Pressure Injuries

Pressure Injuries

Lawrence J. Gottlieb

Maureen Beederman


  • Pressure injuries typically occur over bony prominences and are dependent on patient positioning.

    • Supine: greatest pressure overlying heels, sacrum, occiput, and scapula

    • Sitting: greatest pressure at ischial tuberosities, elbows

    • Lateral decubitus: greatest pressure over greater trochanters (often accompanied by hip flexion contractures), fibular head, and malleoli

    • Pressure injuries also occur due to inadvertent pressure from external objects pressing on the skin (ie, IV connectors, side rail of bed pressing on the skin or small object in shoe of the patient with neuropathy) or securing devices too tight (ie, nasal tubes, CPAP devices).

  • Extrusion of internal objects (ie, hardware or internal prosthetic or tubing) is generally caused by the same pathophysiology of classic pressure injuries over bony prominences.


  • Unrelieved pressure

    • External pressure greater than capillary pressure leads to decreased blood flow and tissue ischemia, eventually causing tissue necrosis.

    • Pounds-per-square-inch pressure highest in thin patients over bony prominences. Obese patients are able to distribute pressure better.4

  • Reperfusion injury

    • Tissue loss after restoration of blood flow and generation of oxygen free radicals after relief of pressure

  • Deformation injury of cells

    • Local cell damage and death

  • Tissue breakdown may also occur due to

    • Friction

    • Shearing forces

    • Moisture/maceration

  • Tissue breakdown is more likely with circulatory disturbances.

  • The presence of infection and edema can influence the wound environment and ultimately the extent of necrosis.


  • Pressure injuries are “inside-out” injuries caused by soft tissue damage from unrelieved pressure on the skin, typically overlying bony prominences.

  • Tissues most sensitive to pressure die first.

    • Nerve and muscle are the most sensitive to ischemia from pressure, which is why there is no muscle or major nerves between the skin and bony prominences in any area of the body.

    • Subcutaneous fat dies first in the typical pressure injury occurring over bony prominences.

    • Skin is one of the most resistant tissues to pressure. The earliest changes seen in the skin (ie, swelling and erythema of stage 1 pressure injuries) generally reflect injury to the tissues beneath.

    • Skin breakdown without underlying tissue loss (stage II) is generally due to shearing, friction, and maceration and not pressure per se.

    • The tissue type most resistant to pressure is fascia, which has very low metabolic demands.

  • “Iceberg effect”: by the time that there is any evidence of pressure injury in the skin, there is significant tissue destruction beneath; the skin findings are only the “tip of the iceberg.”

  • Although pressure injuries are typical in debilitated, immobile, and/or insensate patients, they are not inevitable and indeed should be preventable in most situations.

  • Prevention is directly related to educating and motivating patients and or caregivers in

    • Recognizing risks in various situations

    • Pressure-relief training

      • Relieving pressure every 15 minutes when seated or for 5 minutes every 2 hours when in decubitus position will generally prevent pressure injuries.

    • Providing resources (eg, cushions for seats)

    • Compliance

  • Change in caregivers and/or intermittent psychological disturbance (such as depression) correlate with pressure injury development and recurrence.

  • Evaluation and coordination with a rehabilitative team preoperatively leads to the least incidence of recidivism.5,6


  • Patients at risk

    • Patients with diminished mobility

      • Paralyzed patients

        • Spinal cord injury, disease, or dysfunction

        • Patients under anesthesia or deep sedation during surgery or undergoing procedure or treatment requiring prolonged immobilization (eg, ECMO)

      • Patients requiring others to move them

        • Patients with quadriplegia

        • Patients who are debilitated due to cerebral dysfunction (stroke, intoxication, infection)

    • Debilitated patients in acute care and long-term care facilities

    • Patients with diminished sensation

      • Spinal cord injury, disease, or dysfunction

      • Peripheral neuropathy

  • Assess for muscle spasticity, which increases the risk of shearing forces and friction and postoperative healing issues if not controlled.

  • Assess for joint contractures, which make avoiding pressure on bony prominences very difficult for health care providers.

  • Assess for tunneling and pseudobursa formation.

  • Assess for involvement of joint spaces and other adjacent structures.

  • Assess for bone exposure.

  • Assess for infection: soft tissue and bone.

  • Assess for urinary tract infections, in patients with spinal cord dysfunction.

  • Assess patient and caregiver knowledge, home resources, likelihood of being compliant, and potential social/psychological issues, all of which can affect incidence of recurrence.


  • X-rays are helpful for assessment of osteoporosis, fractures, and heterotopic ossification.

  • Radionuclide bone scans are helpful in assessing activity of heterotopic ossification.

  • MRI is the best diagnostic imaging to evaluate for acute osteomyelitis; however, bone biopsy remains gold standard for the diagnosis of osteomyelitis.

  • CT scan or MRI and sinograms are helpful to evaluate for sinus tracts, fluid collections, and tunneling in the pelvis or possible involvement of rectum.


  • Nonoperative management of pressure injuries is appropriate in patients who

    • Are prohibitive surgical risk due to comorbidities

    • Demonstrate that they would not be compliant with postoperative regimens

    • Need to be prepared for possible operative management in the future

  • Optimize nutrition (sufficient protein, vitamins/minerals).

  • Monitor prealbumin levels.

  • Check vitamin D levels.

  • Promote optimization of general medical care.

  • Evaluate cardiovascular, pulmonary, and genitourinary systems.

  • Promote smoking, alcohol, and drug cessation.

  • Promote treatment of depression.

  • Optimize wound conditions.

    • Quantitative bacteriologic assessment of wound with wound tissue biopsy

    • Pathologic assessment of long-standing (more than 5 years) wounds with wound tissue biopsy

    • Offloading/frequent turning for pressure relief

      • Air mattresses/cushioning

  • Provide patient and caregiver education.

  • Prevent spasticity.

    • Medical management: baclofen, dantrolene, diazepam, botulinum toxin

    • Surgical management: rhizotomy, baclofen pump, peripheral nerve blocks

  • Infection control

Feb 27, 2020 | Posted by in Pediatric plastic surgery | Comments Off on Pressure Injuries

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