Part V • Trunk And Lower Extremity

Chapter 66: Pressure Sores

Questions: 11
Answered: 0/11
Score: 0%
1 2 3 4 5 6 7 8 9 10 11
Question 1 of 11 SITES OF PRESSURE SORE DEVELOPMENT
What is the most common anatomic site for development of a pressure sore?
A
Ischial tuberosity
B
Greater trochanter
C
Scalp
D
Sacrum
E
Heel
✓ Correct Answer: D. Sacrum
Clinical Explanation

The site of pressure sore development will depend on several factors such as patient’s mobility, body mass index, positioning, and local anatomy. However, the most common overall site is the sacrum (28–36%). This occurs most frequently in bed-bound patients, particularly those with spinal cord injuries and other individuals such as frail, elderly patients with decreased mobility who spend long periods of time in a lying position. Other common anatomic sites are the ischial tuberosity (17–20%) in seated patients who spend long periods in wheelchairs, for example. The heels are also quite commonly affected (9%) in bed-bound patients lying supine. The greater trochanter is at risk in individuals lying in a lateral position for extended periods. The posterior scalp (occiput) is at risk for patients in intensive care for extended periods due to immobility.1

References:
  • 1. Ricci JA, Bayer LR, Orgill DP. Evidence-based medicine: the evaluation and treatment of pressure injuries. Plast Reconstr
  • Surg 2017;139(1):275e–286e
Question 2 of 11 ETIOLOGIC FACTORS IN PRESSURE SORES
Which one of the following is an extrinsic factor in development of pressure sores?
A
Ischemia
B
Infection
C
Malnutrition
D
Smoking
E
Moisture
✓ Correct Answer: E. Moisture
Clinical Explanation

Causal factors in the development of pressure sores can be classified as intrinsic or extrinsic. Key extrinsic factors are the forces of shear, friction, and pressure (compression). However, moisture is also an extrinsic factor, and this increases the risk of pressure sore development in incontinent patients. Intrinsic factors include ischemia, infection, sensory loss, vascular disease, altered consciousness, decreased autonomic control, anemia, and malnutrition. Management of pressure sores is based on addressing both intrinsic and extrinsic factors.1–4

References:
  • 1. Janis JE, Kenkel JM. Pressure sores. Sel Read Plast Surg 2003;9(39):1–42
  • 2. VanGilder C, Amlung S, Harrison P, Meyer S. Results of the 2008–2009 International Pressure Ulcer Prevalence Survey
  • and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage 2009;55(11):39–45
  • 3. O’Sullivan KL, Engrav LH, Maier RV, Pilcher SL, Isik FF, Copass MK. Pressure sores in the acute trauma patient: incidence
  • and causes. J Trauma 1997;42(2):276–278
Question 3 of 11 THE BRADEN SCALE
When considering a patient’s risk of pressure sore development, which one of the following scores indicates the highest risk on the Braden scale?
A
0
B
3
C
6
D
9
E
12
✓ Correct Answer: C. 6
Clinical Explanation

is one example. It has subscales, including sensory perception, skin moisture, activity, mobility, nutrition, and local mechanical forces that act on wounds. Composite scores range from 6 to 23, with lower scores indicating an increased risk for pressure sore development.1,2 Other systems include the Waterlow score, which places patients in different risk categories (low, medium, and high) based on factors such as body mass index (BMI), skin type, sex, malnutrition, continence, mobility, and age.3 Although the assessment and scoring of a pressure sore are typically undertaken by the nursing team, understanding the workings of these systems is highly relevant to the surgical team both for delivery of high- quality, safe patient care and for the preparation for clinical exams. Assessment of pressure areas now forms part of the surgical check listing process before starting and after completing surgery. This is particularly important in longer procedures and in high-risk patients.

