Interesting Case Series

Sacral Pressure Ulcer in a 60-Year-Old Man

Ian C. Hoppe, BA, and Kevin R. Knox, MD

Department of Surgery, Division of Plastic Surgery, New Jersey Medical School,
UMDNJ, Newark

Correspondence: hoppeic@umdnj.edu

DESCRIPTION

A 60-year-old man presents with a foul smelling sacral decubitus ulcer.

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QUESTIONS

1. How are pressure ulcers staged and what are the primary risk factors
for their development?

2. What is the physiological cause of pressure ulceration?

3. What methods are available for evaluating the risk of pressure ulcer
formation?

4. If you are consulted for this patient, what treatment options are available
to you?

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DISCUSSION

Pressure ulcers are staged according to 4 different levels. Stage I ul-

cers involve intact skin with nonblanching erythema. Stage II involves
ulceration into dermis. Stage III involves ulceration through subcuta-
neous soft tissue. Stage IV involves ulceration extending to bone, joint,
or viscera. Primary risk factors for ulceration include immobility, in-
continence, decreased mental status, and poor nutritional status.
Pressure ulcers occur when forces on tissue exceed capillary bed
pressure (12 mm Hg on the venous end and 32 mm Hg on the arterial
end). This ischemia should be present for a time long enough to cause
tissue necrosis. Medically compromised patients are more susceptible
to ischemic pressure necrosis. There is an inverse relationship between
pressure and duration of time required to cause ulceration. Skin is the
last tissue to be affected in pressure ulcers with the muscle overlying
the bone being affected first.
The risk for developing pressure ulcers is determined using the
Braden Scale or Norton Scale, among others. The Braden Scale is more
widely applicable, whereas the Norton Scale is used more with elderly
patients in a hospital setting. Categories assessed in the Braden Scale
include sensory perception, moisture, activity, mobility, nutrition, and
friction and shear. All categories are given a number from 1 to 4; except
friction and shear that are given a number from 1 to 3. A Braden Scale
score of 16 or less indicates a need for pressure sore prevention proto-
cols. Categories assessed in the Norton Scale include physical condition,
mental condition, activity, mobility, and incontinence. All are given a
number from 1 to 4, with a score of 14 or less indicating the need for
pressure sore prevention protocols.
When presented with a patient, as shown here, the first goal is to
optimize the patient’s medical status to facilitate postoperative recov-
ery. The wound is then managed by performing an aggressive operative
debridement to remove all necrotic tissue and minimize bacterial load.
If the patient is unable to undergo surgery due to poor medical condi-
tion, alternative debridement options include mechanical debridement,
enzyme therapy, or maggot therapy. Once the wound bed is prepared,
treatment options include secondary closure with local management,
using negative pressure or a wide array of dressing options, versus flap
closure. Flaps should be well vascularized, muscle-based, and chosen to
maintain future surgical options.

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REFERENCES
Wong TC, Ip FK. Comparison of gluteal fasciocutaneous rotational flaps and myocutaneous flaps for the
treatment of sacral sores. Int Orthop. 2006;30:64–7.
Granick MS, McGowan E, Long CD. Outcome assessment of an in-hospital cross-functional wound care
team. Plast Reconstr Surg. 1998;101:1243–7.
Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Multi-site study of incidence of pressure ulcers
and the relationship between risk level, demographic characteristics, diagnoses, and prescription
of preventive interventions. J Am Geriatr Soc. 1996;44:22–30.
Bauer JD, Mancoll JS, Phillips LG. Pressure Sores. In: Thorne CH, Beasley RW, Aston SJ, Bartlett SP,
Gurtner GC, Spear SL, eds. Grabb and Smith’s Plastic Surgery. Philadelphia: Lippincott Williams
& Wilkins; 2006:723–9.
Norton D, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in hospitals. 2nd
ed. Edinburgh, UK: Churchill Livingston;. 1975:193.

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