Pressure Sores

A 76-year-old immobile woman in a long-term care facility has intact sacral skin with persistent dark maroon discoloration that does not blanch. The area is painful and boggy, but there is no open wound or visible blister. What is the most accurate diagnosis and initial management?

A 68-year-old paraplegic man presents with a sacral ulcer covered by thick black eschar. He has fever, tachycardia, foul drainage, surrounding erythema, and fluctuance extending beyond the visible wound. What is the most appropriate next management step?

A 59-year-old man with spinal cord injury has a chronic stage 4 ischial pressure ulcer that probes to bone. Magnetic resonance imaging suggests osteomyelitis, but there is no acute sepsis. He is being considered for definitive flap reconstruction. What is the most reliable method to confirm the diagnosis and guide antimicrobial treatment?

A 62-year-old paraplegic man has a clean stage 4 sacral pressure ulcer after serial debridement. He continues to smoke, has severe protein-calorie malnutrition, frequent fecal contamination, and cannot reliably follow a pressure-relief program. What is the most appropriate next step?

A 57-year-old paraplegic woman undergoes excision of a chronic sacral pressure ulcer, including the surrounding scarred bursa and prominent devitalized bone. The defect is broad but shallow, and local gluteal tissue is available. What is the most appropriate reconstruction?

A 54-year-old wheelchair-dependent man has a recurrent ischial pressure ulcer after a previous posterior thigh flap. Examination shows a deep bursa extending beneath the ischial tuberosity with a narrow skin opening and substantial dead space. What is the most important operative principle?

A 61-year-old paraplegic man presents with a stage 4 trochanteric pressure ulcer. After debridement, the greater trochanter is exposed and a large cavity extends beneath the surrounding skin. What is the most appropriate reconstructive approach?

An 80-year-old bedbound woman has a dry, firmly adherent black eschar over the heel. There is no erythema, drainage, fluctuance, edema, or systemic infection, and arterial assessment shows severely impaired distal perfusion. What is the most appropriate management?

A 65-year-old man has a stage 4 sacral pressure ulcer that is clean after debridement but is repeatedly contaminated by uncontrolled fecal incontinence despite an organized bowel-care program. A large flap reconstruction is planned. What is the most appropriate management?

A 58-year-old paraplegic woman undergoes flap reconstruction of an ischial pressure ulcer. On postoperative day 3, the flap is viable and the incision is intact. She asks to resume wheelchair sitting because she has no pain. What is the most appropriate postoperative plan?

A 71-year-old bedbound man has a shallow sacral ulcer with partial-thickness skin loss and a pink moist wound bed. No adipose tissue, slough, granulation tissue, or deeper structures are visible. What is the correct pressure-injury stage and most appropriate initial management?

A 63-year-old paraplegic man has a chronic ischial pressure ulcer with copious drainage. Examination shows a 2-cm skin opening, but a probe passes 9 cm beneath the surrounding skin toward the ischial tuberosity. What is the most appropriate next step in defining the wound before reconstruction?

A 56-year-old man with a spinal cord injury has a chronic sacral ulcer and severe lower-extremity spasticity. Repeated involuntary movements create shear across the wound and have caused two previous flap dehiscences. What is the most appropriate management before another reconstruction?

A 74-year-old woman with advanced dementia is bedbound and has a clean stage 3 trochanteric pressure injury. She has severe frailty, progressive weight loss, limited life expectancy, and cannot participate in a prolonged postoperative offloading program. What is the most appropriate treatment plan?

A 60-year-old paraplegic man has a chronic stage 4 ischial ulcer. After radical debridement, the ischial tuberosity remains prominent but appears viable and is not infected. What is the most appropriate bone-management principle?

A 67-year-old woman has a stage 4 sacral pressure ulcer after debridement. The wound is clean and granulating, with no exposed major vessel, untreated necrosis, or active osteomyelitis. Definitive flap surgery must be delayed for medical optimization. What is the most appropriate interim wound-management option?

A 58-year-old man with paraplegia has a recurrent sacral pressure ulcer after two previous local flap procedures. During planning, the surgeon notes that several additional regional flap territories remain unused. What is the most appropriate reconstructive principle?

A 64-year-old wheelchair user presents with recurrent bilateral ischial ulcers. Pressure mapping shows extreme focal loading under both ischia caused by a poorly fitted wheelchair and a collapsed cushion. What is the most important intervention before definitive flap reconstruction?