References:
  • 1. Chen HL, Cao YJ, Zhang W, Wang J, Huai BS. Braden scale (ALB) for assessing pressure ulcer risk in hospital patients: a
  • validity and reliability study. Appl Nurs Res 2017;33:169–174
  • 2. Bergstrom N, Braden BJ. Predictive validity of the Braden Scale among Black and White subjects. Nurs Res
  • 2002;51(6):398–403
  • 3. Waterlow J. Pressure sores: a risk assessment card. Nurs Times 1985;81(48):49–55
  • PRESSURE SORE STAGING
  • 4. A patient has a pressure sore on the left heel measuring 5 cm. It involves full-thickness tissue loss to, but not
  • through, fascia or bone. What stage is this sore?
  • C. Stage III
  • Pressure sores are graded into one of four stages according to the National Pressure Ulcer Advisory Panel. Stage I
  • involves nonblanching erythema of intact skin. Stage II is a partial-thickness defect presenting as a blister. Stage
  • III is a full-thickness skin defect, as in this case, that does not go through fascia. Stage IV includes underlying bone,
  • muscle, tendon, or joint capsule. In cases in which full assessment is not possible clinically (e.g., soft tissue cover
  • obscures deeper structures) two alternative grades can be used: unstageable and suspected deep.1 Pressure sores
  • evolve over time, so they should be repeatedly inspected during the early stages to prevent under-staging because
  • of overlooked deep tissue damage (Fig. 66.1). Assessment of pressure areas is now part of the World Health
  • Organization (WHO) checklist during surgery, so all surgeons should be regularly involved in this assessment.
  • Being able to reliably assess grade of the pressure sore in the context of a patient’s overall health is important
  • with respect to selecting the best management plan for them.1–3
  • A
  • B
  • C
  • D
  • E
  • F
  • Fig. 66.1 National Pressure Ulcer Advisory Panel stages. A, Stage I. B, Stage II. C, Stage III. D, Stage IV. E, Unstageable.
  • F, Suspected deep tissue injury. (Adapted from National Pressure Ulcer Advisory Panel (NPUAP). Pressure ulcer stages/
  • categories 2007. Available at http://www.npuap.org/resources/educational-and-clinical-resources/.)
  • 1. National Pressure Ulcer Advisory Panel (NPUAP). Pressure Ulcer Stages/Categories 2007. Available at http://www.npuap.
  • org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescat-egories/
  • 2. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory
  • Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs
  • 2016;43(6):585–597
  • 3. Spear M. Pressure ulcer staging-revisited. Plast Surg Nurs 2013;33(4):192–194
Question 4 of 11 PRESSURE SORE STAGING
A patient has a pressure sore on the left heel measuring 5 cm. It involves full-thickness tissue loss to, but not through, fascia or bone. What stage is this sore?
A
Stage I
B
Stage II
C
Stage III
D
Stage IV
E
Unstageable
✓ Correct Answer: C. Stage III
Clinical Explanation

4. Enis JE, Sarmiento A. The pathophysiology and management of pressure sores. Orthop Rev 1973;2:25–34

Question 5 of 11 PRESSURE VALUES RECORDED IN PRESSURE SORE STUDIES
What is the external pressure measured at the ischial tuberosity of a patient who is sitting with feet supported according to the scientific literature?
A
12 mm Hg
B
32 mm Hg
C
45 mm Hg
D
80 mm Hg
E
100 mm Hg
✓ Correct Answer: E. 100 mm Hg
Clinical Explanation

