Pressure ulcers, also known as bedsores, are a unique subset of wounds caused by prolonged pressure or pressure combined with shear. [1] These injuries primarily affect areas over bony prominences and are particularly common in patients with limited mobility. Early identification and management are critical to prevent further tissue damage and systemic complications. [1][2]

Predisposing Factors

Pressure ulcers can occur due to various intrinsic and extrinsic factors [2]:

• Intrinsic factors:
  • Limited mobility or immobility.
  • Poor nutritional status or malnutrition.
  • Advanced age leading to frail skin.
  • Advanced age leading to frail skin.
  • Neurological conditions causing reduced sensation (e.g., spinal cord injury).
• Extrinsic factors:
  • Prolonged pressure, particularly over bony prominences.
  • Shear forces during repositioning or transfers.
  • Excessive moisture from incontinence or sweating.
  • Use of inappropriate support surfaces.

History and Examination

A structured history aids in understanding the aetiology and guiding management. Consider the above predisposing factors when taking a history. The AMPLE framework is useful for the history:

• A: Allergies.
• M: Medications
  • Immunosuppressive drugs can contribute to poor wound healing. Steroids affect wound healing and skin quality.
• P: Past medical history.
• L: Last meal and drink
  • Less relevant as the majority of pressure ulcer patients are managed non-surgically.
• E: Events
  • Duration of pressure ulcer
  • Evolution of the ulcer (improving/worsening)
  • Investigations including wound swabs
  • Current treatment.

Clinical Examination

• General Examination: Systemic review looking at general health
• Local examination of ulcer: Follow the Look, Feel, Move approach.
  • Look:
    • Site, size, depth, quality of the surrounding skin and presence of infection.
  • Feel: Assess the depth, if there is any collection or discharge. Assess if there is any bony tenderness or crepitus.
  • Move: Asses if the surrounding skin is fixed or mobile to help aid in the decision-making regarding surgery.

Staging and Classification 

Pressure ulcers are classified using the NPUAP/EPUAP system: [3]

• Stage 1: Non-blanchable erythema.
• Stage 2: Partial-thickness skin loss.
• Stage 3: Full-thickness skin loss with visible fat.
• Stage 4: Full-thickness tissue loss with exposed bone or muscle.

Figure 1 Illustrating the different stages of pressure sores. Adopted from verywellhealth.com^A

Risk Assessment and Scoring

Utilise standardised tools such as:[2]

• Braden Scale: Evaluates sensory perception, activity, mobility, moisture, nutrition, and shear.
• Waterlow Score: Considers BMI, continence, age, and skin condition.[4]

These tools identify patients at higher risk and prompt timely preventive strategies.

Investigations

To evaluate the extent and complications of pressure ulcers, the following investigations may be performed:

• Laboratory Tests:
  • Full blood count (FBC) to detect infection or anaemia.
  • C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) to assess inflammation.
  • Serum albumin and prealbumin levels to evaluate nutritional status.
  • Blood cultures in cases of suspected sepsis.
• Imaging Studies:
  • X-rays: May indicate osteomyelitis in deep or chronic ulcers.
  • MRI: For detailed soft tissue and bone evaluation, especially when osteomyelitis is suspected.
  • Ultrasound: To assess underlying abscesses or fluid collections if present.
• Wound Culture and Sensitivity:
  • Swab and/or tissue biopsy for microbial identification and antibiotic sensitivity testing.
  • Bone biopsy: definitive investigation for diagnosing osteomyelitis.

Prevention and Management Strategies:

MDT approach

Optimising all predisposing factors is vital to the management of pressure ulcers and can be achieved with an MDT approach involving the following members:

• Plastic surgery team
• Dieticians and nutritionists
• Physiotherapists and occupational therapists,
• Tissue viability nurses
• District nurses
• The patient and any carers
  • Patient education and compliance is important for successful management.

Repositioning technique

• Reposition patients every 2 hours to redistribute pressure.
• Use lifts and aids to prevent shear and friction during movement.
• Patients who are wheelchair bound / chair bound still have to reposition every 2-3 hours.

Support surfaces

• Provide high-specification foam mattresses or alternating pressure mattresses for at-risk individuals.
• Utilize pressure-relieving cushions for seated patients.

Skin care

• Maintain skin hygiene and hydration.
• Apply barrier creams to protect from moisture-related damage.

Nutrition and Hydration

• Address malnutrition with protein-rich diets.
• Ensure adequate hydration to promote skin integrity.

Conservative treatment options

• Wound Care:
  • Clean wounds with saline or appropriate wound cleansers.
  • Apply dressings based on wound characteristics (e.g., foam, hydrocolloid, alginate).
  • Debridement
    • Chemical debridement is commonly performed by using active topical creams/gels and dressings
  • Vacuum-Assisted Closure (VAC):
    • Utilize negative pressure wound therapy to promote granulation and reduce exudate.
• Infection Management:
  • Use topical or systemic antibiotics if infection is present.
  • Monitor for signs of systemic infection (e.g., fever, increased WBC count).
• Nutritional Support:
  • Ensure adequate protein and calorie intake to support healing.
  • Administer supplements as needed (e.g., vitamin C, zinc).

Surgical treatment

• Debridement:
  • Removal of necrotic tissue
• Wound reconstruction:
  • The aim is to provide a robust wound cover which can range from skin grafts to different flap options (local, regional or free flaps)
    • Plastic surgeons will base their reconstructive choice on multiple factors and may choose from skin grafts, local flaps, regional flaps or free flaps.
    • Surgical management may lead to more harm than good and should be considered carefully.
• Other surgical considerations:
  • Orthopaedic surgeons may be involved in bone debridement.
  • General surgeons may be involved in creating a diversion ileostomy or colostomy as part of wound management.
  • Urology surgeons may be involved in the insertion of a suprapubic catheter as part of wound management.

Documentation and Communication 

• Maintain meticulous records of assessments, interventions, and outcomes.
• Communicate findings and management plans effectively when transferring patients to specialized care.

Summary 

Effective prevention and management of pressure ulcers require a multidisciplinary approach, early recognition of risk factors, and adherence to evidence-based protocols. By implementing structured assessment tools and preventive measures, healthcare providers can significantly improve patient outcomes and quality of life.

Written and prepared by Yousef Abdalazeem (Plastic surgery registrar) and Miss S.Yao (Plastics surgery Consultant)

Checked and reviewed by Mr. Martin Van Carlen (ST8 Plastic Surgery) and Jonathan Van (Plastic surgery registrar)

References

1. Braden, B., & Bergstrom, N. (1987). A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing, 12(1), 8-12.
2. National Pressure Injury Advisory Panel. (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline.
3. NICE. (2014). Pressure ulcers: prevention and management. Clinical guideline CG179. National Institute for Health and Care Excellence.
4. Waterlow, J. (1985). Pressure sore risk assessment in clinical practice. Nursing Times, 81(48), 49-55.

Illustration:

A. Giorgi A., How Different Stages of Pressure Ulcers Look, Verywellhealth website [https://www.verywellhealth.com/pressure-ulcer-7549469]