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Clinical Summary

Decubitus ulcers develop when soft tissue is compressed between a bony prominence and a hard external surface. Tissue compression results in decreased blood flow, tissue ischemia, and cell death. Pressure, shearing forces, friction, and excessive moisture contribute to formation. Areas commonly affected include the sacrum and heels. Immunocompromised, nursing home, neurologically impaired, and immobilized trauma patients are at high risk.

Stage I ulcers are characterized by an area of nonblanchable erythema over intact skin. Stage II appears as a shallow, open sore with a pink wound base. When the wound is full thickness with no muscle, tendon, or bone exposed, it is defined as stage III. If muscle, tendon, or bone is exposed, it is stage IV. Some wounds may have an area of black eschar over them; these wounds cannot be categorized since injury depth cannot be determined.

Management and Disposition

Prevention is key. All patients who have decreased mobility, such as trauma and nursing home patients, should have their entire skin surface regularly checked for skin breakdown and should be repositioned frequently. Backboards, c-collars, and other immobilizing devices should be removed as soon as possible.

Treatment includes pain relief, keeping the affected area clean, and keeping pressure off the area to prevent further tissue destruction. There are multiple commercial products available (hydrocolloid dressings) to use for the treatment of pressure ulcers. Frequent monitoring is required, and consultation with wound care specialists or a surgeon may be necessary for advanced ulcers. The main complications of decubitus ulcer formation include infection and skin dehiscence.

FIGURE 18.56

Stage II Decubitus Ulcer. Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. (Photo contributor: Suzanne Dooley-Hash, MD.)


  1. Decubitus ulcers are divided into four stages. If an eschar is present, the ulcer cannot be categorized.

  2. Remove hard external surfaces and immobilizing devices as soon as possible.

FIGURE 18.57

Stage III Decubitus Ulcer. Stage three decubitus ulcers extend into the subcutaneous tissue. (Photo contributor: David Effron, MD.)

FIGURE 18.58

Stage IV Decubitus Ulcer. Full-thickness tissue loss with exposed muscle. (Photo contributor: Lawrence B. Stack, MD.)

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