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Flashcards in Pressure Sore Deck (32):

An otherwise healthy 55-year-old man with paraplegia is evaluated because of a recurrent ischial pressure ulcer. History includes previous coverage of the ulcer with a posterior thigh rotation-advancement flap. After appropriate optimization of both patient and wound, which of the following is the most appropriate surgical intervention for reclosure of the wound?

A) Gracilis musculocutaneous flap
B) Inferior gluteal flap
C) Re-rotation of posterior thigh flap
D) Tensor fascia lata flap
E) V-Y hamstring flap

The correct response is Option C.

The most appropriate surgical treatment option would be to re-rotate the posterior thigh flap.

One of the main principles in surgical flap closure of pressure ulcers (PUs) is to utilize large rotation flaps so that they may be re-rotated in the case of recurrences. Although it is debatable whether to re-flap a patient who has a PU recurrence, some clinical situations require a redo flap closure. In those circumstances, instead of using a new flap or donor site, re-elevation of the original flap and re-advancing it is usually the first-line flap option. The posterior thigh flap is a fasciocutaneous flap based on the descending branch of the inferior gluteal artery (if elevated as a purely V-Y flap, or if raised as a superiorly based "tongue" flap). However, if elevated as a rotation-advancement flap, it also has blood flow from medial or lateral thigh skin perforators depending on where the flap incisions are made on the posterior thigh.

In all forms of the flap, the entire posterior thigh skin and fascia is elevated off the hamstring muscles (semitendinosus, semimembranosus, biceps femoris), thus severing all the musculocutaneous perforators from those muscles to the overlying skin and fascia. Therefore, the V-Y hamstring flap (a musculocutaneous flap) is not available after a posterior thigh flap has been raised. Though the inferior gluteal artery flap, gracilis, and possibly the tensor fascia lata flaps may be used, they are not the most appropriate surgical option when a re-rotation thigh flap is still available.



A 45-year-old man is hospitalized in the intensive care unit for 3 weeks after sustaining blunt force trauma to the head during an assault and develops a pressure ulcer over the right ischium. Six weeks later, the wound has not healed despite multiple bedside debridements and daily wound care. The patient is ambulatory. Physical examination shows an 8 × 4 × 4-cm stage III pressure ulcer at the right inferior gluteal fold with an indurated bursa. After nutritional optimization, which of the following surgical techniques is most appropriate for closure after excising the bursa?

A) Gracilis musculocutaneous rotation flap
B) Negative pressure wound therapy then primary closure
C) Posterior thigh fasciocutaneous rotation flap
D) Superiorly based gluteal musculocutaneous rotation flap
E) Tensor fasciae latae island rotation flap

The correct response is Option C.

The best reconstructive option for an ambulatory patient with a chronic ischial pressure sore is to spare muscle and use a fasciocutaneous flap. Fasciocutaneous flaps offer an axial blood supply with durable coverage and minimal potential for a functional deformity. The flaps closely reconstruct the normal anatomical arrangement over bony prominences. Disadvantages include limited bulk to fill large defects.

Musculocutaneous flaps offer excellent blood supply and bulky tissue and can be re-rotated like fasciocutaneous flaps. However, in an ambulatory patient, they may cause functional impairment.

The tensor fasciae latae flap is occasionally used to close the ischial ulcer. Unfortunately, the distal aspect of the flap that is used to reach the ischial region is usually too thin to offer adequate padding to be effective. Therefore, this is not the most appropriate option.

Primary closure is associated with an increased rate of wound recurrence. A large dead space is usually present due to the absence of tissue, and the induration of adjacent areas makes them difficult to mobilize for a tension-free closure.



A 66-year-old man with paraplegia is evaluated because of a 6-month history of Grade IV pressure ulcer. Medical history includes multiple debridements with appropriate off-loading and good wound care. The patient shows no clinical improvement. Chronic osteomyelitis is suspected. Which of the following is the most appropriate next step in diagnosis?

A) Bone biopsy
B) CT scan
C) Dual energy x-ray absorptiometry (DEXA) scan
E) Triphasic technetium scan

The correct response is Option A.

The accurate diagnosis of chronic osteomyelitis in long-standing wounds can be extremely difficult. The gold standard to diagnose chronic osteomyelitis is bone biopsy. Bone biopsy can provide histopathologic as well as microbiologic data that are sensitive and specific for chronic osteomyelitis.

Triphasic technetium-99 bone scan or scintigraphy is a nuclear study that serves as a functional test to assess bone metabolism. MRI uses a magnetic field and radio waves to reconstruct anatomical structures of interest. CT scan can reveal small areas of osteolysis, small foci of gas, or foreign bodies. Triphasic bone scan, MRI, and CT scan have all been used to evaluate for osteomyelitis clinically. However, these studies lack specificity and can be misleading in the presence of a chronic soft-tissue injury or previous bony injury from prior debridements.

A dual energy x-ray absorptiometry (DEXA) scan is a low-exposure x-ray study measuring bone density in order to assess for osteoporosis. It has no role in evaluating osteomyelitis.



A 50-year-old man with paraplegia and diabetes mellitus is evaluated because of an ischial stage 4 pressure ulcer. Optimizing the patient’s nutrition and diabetic control is attempted, and aggressive resection of the ulcer and underlying bone with a locoregional flap closure is planned. Which of the following characteristics places this patient at increased risk for late recurrence of the ulcer?

A) Age greater than 45 years
B) Defect size greater than 20 cm2
C) Hemoglobin A1c of less than 6%
D) Location of ulcer
E) Osteomyelitis confirmed by bone biopsy

The correct response is Option D.

The risk factor in this patient associated with the greatest risk of late recurrence is ischial ulcer location.

