Dr. Binaya kumar Padhi presented on decubitus ulcers (pressure sores). He defined decubitus ulcers as traumatic ulcers caused by direct pressure or shearing forces on bony tissues, leading to tissue necrosis and ulceration. Risk factors include immobility, malnutrition, and spinal cord injury. Prevention focuses on frequent repositioning to reduce pressure, maintaining good nutrition, and early mobilization. Treatment involves wound cleaning, debridement of necrotic tissue, dressing changes, and sometimes flaps or skin grafts. Managing underlying risks and recurrent pressure is important for healing.

1. Presenter-
Dr. Binaya kumar Padhi
PGT, Department of General surgery
HMCH, Bhubaneswar

2. Definition
 Decubitus ulcer is a representative of traumatic ulcer due
to direct pressure on bony tissues or shearing forces
resulting in micro vascular compromise, leading to tissue
necrosis and ulceration
 In Latin “decumbere” means “to lie down ’’ and decubitus is
the posture adopted by a person who is lying down
 Synonym-
 Bed sores
 Trophic ulcer
 Ischemic ulcer
 Necrotic ulcer
 The most preferred term is ‘pressure sores’ because it best
suggests the true cause of these lesions

3. History
 1853- Brown- Sequard- identified pressure and
moisture as the major cause of ulceration.
 1873-Paget- Defined pressure sores as the sloughing
and death of a part produced by the pressure
 1879-Charcot’s theory-stated that nerve injury causes
the release of a neurotrophic factor that resulted in
tissue necrosis.
 1940-Munro-spinal cord injury caused a disturbance
of the ANS resulted in a decrease of the peripheral
reflexes and predisposed to skin ulcerataion . For this
reason ,he considered pressure sores as an inevitable
complication of SCI

4. Epidemiology
 Pressure sores are common conditions among patients
hospitalised in acute and chronic care facilities.
 Common among hospitalised and accounts for 3-10%
of hospitalised patients
 Prevalence rate as high as 25-33% in SCI
 It is most common around the hips (70%)
 Lower extremities (15-25%)

5. Risk factors
 Spinal cord injury
 Traumatic brain injury
 Neuromuscular disorder
 Immobility
 Malnutrition
 Fecal and urinary incontinence
 Chronic systemic illness
 Fractures
 Aging of skin –decresed epidermal turnover
-dermo-epidermal junction flattens
-fewer blood vessels
 Decresed pain perception

6. Risk factors

7. Thermodynamics, Metabolism and pressure in
relation to decubitus ulcer
 Thermodynamic factors- skin-surface interface
 As temperature increases, skin becomes more
metabolically active and O2 demand increase
 With increased pressure, metabolic demands not able
to be met and skin becomes hypoxic.
 Hypoxic skin more susceptible to breakdown
 Adding friction and shear to already fragile skin is the
‘perfect storm’.

8. The 4 forces involved in decubitus ulcer
 Pressure-forces applied to soft tissue between hard
surface and bony prominence. When skin and the
underlying tissues are trapped between bone and a
surface such as wheel chair or bed, blood flow is
restricted. This deprives tissue of oxygen and other
nutrients tissue death
 Friction-resistance of one body sliding or rolling over
another. Making skin more succeptible to pressure
sore

9.  Shear -this occurs when skin moves in one
direction and the underlying bones
moves in another
- Sliding down in bed or chair or raising
the head of bed more than 30 degree is
especially causes shearing, which
stretches and tears cell membranes and tiny
blood vessels
-Especially affected are areas such as
tailbone where skin is already thin and
fragile
 Strain-tissue deformation in response to injury

10. Pressure and Shear

12. McClemont pressure Theory
McClemont (1984) discovered that the pressure exerted on the deeper tissues was far greater than
that at the surface, resulting in a greater degree of tissue damage nearer the bone than on the skin
surface. This phenomenon is known as McClemont's 'cone of pressure theory ’

13.  When a person is lying or sitting, pressure is transferred from the
external surface, through the layers of the skin, toward the underlying
bone. Skin, blood vessels, subcutaneous fat and muscle are compressed
between the bone (which acts as a counter pressure) and the external
surface.
 This results in a cone, or pyramid shaped, pressure gradient. The apex
of the cone equates to the bony surface where tissue interface pressures
are highest. This leads to the intensity of pressure being up to five
times greater on deep tissues (muscles/bony surfaces) than that on the
epidermis.
 Deep tissue necrosis often occurs first at the bony interface as a result
of this pressure, and the fact that muscle tissue is more sensitive and
less resistant to pressure than the skin. Pressure exerted at the bony
interface then emerges at a point in the surface of the skin. A small,
inflamed area, over a bony prominence, may indicate tissue breakdown
that is much deeper and wider than indicated at the surface of the skin

14.  Most susceptible tissue to pressure injury
-Muscles >> subcutaneous fat >>dermis
-Greatest pressure at bony prominence (Cone
distribution)
Pressure distribution
 Sitting position- Ischial tuberosity (100mm Hg)
 Supine position – Sacrum (150mm Hg) and Heel (40
mm Hg)
 Prone position- knee and chest (40mm Hg)

15. patho-physiology
1
• Various risk factors act on areas of soft tissues overlying bony
prominence
• Excess of arteriolar pressure >32mm of Hg
• Venous capillary closing pressure >8-12mm of Hg
2
• Occlusion and tearing of small blood vessel
• Decreased tissue perfusion
• Decreased oxygen and nutrient to tissue
3
• Tissue hypoxia
• Ischemic necrosis
• Increased waste product and free radicals

