Bed Sores in Unusual Places (Heel, Scalp, Upper Back, Knee)

Development of Bed Sores

Bed sores, or pressure ulcers, can develop on unusual parts of the body, such as the heel, scalp, upper back, and knee, when a patient remains in the same position on a bed for an extended period. These bed sores can appear on one side or both sides of the body. Typically, bed sores in these locations develop when the patient is malnourished and debilitated. These pressure sores often coexist with bed sores in more common locations, such as the sacrum, ischium, and trochanteric region.

• Bedsores over these places develop usually when the patient is very malnourished and debilitated.
• Usually, pressure sores over these places develop with coexistent bed sores over the sacrum , ischium , and trochanteric region.
• When the patient is nursed in a straight supine position, the chances of developing bed sores over the heel, upper back, and scalp are high.
• When the patient is nursed in a prone position, the chances of developing bed sores over the forehead, knee, and chest are high.

When Do People Get Bed Sores in Unusual Locations?

Bed sores in unusual locations often occur when the patient is seriously ill and unable to move due to factors such as paralysis, trauma, fractures, old age, or prolonged hospitalization, especially in the ICU or on a ventilator.

Categories of Bed Sores

Bed sores are categorized based on the extent of damage:

• Category I: Generalized redness over the pressure areas.
• Category II: Partial loss of skin, similar to an injury from forceful rubbing.
• Category III and IV: Full-thickness loss of skin and muscle in category III, with exposed bones in category IV.

Regardless of the stage, relatives or attendants should consult a plastic surgeon immediately to prevent further progression.

Treatment at Kayakriti

For Categories I and II Bed Sores:

Patients with Category I or II bed sores may not require admission if other comorbidities and factors are well controlled. They are educated about wound management and are given specific dressings and oral antibiotics. Follow-up is typically scheduled every week initially and later once or twice a month for three months after complete healing.

For Categories III and IV Bed Sores:

Patients with Category III or IV bed sores require hospital admission. A comprehensive evaluation of their nutritional status and surgical fitness is conducted. After admission, a pre-anesthetic checkup is performed. Clearances from specialists, such as neurologists, cardiologists, and physicians, are obtained to ensure surgical fitness. Once the patient is vitally stable and medically cleared, surgical correction is planned.

• Single-Stage Surgery: In most cases, a single-stage surgery is performed. This involves proper debridement, total excision of the bed sore, removal of the infected portion of the underlying bone, and definitive flap cover in the same sitting.
• Local Flap Closure: The wound is usually closed with local flaps, utilizing skin and soft tissue from the surrounding normal area. Common flaps used for closure include transposition flaps, rotation flaps, V to Y advancement flaps, and others. Dr. Amit Agarwal offers various flap options for the coverage of pressure sores at these unusual locations.

A suction drain is also placed under the flap to drain any fluid collected underneath and prevent the formation of a cavity between the wound and the flap.

In some cases, two-staged surgery may be required.

Recovery After Surgery

• After surgery for bed sores in unusual locations, patients are nursed in a prone position, and an air mattress is used.
• Proper hygiene must be maintained, Foley catheterization is performed, and the flap is regularly monitored for any color changes or signs of infection.
• Patients are placed on a soft diet for a few days to reduce the frequency of stools.
• Dressing changes are conducted every alternate day, and patients are typically kept in the hospital for at least one week.
• The suction drain is removed once the drainage is reduced to less than 10-15 ml in 24 hours. Sutures are removed after 2 weeks.
• Once the flap has settled, and the patient is vitally stable, discharge is planned.

Patients receive instructions for home care, including the use of an air mattress, hygiene practices, and regular side-to-side turning. Follow-up visits are scheduled after one week and later once or twice a month for three months.