The treatment of pressure ulcers remains a difficult problem for medical practitioners and plastic surgeons. In a recent study, risk factors were identified as predictors of flap failure after resection and reconstruction with a flap. Factors associated with dehiscence include age less than 45 years, history of previous same-site surgery failure, albumin concentration of less than 3.5 mg/dL, and poor diabetic control (hemoglobin A1c of more than 6%). Factors associated with recurrence include ischial wound location, previous same-site surgery failure, and poor diabetic control. Osteomyelitis confirmed by bone biopsy and size of defect were not associated with dehiscence or recurrence. Patients with multiple risk factors showed a dramatic trend toward dehiscence and flap failure.

Other studies corroborate the finding that ischial ulcer location is difficult for achieving coverage. This is most likely secondary to the high pressure over the ischial tuberosities in the seated position. Pressure maps have shown that, when seated, the pressure exceeds 80 to 100 mmHg compared with supine sacral pressures of 60 mmHg.



A 47-year-old man with complete T12 paraplegia presents with a 5 × 5 × 4-cm stage IV sacral pressure ulcer. Physical examination shows the wound is clean with granulation tissue. Coverage with a local tissue flap is planned. In designing the flap, careful consideration must be made regarding which of the following?

A) Avoiding incisions near the anus to minimize bacterial contamination
B) Confining scar to a cosmetically acceptable location
C) Designing incisions allowing for future re-advancement
D) Localizing individual perforators
E) Preserving sensory innervation

The correct response is Option C.

A systematic review of the literature was performed by Sameem et al., to determine the relative efficacy of musculocutaneous versus fasciocutaneous versus perforator flaps in the treatment of pressure ulcers. In their analysis, they concluded that all flaps had a significant recurrence and complication rate; however, there was no difference between the types of flaps used. Their paper did not specifically address the issue of how patients’ conditions were subsequently managed when they did develop a recurrence. This is important, because a key surgical strategy is to consider the need for subsequent surgical procedures; in fact, perhaps more critical than the composition of the flap and the nature of its blood supply is the design of the flap and where the incisions are planned. A fundamental principle in surgical management of pressure ulcers is being able to provide healthy vascularized tissue into the wound bed and to completely obliterate dead space. Furthermore, the flap should be designed such that if a recurrence develops, the patient continues to have surgical options available, such as re-advancement or re-rotation of the prior flap(s).

Preservation of sensory innervation is important for patients who still have sensation in this area. However, in patients who are completely paraplegic, there is a lack of adequate sensory innervation and a lack of the ability to ambulate, which is what ultimately leads to the development of pressure ulcers.

Confining the scar to a cosmetically acceptable location is not a major priority in managing pressure ulcers. The cosmetic appearance of scars in this area is relatively unimportant in light of the presence of an open wound.

Localizing individual perforators is not necessary when large rotation or advancement flaps are designed. In those situations, a broad blood supply is maintained, and multiple perforators are typically kept intact and do not require individual localization or dissection. However, it is important when a single perforator flap is being designed. Perforator flaps when used as pedicle flaps may be more prone to venous congestion and slightly higher complication rates due to the delicate dissection and isolation of the sole blood supply, which in turn is more prone to mechanical twisting and kinking. Perforator flaps ideally preserve the muscular function of the donor site, which may not be important in a patient who is paraplegic.



A 21-year-old ambulatory man with spina bifida at the level of S2 is scheduled to undergo closure of a stage IV ischial decubitus ulcer. Rotational flap closure is planned. Which of the following flaps is most appropriate considering wound closure and ambulation?

A) Gluteal thigh
B) Gluteus muscle
C) Hamstring
D) Reverse latissimus dorsi
E) Vastus lateralis

The correct response is Option A.

This patient, who has S2 paraplegia, has complete muscle function in the upper extremities, thoracic musculature, hips, and knees. Thus, detachment and relocation of hamstring muscles, the primary flexors of the knee, would greatly decrease this patient’s ability to ambulate. Although the vastus lateralis is a significant knee extender, and the use of this muscle would weaken the function of the quadriceps, other quadriceps muscles (vastus intermedius, vastus medialis, and rectus femoris) can sufficiently compensate for its loss.

Reverse latissimus dorsi can be useful for lower back and sacral coverage, but it does not have sufficient reach to cover the ischium. Tensor fascia lata assists in femoral flexion and abduction, but it is a minor muscle and has little functional impact. Gluteal thigh flaps are based on the descending gluteal artery and are typically raised as fasciocutaneous flaps. Thus, it would have little effect on ambulation or lower extremity motion.


A 50-year-old woman is scheduled to undergo debridement and reconstruction of a Stage IV sacral pressure sore. Which of the following is the most appropriate method of reconstruction?

A) Free tissue transfer
B) Full-thickness skin grafting
C) Inferior gluteus maximus island flap
D) Split-thickness skin grafting
E) V-Y fasciocutaneous flap

The correct response is Option E.

Local flaps in the gluteal region are the first choice for reconstruction of sacral pressure sores. Various designs of gluteal fasciocutaneous and musculocutaneous flaps are commonly used. The gluteal fasciocutaneous V-Y advancement flap is a method that has been preferred for management of these ulcers. Use of this type of flap conserves the gluteus maximus muscle and does not preclude ambulation in a mobile patient. Fasciocutaneous flaps, which are less sensitive to ischemia and more resistant to pressure than muscle flaps, have high mechanical resistance. These flaps are especially useful in wounds of limited depth, as are many in the sacral area.

Traditional wound closure of back defects under tension, with skin (split- or full-thickness) grafts or local random transposition flaps, is a poor choice for the patient with a complicated posterior trunk wound. These treatment options fail because of the poor tissue vascularity and the presence of a significant zone of injury that produced the wound breakdown in the first place.

The majority of the defects encountered in the posterior trunk can be reconstructed with local flaps. In cases of irradiation of the spine, extensive trauma, or significant debridement of surrounding tissue, the patient may be left with poor local solutions for providing vascularized tissue to the wound. In these rare cases, free tissue transfer is used to provide coverage.


A 53-year-old ambulatory man comes to the office because of a chronic pressure ulcer of the inferior portion of the left buttock that developed during a prolonged hospitalization 1 year ago. Repeated packing and dressing changes have not been successful in healing. Which of the following is the most appropriate surgical option?

