What is the difference between sacral and ischial wounds

Diagnosis of pressure injury is based on clinical evaluation. A pressure injury is typically identified by its characteristic appearance and by its location over a bony prominence. The sacrum is the most common location, followed by the heels. Injuries caused by arterial and venous insufficiency or diabetic neuropathy may mimic pressure injuries, particularly on the lower extremities, and can also be worsened by the same forces that cause or worsen pressure injuries.

Depth and extent of pressure injuries can be difficult to determine. Serial staging and photography of wounds is essential for monitoring injury progression or healing. Many healing scales are available. Routine wound culture is not recommended because all pressure injuries are heavily colonized by bacteria. A nutritional assessment is recommended in patients with pressure injury, particularly those with stage 3 or 4 pressure injuries. Undernutrition requires further evaluation Diagnosis Protein-energy undernutrition PEU , previously called protein-energy malnutrition, is an energy deficit due to deficiency of all macronutrients.

It commonly includes deficiencies of many micronutrients Nonhealing injuries may be due to inadequate treatment but should raise suspicion of a complication. Tenderness, erythema of surrounding skin, exudate, or foul odor suggests an underlying infection. Fever and leukocytosis should raise suspicion of cellulitis, bacteremia, or underlying osteomyelitis. If osteomyelitis is suspected, complete blood count, blood cultures, and erythrocyte sedimentation rate or C-reactive protein is recommended.

Osteomyelitis is confirmed ideally by bone biopsy and culture, but this is not always feasible. Imaging tests lack the combination of high sensitivity and specificity. MRI is sensitive but not specific and can help define the extent of pressure injury spread. MRI with gadolinium can help identify draining or communicating sinus tracts.

Prognosis for early-stage pressure injuries is excellent with timely, appropriate treatment, but healing typically requires weeks. If care of the injury and management of concurrent disorders cannot be improved, long-term outcome is poor, even if short-term wound healing is accomplished.

See also the American College of Physicians' guidelines for preventing and treating pressure ulcers. Reducing tissue pressure is accomplished through careful positioning of the patient, protective devices, and use of support surfaces. Frequent repositioning and selection of the proper position is most important. A written schedule should be used to direct and document repositioning. Elevation of the head of the bed should be minimal to avoid the effects of shearing forces.

When repositioning patients, lifting devices eg, a Stryker frame or bed linen should be used instead of dragging patients to avoid unnecessary friction.

Patients placed in chairs should be repositioned every hour and encouraged to change position on their own every 15 minutes. Protective padding such as pillows, foam wedges, and heel protectors can be placed between the knees, ankles, and heels when patients are supine or on their side. Windows should be cut out of plaster casts at pressure sites in patients immobilized by fractures.

Soft seat cushions should be provided for patients able to sit in a chair. Support surfaces under patients confined to a bed can be changed to reduce pressure. They are often combined with other measures when treating pressure injuries. Support surfaces are classified based on whether they require electricity to operate.

Static surfaces do not require electricity, whereas dynamic surfaces do. Although dynamic surfaces are usually recommended for more severe pressure injuries, no conclusive evidence favors dynamic over static surfaces. Static surfaces include air, foam, gel, and water overlays and mattresses. Egg-crate mattresses offer no advantage.

In general, static surfaces increase surface support area and decrease pressure and shearing forces. Static surfaces have traditionally been used for pressure injury prevention or stage 1 pressure injuries. Dynamic surfaces include alternating-air mattresses, low-air-loss mattresses, and air-fluidized mattresses. In addition to reducing pressure, some mattresses increase the area of support, reduce heat and promote cooling, and decrease shear.

Alternating-air mattresses have air cells that are alternately inflated and deflated by a pump, thus shifting supportive pressure from site to site. Low-air-loss mattresses are giant air-permeable pillows that are continuously inflated with air; the air flow has a drying effect on tissues. These specialized mattresses are indicated for patients with stage 1 pressure injuries who develop hyperemia on static surfaces and for patients with stage 3 or 4 pressure injuries.

Air-fluidized high-air-loss mattresses contain silicone-coated beads that liquefy when air is pumped through the bed. Advantages include reduction of moisture and cooling. These mattresses are indicated for patients with nonhealing stages 3 and 4 pressure injuries or numerous truncal injuries see Table: Options for Support Surfaces Options for Support Surfaces Pressure injuries are areas of necrosis and often ulceration also called pressure ulcers where soft tissues are compressed between bony prominences and external hard surfaces.

