Pressure Sore Management

NON-PARAPLEGIC PRESSURE SORES The usual sites of pressure sores in the non-para-plegic are the sacral area and heel, occasionally the iliac crest, and the background to their occur-rence is immobility of the patient. Although immobility is ultimately responsible for the local pressure being prolonged for sufficiently long to produce the local ischaemia which leads to the sores, other factors are usually present which predispose to their occurrence.

Sores occur most often as a complication of an emaciating illness. Loss of subcutaneous fat reduces the cushion it provides and, coupled with the reluctance of the patient to move as a consequence of the lassitude typical of such an illness, combines to create the conditions for their occurrence. When a pressure sore arises in a relatively young patient, a neurological factor, such as multiple sclerosis, is virtually always present.

Management of such a sore depends on the
sites involved, how extensive each sore is and, most of all, to what extent the progress of the debilitating illness can be halted and, hopefully, reversed. In this respect the most important assessment of the plastic surgeon is whether the sore is extending in extent or depth, is static, or is showing signs of healing with marginal epithelialisation.
While the sore is extending the plastic sur-
geon has no active role to play.

The problem is essentially one of nursing and medical care. Once the sore has become static and, even more, shows signs of healing, the question becomes one of deciding whether meeting the conditions needed for successful reconstruction of the ulcer,
whether by graft or flap, might halt or even re-verse the improvement in the patient’s medical state.

A most important element in making the decision is to appreciate that the change from the bedridden to an ambulant state is likely to allow the healing process to progress, even though healing may be by marginal epithelialisation, and will be a slow process.
The patient at very least must be able to keep pressure off the site of the sore before active sur-gery can even be contemplated.

This aspect of the problem has to be emphasised very strongly, and the need to observe it is paramount, even if it pre-cludes surgery in the majority of patients. If this is not strictly observed, it is virtually certain there will be a failure to achieve healing in the short term or to maintain healing in the long term.
In practice, the number of patients suitable for an aggressive surgical approach to the problem is very small. The solution lies more often in get-ting the patient ambulant.

Ambulation immedi-ately relieves pressure on the typical ulcer sites, allowing spontaneous healing to begin. A strik-ing example of this is seen in the pressure sore of the heel, typically sited posteriorly over the tendo Achillis and the adjoining os calcis, which begins to heal as soon as the patient begins to walk and pressure is transferred to the normally weightbearing part of the heel. Certainly one should not rush into surgical treatment of such sores.

Management is most difficult when it is appar-
ent that the patient is likely to be permanently bedridden. Considerable judgment is required in managing such a situation, and sympathy for the unfortunate patient must not be allowed to override a realistic assessment of the problem. The decision is usually in the direction of saying that surgery is contraindicated.

The dilemma is seen in its most acute form in the patient, frequently young, who is suffering from multiple sclerosis, and who has developed
a pressure sore. The harsh fact is that the devel-opment of a pressure sore is often the first step in the downward course of the patient with multi-ple sclerosis, and the question the surgeon must ask himself is whether his surgery will not have the effect of accelerating the downward course.

Pressure Sore Management

Such a patient virtually always requires a flap to reconstruct the defect and the position which has to be maintained for a successful result all too often results in a fresh pressure sore elsewhere.
When a decision has been made that the defect should be treated surgically the choice lies between a graft and a flap and the selection depends on the character of the defect.

The defect with little or no undermining is likely to be suitable for grafting; the defect with signifi-cant undermining is rarely suitable for grafting, and requires a flap. The flaps suitable for the various sites are largely similar to those used in the paraplegic patient.
The sore involving the heel is best left to heal
spontaneously no matter how long it takes.

The alternative reconstructions make demands on the patient which are not acceptable in the age group typically involved.