A) Excision of ulcer bursa and primary closure
B) Reconstruction with a posterior thigh fasciocutaneous rotation flap
C) Reconstruction with a superiorly based gluteal musculocutaneous rotation flap
D) Reconstruction with a tensor fasciae latae island rotation flap
E) Reconstruction with a V-Y hamstring musculocutaneous advancement flap

The correct response is Option B.

The best choice for managing an ambulatory patient with a chronic pressure sore is using a posterior thigh fasciocutaneous rotation flap. Fasciocutaneous flaps offer an axial blood supply with durable coverage and minimal potential for a functional deformity. The flap more closely reconstructs the normal anatomic arrangement over bony prominences. Disadvantages include limited bulk for large ulcers that have a significant three-dimensionality.

Musculocutaneous flaps offer excellent blood supply and bulky tissue and can be re-rotated like fasciocutaneous flaps. However, in an ambulatory patient they may cause functional impairment.

The tensor fasciae latae flap is occasionally used to close the ischial ulcer. Unfortunately, the distal aspect of the flap that is used to reach the ischial region is usually too thin to offer adequate padding to be effective. Therefore, this flap is not the best option.

Primary closure is associated with a high recurrence rate. A large dead space is usually present due to the absence of tissue, and the induration of adjacent areas makes them difficult to mobilize for a tension-free closure.



A 60-year-old man with paraplegia who lives in an assisted care facility is evaluated because of a Stage II pressure sore of the right ischium. He spends each day sitting in a wheelchair. He smokes one pack of cigarettes daily. Which of the following is the most appropriate treatment?

A) Coverage with a lumbosacral flap
B) Coverage with a posterior hamstring musculocutaneous flap
C) Coverage with a tensor fasciae latae flap
D) Excision and direct closure
E) Placement of a hydrocolloid dressing

The correct response is Option E.

Stages I and II pressure sores usually can be managed nonsurgically. Stage I pressure sores are non-blanchable erythema of intact skin and usually resolve after 1 hour. Stage II is partial-thickness skin loss presenting clinically as a blister, abrasion, or shallow crater. Stage III pressure sores are full-thickness tissue loss down to, but not through, fascia. Stage IV pressure sores are full-thickness loss with involvement of underlying muscle, bone, tendon, ligament, or joint capsule.

A tensor fasciae latae flap would usually be the flap of choice for a Stage III or IV trochanteric pressure sore.

A lumbosacral flap would usually be used for a Stage III or IV sacral decubitus ulcer.

With reported recurrence rates up to 82%, cessation of smoking would be recommended before operating on a Stage III or IV pressure ulcer. Unless predisposing factors can be controlled, there is no reason to provide treatment to a clean Stage III or IV decubitus ulcer.

Excision and closure has a high failure rate and would not be indicated for a Stage II pressure sore.



A 24-year-old man with T11 paraplegia is scheduled to undergo reconstruction of a Stage IV ischial pressure sore with an inferior gluteal artery thigh flap. Medications include intravenous administration of empiric clindamycin every 6 hours for osteomyelitis. To determine the presence of osteomyelitis in this patient, which of the following is the most appropriate next step?

A ) Bone biopsy
B ) CT scanning
C ) Indium scanning
D ) Plain-film x-ray study
E ) Swab culture

The correct response is Option A.

Bone biopsy is the definitive diagnostic method to determine the presence of osteomyelitis. The pathologic examination of bone biopsy specimen remains the most accurate method of diagnosing osteomyelitis underlying pressure ulcers. Lewis et al. demonstrated that core needle bone biopsy is both sensitive and specific for the diagnosis of osteomyelitis, 73% and 96% respectively. Bone biopsy has been shown to be highly sensitive and specific in predicting which patients undergoing reconstruction with a flap are at an increased risk for developing postoperative complications consistent with osteomyelitis.

CT scanning can be useful in identifying a more detailed extent of bone involvement, but the sensitivity and specificity are 50% and 88%, respectively.

Indium scanning uses radiolabeled leukocytes that accumulate in sites of infection and inflammation. Inflammation and infection in the bone marrow have very high sensitivity but low specificity, 100% and 50%, respectively.

Plain-film x-ray study can be confirmatory but not very specific with a sensitivity and specificity of 88% and 32%, respectively.

A result of more than 10 organisms per gram of tissue is diagnostic for invasive infection and is predictive of failure of surgical closure. Swab cultures are generally unreliable and discouraged. They often represent only surface contaminants and do not correlate well with bone cultures.


A 45-year-old quadriplegic woman is scheduled to undergo reconstruction of a Stage IV left ischial pressure sore that is next to the anus with a tensor fascia lata flap. Which of the following is the most appropriate treatment before flap reconstruction in this patient?

A ) Administration of baclofen
B ) Administration of ferrous sulfate
C ) Diverting colostomy
D ) Local application of collagenase

The correct response is Option C.

Alteration of the bowel routine or even a diverting colostomy should be considered in patients with perineal wounds to reduce fecal soiling of the wound. This minimizes the bacterial contamination of the wound, thus making the wound suitable for closure and reducing the likelihood of reconstructive failure.

Involuntary muscular spasms contribute significantly to pressure sore development, especially in spinal cord–injured patients. This damage occurs through shear forces on soft tissues. Medical therapies include the use of diazepam, baclofen, and dantrolene.

Special considerations in the paraplegic or quadriplegic patient include the management of fecal soilage of the wound and treatment of spasm and contractures. Medical management of spasticity should be optimized.

Anemia is common in the pressure sore population and is caused by an inability to use relatively normal iron stores. For this reason, iron treatment is useless, and it may lead to iatrogenic hemochromatosis.

For all patients with pressure sores, regardless of whether they will progress to surgical closure or not, the principles of wound management apply. Debridement of devitalized tissue and dressing care to gain control of the wound are important.



Elevation of the semimembranosus, semitendinosus, and biceps femoris muscles during flap harvest is most appropriate for coverage of which of the following types of pressure sore?

