Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Heel Sores

Basics
Description
  • Heel sores occur when the skin over the heel breaks down because of pressure.
  • Generally caused by prolonged lying in bed, as in patients in intensive care units or nonambulatory bedridden individuals
  • Also can occur in a patient in a lower extremity cast
  • Classification by depth is used most commonly.
    • Stage I: Nonblanchable erythema of the skin, intact epidermis
    • Stage II: Partial-thickness skin loss involving the epidermis and possibly the dermis; may involve cracking or blistering of the skin
    • Stage III: Full-thickness skin loss extending to but not through the fascia
    • Stage IV: Extensive full-thickness ulceration extending to bone, tendon, or other deep structures
  • Synonyms: Bedsores; Heel or foot ulcers
Geriatric Considerations
Geriatric patients are at high risk for heel sores because of their thinner skin and their higher probability of being immobilized in bed.
 
General Prevention
  • Instruct patients and nursing staff to prevent progression of early partial-thickness lesions.
  • Avoid prolonged periods of recumbency in the same position.
    • Bed-bound patients should be repositioned frequently and have their heels elevated off the bed.
  • Do not allow patients in casts to rest on their heels for lengthy periods.
Epidemiology
  • One of the most common complications in the postoperative or rehabilitative setting
  • More common in elderly or debilitated patients
Incidence
In hospitalized patients, the incidence of heel ulcers is reported to be up to 18% .
 
Risk Factors
  • Diabetes mellitus
  • Lower extremity neuropathy
  • Lower extremity vascular disease
  • Poor nutrition
  • Nonambulatory
  • Bed-bound status
Etiology
  • Direct pressure from the weight of the foot and shear forces from movement create trauma to the heel’s capillary bed and small vessels, which can lead to local ischemia and tissue necrosis.
  • These sores generally occur in patients who have limited mobility, neuropathic skin, vascular disease, or diabetes.
  • They also can occur in postoperative patients with limited mobility who are bed-bound and are subjected to prolonged pressure over the heels.
  • They may occur in patients with casts because of excess pressure or decreased padding.
Associated Conditions
  • Paralysis
  • Diabetes mellitus
  • Loss of sensation/neuropathy
  • Contracture
Diagnosis
Signs and Symptoms
History
  • Initially presents as pain and softening over the heel region
  • May occur without the warning symptom of pain in the patient with decreased or impaired sensation
  • Particular attention should be paid to at-risk individuals, including immobilized patients or those with predisposing risk factors.
Physical Exam
  • The skin over the heel should be inspected for changes, including signs of early alteration (erythema) or more progressive injury (cracks, ulcers, and skin breakdown).
  • The heel may be tender to palpation, even if no obvious skin changes are present.
    • A dark purple or red lesion that does not blanch with pressure is a sign that breakdown will occur eventually.
  • More advanced lesions will have increasing levels of damage, including exposure of tendon and bone in stage IV lesions.
  • The wound should be inspected for surrounding cellulitis and purulent drainage.
  • Pain with ROM of the foot or ankle joints may suggest joint involvement and septic arthritis.
  • A thorough motor and sensory examination should be performed.
Tests
Lab
  • If the wound appears infected, check the complete blood count, differential, ESR, and C-reactive protein.
  • If poor nutrition is suspected, albumin and prealbumin levels should be checked.
Imaging
  • Radiography:
    • Routine AP and lateral foot and ankle films are helpful in distinguishing bone destruction and osteomyelitis.
    • Superficial soft-tissue breakdown may show no radiographic change.
  • Suspected osteomyelitis should be evaluated with MRI and/or tagged white-blood cell nuclear medicine imaging.
Diagnostic Procedures/Surgery
  • Areas of necrotic tissue should be debrided to enhance healing and to determine the full extent of the ulceration.
  • Progression of these ulcerations to osteomyelitis and systemic infection may necessitate more aggressive debridement or amputation.
Pathological Findings
  • Heel sores are caused primarily by ischemia from prolonged pressure over the heel.
  • As the ischemia and pressure persist, the skin and soft tissues overlying the heel become necrotic, break down, and ulcerate.
  • In chronically debilitated and diabetic patients, these lesions easily become infected and can eventually result in osteomyelitis or septic arthritis.
Differential Diagnosis
  • Osteomyelitis
  • Soft-tissue abscess
  • Cellulitis
  • Fracture
  • Septic arthritis
Treatment
General Measures
  • Prevention is key: At-risk patients must be instructed in meticulous foot care and shoe selection.
    • Bed-bound patients need good heel padding and frequent turning.
  • Patients with diabetes or neuropathy should wear appropriate shoes and perform daily inspection of the feet.
  • Treatment should be initiated at the earliest signs of skin breakdown.
  • Superficial heel sores generally respond to pressure relief and padding over the affected area.
  • Deeper ulcerations generally require surgical debridement and may require removal of infected bone or partial amputation.
  • Broad-spectrum antibiotics are indicated for infected ulcers.
    • Such infections often are polymicrobial, including aerobic, anaerobic, and Gram-negative species.
  • Patients in casts complaining of heel pain should have the cast removed to assess the skin adequately.
Nursing
  • The nursing staff is critical to the prevention of heel ulceration.
    • Prevention is assisted by changing patient position and removing pressure from the heels.
    • The presence of heel ulcers should be identified and conveyed to physician staff for treatment.
Special Therapy
Physical Therapy
  • Whirlpool therapy to debride necrotic tissue may be helpful.
  • Physical therapists can be integral in monitoring for pressure relief.
Medication
Antibiotics with broad-spectrum coverage are required to manage the polymicrobial infections associated with these types of foot ulceration.
 