However, frequent reapplication every hour is necessary to maintain the protective effect. Cleaning should be done initially and with each dressing change. Normal saline is usually the best choice. Cleaning often involves irrigation at pressures sufficient to remove bacteria without traumatizing tissue; commercial syringes, squeeze bottles, or electrically pressurized systems can be used. Irrigation may also help remove necrotic tissue debridement.

Alternatively, a mL syringe and an gauge IV catheter can be used. Irrigation should continue until no further debris can be loosened. Antiseptics iodine, hydrogen peroxide and antiseptic washes can destroy healthy granulation tissue and thus should be avoided. Debridement is necessary to remove necrotic tissue. Necrotic tissue serves as a medium for bacterial growth and blocks normal wound healing. Methods include. Mechanical debridement: This method includes hydrotherapy eg, whirlpool baths, pulsatile lavage and most commonly wet-to-dry dressings Nonocclusive dressings Topical dermatologic treatments are grouped according to their therapeutic functions and include Cleansing agents Moisturizing agents emollients, skin hydrators, and softeners Drying agents Cleaning wounds by irrigation at sufficient pressures can also accomplish mechanical debridement.

In wet-to-dry dressings, exudate and necrotic tissue adhere to a gauze dressing as it dries so that removal of the gauze thus debrides the wound; this method must be used cautiously because dressing changes are painful and may remove underlying healthy granulation tissue. Sharp surgical debridement: This method involves using a sterile scalpel or scissors to remove eschar and thick necrosis. Autolytic debridement may be used for smaller wounds with little exudate.

This method should not be used if a wound infection is suspected. It can also be used for patients whose caretakers are not trained to do mechanical debridement or for patients unable to tolerate surgery. It is most effective after careful and judicious cross-hatching of the wound with a scalpel to improve penetration.

Biosurgery: Medical maggot therapy is useful for selectively removing dead necrotic tissue; maggots fly larvae eat only dead tissue. This method is most helpful in patients who have exposed bone, tendons, and joints in the wound where sharp debridement is contraindicated. Dressings Dressings Topical dermatologic treatments are grouped according to their therapeutic functions and include Cleansing agents Moisturizing agents emollients, skin hydrators, and softeners Drying agents Dressings should be used for stage 1 pressure injuries that are subject to friction or incontinence and for all other pressure injuries see Table: Options for Pressure Injury Dressings Options for Pressure Injury Dressings Pressure injuries are areas of necrosis and often ulceration also called pressure ulcers where soft tissues are compressed between bony prominences and external hard surfaces.

In stage 1 pressure injuries subject to increased friction, transparent films are sufficient. For injuries with minimal exudate, transparent films or hydrogels, which are cross-linked polymer dressings that come in sheets or gels, are used to protect the wound from infection and create a moist environment. Transparent films or hydrogels should be changed every 3 to 7 days.

Hydrocolloids, which combine gelatin, pectin, and carboxymethylcellulose in the form of wafers and powders, are indicated for pressure injuries with light-to-moderate exudate and must be changed every 3 days. Alginates polysaccharide seaweed derivatives containing alginic acid , which come as pads, ropes, and ribbons, are indicated for absorbing extensive exudate and for controlling bleeding after surgical debridement. Alginates can be placed for up to 7 days but must be changed earlier if they become saturated.

Foam dressings can be used in wounds with various levels of exudate and provide a moist protective environment for wound healing. Foam dressings must be changed every 3 to 4 days. Waterproof versions protect the skin from incontinence. Pressure injuries can cause significant pain. Pain should be monitored regularly using a pain scale.

Primary treatment of pain is treatment of the injury itself, but a nonsteroidal anti-inflammatory drug or acetaminophen is useful for mild-to-moderate pain. Opioids should be avoided, if possible, because sedation promotes immobility.

However, opioids or topical nonopioid preparations such as mixtures of local anesthetics may be necessary during dressing changes and debridement. In cognitively impaired patients, changes in vital signs can be used as indicators of pain. Pressure injuries should be continually assessed for signs of bacterial infection such as increased erythema, foul odor, warmth, drainage, fever, and elevated white blood cell count.

Impaired wound healing should also raise concern of infection. These abnormal findings indicate a wound culture should be done. However, because all pressure ulcers are colonized, results should be interpreted with caution; bacterial count rather than bacterial presence should guide treatment.

Local wound infection can be treated topically with agents such as silver sulfadiazine , mupirocin , polymyxin B , and metronidazole. Silver sulfadiazine and similar opaque topical agents should be used cautiously because they can impair visualization of the underlying wound and can be difficult to remove.