A ) Calcaneal
B ) Ischial
C ) Sacral
D ) Trochanteric

The correct response is Option B.

The semimembranosus, semitendinosus, and biceps femoris muscles constitute a posterior thigh flap. This flap is more commonly used to treat ischial pressure wounds. Ischial pressure sores occur in patients who are sitting, and the vast majority of patients are paraplegic. These wounds are commonly large and require a bulky flap to completely close the defect. There are a wide variety of flaps available to cover defects in this area, but consideration should be given to potential recurrence as well as to the development of pressure sores in other nearby sites when a surgical ladder or algorithm is considered. Therefore, many surgeons choose to address the ischium with leg flaps first. These are reliable, can often be re-advanced, and do not interfere with more superiorly based flaps if needed for the sacrum or trochanter. Small- to medium-sized defects can be addressed with posterior thigh flaps, such as the biceps femoris alone, when a patient is ambulatory, or with the addition of the semimembranosus and semitendinosus when the patient is not ambulatory. These have an excellent blood supply, are typically designed in a V-Y fashion, and can often be re-advanced in the case of recurrence. Fasciocutaneous flaps preserve muscle, providing coverage for shallow wounds. A posteromedial fasciocutaneous flap can also be elevated based on perforators from the gracilis or adductor magnus. It has an excellent arc of rotation and does not contain muscle. The tensor fascia lata flap can also be used and, in fact, can be designed as a sensate flap in some spinal cord–injured patients with an injury below L3. The tissue over the gluteus maximus can be used and can contain either musculocutaneous or fasciocutaneous components.

Thoracolumbar and lumbar defects are best reconstructed with flaps based on the latissimus dorsi muscle. Options for closure include musculoskeletal advancement flaps, a latissimus musculocutaneous flap with a thoracolumbar extension, and, for large wounds, a composite latissimus dorsi and gluteus maximus flap. In certain cases, the omentum can be tunneled and used to cover the lumbar region when no other flaps are available.

Sacral wounds are usually covered with gluteal muscle flaps. Sacral pressure sores develop from patients lying in a supine position. If these are small and occur as a result of acute or short-term disability, they can often heal with conservative treatment. Skin grafting is usually not successful. The recurrence rates have been reported to be as high as 70% when using these methods in this location; so again, more reliable coverage should be considered. The mainstay coverage is the soft tissue overlying or including the gluteus maximus muscle, depending on the volume of tissue needed. Again, these are commonly designed as rotational flaps but can be advanced. Additional useful options include the use of a perforator island flap, such as the superior gluteal artery perforator described by Lee, et al.

Trochanteric wounds are usually covered with tensor fascia lata muscle. Trochanteric defects result most often from patients lying in the lateral decubitus position. Unfortunately, this is often because the patients are debilitated and, in many cases, have hip and lower extremity contractures. This makes a reliable closure difficult and recurrence common. The method that has been used most commonly is the tensor fascia lata flap. It can be raised as a muscle-only flap or with skin and muscle. It can also be used as an island flap, and even a free tensor fascia lata flap has been described. Again, this can be sensate in patients with spinal innervation above L3. Of note, tissue expansion has been attempted in closure in a number of settings to bring in sensate tissue. A secondary option is the vastus lateralis flap, and a number of flaps based on the gluteus muscles have been described.



A 40-year-old ambulatory man comes to the office because of a Stage IV pressure sore over the left ischium. He has no history of pressure sores, adheres to a nutritional diet, and does not smoke cigarettes. He is motivated to avoid recurrence. The most appropriate treatment is debridement followed by coverage with which of the following?

A) Gluteal fasciocutaneous flap
B) Gracilis muscle flap
C) Posterior thigh musculocutaneous flap
D) Split-thickness skin graft
E) Tensor fascia lata flap

The correct response is Option A.

The gluteal fasciocutaneous flap is the most appropriate choice because it spares muscle in this ambulatory patient.

Musculocutaneous flaps provide blood supply and bulky padding and are effective in treating infected wounds. Fasciocutaneous flaps offer an adequate blood supply, durable coverage, and minimal potential for a functional deformity. They more closely reconstruct the normal anatomic arrangement over bony prominences. The surgeon should consider the need for subsequent surgical procedures.

Skin grafting only has a 30% success rate in the scenario described, as grafting tends to provide unstable coverage.

The tensor fascia lata flap is the best first choice for trochanteric pressure sores. The tensor fascia lata flap typically is too thin to offer adequate padding in the scenario described.


A 38-year-old man with paraplegia and a Stage IV ischial pressure sore undergoes complete debridement of the soft tissue and bone and coverage with a gluteal rotation flap. Which of the following is the earliest postoperative time to allow sitting in order to promote flap healing and rehabilitation?

A) Limited sitting at 48 hours
B) Limited sitting at 1 week
C) Limited sitting at 3 weeks
D) Unlimited sitting at 4 weeks
E) Unlimited sitting at 6 weeks

The correct response is Option C.

Prevention of pressure sore recurrence following flap coverage requires careful attention at every stage of care – from patient selection and preoperative preparation to intraoperative technique and postoperative care. Postoperative bed rest in a pressure-relieving mattress, such as a fluid-air bed, is essential to allow for proper healing of the flap. Standard regimens have suggested avoidance of sitting for 3 weeks, though one small study demonstrated equal outcomes at 2 weeks for patients with no complications during the procedure. Recurrence rates are high despite the best of care, and allowing patients to place pressure on the suture line prior to a period of 2 to 3 weeks is likely to result in dehiscence. Unlimited sitting may never be possible in many patients. Frequent position changes and inspection for skin breakdown will always be required for proper ulcer prevention.



A frail 89-year-old man is brought to the office because he has had a large pressure sore on the sacrum for the past 2 months. Medical history includes type 2 diabetes mellitus and multi-infarct dementia. He is incontinent of stool and urine. Which of the following factors is the most important contributor to the development of the pressure ulcer in this patient?

