Bedsores

Bedsores — also called pressure ulcers and decubitus ulcers — are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. People most at risk of bedsores have medical conditions that limit their ability to change positions or cause them to spend most of their time in a bed or chair. Bedsores can develop over hours or days. Most sores heal with treatment, but some never heal completely. Bedsores fall into one of several stages based on their depth, severity and other characteristics. The degree of skin and tissue damage ranges from red, unbroken skin to a deep injury involving muscle and bone.

Common sites of pressure ulcers
For people who use wheelchairs, bedsores often occur on skin over the following sites:

• Tailbone or buttocks
• Shoulder blades and spine
• Backs of arms and legs where they rest against the chair

For people who need to stay in bed, bedsores may happen on:

• The back or sides of the head
• The shoulder blades
• The hip, lower back or tailbone
• The heels, ankles and skin behind the knees
  
  

Treatment –

Reducing pressure

The first step in treating a bedsore is reducing the pressure and friction that caused it. Strategies include:

Repositioning
Repositioning. If you have a bedsore, turn and change your position often. How often you reposition depends on your condition and the quality of the surface you are on.

Using support surfaces

Use a mattress, bed and special cushions that help you sit or lie in a way that protects vulnerable skin.

Cleaning and dressing wounds

Care for pressure ulcers depends on how deep the wound is. Generally, cleaning and dressing a wound includes the following:

Cleaning.

If the affected skin isn’t broken, wash it with a gentle cleanser and pat dry. Clean open sores with water or a saltwater (saline) solution each time the dressing is changed.

Putting on a bandage.

A bandage speeds healing by keeping the wound moist. It also creates a barrier against infection and keeps skin around it dry. Bandage choices include films, gauzes, gels, foams and treated coverings. You might need a combination of dressings.

Removing damaged tissue
To heal properly, wounds need to be free of damaged, dead or infected tissue. The doctor or nurse may remove damaged tissue (debride) by gently flushing the wound with water or cutting out damaged tissue.

Other interventions include

Drugs to control pain.

Nonsteroidal anti-inflammatory drugs — such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) — might reduce pain. These can be very helpful before or after repositioning and wound care. Topical pain medications also can be helpful during wound care.

A healthy diet.

Good nutrition promotes wound healing.

Surgical interventions-

A large bedsore that fails to heal might require surgery. One method of surgical repair is to use a pad of your muscle, skin or other tissue to cover the wound and cushion the affected bone (flap surgery).
Surgical reconstruction is defined as any surgical procedure that leads to primary closure of the wound.
A diverse spectrum of surgical procedures can be performed to help heal pressure ulcers; but selection is based on wound level. Many surgical procedures start with thorough debridement, involving excision of the fibrotic capsule or bursa that forms around the chronic wound, to healthy bleeding tissue. If the residual tissue is badly scarred, skin is subject to further breakdown. If there is underlying dead or infected tissue or heterotrophic ossification (formation of ectopic bone) this should be debrided.
Once surgical debridement has been performed, other reconstructive surgeries are considered to close the wound.

1. Primary wound closure:
   involves direct advancement of the wound edges either directly or in layers to close the wound.
2. Skin grafts:
   involve harvesting a thin piece of skin that is surgically removed from a donor area to replace skin in the defect or denuded area. Skin grafts are occasionally used to treat pressure ulceration when all precipitating factors for pressure sore formation have been removed. They are used to facilitate quick wound cover and subsequently to accelerate wound healing
3. Local random pattern flaps:
   this reconstructive method involves surgically moving the local tissues around the wound, based on a random pattern of blood supply, into the wound defect.
   Regional flaps including:
4. • muscle or musculocutaneous flaps
   • fascial or fasciocutaneous
   • perforator flaps
5. Free flaps:
   this surgical approach involves raising a defined island of tissue with an artery and vein that is surgically detached and moved to the site of the wound where other local arteries or veins of similar size are identified and then the vessels are surgically anastomosed to re‐establish blood flow to the island of tissue
6. Tissue expansion:
   Eventually the extra skin recruited can be used to close the wound . All of the above approaches can be performed as a one‐stage procedure, or part of a multistage procedure to increase the likelihood of the tissue surviving manipulation, reduce the overall surgical impact on the patient and ensure that all infected or aggravating factors are minimised. This is particularly important as the skin quality around pressure ulcers is usually sub‐optimal.Surgery is indicated when conservative measures have failed to accelerate the healing process in pressure ulceration, but only when all other parameters are optimised. Thus, surgical closure is often reserved for more complex pressure ulcers (most often stage III or IV but occasionally stage II), with strong consideration of the probability of ulcer recurrence in each individual.The underpinning rationale for reconstructive surgery is that following the removal of devitalised tissue, the wound defect is filled with vascularised healthy tissue with adequate skin cover, which then forms a healed wound.