, debridement (mechanical, autolytic, enzymatic, sharp), and local wound care of pressure injuries

Local wound care should be adjusted based on the nature of the wound (exudative, granulating, fibrinous).

Pressure relief through frequent repositioning and protective padding; support surfaces that minimize pressure and reduce shear.

Prevent contamination from urinary and fecal soiling.

Routine inspection by caregivers for early pressure changes and timely referrals during growth spurts for assessment of orthotics, prosthetics, or wheelchairs are critical.