A ) Fecal and urinary incontinence

B ) Inadequate cushioning on the wheelchair 

C ) Malnutrition 

D ) Poorly controlled diabetes mellitu

E ) Prolonged bed rest

The correct response is Option E. 

The most important factor in the development of pressure sores is excessive and prolonged pressure above end capillary pressure (32 mmHg). Pressure greater than 70 mmHg for 2 hours has been shown to cause irreversible tissue ischemia. Pressure sores in the sacrum, heel, and occiput occur from lying in the prone position because pressures range from 40 to 60 mmHg. For patients with altered levels of awareness, position changes at least every 2 hours and a pressure-relieving mattress are essential for prevention of ulcers. 

Ulcers in the ischium occur from prolonged pressure in the sitting position. Proper wheelchair cushioning is a hallmark of prevention. 

Diabetes, incontinence, and malnutrition are common exacerbating factors in pressure sores, although they are secondary to pressure as the most important factor in ulcer development. The patient described is likely to have decreased serum protein levels, which will result in inhibited wound healing. Incontinence can result in skin maceration, contamination of open sores, and delayed healing. Without strict glucose control, chronic wounds are unlikely to heal normally. 



A 45-year-old man with T4 paraplegia has an ulcer of the right ischium that extends to the underlying bone. Which of the following stages best describes the wound?

(A) I

(B) II


(D) IV

The correct response is Option D.

This wound is described as a stage IV pressure ulcer because the depth of involvement extends down into muscle.

The most widely accepted classification system for decubitus ulcers is that of the National Pressure Ulcer Advisory Panel (NPUAP), which is a modification of Shea €™s classification. The four-stage classification is designed only to describe the depth of a visible ulcer at the time of examination. It is not designed to follow progression or regression of the wound or to document healing.

Stage I describes pressure ulcers with intact skin with signs of impending ulceration: blanching and/or nonblanching erythema, warmth, and induration. These are reversible and can improve with pressure reduction.

Stage II describes shallow pressure ulcers with pigmentation changes that may appear as an abrasion, blister, or superficial ulcer. These are also reversible.

Stage III describes pressure ulcers with a full-thickness loss of skin with extension through the subcutaneous tissue but no penetration of the underlying fascia.

Stage IV describes pressure ulcers with full €‘thickness loss of skin with penetration into the deep fascia, resulting in muscle, bone, tendon, or joint involvement. Osteomyelitis and severe undermining of adjacent tissue are often present.

Stages III and IV describe pressure sores that usually require surgical intervention.



A 53-year-old man has a Stage III pressure sore on the ischium. Negative-pressure wound therapy is planned. Which of the following wound characteristics is most likely to impair the efficacy of this treatment modality?

(A) Depth

(B) Diameter

(C) Edema

(D) Fibrosis

(E) Undermining

The correct response is Option D.

Chronic, fibrotic pressure sores are characterized by impaired wound healing and, therefore, respond poorly to negative-pressure wound therapy (NPWT). Debridement of fibrotic tissue and devitalized tissue in these pressure sores improves the response to NPWT.

NPWT is most appropriate for management of full €‘thickness pressure sores that are large enough for adequate contact between the foam dressing and the wound bed and for safe removal of the foam. NPWT can be used successfully for management of large pressure sores, shallow or deep pressure sores, and those with undermining or tunneling.

If the patient is a surgical candidate, NPWT can be used to temporize the wound until the patient has been readied for surgery (nutrition, antibiotics, stabilization of coagulopathy, etc.). NPWT may allow wound improvement such that a lesser surgical procedure may be done. If the pressure sore deteriorates or fails to progress in two to four weeks, NPWT may need to be discontinued.



A 49-year €‘old woman with a 20-year history of paraplegia comes to the office for consultation regarding a chronic ulcer of the right ischium. She has been treating the wound twice daily with saline-soaked gauze dressings. Wound drainage has increased and become foul-smelling during the past week. The patient has smoked one pack of cigarettes daily for the past 15 years. Height is 5 ft 1 in and weight is 92 lb. The patient breathes comfortably on room air, is afebrile, and is not in acute distress. Physical examination of the ischial region shows a 5-cm-deep wound that is necrotic and extends to the ischial bone. Hip flexion contractures are noted. Culture of the wound shows gram-positive cocci and gram-negative rods. Laboratory studies show the following:

Hemoglobin 9.1 g/dL

Hematocrit 27%

Leukocyte count 12.5/mm3

Serum albumin 2.4 g/dL


Leukocytes Many

Leukoesterase Positive

Which of the following is the most appropriate next step in management?

(A) Bone scan

(B) Debridement and closure of the wound with a muscle flap

(C) Excision of the ulcer

(D) In-office debridement and application of collagenase dressings

(E) Intravenous antibiotic therapy


The correct response is Option C.

The patient described has an ischial decubitus ulcer resulting from prolonged pressure in the sitting position. The wound necrosis, elevated white blood cell count, and Gram stain merit immediate surgical intervention. The best immediate surgical option is complete ulcer excision including the underlying bursa and exposed ischium. Bone should be resected until firm, bleeding cortex is encountered and debrided bone should be sent for culture. The extension of the ulcer to bone indicates clinical osteomyelitis, and a bone scan will not change management in this patient.

Office debridement and chemical debridement dressings are not sufficient treatments for a wound of this severity. Although culture €‘specific antibiotics are an essential part of treatment, this patient €™s clinical status will not improve without debridement of all nonviable tissues. This patient has multiple risk factors for healing problems and ulcer recurrence, including malnutrition, systemic infection, smoking, and contractures that will inhibit rehabilitation and positioning. A single-stage debridement and flap reconstruction can be performed in optimal patients. Considering this patient €™s high risk of recurrence, debridement should be followed by wound care, antibiotics, nutritional optimization, smoking cessation, and physical therapy to improve her hip contractures. After her overall health status improves, flap reconstruction will have a higher chance of success. Recurrence of ulceration is extremely common over the long term, exceeding 50%. Having a patient willing to make the lifestyle changes and sacrifices necessary to avoid excess pressure and maintain optimal health cannot be overemphasized as the key to long €‘term success.



