Pressure Sores

What is the etiology of pressure sores?

Pressure sores arise as a result of tissue ischemia developing from pressure over a bony prominence. Pressure between the surface the patient rests on and the underlying bone may approach or exceed the patient’s blood pressure, leading to tissue ischemia and/or tissue death.

What are the risk factors of pressure sore development?

Increased age, spinal cord injury, spasticity, decreased skin sensation, paraplegia, quadriplegia, prolonged immobilization, bowel or bladder incontinence. Malnutrition is not proven to be a risk factor.

Where are the most common sites of pressure sores?

The most common site is overlying the ischial tuberosity, followed by the trochanters or the sacrum.

What are the stages of pressure sores?

Revised in 2007, the National Pressure Ulcer Advisory Panel stages are the following:

Suspected deep tissue injury: Areas of purple or maroon discoloration with intact skin or blistering in the setting of excessive pressure and shear.

Stage I: Intact skin with nonblanching erythema, usually over a bony prominence.

Stage II: Partial-thickness loss of dermis.

Stage III: Full-thickness skin loss with visible subcutaneous fat, which may extend down to the deep fascia. There may be slough in the wound and undermining or tunneling.

Stage IV: Full-thickness tissue loss beyond the deep fascia with exposed bone, tendon, or muscle.

Unstageable: Excessive slough or eschar prevents accurate assessment of wound depth.

What are some basic principles guiding pressure sore treatment and reconstruction?

All contributing factors to the etiology of the pressure sore should first be addressed. For example, incontinence must be controlled or else any interventions will inevitably fail. A recent illness in the patient or loss of family support may even be contributing factors.

Stages I and II—These wounds are considered reversible, and with proper local wound care, adequate nutritional support and pressure off-loading adjuncts, they often heal without surgical intervention.

Stages III and IV—Usually require surgical intervention in addition to pressure off-loading adjuncts. All nonviable tissue should be debrided and then soft-tissue coverage should be undertaken. In the paraplegic population, spasticity should be addressed as this can cause flap breakdown by making pressure problems worse or causing shearing.

What infections are commonly associated with pressure sores?

Urinary tract infections and pneumonia. For the majority of patients with spinal cord injury and pressure sores who present with a fever, the source will be the urinary tract or the lungs. Fever is much less commonly caused by the pressure sore, as this is usually a clean, contaminated wound that is adequately draining.

What laboratory tests are useful in the diagnosis of osteomyelitis in a pressure sore?

A white blood cell count will often be elevated in osteomyelitis; however, it is nonspecific. An elevated erythrocyte sedimentation rate >120 mm/hr is much more specific for osteomyelitis.

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