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
In his practice, Dr. Wendelken most often finds pressure ulcers on the heel, typically the retrocalcaneal surface and the lateral heel. He also encounters numerous pressure ulcers on the ankle over the malleolus as well as pressure ulcers along the lateral aspect of the foot (base of the fifth metatarsal at the styloid process). In his clinic, Dr. Suzuki has seen quite a few “ankle” pressure ulcers over the lateral malleolus or even the medial malleolus as some of his patients sleep on their sides. This may turn the ulcer into a chronic ulceration at the tip of the malleolus, according to Dr. Suzuki.
Additionally, Dr. Wendelken finds pressure ulcers in areas such as the medial first and lateral fifth metatarsal heads. Other less common areas where pressure ulcers form are the proximal fibula head and the anterior ankle, according to Dr. Wendelken. He notes the anterior ankle ulcer is commonly caused by a dressing that one did not properly apply and is usually too tight.
In his practice, Dr. Sage most often sees pressure ulcers on hospital patient consults, usually in seriously ill patients who have been on prolonged bed rest. He notes that he does not see nursing home patients or make house calls.
What kind of offloading boot or brace do you prescribe to your pressure ulcer patients?
When making a boot selection, Dr. Suzuki first asks if the patient is ambulatory or not. If the patient is ambulatory, he prefers to use a hard brace pressure relief ankle foot orthosis (PRAFO) boot. Dr. Suzuki notes the PRAFO completely offloads the heel while allowing the patient to ambulate to some extent (i.e. bed to bathroom and back) as such boots have a sole with some traction. However, he notes that such “hard” braces are not very comfortable and some patients may complain about that, and may refuse to wear them.
On the other hand, Dr. Suzuki notes that if the patient is bedridden or very minimally ambulatory, he prescribes Prevalon boots (Sage Products), which are very soft pillow boots with three Velcro straps. He notes Prevalon boots do offload the heel completely while the Velcro strap prevents the Achilles contractures by keeping the ankle at 90 degrees. The only drawback with the Prevalon boot is it does not have a rigid sole and it is not meant for patients to walk on, according to Dr. Suzuki.
Dr. Sage also prescribes Prevalon boots, calling them light, extremely soft and well cushioned. He notes the boots provide protection for the heel, malleoli and forefoot. Dr. Suzuki asks hospitalized patients to elevate their legs off the bed. If they are too weak to elevate their legs or if they are unconscious (such as patients in the intensive care unit), he would order these offloading boots immediately. He does not believe in using “a pillow under the calf” for more than a few hours as the pillow can easily slide off the bed or move out of place too easily.
If Dr. Sage anticipates that an inpatient is likely to have prolonged immobility, he will prescribe such protection prophylactically. If there is drainage from any wound, he has patients cleanse the area daily, apply a topical product such as Silvadene and use a light gauze and Kerlix dressing to cover the wound as necessary to absorb the drainage. He emphasizes the importance of offloading.
Depending on the stage of the ulcer, Dr. Wendelken prescribes a number of offloading boots for pressure redistribution. He has lately had “great results” with the Waffle Heel Elevator Custom (EHOB).
Dr. Suzuki doesn’t think “heel cradle cushions” are effective for pressure ulcers.
“I despise those heel cradle cushions,” says Dr. Suzuki. “They are widely used pillow boots that are attached directly to the heel itself. They add bulk to the heel and do nothing to prevent or offload heel pressure ulcers.”
Do you recommend or prescribe a bed or mattress for their pressure issues?
Dr. Suzuki routinely recommends beds and mattresses. As he notes, the general recommendation on beds is that patients with minor pressure ulcers (stage 1 or 2) should have a memory foam mattress or mattress topper (overlay) a minimum of 3 inches high, which patients can buy without prescriptions in most bedding stores and in larger markets at stores like Costco or Target. Dr. Suzuki says patients with more substantial pressure ulcers (stage 3 or 4) will most likely need a powered air bed (i.e. low air loss, air fluidized, etc.), saying that will require prescriptions, detailed medical records for submission, and help from a local medical supply durable medical equipment company.
Dr. Wendelken notes a group 1 mattress overlay may be indicated and is covered by the Centers for Medicare and Medicaid Services (CMS) if the mattress meets the following conditions:
• the patient is completely immobile (i.e., the patient cannot make changes in body position without assistance); or
• the patient has limited mobility (i.e., the patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of the conditions A-D below); or
• the patient has any stage pressure ulcer on the trunk or pelvis, and at least one of the conditions A-D below.
A. Impaired nutritional status
B. Fecal or urinary incontinence
C. Altered sensory perception
D. Compromised circulatory status
Dr. Wendelken notes that in each case, the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface.
After trying to get insurance to reimburse for these items with a medical supply store and being unable to get timely reimbursement, Dr. Suzuki advises patients to purchase mattresses with a small expectation that they may be reimbursed by their insurance later.
Dr. Sage notes that occasionally a patient may require an air mattress to treat or prevent decubitus ulcers at multiple sites, but he notes the primary medical or surgical service generally prescribes this. He notes a patient with multiple decubitus ulcers is rarely, if ever, admitted to the podiatry service alone.
Dr. Sage is a Professor and the Chief of the Section of Podiatry at the Department of Orthopaedic Surgery and Rehabilitation at the Loyola University Stritch School of Medicine in Maywood, Ill.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles, and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.
Dr. Wendelken is a licensed RN who specializes in emergency medicine. He is affiliated with the Calvary Hospital Center for Palliative and Curative Wound Care in Bronx, NY. He is an Adjunct Professor in the Department of Radiology at the Temple University School of Podiatric Medicine in Philadelphia. Dr. Wendelken is a principal in BioVisual Technologies, LLC, and is the inventor of PictZar® Digital Planimetry software program.
1. Available at http://www.npuap.org/resources/educational-and-clinical-resources/pressu... .
2. McGovern J, DiPerri J. Heel pressure ulcer prevention: a comparative effective evaluation. Presented at the 25th Annual Symposium on Advanced Wound Care Spring (SAWC Spring)/Wound Healing Society (WHS), April 19-22, 2012.
3. Burda V. A successful heel ulcer prevention program resulting in 95% reduction of heel ulcer incidence. Abstract/poster presented at the Symposium on Advanced Wound Care. Tampa, Fla. April 28, 2007.