Capillary blood pressure ranges from 12 mm Hg at the venous end to 32 mm Hg at the arterial end. If external pressure exceeds the capillary opening pressure, then perfusion is reduced. For short time periods, this will have no detrimental effect. However, if it is continued for an extended time, ischemia and tissue damage will occur. An inverse relationship exists between the amount of pressure and the duration required to cause pressure necrosis. Animal studies have shown that a pressure of 70 mm Hg applied over 2 hours was sufficient to cause pathologic changes in dogs. In a porcine model, pressure of 100 mm Hg for only 10 minutes caused muscle necrosis. Changes in the skin occur later than those in muscle, suggesting that pressure sores begin deep and the skin changes are late signs. Lindan et al1 performed a landmark study in 1965. They observed pressures of up to 60 mm Hg in the sacral area of humans who were in a supine position (Fig. 66.2). Pressure in the heels, occiput, and buttocks was approximately 40 mm Hg. Measurements of patients in the seated position were greatest at the ischial tuberosities and were in the order of 100 mm Hg. This helps explain the high incidence of ischial pressure sores. A B C D Fig. 66.2 Pressure-distribution maps (in mm Hg) of a male figure. A, Supine. B, Prone. C, Sitting with feet hanging freely. D, Sitting with feet supported. (Adapted from Lindan O, Greenway RM, Piazza JM. Pressure distribution on the surface of the human body. I. Evaluation in lying and sitting positions using a bed of springs and nails. Arch Phys Med Rehabil 46:378, 1965.)

References:
  • 1. Lindan O, Greenway RM, Piazza JM. Pressure distribution on the surface of the human body. I. Evaluation in lying and
  • sitting positions using a “bed of springs and nails.” Arch Phys Med Rehabil 1965;46:378–385
Question 6 of 11 PREVENTION OF PRESSURE SORES
Which one of the following is aimed at treating pressure sores on the basis of Kosiak’s principle?
A
Meticulous skin care
B
Care with transfers
C
Minimization of spasticity
D
Regular turning
E
Smoking cessation
✓ Correct Answer: D. Regular turning
Clinical Explanation

All of the choices are vital components of prevention and nonsurgical management of pressure sores. However, according to the Kosiak’s principle, tissues tolerate increased pressure if it is interspersed with pressure-free periods.1 Seated patients should therefore be lifted every 10 minutes for 10 seconds, and supine patients should be turned every 2 hours. Kosiak2 first demonstrated the principle in 1959 by applying varying loads to the trochanters and ischial tuberosities of dogs. He found that high loads for short periods or low loads for long periods caused pressure ulcers. He later used a rat model to show that removal of pressure for short periods of time provided relief and resulted in less tissue damage.3 Tissues are more susceptible to a constant load as opposed to an intermittent load. Similarly, Dinsdale4 showed prevention of injury when pressure was relieved for short durations, for example, 5 minutes of relief from a pressure of more than 400 mm Hg.

References:
  • 1. Kosiak M, Kubicek WG, Olson M, Danz JN, Kottke FJ. Evaluation of pressure as a factor in the production of ischial ulcers.
  • Arch Phys Med Rehabil 1958;39(10):623–629
  • 2. Kosiak M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil 1959;40(2):62–69
  • 3. Kosiak M. Etiology of decubitus ulcers. Arch Phys Med Rehabil 1961;42:19–29
  • 4. Dinsdale SM. Decubitus ulcers: role of pressure and friction in causation. Arch Phys Med Rehabil 1974;55(4):147–152
Question 7 of 11 ASSESSMENT OF PRESSURE SORES
A patient is referred to you with a grade IV pressure sore in the sacral region. The patient has multiple comorbidities and sepsis. Osteomyelitis is suspected. Which one of the following tests is the benchmark for diagnosis?
A
Culture swab
B
Contrast CT
C
MRI
D
Bone biopsy
E
Plain radiographs
✓ Correct Answer: D. Bone biopsy
Clinical Explanation

The benchmark test for diagnosis of osteomyelitis within a deep pressure area is a positive bone biopsy. However, this is not always technically possible unless the patient is in the OR. Routine microbiology swabs from pressure sores will show growth of multiple organisms and interpretation of these results needs to be combined with a clinical evaluation to assess for evidence of local infection. The best noninvasive option for patients with suspected osteomyelitis would be an MRI. Plain radiographs and CT may be useful but are less accurate. The clinical importance of osteomyelitis is that if the extent is unknown or underappreciated, then any reconstruction is destined to fail.1–3

