Current Insights On Treating Heel Pressure Ulcers

Clinical Editor: Kazu Suzuki, DPM, CWS

   Heel pressure ulcers can be particularly challenging for podiatric physicians, given the risk of complications, offloading challenges and the compromised vascular status of high-risk patients. Accordingly, our expert panelists share their perspectives in providing wound care for these patients.

   Q: How do you dispense offloading devices for pressure ulcers of heels?

   A: Kazu Suzuki, DPM, CWS, considers factors such as the patient’s weight, sensory perception (neuropathy), activity level and mobility level, as well as skin perfusion pressure (SPP). Richard Brietstein, DPM, CWS, also recommends checking the perfusion to the lower extremity. If the patent has been hospitalized recently, Dr. Suzuki checks the patient’s medical records for Braden Scale scores, which list the clinically validated risk level for developing pressure ulcers.

   For example, if the patient is at low risk of developing such ulcers, is relatively light, mobile and has good protective sensation, this patient may do fine with a few pillows under the calf and verbal instructions on offloading, according to Dr. Suzuki. If a patient has good perfusion and some mobility, Dr. Brietstein dispenses a foam waffle boot or a L’Nard splint (LaMed). Caroline E. Fife, MD, says L’Nard splints are the only splints she uses because “they completely offload the heel.”

   If patients are obese, immobile and bedridden, Dr. Suzuki notes they will require more rigid “ankle brace”-like offloading devices, such as a Pressure Relief Ankle Foot Orthosis (PRAFO), to suspend the heels completely off the bed. Alternately, a softer foam-based boot, like Heelift (Alimed) or a Rooke boot, may be more comfortable and acceptable to more patients, according to Dr. Suzuki.

   When it comes to patients with poor perfusion and little or no mobility, Dr. Brietstein tends to stay away from dispensing any offloading device with straps, which may cause other areas of increased pressure that may lead to tissue breakdown. Accordingly, with these patients, he will most likely order pillows beneath the calves to offload the heels.

   Q: How about the local wound care of heel pressure ulcers? Do you treat these ulcers any differently than wounds with other etiologies?

   A: Dr. Fife says one should not debride a stable, uninfected eschar on the heel or anywhere on the foot until one has performed a vascular assessment to determine whether the patient is able to heal the wound. In this respect, heel ulcers are very different from wounds on other areas of the body, according to Dr. Fife. In other body areas, she says it is typical for a physician to see an eschar and start to debride it immediately. However, when it comes to heel pressure ulcers, she says it is common for physicians to leave eschars in place and even paint them with Betadine to keep them dry.

   Dr. Brietstein advises that one should consider all of the parameters in the algorithm that contribute to good wound care outcomes. However, with this particular subset of patients, perfusion, nutritional status and the presence of infection play pivotal roles in the capacity to heal wounds. Accordingly, Dr. Brietstein says he “would temper (his) aggressiveness.” If an individual has poor nutrition and poor perfusion, Dr. Brietstein treats that patient conservatively via enzymatic debriding agents or possibly Betadine solution.

    “I would not surgically debride these patients for fear of creating a larger non-healing wound, which could possibly lead to limb loss,” explains Dr. Brietstein. He says it is critical to facilitate appropriate consults to ensure optimal nutrition for these patients.

   When it comes to the care of patients with pressure heel ulcers, Dr. Suzuki suggests establishing the therapeutic goal at the outset of treatment. Are you looking to provide curative/rehabilitative care or palliative/comfort care? On the other hand, if the patient is very old, very ill or has been non-ambulatory for a long time, Dr. Suzuki strives for pain relief rather than a clinical cure.

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