16. Vulnerable areas in different position

17. Vulnerable areas

19. Most common areas

20. Staging of bed sores
(As per the American National Pressure Ulcer Advisory Panel )

25. Management
 Multidisciplinary approach required
 Surgeon
 Plastic surgeon
 Neurosurgeon
 Orthopedic surgeon
 Nurses
 Social workers
 Physician
 Dietician
 Physiotherapy

26. Diagnosis
Aim
 Determining the vulnerable individual
 Risk assessment
 Skin assessment
 Ulcer assessment

27. People vulnerable are
 Post operative period/post surgery
 Those who are under Critical care
 Orthopedic patient
 Spinal injured
 Diabetic people
 Affected by Peripheral vascular disease
 Previous history of pressure ulcers
 Extreme age

28. Risk assesment

31. If ulcer is present
 Look for
 -persistent erythema
 Non blanching erythema
 Blisters
 Localised heat
 Localised edema
 Localised induration
 Localised coldness
 Site,size,shape, surrounding, edge, base and colour
 Any discharge
 Necrotic tissue
 odour

32. Ulcer assessment

33. Investigation
 Blood sugar, CBC, CRP, ESR
 Wound swab microscopy ,culture and sensitivity
 Serum protein assessment (Albumin)
 Biopsy from the edge of the ulcer
 X –ray of the affected part

34. Prevention
1.Repositioning
 Frequency- 2hrly on bed and 15min on wheel chair
 Assisted or by self
 Use of devices like specialised wheel chair or mattress
2.protect bony areas
 Special cushions
 Foam mattress pad
 Air/water filled mattress

35.  3. Skin care
 Bathing
 Skin protecting agent (Talcum powder)
 Frequent skin inspection
 Managing incontinence/UTI
4. Improve nutrition
 High protein ,high carbohydrate diet
 Dietary supplement vit. C, Vit A and Zinc

36.  5. Early mobilization
 6. Quit use of tobacco
 7. Control spasticity
 8. Adequate pain control
 9.Psychological counseling
 10.Pressure measurement by means of specialized
pressure mat

38. Treatment
 Non surgical
 Pressure reduction method
 change of position every 2hr
 Mattress system
 Management of patient factors like infection, Diabetes,
nutrition and supplement
 Cleaning of the wound and dressing, control of
incontinence
 Management of pain and spasm to avoid further injury
 Educating the care giver

42. operative
 Pre operative consideration
 Determine whether the underlying cause can be
eliminated post operatively
 Patient/ care giver education about the
treatment
 Nutritional consideration (s. albumin
>3.5gm/dL)
 wound debridement
 To rule out presence of osteomyelitis
 Sterilization of urinary tract

43. Debridement
 Contraindication
 Absence of necrotic tissue
 Granulation tissue is present

44.  Intra operative
 Excision of the ulcer, surrounding scar and soft tissue
calcification
 Radical removal of underlying bone and any heterotopic
ossification
 Padding of bone stumps and filling dead space with fascia
or muscle flaps
 Resurfacing with large regional pedicle flap
 Grafting the donor site of the flap with thick split skin

45.  Example of flaps to be raise include
 Tensor fascia latae flap
 Transverse lumbosacral flap
 Sliding gluteal flap
 Hamstring V-Y advancement flap
 Rhomboid double Z plasty
 Gluteus maximus island flap

46. Vacuum Assisted Closure

48. Post operative measures
 Continue care similar to pre-operative care
 Prevent pressure or shearing force
 Drain
 Psychosocial support
 Rehabilitative care
 Prevention of contamination (with feces , urine)
 Prevention of recurrence

49. Specific treatment guided by stage
 Stage-I covered with transparent film
- Protection and prevent from further progression

50. Stage-II ulcer
 Require moist wound environment and minimal
debridement
 Semi-occlusive (transparent film) or occlusive
dressings (hydrocolloids or hydrogels)
 Contraindication-infection

51. Stage-III and Stage-IV ulcer
 Through debridement of necrotic tissue
 Cover with appropriate dressings
 Treatment of infection

52. Role of antibiotics
 Indications
 In infected decubitus ulcer
-Antibiotics(adjunctive) + Debridement
-Prevent the infection from spreading
 Topical antibiotics should be avoided
 Antiseptic cream (Nano silver cream ) may be applied
topically

53. PUSH tool for Ulcer healing
 The Pressure Ulcer Scale for Healing (PUSH) tool is a fast and accurate
tool used to measure the status of pressure wounds over time. The tool
was designed by the National Pressure Ulcer Advisory Panel (NPUAP)
and has been validated many times.

54. •Document all observation over time
.Describe each ulcer to track progress of healing

55. Complications
 Osteomyelitis
 Pyoarthrosis
 Anemia
 Urethral fistula
 Recurrence
 Autonomic dysreflexia (Spinal cord injury cases during
debridement)
 Malignant transformation
 Depressive illness
 Hematoma and seroma (after reconstructive surgery )

56. Conclusion
 Decubitus ulcer management is challenging both to
the patient and the managing team. It is associated
with high morbidity, mortality and economic burden.
 Always remember that it is easier to prevent than treat
a decubitus ulcer.
 The preventive approach on a hospitalised patient can
be easily remembered as a mnemonic “ NO ULCERS
SKIN ”

57. NO ULCERS Nutrition and fluid status
Observation of skin
Up and walking or assist with position changes
Lift, don’t drag
Clean skin and continence care
Elevate heels
Risk assessment
Support surfaces
SKIN Surface selection
Keep turning
Incontinence management
Nutrition