A 2-week trial of topical antibiotics for all clean pressure injuries that do not heal despite 2 to 4 weeks of proper treatment is recommended. Narrow-spectrum systemic antibiotics should be given for cellulitis, bacteremia, or osteomyelitis; usage should be guided by tissue culture, blood culture, or both or clinical suspicion and not by surface culture.

Limiting the use of broad-spectrum antibiotics is important to help prevent adverse effects and to help prevent inducing bacterial resistance and disrupting the skin and gut microflora.

Undernutrition is common among patients with pressure injuries and is a risk factor for delayed healing. Markers of undernutrition include albumin Negative-pressure therapy: Negative-pressure therapy vacuum-assisted closure, or VAC applies suction to the wound.

It can be applied to clean wounds. High-quality evidence of efficacy does not yet exist, but negative-pressure therapy has shown some promise in small studies. Topical recombinant growth factors: Some evidence suggests that topical recombinant growth factors eg, nerve growth factor, platelet-derived growth factor and skin equivalents facilitate wound healing.

Electrical stimulation therapy: Electrical stimulation therapy combined with standard wound therapy can increase wound healing. Therapeutic ultrasonography: Ultrasonography is sometimes used, but there is no good evidence of benefit or harm. Electrical magnetic, phototherapy laser heat, massage, and hyperbaric oxygen therapies: No evidence supports efficacy of these treatments. Large defects, especially with exposure of musculoskeletal structures, require surgical closure.

Skin grafts are useful for large, shallow defects. However, because grafts do not add to blood supply, measures must be taken to prevent pressure from developing to the point of ischemia and further breakdown.

Myocutaneous flaps, because of their pressure-sharing bulk and rich vasculature, are the closures of choice over large bony prominences usually the sacrum, ischia, and trochanters. Surgery may rapidly improve the quality of life in patients with pressure injuries. Surgical outcomes are best if preceded by optimal treatment of undernutrition and comorbid disorders. Treatment and prevention overlap considerably. The mainstay of prevention is frequent repositioning.

Patients who cannot move themselves must be repositioned and cushioned with pillows. Patients must be turned even when they are lying on low-pressure mattresses. Pressure points should be checked for erythema or trauma at least once per day under adequate lighting. Patients and family members must be taught a routine of daily visual inspection and palpation of sites for potential injury formation. Daily attention to hygiene and dryness is necessary to prevent maceration and secondary infection.

Protective padding, pillows, or sheepskin can be used to separate body surfaces. Bedding and clothing should be changed frequently. In incontinent patients, injuries should be protected from contamination; synthetic dressings can help.

Skin breakdown can be prevented with careful cleansing and drying patting and not rubbing the skin and using anticandidal creams and moisture barrier creams or skin-protective wipes.

Use of adhesive tape should be minimized, because it can irritate and even tear fragile skin. Areas subject to friction may be powdered with plain talc. Use of cornstarch is discouraged because it may allow microbial growth.

Most importantly, immobilization should be avoided. Sedatives should be minimized, and patients should be mobilized as quickly and safely as possible. Pressure injuries can develop secondary to immobilization and hospitalization, particularly in patients who are elderly, incontinent, or undernourished.

Base the risk of pressure injury on standardized scaling systems as well as on the assessment of skilled clinicians. Pressure injuries are staged according to depth, but tissue damage may be deeper and more severe than is evident from the physical examination.

Assess patients with pressure injuries for local wound infection sometimes manifesting as failure to heal , sinus tracts, cellulitis, bacteremic spread eg, with endocarditis or meningitis , osteomyelitis, and undernutrition. Treat and help prevent pressure injuries by reducing skin pressure, repositioning frequently, and using protective padding and support surfaces that can be dynamic powered electrically or static not powered electrically.

Apply transparent films or hydrogels if exudate is minimal , hydrocolloids if exudate is light to moderate , alginates if exudate is extensive , or foam dressings for various amounts of exudate. Treat pain with analgesics, local wound infection with topical antibiotics, and cellulitis or systemic infections with narrow-spectrum systemic antibiotics.

Help prevent pressure injuries in at-risk patients with meticulous wound care, pressure reduction, and avoiding any unnecessary immobilization. The following are some English-language resources that may be useful. American College of Physicians: Guidelines for preventing and treating pressure ulcers.

Braden Scale for predicting pressure sore risk. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world.

The Merck Manual was first published in as a service to the community. Learn more about our commitment to Global Medical Knowledge. I first became aware of the need for the type of visual aid described in this article when I noted that the coding system did not include all possible anatomic locations required for pressure ulcer diagnosis and documentation, forcing nurses to sometimes use inaccurate terminology when describing the location of pressure injuries in the buttocks area.

