College of  LONG TERM CARE

This is a dry eschar of the heel. The eschar acts as a biologic dressing and should not be debrided, unless there is underlying infection as noted by draining pus. Patients who have lower extremity ulcers of any kind should always have peripheral arterial disease, venous insufficiency, and diabetic disease ruled out as a a cause prior to classifying the wound as a pressure ulcer. The appropriate assessment for vascular disease can be seen below. Recommended treatment is to offload the heel with proper devices or pillows. Heel protectors are not a recommended form of offloading. The site should be kept clean, dry, and intact. Certain dressings and ointments can be used on these wounds which include but are not limited to 1. Granulex, 2. Xenaderm, 3. Proderm, 4. Betadiene (controversial), 5. Iodosorb (controversial), or cover with gauze without ointments or creams.

Prevalon boots are appropriate offloading devices for lower extremity wounds, as they remove pressure contact from the surface of the heel and malleolus.

Dry Gangrene of the lower extremity and distal toes must be managed carefully, as it can rapidly decline into wet gangrene, which is life threatening. In general Dry Gangrene is a localized process without evidence of cellulitis, no purulent drainage, no evidence of systemic infection, with fever, or septic symptoms. Dry gangrene can be managed expectantly, but may decline. Wet gangrene must be treated with systemic antibiotics and removal of infection either with amputation or aggressive debridement. Proper treatment for Dry Gangrene is to protect the area from trauma, and can be managed by keeping the area dry and clean. Because the majority of these wounds result from vascular disease, all pressure should be removed with specialized cages for bed sheets, do not use socks, etc.

Palpation of Medial Malleolus pulse to assess for clinical arterial disease. The medial malleolar artery is located  behind the tendons of the extensor hallucis longus and tibialis anterior muscles, to the medial side of the ankle.

Heel protectors are not an appropriate offloading device, as they do not offload the heel from the mattress surface.

This is a blood filled blister of the heel. Blood blisters are classified as suspected Deep Tissue Injury according to the NPUAP guidelines. In general these should not immediately be classified as pressure ulcers, as they may be caused by underlying vascular or diabetic disease. A proper assessment and work-up must be done prior to diagnosis. These blisters should not be popped, opened, or unroofed. They must be left intact, clean, and dry. Certain dressings and ointments can be used on these wounds which include but are not limited to 1. Granulex, 2. Xenaderm, 3. Proderm, 4. Betadiene (controversial), 5. Iodosorb (controversial), or cover with gauze without ointments or creams.

Great care must be taken when applying wound dressings in the form of kerlix gauze wraps to wound dressings. If the wrapping is too tight it may cause further arterial occlusion and the formation of additional wounds.

Assessment of the dorsalis pedis pulse is an important component in determining the etiology of the lower extremity chronic wound. The dorsalis pedis artery can be palpated or found lateral to the extensor hallucis longus tendon on the dorsal surface of the foot, distal to the navicular bone.

Diabetic foot ulcers are notoriously difficult to heal. Diabetes is a disease which leads to insulin resistance and elevated blood sugars. Over time the disease causes medium and small sized arterial calcification, visual impairment, sensorimotor decline, and impaired immunity. Diabetic ulcers result from trauma in patients who have advanced diabetes. The wounds must be protected and kept clean. Diabetes is the leading cause of amputations in the United States. Poorly controlled blood sugars can lead to further worsening of lower extremity diabetic ulcers. The wound above is a chronic wound with 100% granulation tissue in the wound and a calloused edge. Calloused edges are a result of over growth of keratinocytes, important wound healing cells. These edges must be sharply debrided for ingrowth of new tissue. In addition healthy granulating tissue beds like those above can be treated with hydrogels, collagens, and other dressings. Regranex, Platelet Derived Growth Factor, is an optional FDA approved ointment for healing diabetic ulcers.