A 45-year-old man with paraplegia undergoes closure of a 10-cm-diameter pressure ulcer on the ischium. After debridement, which of the following is the definitive management for wound closure?
(A) Girdlestone arthroplasty
(B) Gracilis muscle flap
(C) Vacuum-assisted closure
(D) Vastus lateralis flap
(E) V-Y hamstring advancement flap


The correct response is Option E.

Although all of the procedures mentioned may be useful in the treatment of this pressure sore (except the Girdlestone procedure), the most definitive method of wound closure is the V-Y hamstring advancement flap. The Girdlestone procedure involves resection of the proximal femur and is used in certain cases of trochanteric ulcers (but not ischial ulcers). The gracilis muscle flap would be too small to adequately close this 10-cm-diameter pressure ulcer. The vacuum-assisted closure technique may eventually lead to wound closure, but it would be slower than muscle flap transposition and probably would not provide adequate soft-tissue coverage for a stable wound in this pressure-sensitive area. The vastus lateralis flap is well described for trochanteric coverage but is not used for closure of ischial ulcers. 


A 36-year-old man with paraplegia is brought to the office for evaluation of a pressure ulcer. Physical examination shows a grade IV wound over the trochanter. Which of the following tests is most appropriate to confirm the diagnosis of osteomyelitis?

(A) Bone biopsy
(B) Bone scan
(C) CT scan
(E) Radiographs

The correct response is Option A.

Bone biopsy is still the gold standard for confirming osteomyelitis, which is suggested in this patient. An additional benefit of the biopsy is having a tissue specimen for culture and sensitivity, which would be useful for identifying specific antibiotic treatment. Of the incorrect options, an MRI may be the second best modality to rule out an invasive, deep osteomyelitis of the pelvis. In one study examining MRI of the pelvis in paraplegics, MRI used for the diagnosis of osteomyelitis yielded a sensitivity of 98% and a specificity of 89% compared with bone biopsy. MRI is better than radionuclide studies for differentiating osteomyelitis from soft tissue infection with periostitis. Radiographs and CT scans are not as sensitive or specific as other imaging studies.


A pressure sore involving full-thickness skin and subcutaneous tissue to the level of the underlying muscle fascia is classified as which of the following?

(A) Grade I
(B) Grade II
(C) Grade III
(D) Grade IV

The correct response is Option B.

A lesion with this description is classified as a Grade II pressure sore. Pressure sores are classified by depth of necrosis. Grade I pressure sores extend to the epidermis and superficial dermis only. Grade II pressure sores involve full-thickness skin and extend to adipose tissue. Grade III pressure sores involve full-thickness skin and extend to subcutaneous tissue and underlying muscle. Grade IV pressure sores extend through all layers into the underlying bone or joint space.

Common risk factors for developing a pressure sore include neurologic impairment, old age, and hospitalization. Generally, the greater the number of risk factors, the greater the patient’s risk of developing a pressure sore.


A 45-year-old man with paraplegia (Ashworth 5 spasticity) recently underwent coverage of a superficial, cleanly debrided trochanteric hip ulcer with a tensor fascia lata transposition flap (shown above). Which of the following interventions is most appropriate to ensure stable coverage of the wound?

(A) Intrathecal administration of baclofen via an implantable pump 
(B) Parenteral administration of a broad-spectrum antibiotic for six weeks
(C) Retrogasserian rhizotomy 
(D) Ten weeks of bed rest on an air-fluidized mattress (Clinitron)

Q image thumb

The correct response is Option A.

To decrease spasticity, baclofen should be administered by an implantable pump before and after flap coverage. Spasticity contributes to flap breakdown by shearing force and should be controlled to ensure stable coverage of the wound. In some studies, flap failure has occurred in nearly 90% of patients with pressure sores. Prevention of this serious complication requires close control of all variables, including nutrition and postoperative pressure management. Long-term parenteral administration of antibiotics plays no role in the stability of coverage of a clean superficial wound. Ten weeks of bed rest on an air-fluidized mattress is not likely to be useful for a pressure ulcer in a lateral area. Retrogasserian rhizotomy, which interrupts the trigeminal (V) nerve, is not appropriate for this patient.


A 28-year-old man with a 10-year history of paraplegia has septicemia and a large grade IV pressure ulcer over the greater trochanter. MRI shows communication with the hip joint. After excision of the ulcer, which of the following is the most appropriate next step in management?

(A) Administration of a culture-specific antibiotic for six weeks
(B) Coverage with a tensor fascia lata flap
(C) Coverage with a total thigh flap
(D) Coverage with a vastus lateralis flap
(E) Resection of the femoral head

The correct response is Option E.

The most appropriate management of this patient’s pressure ulcer is resection of the femoral head, also known as Girdlestone arthroplasty. The sinogram finding of communication of the ulcer with the hip joint is consistent with osteomyelitis, which typically occurs in association with pyarthrosis. Resection of the femoral head will effectively remove the infected tissue in this patient, and vascular tissue should be used to obliterate the dead space. The vastus lateralis flap can be advanced into the acetabular fossa as a muscle or musculocutaneous flap.

Administration of an antibiotic for six weeks will control wound sepsis but will not treat osteomyelitis.

The tensor fascia lata flap is a sensate flap that is appropriate for coverage of less extensive trochanteric ulcers. This flap lies proximal to the site of the ulcer and can be easily transferred. Its vascular pedicle is based on perforating vessels from the tensor fascia lata muscle. However, it cannot be used alone in a patient with osteomyelitis.

Coverage with a total thigh flap is appropriate only as an end-stage procedure in a patient who has undergone amputation of the lower limb.


A 28-year-old man with quadriplegia is undergoing debridement of a massive grade IV sacrococcygeal pressure ulcer. The entire coccyx and a large portion of the sacrum are necrotic. Which of the following is the highest level at which bony debridement can be performed without entering the dural space? 

