Introduction
Pressure (decubitus) ulcers, also known as bedsores, are skin and soft
tissue injuries that arise from constant or prolonged pressure exerted
on the skin (Zaidi, 2022). An increasing number of people are affected
by pressure injuries as our population grows and ages (Boyko, 2016).
Pressure injuries frequently precipitate chronic wounds resulting in
significant morbidity, mortality, and economic burden on both the
patient and the healthcare system (Afzeli, 2020). Pressure injuries may
develop in hospital and long-term care settings with orthopedic wards
estimated to have the highest incidence of pressure injuries (Afzeli
2020). The reported prevalence of pressure injuries in long-term care
facilities varies widely, ranging from 3.4-32.4% while hospital
incidence rates range from 4% to 38% (Anthony 2019 & Afzeli 2020).
The etiology of pressure ulcers is multifactorial with risk factors
including but not limited to neurologic disease, cardiovascular disease,
and malnutrition (Zaidi 2022). Prolonged external pressure for as little
as two hours can lead to the formation of a pressure ulcer (Zaidi 2022).
Physiologic factors that incite pressure injuries include reperfusion
injury and impaired lymphatic drainage (Boyko, 2016).
A number of complications may result from pressure ulcers with the most
common being infection, which is often polymicrobial (Zaidi, 2022). The
infection may spread to deeper tissues inciting periostitis,
osteomyelitis, septic arthritis and the formation of sinuses from tissue
loss (Zaidi 2022).
Stage I and II pressure ulcers are managed conservatively with
appropriate wound care and elimination of causative factors, while more
severe ulcers (stage III or IV) or ulcers with concomitant necrosis,
osteomyelitis, or systemic infection may often require operative
intervention. More severe pressure ulcers may require adjunctive
procedures such as bedside debridement, negative pressure wound therapy,
fecal/urinary diversion, and ultimately operative care. Since
complication rates after flap reconstruction of pressure injuries are
high, affecting 59% of patients (Bamba 2017), those who are poor
surgical candidates should generally not undergo reconstructive
procedures.
We present a unique case of a chronic ischial tuberosity pressure wound
(ITPW) with multi-focal arterial and venous hemorrhage which required
emergent exploration in the operating room.