Pressure Sores

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


  • 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


  • 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) 


  • 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


  • 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

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