A 55-year-old paraplegic man undergoes flap closure of a trochanteric pressure ulcer. On postoperative day 6, the incision begins draining cloudy fluid, and the flap becomes erythematous and tender. Ultrasound shows a deep collection beneath the flap, but the flap remains perfused. What is the most appropriate next management step?

A 61-year-old man with a chronic sacral pressure ulcer has urinary incontinence that repeatedly macerates the wound despite absorbent products and scheduled bladder care. He is being evaluated for flap reconstruction. What is the most appropriate management before surgery?

A 69-year-old bedbound woman has intact sacral skin with nonblanchable erythema that remains red after pressure is relieved. There is no blister, ulceration, maroon discoloration, or palpable fluctuance. What is the most accurate diagnosis and initial management?

A 58-year-old paraplegic man has a chronic sacral wound completely covered by moist yellow slough. The true depth cannot be visualized, and no bone or tendon is exposed. What is the correct classification?

A 64-year-old wheelchair-dependent man presents with a chronic stage 4 ischial pressure ulcer. He has fever, foul drainage, leukocytosis, and crepitus extending into the perineum. The skin surrounding the ulcer is dusky and rapidly worsening. What is the most appropriate next management step?

A 55-year-old paraplegic man has a recurrent ischial pressure ulcer and severe hip flexion contractures that prevent neutral positioning. Previous flap closure failed because the reconstructed area remained under constant tension and pressure. What is the most appropriate management before another flap procedure?

A 72-year-old man with peripheral arterial disease has a lateral malleolar pressure ulcer with dry necrosis and weak pedal pulses. There is no cellulitis or systemic infection. Flap reconstruction is being considered. What is the most appropriate next step?

A 60-year-old paraplegic woman has a clean stage 4 ischial pressure ulcer and is nutritionally optimized. She has a chronic suprapubic catheter and a reliable bowel program. During evaluation, she reports daily cigarette smoking and refuses cessation. What is the most appropriate recommendation?

A 57-year-old man undergoes flap closure of a sacral pressure ulcer. On postoperative day 2, the flap becomes pale and cool with delayed capillary refill, and the distal suture line is under visible tension. What is the most appropriate next management step?

A 62-year-old paraplegic man presents six months after successful ischial flap reconstruction with a small recurrent ulcer at the flap margin. Pressure mapping shows that he performs wheelchair pressure relief only once every three hours. What is the most important management intervention?

A 65-year-old bedbound woman has a sacral pressure wound with exposed subcutaneous fat and granulation tissue. Fascia, muscle, tendon, cartilage, and bone are not visible or directly palpable. There is no obscuring slough or eschar. What is the correct stage?

A 59-year-old paraplegic man has a chronic recurrent sacral pressure ulcer. During debridement, the surgeon finds extensive scarred pseudobursa, necrotic tissue, and a sharp sacral bony prominence. What is the most appropriate operative strategy before flap inset?

A 63-year-old paraplegic man has had a sacral pressure ulcer for 12 years. During the past three months, the wound has developed a raised irregular edge, increased bleeding, malodor, and progressive enlargement despite appropriate offloading and wound care. What is the most appropriate next management step?

A 58-year-old paraplegic woman undergoes gluteal flap reconstruction of a sacral pressure ulcer. Six hours later, the reconstructed area becomes rapidly swollen and tense, the drain fills with fresh blood, and the distal flap becomes congested. Her blood pressure is falling. What is the most appropriate next management step?

A 66-year-old man with a stage 4 ischial pressure ulcer is referred for flap closure. He has lost 12% of his body weight in three months, reports poor oral intake, and has marked muscle wasting. The wound is clean and there is no acute infection. What is the most appropriate next step?

A 70-year-old man with diabetes has a stage 4 heel pressure ulcer with exposed calcaneus and biopsy-confirmed localized osteomyelitis. Vascular studies show adequate perfusion for healing, and he has useful ambulatory potential. What is the most appropriate limb-preserving management?

A 42-year-old man with a spinal cord injury above T6 undergoes bedside debridement of a sacral pressure ulcer. During the procedure, he develops sudden severe hypertension, pounding headache, facial flushing, sweating, and bradycardia. What is the most appropriate immediate management?

A 55-year-old paraplegic man develops a third recurrence of an ischial pressure ulcer after technically successful flap reconstruction. Video assessment shows that he repeatedly drags his pelvis across the wheelchair during transfers, creating substantial shear at the flap margin. His cushion and sitting schedule are otherwise appropriate. What is the most important intervention before another reconstruction?