Occiput (infants and long-term bedbound/intubated pts).
Clinical Features
Classification / Staging System (NPUAP/EPUAP):
Stage 1: Intact skin with non-blanchable erythema, usually over a bony prominence. May exhibit local warmth, edema, or induration.
Stage 2: Partial-thickness skin loss involving epidermis and/or dermis. Presents as a shallow open ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister. No slough or subQ fat visible.
Stage 3: Full-thickness skin loss. Subcutaneous fat visible, but bone, tendon, or muscle is not exposed. Slough or eschar may be present. Undermining and tunneling may occur.
Stage 4: Full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Slough/eschar often present; high risk of osteomyelitis. Palpable bone often present.
Unstageable: Full-thickness tissue loss where base is obscured by slough (yellow, tan, gray) and/or eschar (tan, brown, black). True depth cannot be determined until slough/eschar is removed.
Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.
Diagnosis
Initial/Screening:
Clinical inspection, measurement, and anatomical staging.
Probe-to-bone test: Palpating hard, gritty bone with a sterile metal probe at the ulcer base has high positive predictive value for underlying osteomyelitis.
Inflammatory markers: ESR and CRP (markedly elevated if osteomyelitis or deep space infection is present).
CBC: Leukocytosis indicates systemic infection or local soft tissue invasion.
Imaging:
Initial: Plain radiograph (X-ray) of the underlying bone (evaluates for cortical lysis, periosteal reaction; low sensitivity early).
Confirmatory / Gold Standard Imaging: MRI without and with IV contrast (highest sensitivity and specificity for osteomyelitis, deep abscess, or sinus tracts).
Microbiology / Biopsy:
Superficial swab cultures are CONTRAINDICATED (identifies surface colonization, not true infection).
Definitive diagnosis of wound infection requires deep tissue biopsy or needle aspiration of the ulcer base after wound debridement.
Bone biopsy and culture: Gold standard for confirming osteomyelitis.
Differential Diagnostics
Venous Stasis Ulcers:
Diff by location (medial malleolus), irregular shaggy borders, copious exudate, and surrounding stasis dermatitis (erythema, hemosiderin hyperpigmentation, lipodermatosclerosis); peripheral pulses usually intact.
Arterial (Ischemic) Ulcers:
Diff by location at the distal tips of digits or lateral malleolus; characteristic “punched-out” clean margins, pale/necrotic base, loss of hair, thin shiny skin, cool extremities, diminished/absent distal pulses, and pain exacerbated by leg elevation.
Diabetic Neuropathic Ulcers (Mal Perforant):
Diff by location over pressure-bearing plantar surfaces (e.g., metatarsal heads, heels); painless due to peripheral sensory neuropathy; characteristically surrounded by a thick keratotic rim (callus).
Pyoderma Gangrenosum:
Diff by rapid progression, extreme pain out of proportion to exam, violaceous undermined border, association with IBD or rheumatoid arthritis, and pathergy (lesions worsen after debridement or surgical trauma).
Marjolin Ulcer:
Diff by non-healing chronic wound undergoing malignant transformation into squamous cell carcinoma (SCC); presents with everted borders, exuberant granulation tissue, or vegetative mass; diagnosed via biopsy of the ulcer margin.
Management
General Measures (Prevention & Pressure Relief - First-Line):
Repositioning: Turn bedbound pts every 2 hours; chairbound pts every 15 to 60 minutes.
Support Surfaces: Pressure-reducing dynamic or static foam/air/alternating-pressure mattresses and heel offloading boots.
Optimize Nutrition: Ensure adequate caloric intake (30–35 kcal/kg/day) and high protein (1.25–1.5 g/kg/day); correct vitamin C and zinc deficiencies.
High-Yield Exception: Dry, intact, non-fluctuant eschar on the heel should NOT be debrided if there is no erythema, edema, or fluctuance; it serves as a natural physiologic barrier.
Antimicrobial Therapy:
Topical Abx: Generally not recommended due to contact dermatitis risk and bacterial resistance.
Systemic IV Abx: Reserved strictly for pts with systemic signs of infection (sepsis), advancing cellulitis, or confirmed osteomyelitis (empiric coverage with Vancomycin + Piperacillin-Tazobactam or Cefepime; narrow based on deep cultures).
Surgical Management (Refractory / Extensive):
Myocutaneous or fasciocutaneous rotation/transposition flap closure after infection is eradicated and healthy granulation base is established.
Complications
Infectious:
Osteomyelitis (most common serious deep complication).
Bacteremia and Sepsis / Septic shock.
Local cellulitis, deep tissue abscess, infectious tenosynovitis.