Within the context of this project, I operationally defined the buttocks as the portion of the posterior lower torso from just superior to the posterior iliac crests proximally to the gluteal creases distally. When selecting codes for location of pressure ulcers involving the posterior lower torso, clinicians are limited to the lower back including coccyx and sacrum , hip, and buttocks defined within the ICD [ International Classification of Disease, 10th Revision ] diagnosis manual as encompassing a large soft tissue area, which is a common site for friction injuries but a less common site for pressure ulcers, which usually occur over bony prominences 1 as well as laterality for the practitioner to choose from, but codes still lack specificity and anatomical correctness.

Despite and subsequent updates to the ICD , there are still no specific anatomical coding designations for the coccyx, ischial tuberosities, the posterior iliac crests, or the trochanters, all of which are common sites for pressure ulcer development. I noticed that practitioners nurses, physicians, APRNs, physician assistants frequently labeled many wounds on the buttocks the larger general surface area from the lower back to the posterior thighs as pressure ulcers.

I also observed multiple types of lesions on the buttocks, including pressure ulcers, moisture-associated skin damage MASD , psoriasis, and friction injuries. I became concerned that some wounds being diagnosed as pressure ulcers were caused by factors other than pressure and shear, and that anatomic locations were being incorrectly identified, partially based on limitations in the ICD coding system then in use.

After realizing that colleagues and I were not describing and diagnosing many wounds similarly, I decided to look for a visual aid to narrow the communication gap.

I initially spoke with WOC nurse colleagues within my facility to determine if they were aware of a visual aid to correctly identify the anatomic location of wounds located on the buttocks and differentiate between bony prominences and soft tissue areas. They were not aware of any such visual aids. They provided support for the idea of creating a visual aid and agreed with my concerns about incorrect diagnoses of buttocks lesions often encountered in clinical practice.

I then completed a Google Image search; I found general anatomical illustrations but nothing specific to my objectives. I also searched Netter Images 4 but did not find a detailed surface anatomy of the buttocks.

This search was based on the key terms "surface anatomy," "skin," "buttocks," and "gluteal area. When these searches failed to produce a useful visual aid, I revisited an article I published in the Journal that described a case series of patients with friction injuries.

I began by locating photos of several patients' buttocks areas; all identifying markers and dates were removed. Using verbal descriptors from Gray's Anatomy, 6 I drew markings to indicate the different areas of the buttocks based on the location of bony prominences, and I added soft tissue and skin crease locations to complete the initial aid Figure 1.

My daughter, who is a graphic designer, provided substantial assistance in the development of this image. I sent the initial draft to a member of our Department of Anatomy at the University of Nebraska College of Medicine, who kindly responded with suggestions that were used to improve the visual aid, including terminology changes for anatomic accuracy and consistency. The figure was then shown to 2 prominent plastic surgeons in the community who are wound experts; they agreed with the anatomical markings and labels and offered some aesthetic suggestions, which were used to further improve the visual aid.

Lastly, the image was shown to my WOC colleagues and internationally known wound experts on pressure ulcer. Their comments were favorable with only a few minor additional aesthetic changes; no significant changes were made to the anatomical designations or labeling.

The final aesthetic edits were made and a PDF file was created and submitted to our skin wound advisory team, who agreed to place the image in our electronic record to be used by all staff for documentation of wounds on the buttocks surface area. I believe that its incorporation into their documents enables more accurate identification and classification of multiple injuries of the buttocks such as pressure ulcers, friction injuries, and MASD. I have discussed this issue with many clinicians and found that many providers code based on their personal beliefs or preferences since specific locations are not available in the current coding system.

Because of this limitation, it is not possible to accurately identify how many pressure ulcers occur on the sacrum versus the coccyx, versus the posterior iliac crests, versus the ischia, versus the gluteal areas. Accurate identification of wound location also influences the assessment of wound etiology. For example, suspicion of a pressure ulcer is heightened when it occurs over a bony prominence, while MASD is considered more likely when skin damage follows the path taken by urine or stool in the incontinent person.

Therefore, the ability to accurately identify anatomical location would be helpful to all clinicians in making appropriate diagnoses and implementing appropriate management plans. Accurate determination of location and etiology also may reduce the risk of withheld reimbursement due to inaccurate labeling of a moisture or friction wound as a pressure ulcer.

Accurate description of wound location is an important element of wound assessment, and a contributing factor to correct determination of wound etiology.