Localized soft tissue injury resulting from unrelieved pressure. Normally over a bony prominence. 

Pathophysiology: 

• When compression of soft tissue exceeds the capillary pressure it leads to ischemia that if not relieved will progress to necrosis and ulceration even in well-vascularized areas

Factors that directly contribute to pressure sore formation: 

• Decreased mobility 
• Decreased sensation 
• Friction 
• Moisture 

Factors the indirectly contribute to pressure sore formation: 

• Poor nutrition 
• Diabetes 
• Age

Staging: 

• Stage I – well circumscribed, nonblanching erythema
• Stage II – partial thickness skin loss
• Stage III – full thickness skin loss involving subcutaneous tissue down to muscle fascia
• Stage IV – through muscle, to bone, with undermining or sinus tracts
• Suspected Deep Tissue Injury: maroon color to intact skin with likely underlying deep tissue injury 
• Unstageable: full thickness ulcer with eschar at the base 

Treatment – directed by stage 

• Stage I-II – nonsurgical
• protective barriers
• maintain moist wound environment
• III-IV
• Debridement
• Dressings to encourage healing
• Reconstructive surgery (last level on the treatment ladder) 

Reconstruction:

• Given the high risk of recurrence of pressure sores following reconstruction, the is to optimize the patient prior to surgery and design a flap that has the possibility for future re-advancement 

• Preoperative Optimization: 

• Nutrition: 
• Serum albumin > 2.0
• 1.5 to 3.0 g/kg/d of protein 
• 25-35 cal/kg of non-protein calories 

• Infection: 
• Soft Tissue:
• Common among wounds – debridement of all non-viable tissue is necessary for wound healing 
• Osteomyelitis:
• Diagnosis: 
• *bone biopsy is gold standard. However, imaging can also be used. A gadolinium MRI is the best imaging study
• Treatment: 
• Both abx and surgical 

• Relief of Pressure:
• Need to come up with strategies preoperatively for relieving pressure over the site of the pressure sore (ex. Air fluid mattress and wheelchair fitting to relieve pressure points). 
• Relieving pressure for 5 minutes every 2 hours will allow adequate perfusion and prevent breakdown 

• Spasm/Contractures:
• These are both common in patients with spinal cord injuries and can contribute to the formation of pressure sores 
• Treatment of spams: medical – baclofen, diazepam, dantrolene 
• Treatment of contractures: start with physical therapy 

• Management of AIC
• Discussion of fecal or urinary diversion if needed 

Common Flaps Used for Pressure Sore Reconstruction by Site: 

• Trochanteric – TFL
• Sacral – lumbosacral advancement 
• Gluteal/ischial – VY advancements 
• Posterior thigh flap
• Pedicle: inferior gluteal artery
• Design: fasciocutaneous – VY, or superiorly based tongue flap
• Note: severs all connections from semitendinosus/semimembranosus/biceps femoris to skin so cannot use any of those as musculocutaneous flaps

• If the patient is non-ambulatory, muscle can be used for reconstruction – this provides the best coverage with the most reliable blood supply without risk of functional imbalance 
• Options: gracilis, gluteal muscle flap

Miscellaneous

• Treatment of Paraplegic Patients: 
• Autonomic dysreflexia 
• Signs: headache, hypertension, bradycardia, flushing, and sweating due to uncontrolled sympathetic response to a stimulus, usually in paraplegics above T6. Stimuli generally include: bladder distention, rectal distention, musculoskeletal injury, pregnancy/labo
• Anesthetic Considerations 
• administration of succinylcholine in paraplegics may cause hyperkalemia (upregulated receptors in damaged muscles). 
• Signs of hyperkalemia: early: peak T waves  late: cardiac arrhythmias. Treatment: calcium carbonate, to stabilize cellular membranes, then bicarb and glucose/insulin to offset the acidosis and bring K back into cells