Diagnosing Different Types Of Heel Ulcers

Guest Clinical Editor: Tamara D. Fishman, DPM

When a patient presents with an ulcer on the heel, one must perform an in-depth examination because distinctions among different types of ulcers can be subtle. Prompt, appropriate treatment is essential and it is also critical to assess predisposing risk factors and what can be done to help minimize these risks. With this in mind, let’s take a look at the following case study. A 58-year-old Caucasian male had recently been hospitalized because he fell and broke his right hip. While he was in the hospital, the patient developed the condition on his right heel (as seen in the photo below). There are no clinical signs of infection or ischemia present on the right heel area. The patient’s past medical history is significant for chronic osteomyelitis in the right leg. What Is The Differential Diagnosis? 1. Stage three pressure ulcer 2. Sickle cell ulcer 3. Venous stasis ulceration 4. Gangrene 5. Unstageable pressure sore Diagnostic Answers 1. A stage three pressure ulcer is not the correct answer because it is difficult to stage a pressure sore with eschar formation. Remember, staging systems were designed to describe the depth of tissue involvement. When there is eschar, it is difficult to accurately assess the depth of tissue involvement. A stage three pressure sore is a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The ulcer presents as a deep crater with or without undermining of adjacent tissue. 2. A sickle cell ulcer is not the correct answer. These ulcers are shallow and usually develop in relation to a sickle cell crisis. In terms of treatment, one would focus on addressing the sickle cell crisis as soon as possible. Daily wound care, maintaining a moist environment and preventing infection are important factors in promoting wound healing and closure. 3. A venous stasis ulceration is not the correct answer. You will usually see these types of ulcers on the medial aspect of the leg. Characteristically, these wounds present with edema, stasis pigmentation, dermatitis and ulceration. The venous stasis ulcer is primarily due to sequelae of chronic venous insufficiency. 4. Gangrene is not the correct answer. Gangrene is necrosis or death of a tissue, usually as the result of ischemia. Although this ulceration appears black in color as gangrene typically presents, the above ulceration is not caused by ischemia. 5. An unstageable pressure sore is the correct answer. This pressure sore is unstageable due to the accompanying eschar. One may stage the pressure sore after removing the eschar. It is crucial for you to assess the patient’s wound by identifying the etiology, his or her past medical history and any prior treatments to date. Remember, blanching erythema at a pressure point is an early sign that a pressure ulcer may be forming. This ulceration is due to continued pressure over a bony prominence. It results from ischemic hypoxia of the tissues, owing to prolonged pressure on a body part. How Should You Treat Unstageable Pressure Sores? A pressure ulcer is defined by the Merck Manual (17th Edition) as ischemic necrosis, an ulceration of tissues overlying a bony prominence that has been subjected to prolonged pressure against an external object (e.g., bed, wheelchair, cast, splint or other object). Pressure sores are also commonly referred to as bedsores, decubitus ulcers and trophic ulcers. These terms originate from the observation that most pressure ulcers develop in patients who are bedridden. However, be aware that patients do not need to be lying down or bedridden to develop pressure ulcers. Pressure sores can occur in patients who are seated, leaning or in any other position. Proper documentation begins with an accurate assessment of the stage of the pressure ulcer. You must document many local factors, such as the location, size, depth or stage, amount, type and any odor of exudate. Document the type of tissue present, such as epithelial, granulation, necrotic, eschar or slough. You should document any signs of clinical infection, such as induration, fever, erythema, edema or purulent drainage or other infections. The initial assessment and documentation is only the beginning of managing patients with pressure sores. You should document the patient’s systemic factors such as nutritional status, particularly the serum albumin levels. Be sure to document any underlying illnesses like diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD) and anemia. Be sure to note any of the patient’s current medications, such as corticosteriods, chemotherapy and NSAIDs. Note the patient’s immune status, age, stresses and continence (urinary and or fecal) status. A Review Of Pressure Ulcer Staging A stage one pressure ulcer may be superficial. It is a non-blanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin color, discoloration of the skin, warmth, edema, induration or hardness of the skin may all be indicators. A stage two ulcer is a partial thickness skin loss involving epidermis, dermis or both. This ulceration is superficial and presents clinically as an abrasion, blister or a shallow crater. A stage three ulcer is a full thickness skin loss that involves damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. This type of ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. A stage four ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, for example: tendon, joint capsule. Undermining and sinus tracts may be associated with this type of pressure ulcer. Stage four pressure ulcers are associated with high morbidity and mortality and may give rise to legal complications. Addressing Major Risk Factors The major risk factors that lead towards the development of a pressure ulcer are obviously pressure, friction, shearing and tissue maceration. Immobility, inactivity, incontinence (both fecal and urinary), poor nutritional status and an altered mental status are additional risk factors. Comatose, CVA and heart patients are also at risk for the development for pressure ulcers. Other keys to managing pressure ulcers include the following key points. • Emphasize hydration and nutrition. • Maintain a moist wound environment. • Monitor all lab tests. • Consult a dietitian for a nutritional evaluation. • Identify and address all underlying medical conditions (via appropriate referrals when necessary) the patient may have. • Choose the most effective support surface for your patient. • Provide prompt treatment for any infections. • Correct the patient’s body position when necessary. • Monitor changes in risk status for your patients and act accordingly. • Consult your physical therapy department. • Provide education to the family members and caregivers if the patient goes home. Final Notes The primary purpose of a pressure ulcer prevention program is being able to identify those patients at risk. Additionally, when a patient’s status changes, you should reevaluate his or her risk at that time. When dealing with immobile patients, one must provide an appropriate pressure relief surface, help establish a turning schedule, reduce shearing and frictional forces, and consult the physical therapy team. Remember, when we do not provide adequate pressure relief and attempt to reduce the risk factors, pressure ulcer prevention will be ineffective. Wound management is a team approach so consult other health care providers when arriving at a treatment plan for your patients. Our treatment goals are directed toward protecting the wound from further trauma, promoting a clean wound bed, preventing infection, maintaining a moist wound environment and paying close attention to all systemic conditions. Dr. Fishman is Chairman of the Wound Care Institute in North Miami Beach, Fla.

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