References:
  • 1. Huang AB, Schweitzer ME, Hume E, Batte WG. Osteomyelitis of the pelvis/hips in paralyzed patients: accuracy and
  • clinical utility of MRI. J Comput Assist Tomogr 1998;22(3):437–443
  • 2. Larson DL, Gilstrap J, Simonelic K, Carrera GF. Is there a simple, definitive, and cost- effective way to diagnose osteomy-
  • elitis in the pressure ulcer patient? Plast Reconstr Surg 2011;127(2):670–676
  • 3. Han H, Lewis VL Jr, Wiedrich TA, Patel PK. The value of Jamshidi core needle bone biopsy in predicting postoperative
  • osteomyelitis in grade IV pressure ulcer patients. Plast Reconstr Surg 2002;110(1):118–122
Question 8 of 11 ASSESSMENT OF OSTEOMYELITIS IN PRESSURE SORES
A patient requires imaging for suspected osteomyelitis from a trochanteric pressure sore. What is the sensitivity of MRI in detecting osteomyelitis?
A
25%
B
56%
C
68%
D
80%
E
97%
✓ Correct Answer: E. 97%
Clinical Explanation

MRI has a high sensitivity and specificity for evaluation of the extent of osteomyelitis. Huang et al1 conducted a study to assess the accuracy and utility of MRI for diagnosing osteomyelitis in pressure sores, using histologic/ microbiologic results as the standard of reference. They compared the extent of infection using MRI and surgical margins. The overall accuracy of MRI was high with only one false-negative MRI study. MRI for the diagnosis of osteomyelitis yielded a sensitivity of 97% and a specificity of 89%. A total of 21 patients underwent limited surgical resection guided by MRI findings in which only the enhancing area was resected. Osteomyelitis recurred only once, at the surgical margins. The authors concluded that MRI is accurate in the diagnosis of osteomyelitis and associated soft tissue abnormalities in spinal cord–injured patients. It can delineate the extent of infection and help to guide limited surgical resection and preserve viable tissue.

References:
  • 1. Huang AB, Schweitzer ME, Hume E, Batte WG. Osteomyelitis of the pelvis/hips in paralyzed patients: accuracy and
  • clinical utility of MRI. J Comput Assist Tomogr 1998;22(3):437–443
Question 9 of 11 DAKIN’S SOLUTION
You are reviewing a patient who has a trochanteric pressure sore, and the nurse suggests cleaning the wound with Dakin’s solution. You have not used this before and decide to research the product before you proceed. Which one of the following statements is correct regarding Dakin’s solution?
A
It contains silver sulfadiazine.
B
It is nontoxic to healthy tissue.
C
It should be used in undiluted form.
D
Treatment duration should be limited to 14 days.
E
It is useful where Pseudomonas is suspected.
✓ Correct Answer: E. It is useful where Pseudomonas is suspected.
Clinical Explanation

Dakin’s solution can be useful for cleaning wounds such as pressure sores that have Pseudomonas growth, but should be used cautiously and for limited periods because of its toxicity to healthy tissue. It contains sodium hypochlorite and boric acid, not silver sulfadiazine. It should be diluted to quarter strength and used for a few days only (not 14 days). Wounds with Pseudomonas typically appear green and have a characteristic malodor. Other popular dressings for pressure sores include hydrogels if there is black eschar, hydrocolloids if there is granulation tissue, and an alginate and absorbent foam in wounds with high exudate. Manuka honey has also become popular for chemical debridement of pressure sores and this works in a number of ways which include antibacterial as well as debriding. The use of a dressing containing silver is particularly useful in cases of Pseudomonas infection. Irrespective of dressing used, the propensity for a pressure sore to heal will be dependent on the vascularity of the wound itself and removal of the instigating cause.1–3