(A) Juncture of S2-3
(B) Juncture of S3-4
(C) Juncture of S4-5
(D) Juncture of the coccyx and sacrum
(E) Mid coccyx

The correct response is Option A.

The juncture of S2-3 is the highest level at which bony debridement can be performed without risking entry into the dural space. Extensive debridement in the dural space may damage the nerve plexuses of the sacrum and coccyx.

The conus medullaris, which is the terminal end of the neural portion of the spinal cord, lies at the level of L2. The cauda equina, or intravertebral portion of the nerves of the lower spine, continues on through the sacral canal to the coccyx, and the dural and subarachnoid sheaths terminate at the level of the second vertebral body. Vascular fibrofatty tissue surrounds the dura mater. The coccyx is formed by the fusion of four rudimentary vertebrae at the end of the spinal cord; it articulates with the caudal end of the sacrum.


A 52-year-old man with quadriplegia has pressure ulcers of the left and right ischia after sitting in his wheelchair for prolonged periods. Physical examination of the ulcers shows involvement of the reticular dermis on the left and exposure of underlying muscle with purulent drainage on the right.

Which of the following is the correct clinical staging of these ulcers?



(A)Stage IStage II

(B)Stage IIStage III

(C)Stage IIStage IV

(D)Stage IIIStage III

(E) Stage III Stage IV

The correct response is Option B.

The National Pressure Sore Advisory Panel Consensus Development Conference has developed a system to classify pressure ulcers according to four stages:

Stage I The skin is intact, but has a red discoloration more than one hour after relief of pressure
Stage II There is a blister or other break in the dermis, with or without infection
Stage III There is subcutaneous destruction into the muscle, with or without infection
Stage IV There is bony or joint involvement, with or without infection

This 52-year-old quadriplegic man has pressure ulcers on both the left and right ischia. Because the pressure ulcer on the left involves the reticular dermis, it would be correctly classified as stage II. In contrast, the pressure ulcer on the right involves muscle and is thus classified as Stage III.

Staging systems for pressure ulcers address depth only and do not consider the presence of osteomyelitis, rates of recurrence, and the nutritional status and compliance of the patient. In addition, they do not necessarily reflect the underlying cause of the ulcer.


Which of the following is the primary advantage of using Integra (artificial skin) for coverage of full-thickness burns?

(A) Allowing for immediate use of cultured epithelial autografts
(B) Allowing for use of thinner autografts
(C) Avoidance of autografting
(D) Complete revascularization within seven days
(E) Prevention of fibroblast ingrowth into the dermal replacement layer

The correct response is Option B.

Integra, or artificial skin, is the most widely used skin substitute. It is a synthetic bilaminar membrane composed of a dermal matrix of porous bovine collagen cross-linked with shark-derived chondroitin-6-sulfate and covered by temporary Silastic epidermis. It does not contain neonatal fibroblasts or autologous keratinocytes. A two-stage application process is required; the initial stage is application of the dressing.

Following its application, the dermal matrix of the Integra dressing acts as a template, becoming infiltrated with host fibroblasts, endothelial cells, and inflammatory cells. The host collagen gradually replaces the bovine collagen during the healing process, and the silicone cover controls moisture loss and protects the wound. Adequate revascularization occurs within two to three weeks, at which time the superficial silicone layer will have sloughed off as a result of ingrowth through the collagen and glycosaminoglycan matrix. At this time, the Integra graft can be removed, and a thinner autograft, such as a very thin sheet of split-thickness skin graft, can be applied for durable coverage.

In addition to allowing for use of thinner autografts, advantages of Integra include immediate temporary coverage, more rapid healing of donor sites, and improved cosmesis.

Because the revascularization process is delayed, cultured epithelial autografts would fail to take if applied immediately because of the lack of vascularization in the wound bed.

Although Integra can be used to cover partial-thickness burns, it does not relieve the need for autografting over full-thickness burns.

As mentioned above, Integra is revascularized in two to three weeks, not within seven days, and allows for fibroblast ingrowth into the dermal replacement layer.


An ambulatory 75-year-old man has a 6-cm grade IV pressure ulcer on the sacrum. The most appropriate management is reconstruction with which of the following?

(A) Bilateral gluteal myocutaneous advancement flaps
(B) Unilateral superior/inferior gluteal myocutaneous rotation flap
(C) Unilateral superior gluteal artery perforator flap
(D) Thin split-thickness skin graft


The correct response is Option C.

The unilateral superior gluteal artery perforator flap is most appropriate for reconstruction of the area of the sacrum affected by the pressure ulcer. Perforator flaps can be based on either the superior or inferior gluteal artery. They provide adequate myocutaneous coverage and at the same time preserve the gluteal muscles on the involved side. As a result, morbidity at the donor site will be minimized, which is especially important in this patient because he is ambulatory.

Although a bilateral superior/inferior gluteal myocutaneous advancement flap supplies sufficient soft-tissue coverage for pressure ulcers, harvest of the inferior and superior gluteal muscles will result in significant morbidity at the donor site. Harvest of a gluteal myocutaneous rotation flap sacrifices muscle function and also is not the procedure of choice in an ambulatory patient. Thin split-thickness skin grafts do not provide stable coverage of pressure ulcers.



A 50-year-old man with a two-year history of paraplegia develops a grade IV right ischial pressure ulcer with a diameter of 4 cm. Total ischiectomy is performed, and the wound is covered with a gluteal thigh flap. Which of the following complications is most likely in this patient?

(A) Flap loss
(B) Left ischial pressure ulcer
(C) Marjolin's ulcer
(D) Pulmonary thromboembolism
(E) Urethrocutaneous fistula

The correct response is Option B.

Although total ischiectomy decreases the rate of recurrence of ischial pressure ulcers, removal of one ischium transfers the weight to the opposite side when the patient sits, increasing the likelihood of an ulcer on that side. One study showed an incidence of contralateral ischial pressure ulcers of 28% in patients who had undergone total ischiectomy. In contrast, patients who underwent total bilateral ischiectomy, in which weight bearing is transferred to the perineum and pelvis, were more likely to develop perineal ulcers and urethrocutaneous fistulas. Fistulas were shown to occur in 58% of patients who had undergone this procedure.

