Inservice Exam - 2005
Pressure Sore

A pressure sore involving full-thickness skin and subcutaneous tissue to the level of the underlying muscle fascia is classified as which of the following?

(A) Grade I
(B) Grade II
(C) Grade III
(D) Grade IV
The correct response is Option B.


A lesion with this description is classified as a Grade II pressure sore. Pressure sores are classified by depth of necrosis. Grade I pressure sores extend to the epidermis and superficial dermis only. Grade II pressure sores involve full-thickness skin and extend to adipose tissue. Grade III pressure sores involve full-thickness skin and extend to subcutaneous tissue and underlying muscle. Grade IV pressure sores extend through all layers into the underlying bone or joint space.


Common risk factors for developing a pressure sore include neurologic impairment, old age, and hospitalization. Generally, the greater the number of risk factors, the greater the patient’s risk of developing a pressure sore.


References:
1. Staas WE Jr, LaMantia JG. Decubitus ulcers and rehabilitation medicine. Int J Dermatol. 1982;21:437.
2. Berlowitz DR, Wilking SVB. Risk factors for pressure sores: a comparison of cross-sectional and cohort-derived data. J Am Geriatr Soc. 1989;37:1043.






A 45-year-old man with paraplegia (Ashworth 5 spasticity) recently underwent coverage of a superficial, cleanly debrided trochanteric hip ulcer with a tensor fascia lata transposition flap (shown above). Which of the following interventions is most appropriate to ensure stable coverage of the wound?

(A) Intrathecal administration of baclofen via an implantable pump
(B) Parenteral administration of a broad-spectrum antibiotic for six weeks
(C) Retrogasserian rhizotomy
(D) Ten weeks of bed rest on an air-fluidized mattress (Clinitron)
The correct response is Option A.

To decrease spasticity, baclofen should be administered by an implantable pump before and after flap coverage. Spasticity contributes to flap breakdown by shearing force and should be controlled to ensure stable coverage of the wound. In some studies, flap failure has occurred in nearly 90% of patients with pressure sores. Prevention of this serious complication requires close control of all variables, including nutrition and postoperative pressure management. Long-term parenteral administration of antibiotics plays no role in the stability of coverage of a clean superficial wound. Ten weeks of bed rest on an air-fluidized mattress is not likely to be useful for a pressure ulcer in a lateral area. Retrogasserian rhizotomy, which interrupts the trigeminal (V) nerve, is not appropriate for this patient.

References:
1. Mess SA, Kim S, Davison S, Heckler F. Implantable Baclofen pump as an adjuvant in treatment of pressure sores. Ann Plast Surg. 2003;51(5):465-467.




A 28-year-old man with a 10-year history of paraplegia has septicemia and a large grade IV pressure ulcer over the greater trochanter. MRI shows communication with the hip joint. After excision of the ulcer, which of the following is the most appropriate next step in management?

(A) Administration of a culture-specific antibiotic for six weeks
(B) Coverage with a tensor fascia lata flap
(C) Coverage with a total thigh flap
(D) Coverage with a vastus lateralis flap
(E) Resection of the femoral head


The correct response is Option E.

The most appropriate management of this patient’s pressure ulcer is resection of the femoral head, also known as Girdlestone arthroplasty. The sinogram finding of communication of the ulcer with the hip joint is consistent with osteomyelitis, which typically occurs in association with pyarthrosis. Resection of the femoral head will effectively remove the infected tissue in this patient, and vascular tissue should be used to obliterate the dead space. The vastus lateralis flap can be advanced into the acetabular fossa as a muscle or musculocutaneous flap.

Administration of an antibiotic for six weeks will control wound sepsis but will not treat osteomyelitis.

The tensor fascia lata flap is a sensate flap that is appropriate for coverage of less extensive trochanteric ulcers. This flap lies proximal to the site of the ulcer and can be easily transferred. Its vascular pedicle is based on perforating vessels from the tensor fascia lata muscle. However, it cannot be used alone in a patient with osteomyelitis.

Coverage with a total thigh flap is appropriate only as an end-stage procedure in a patient who has undergone amputation of the lower limb.


References:
1. Evans GR, Lewis VL, Mason PN, et al. Hip joint communication with pressure sore: the refractory wound and the role of Girdlestone arthroplasty. Plast Reconstr Surg 1993;91:288-294.
2. Mancoll JS, Phillips LG. Pressure sores. In: Achauer BM, Eriksson E, Vander Kolk C, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Vol 1. St Louis, MO: Mosby; 2000:447-462.
3. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. Vol 2. New York: Quality Medical Publishing; 1997:1293-1306.