References:
  • 1. Ueno CM, Mullens CL, Luh JH, Wooden WA. Historical review of Dakin’s solution applications. J Plast Reconstr Aesthet
  • Surg 2018;71(9):e49–e55
  • 2. Norman G, Dumville JC, Moore ZE, Tanner J, Christie J, Goto S. Antibiotics and antiseptics for pressure ulcers. Cochrane
  • Database Syst Rev 2016;4(4):CD011586
  • 3. Chuangsuwanich A, Chortrakarnkij P, Kangwanpoom J. Cost-effectiveness analysis in comparing alginate silver dressing
  • with silver zinc sulfadiazine cream in the treatment of pressure ulcers. Arch Plast Surg 2013;40(5):589–596
Question 10 of 11 PRESSURE SORE SURGERY
When performing surgical debridement and reconstruction of grade IV pressure sores, which one of the following should generally be avoided?
A
Methylene blue application
B
Tumescent infiltration
C
Excision of unaffected bony prominences
D
Obliteration of dead space
E
Flap design to allow re-advancement
✓ Correct Answer: C. Excision of unaffected bony prominences
Clinical Explanation

Although any nonviable or infected bone should be fully debrided, healthy bony prominences should not be routinely excised. If healthy bony prominences are excised to relieve pressure at the site of the sore, this can have unintended consequences from pressure transfer to other sites. An example is perineal ulceration following over-resection of the ischial tuberosity. Coating the bursa with methylene blue dye before excision can help verify that all bursal tissue has been completely excised. Infiltration of the peribursal area with a liposuction solution can help reduce/control bleeding during debridement. During reconstruction, any dead space must be obliterated with the chosen flap. Flaps should always be designed to allow for further revision surgery. For this reason, advancement and rotation flaps are generally preferred.1–3

References:
  • 1. Cushing CA, Phillips LG. Evidence-based medicine: pressure sores. Plast Reconstr Surg 2013;132(6):1720–1732
  • 2. Conway H, Griffith BH. Plastic surgery for closure of decubitus ulcers in patients with paraplegia; based on experience
  • with 1,000 cases. Am J Surg 1956;91(6):946–975
  • 3. Larson DL, Hudak KA, Waring WP, Orr MR, Simonelic K. Protocol management of late-stage pressure ulcers: a 5-year
  • retrospective study of 101 consecutive patients with 179 ulcers. Plast Reconstr Surg 2012;129(4):897–904
Question 11 of 11 RECURRENCE RATES AFTER PRESSURE SORE RECONSTRUCTION
Which one of the following statements is correct regarding recurrence rates after pressure sore reconstruction?
A
Myocutaneous flaps have a higher ulcer recurrence rate than fasciocutaneous flaps.
B
Paraplegic patients have a 30% risk of recurrence at the same site over 18 months.
C
Nonparaplegic patients have a higher rate of recurrence than paraplegic patients.
D
Myocutaneous and fasciocutaneous reconstructions have comparable ulcer recurrence rates in many series.
E
Young posttraumatic paraplegic patients generally heal better than other subgroups.
✓ Correct Answer: D. Myocutaneous and fasciocutaneous reconstructions have comparable ulcer recurrence rates in many series.
Clinical Explanation

series. Several authors have assessed recurrence rates after reconstruction of pressure sores. The overall rates range from 19% at 3.7 years (Kierney et al1) to 69% at 9.3 months (Disa et al2). Disa et al indicated that young posttraumatic paraplegics had a particularly high recurrence rate of 79% at 11 months. In a meta-analysis of pressure sore recurrence rates from 55 studies, Sameem et al3 identified similar recurrence rates with myocutaneous (8.9%) and fasciocutaneous (11.2%) flaps. Perforator flaps appeared to fare best overall with a 5.6% recurrence rate, but the differences between the three flap types were not statistically significant.

References:
  • 1. Kierney PC, Engrav LH, Isik FF, Esselman PC, Cardenas DD, Rand RP. Results of 268 pressure sores in 158 patients managed
  • jointly by plastic surgery and rehabilitation medicine. Plast Reconstr Surg 1998;102(3):765–772
  • 2. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg 1992;89(2):
  • 272–278
  • 3. Sameem M, Au M, Wood T, Farrokhyar F, Mahoney J. A systematic review of complication and recurrence rates of
  • musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Plast Reconstr Surg
  • 2012;130(1):67e–77e

🎉 Chapter Completed!

Proceed to Next Chapter → Back to All Chapters