Managing Pressure Ulcers In The Lower Extremity
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.”