Bedsore & Pressure Ulcers | Wound assessment and readiness for closure

Staging uses the NPIAP system: stage 1 is nonblanchable redness on intact skin; stage 2 is partial-thickness loss with exposed dermis; stage 3 is full-thickness skin loss; stage 4 involves deeper tissue, muscle, bone, tendon, ligament, cartilage or joint structures. Unstageable wounds have full-thickness loss hidden by slough or eschar, and suspected deep tissue injury may appear as persistent deep red, maroon or purple discoloration. Depth can be underestimated until the wound is examined and, if needed, debrided. Pressure ulcers remain a clinical diagnosis, so staging should be confirmed by examination. Commonly affected sites include the coccyx, heels, ankles, elbows, and sacrum and nearby bony areas.

The cavity can contain cyst-like spaces and may open to the skin as a draining sinus. It can extend under the gluteus maximus muscle or the perineum, so the visible opening may not show the full cavity. During surgery, the cavity may be packed with methylene-blue-soaked gauze and excised; residual blue areas indicate inadequate excision. If other methods fail, flap coverage may be considered. Untreated osteomyelitis can lead to progressive amputations, and each flap uses finite tissue. Pressure ulcers can progress from contamination to serious infection, so a small draining opening deserves careful evaluation. Surgery to clean and close the ulcer may be needed when the injury is severe or other treatments fail.

Tunnelling, also called undermining, is tissue destruction around the wound perimeter beneath intact skin, so the wound edges pull away from the base. Because it may be more extensive in one part of the wound, its location and depth should be measured and documented. With sterile gloves, gently probe the wound bed and edges, insert the applicator where the deepest tunnelling occurs, grasp it where it meets the wound edge, remove it while keeping your hand in place, and compare it with a measuring guide to record the length in centimetres. One example showed undermining of about 2 cm almost circumferentially. Careful assessment matters because bacteria can thrive under the skin overhang, and undermining suggests continuing unwanted pressure.

Pressure ulcers can extend through skin and deeper tissues to muscle, tendon or bone. Stage IV means full-thickness tissue loss with involvement of underlying muscle, bone, tendons, ligaments or joint capsule. When bone is exposed or can be felt, clinicians consider bone infection until proven otherwise. A bone biopsy is the gold standard for diagnosis, while MRI can help show extent; bone scans may help rule it out if negative. Infection can damage cartilage and tissue and reduce limb or joint function, and unrecognized bone infection increases illness and cost. Bone and joint infections can develop if a pressure ulcer extends to these areas.

For pressure injuries, the main surgical concern is removing dead tissue and any infected bone so the flap can heal. Evidence describes removing devitalized or infected bone to healthy bleeding bone, sending resected bone for pathology, and taking a separate biopsy from bone that does not look grossly infected for microbiology to guide antibiotics. This is an intraoperative step, not a universal preoperative test. Colour Doppler ultrasound has been described before superthin inferior gluteal artery perforator flap elevation for ischial ulcers to map the dominant perforator and fascial planes. Your ulcer site, depth, infection signs and planned flap determine whether such mapping is useful.

Pressure ulcers form when prolonged pressure damages skin and deeper tissue, sometimes leading to infection. NHS guidance lists urgent warning signs: hot, swollen or red skin, pus from the ulcer, high temperature, and severe or worsening pain. A deep ulcer can expose muscle, tendon or bone, and infection can spread elsewhere in the body. Green or black tissue around the sore and a change in sensation at the edge can also signal infection. In spinal cord injury patients, pressure ulcers can extend into bone or joint, causing osteomyelitis, soft tissue infection and sepsis. These are reasons for urgent hospital care, not routine outpatient review.

Pressure ulcers develop when prolonged pressure damages skin and deeper tissue, and healing depends on removing that pressure and supporting the wound. Conservative care can include pressure relief, cleaning, dressings, debridement of dead tissue, and addressing factors such as incontinence or nutrition. Superficial Stage I and II ulcers may heal with this approach, while Stage III and IV ulcers require flap surgery. Surgery may also be considered when an ulcer is severe or other treatments have not worked, because it can close the defect and shorten healing time. A thorough wound evaluation guides dressing choice, aiming to remove dead tissue, control infection and keep the wound moist.

The wound bed must be clean, with low bacterial colonization below 10^5, no necrotic tissue, infection or purulent discharge. Complete removal of the ulcer, bursa, scar tissue, calcification and nonviable bone is essential, with biopsy sent. Risk factors such as pressure, friction, shear, moisture and malnutrition must be corrected before surgery. Stages I and II may heal with conservative care, while stages III and IV require flap coverage. The flap should fit the defect without excessive tension, obliterate dead space and keep the suture line away from direct pressure. Because recurrence remains high long term, adjacent flap territories should be preserved for future options.

Nutrition is reviewed through food intake, appetite, weight, height, BMI and blood proteins such as prealbumin, albumin and total protein; a dietician may be involved, and zinc or iron are supplemented if deficient. Blood tests include a complete blood count for anaemia or infection and protein levels. Muscle spasms are asked about and controlled, because unrelieved spasticity can worsen ulcers and interfere with positioning and surgery. Ideally, prealbumin should be above 150 g/L, albumin above 35 g/L and haemoglobin above 10 g/dL; patients who struggle to feed orally may benefit from tube feeding. Nutritional aims may include adequate calories and protein per day.

Pressure ulcers arise mainly from prolonged external pressure, with complex tissue injury. Moisture from incontinence or sweat can remove protective oils, macerate skin, and combine with shear and friction to deepen damage. Moisture lesions may look like early pressure ulcers and can become infected quickly. Keeping skin clean and dry, using barrier creams, regular toileting, appropriate pads, nutrition and hydration support healing; pressure relief remains essential. If moisture and pressure both occur, skin and deeper tissues can suffer serious damage. Infection assessment and treatment may also be needed. Moisture alone does not cause a pressure ulcer; it acts with pressure, shear and friction. Barrier creams and prompt pad changes help skin recover.