Managing Pressure Ulcers In The Lower Extremity
Our expert panelists offer essential keys to diagnosis, share their insights on offloading modalities, and discuss mattresses and beds to help resolve pressure issues.
What is your diagnosis and treatment approach when you see a new patient with a pressure ulcer in lower extremities?
Ronald Sage, DPM, notes most pressure or decubitus ulcers of the foot involve the heel. On occasion, they may involve other bony prominences such as the malleoli or the first or fifth metatarsal heads, according to Dr. Sage. He suggests evaluating the wound according to the stages of decubitus ulcers.1 He notes the first stage is non-blanchable erythema, the second is partial thickness skin loss, the third is full thickness skin loss extending through subcutaneous tissue, and the fourth stage is skin loss extending to muscle and bone.
Kazu Suzuki, DPM, CWS, views treating pressure ulcers like treating any other wounds. He starts with a thorough history, figures out when and how the pressure ulcers started, and what kind of pressure formed the ulcers. Similarly, Martin Wendelken, DPM, emphasizes the importance of having a clear understanding of the patient’s activities of daily living and ability to perform those functions, and includes a Braden Scale assessment on the patient.
Oftentimes, Dr. Suzuki sees pressure ulcers starting with a period of immobility, such as when patients are acutely ill and hospitalized for a period of time. Sometimes, Dr. Suzuki notes pressure ulcers may develop slowly at home if patients have inappropriately hard bedding surfaces, poor dental condition (which is extremely common in older patients) and gradual malnutrition, which he notes may cause a slow deterioration of their skin.
Dr. Sage evaluates the wound for signs of infection and evaluates the foot for signs of ischemia. If infection is present, he says debridement and/or antibiotics may be necessary, but he does not debride stable, non-infected blisters or eschars. When a new patient presents with what appears to be a pressure ulcer on the lower extremity, Dr. Wendelken proceeds with a vascular assessment that includes an ankle/brachial index, a neuropathy assessment that utilizes the Semmes Weinstein test, and an assessment of mobility and range of motion.
As part of his workup for pressure ulcers, Dr. Suzuki performs an arterial perfusion test to assess blood flow to the heel in order to figure out the wound healing potential. During the first visit, he will use a laser Doppler machine (Sensilase PAD-IQ, Vasamed) to measure both skin perfusion pressure (SPP) and pulse volume recordings (PVR) to perform this task. Dr. Suzuki makes an appropriate referral to a vascular specialist if he detects an unusually low SPP/PVR reading, which signifies a diagnosis of peripheral arterial disease.
Dr. Sage adds that ischemic extremities may require vascular intervention if the patient is a suitable candidate and he emphasizes the importance of offloading.
Where do you see the pressure ulcer in the lower extremity in your practice?
For the longest time, Dr. Suzuki found the sacral ulcer to be the most prevalent of all pressure ulcers he observed. Now he cites data from the Symposium on Advanced Wound Care Spring/Wound Healing Society (SAWC Spring/WHS) and other national conferences that the posterior heel pressure ulcer may have become the number one most common pressure ulcer, closely followed by sacral ulcers.2,3