This set of clinical photos from a 90 year old bedbound lady with diabetes, peripheral vascular disease and advanced vascular dementia shows the presence of an unstageable right ankle bed sore. There is a blackish eschar covering the wound base with adjacent erythema of the skin. Pus was expressed from the wound margin when pressure was applied over the wound. Examination of the right lower limb also showed weak distal pulses and poor capillary refill. X-ray of the right calcaneum showed osteomyelitic changes (white arrows). In view of the severe infection as well as poor circulation due to the underlying peripheral vascular disease, above knee amputation was suggested but was refused by the patient’s relatives. The patient received daily wound dressings and a prolonged course of intravenous ampicillin and cloxacillin. Unfortunately, this patient passed away because of hospital-acquired pneumonia. Principles in the management of pressure sores include: regular turning of the patient every 2 hours, daily wound dressing, attention to nutritional status, maintenance of hemoglobin to a satisfactory level and use of antibiotics in the case of active infection.
Pressure sores could be staged as follow:
- Stage 1: intact skin with non-blanchable redness
- Stage 2: partial thickness loss of dermis (red-pink wound bed, no slough), including intact or ruptured serum-filled blister
- Stage 3: full thickness skin loss, subcutaneous fat may be visible (+/- slough not obscuring the view of depth of involvement)
- Stage 4: full thickness skin loss with exposed bone, tendon or muscle
- Unstageable: full thickness tissue loss; base of ulcer covered by slough and/or eschar in the wound bed
- Suspected deep tissue injury: purple or maroon localized area of discolored intact skin or blood filled blister due to damage of the underlying tissue from pressure and/or shear