Surgery
  • Generally, soft-tissue debridement of the affected tissues is indicated.
  • This debridement usually can be done in an outpatient or clinic setting.
  • Extensive necrotic tissue or the presence of osteomyelitis may require formal surgical debridement in the operating room.
Follow-up
Disposition
Issues for Referral
  • Because poor nutrition may contribute to the formation of ulcers and may inhibit healing, a nutrition consultation should be considered.
  • Consulting a wound care specialist also may be helpful.
Prognosis
  • Stage I and Stage II ulcers have a good prognosis.
  • Stage III and Stage IV ulcers have a poorer prognosis.
  • Prognosis also depends on the severity of underlying disease, patient age (younger is better), presence of deep infection, activity level (e.g., bedridden), and nutritional deficit.
Complications
  • Osteomyelitis
  • Septic arthritis
Patient Monitoring
Heel ulcers should be monitored closely because patients are at high risk for disease progression if the ulcer is not treated aggressively.
 
Miscellaneous
Codes
ICD9-CM
707.13 Decubitus ulcer of heel
 
Patient Teaching
Patients at risk for heel sores should be educated in foot care and shoe selection.
 
Prevention
  • Prevention is key: Careful attention should be paid to the heels of at-risk patients, including those bed-bound, diabetic, neuropathic, and with casts.
  • Bed-bound patients should be rotated frequently.
  • Patients with early changes or heel pain should be treated aggressively with removal of pressure from the heels.
  • Patients’ heels should be well padded when casts are applied.
FAQ
Q: What can be done to prevent heel ulcers?
A: Heel position should be changed frequently and patients should be monitored for early signs of ulceration.
 
Q: Which patients are at risk for heel ulcers?
A: Patients who are bed-bound or who have a history of vascular disease, diabetes, or neuropathy are at high risk. People who have casts also are at increased risk.
 
Q: What should be done for patients who have ulcers?
A: The pressure should be removed from the heel. Any necrotic tissue should be debrided. Patients with signs of infection should be treated aggressively with antibiotics. Deep ulcerations and infections may require surgical management.

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