Necrosis leading to flap loss is rare in flap transfers involving a major vascular pedicle.

Marjolin's ulcer, or malignant degeneration, has an incidence of 0.5% in patients with pressure ulcers, and also occurs in other types of chronic wounds. Aggressive squamous cell carcinomas are associated; lymph node involvement is estimated at 60%, and mortality rates are high.

Thromboembolism is a frequent cause of death immediately after the onset of paraplegia but is not common in patients with long-term paraplegia undergoing routine excision and reconstruction procedures.



In a patient who has a large, deep, chronic grade III pressure ulcer of the ischium, calcium alginate dressings are most likely to be used because they have which of the following properties?

(A) Ability to absorb exudate
(B) Ability to provide a moist environment for epithelialization
(C) Antiinflammatory activity
(D) Antimicrobial activity
(E) Hemostatic activity

The correct response is Option A.

Calcium alginate dressings are xerogels, or dry dressings that become gel-like in the presence of exudate; therefore, they are commonly used for grossly exudative wounds, such as deep ulcers, because they are able to absorb a large quantity of exudate. These dressings contain mannuronic and guluronic acids and are derived from Laminaria seaweed. Patients with exudative wounds typically require frequent dressing changes with other types of dressing because maceration (resulting from the excess moisture) can develop around the margins of the wound. In contrast, alginate dressings need to be changed only every 24 to 48 hours.

Alginate dressings provide a moist environment that is conducive to wound healing, but secondary bio-occlusive dressings should also be applied to prevent drying. They provide an environment that is favorable to epithelialization, which is less pertinent than contraction in a patient with a pressure ulcer. Alginates are thought to decrease infection by trapping microorganisms and cellular debris, but do not have inherent antimicrobial properties. Because these dressings promote inflammation, they can cause foreign body reactions in some patients. Calcium alginates have procoagulant activity and have been used to cover skin graft donor sites, but this is not a factor in a patient who has a chronic wound.



An 18-month-old boy has a 25-cm pigmented lesion on his back. Which of the following is the most appropriate management?

(A) Observation with photographic mapping
(B) Intralesional injection of interferon gamma
(C) Dermabrasion
(D) Tunable dye laser ablation
(E) Excision


The correct response is Option E.

This 18-month-old boy has a giant congenital nevus on the back. Congenital nevi can be classified as "giant" according to several criteria, including those lesions that are larger than 20 cm in diameter, lesions that are greater than twice the size of the patient's palm, and those nevi for which excision and primary closure cannot be performed as a single procedure. Because of the potential for malignant transformation, surgical excision of the entire lesion is recommended. Although the actual risk for melanoma is controversial, one study reported that approximately 8% of patients with giant congenital nevi developed melanoma during the first 15 years after the initial appearance of the nevus.

Although observation with serial photographic mapping is advocated in patients with familial dysplastic nevus syndrome, it is not appropriate in a patient with a giant congenital nevus because of the association with malignancy. Intralesional injection of interferon gamma is indicated for patients who have confirmed malignant melanoma. Dermabrasion and laser ablation will not remove all of the immature melanocytes within the lesion. In addition, the resultant hypopigmentation seen following treatment may hinder any future monitoring for signs of malignant degeneration.



A 20-year-old man with paraplegia has a large grade IV pressure ulcer of the left ischium. He previously underwent ligation of the profunda femoris artery on the left. Which of the following flaps is most appropriate for reconstruction in this patient?

(A) Gluteal thigh flap
(B) Gracilis flap
(C) Rectus femoris flap
(D) Tensor fascia lata flap
(E) Vastus lateralis flap

The correct response is Option A.

The gluteal thigh flap is most appropriate for reconstruction of this paraplegic patient's ischial pressure ulcer because this is the only flap of those listed whose regional arterial vascularity is provided by a source other than the profunda femoris artery, namely the inferior gluteal artery and venae comitantes. As much as 10 cm * 35 cm can be harvested with this flap. It is frequently transferred as a fasciocutaneous flap with elevation of the inferior portion of the gluteus maximus muscle to the lateral edge of the sacrum.

The gracilis myocutaneous and rectus femoris flaps have a type II vascular pattern and can also be used for coverage of most ischial pressure ulcers. Circulation is provided by the profunda femoris artery via the ascending branch of the medial circumflex artery and venae comitantes for the gracilis flap and via the descending branch of the lateral circumflex artery and venae comitantes for the rectus femoris flap.

In contrast, the tensor fascia lata and vastus lateralis flaps both have a type I vascular pattern. The tensor fascia lata flap can be used for coverage of trochanteric, ischial, and sacral pressure ulcers and the vastus lateralis flap for coverage of trochanteric and ischial pressure ulcers. Like the rectus femoris flap, circulation of the vastus lateralis flap is provided by the profunda femoris artery via the descending branch of the lateral circumflex artery and venae comitantes. In contrast, vascularity of the tensor fascia lata flap is provided by the profunda femoris via the ascending branch of the lateral circumflex artery and venae comitantes.



In paraplegic patients with chronic pressure ulcers, which of the following is the most common cause of death?

(A) Pulmonary sepsis
(B) Pulmonary thromboembolism
(C) Renal failure
(D) Sepsis secondary to pressure ulcers
(E) Urosepsis

The correct response is Option C.

In paraplegic patients with chronic pressure ulcers, renal failure secondary to chronic amyloidosis is the most common cause of death. Pulmonary sepsis, thromboembolism, and respiratory failure are frequent causes of death immediately following the traumatic onset of paraplegia but not in patients with long-standing paraplegia who subsequently develop pressure ulcers. Sepsis secondary to pressure ulcers is uncommon. Although urosepsis is a common problem for patients with long-standing paraplegia, antibiotics decrease the likelihood of death.