1. Pressure Sores
高雄榮總整形外科
朱俊旭 醫師

3. Introduction
Treatment of pressure sores remains a significant challenge to the medical community.
Team works: physicians ( PS, GS, Ortho, Internal medicine, endocrinology, and neurology ), nurses, nutritionists, mental health experts.

4. Definition Pressure sore, decubitus ulcer, bedsore
Unrelieved pressure, altered sensory perception, incontinence, exposure to moisture, altered activity and mobility, friction, and shear force.

5. TABLE 1. Pressure sore staging
Stage Description
Stage I Skin intact but reddened for more than 1 hour after
relief of pressure
Stage II Blister or other break in dermis ± infection
Stage III Subcutaneous destruction into muscle ± infection
Stage IV Involvement of bone or joint ± infection

6. Cone shaped pattern of injury resulting from unrelieved
pressure. The highest pressure and greatest injury is deep
, adjacent to the bone. The cutaneous wound is only the “
tip of the iceberg.”

7. Epidemiology
In general, approximately 9% of all hospitalized patients develop pressure sores.
In paraplegic patients: ischial, trochanteric and sacral regions --- most common sites.
In acute care patients with bedridden: sacral (36%), heel (30%), and ischial-trochanteric-malleolar(6%)

8. Pathophysiology (1) Extrinsic factors: pressure, shear, friction.
Intrinsic factors: local ischemia, fibrosis, diminished autonomic control, infection, patient age, sensory loss, impaired mobility, decreased mental status, fecal or urinary incontinence, small vessel occlusive disease, anemia, and hypoproteinemia.

10. Pathophysiology (2)
Infection: compressed skin has less resistance to bacterial invasion.
Edema: the result of inflammatory mediators released in response to the trauma of compression.

11. Preoperative Care (1)
Nutrition: nonprotein calories 25-35cal/kg; protein  1.5 to 3.0 gm/kg per day.
Vitamins A & C
Zinc: epithelization and fibroblast proliferation
Ca2+ , Fe2+

12. Preoperative Care (2)
Infection control: the most common organisms cultured from pressure sores include common skin flora (Staphylococcus, Streptococcus, Corynebacterium) and enteric organisms (Proteus, E.coli, and Pseudomonas).

13. Preoperative Care (3)
Relief of Pressure: turning the patient at intervals (change position q2h)
Spasm treatment: Spasticity (spinal cord injury), 100 % in C-spine injury, 75% in T-spine injury, 50% in L-spine injury.
Valium 10 mg q8h, baclofen 10 mg q6h, Dantrolene 25 mg iv. q12h

14. Surgical Treatment Three principles:
Excisional debridement of the ulcer
Partial of complete ostectomy to reduce the bony prominence
Closure of the wound

15. Ischial pressure sore

17. Pressure sore closure
Musculocutaneous flaps: excellent blood supply, provision of bulky padding, against infection
Fasciocutaneous flaps: adequate blood supply, durable coverage, minimal functional deformity

28. Complication
Recurrence: the most common complication associated with pressure sore reconstruction.
Carcinoma:
(1) In 1828, Jean Nicholas Marjolin --- a tumor was present in a chronic wound.
(2) Dupuytren proved it as a malignancy.

29. Marjolin’s ulcer Carcinoma arising in a chronic wound.
SCC--- the most common cell type
Their metastatic rate, as compared to that of Marjolin ulcers arising in burn scars, is significantly higher at 61 % versus 34%.
More aggressive, poor prognosis