Prevention and Management of Heel ulcer in Orthopedics

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The Danger of Heel Ulcers

Pressure ulcers and, in particular, heel ulcers are common facility-acquired skin tissue injuries that occur most frequently among immobile patients in long-term, acute care facilities. Surgical patients are among the most susceptible. Heel ulcers are painful and physically debilitating. Left untreated, they can lead to serious complications, such as infection, cellulitis, osteomyelitis, septicemia, limb amputation, or death, and can increase healthcare and litigation costs.

 

Prevalence of Heel Pressure Ulcers

Ulcers Heel pressure ulcers occur as the result of direct sustained pressure from lying in a bed. Of particular concern is skin tissue that is compromised by maceration, friction or dryness. Long-term care facilities report incidences of pressure ulcers among patients as high as 27%, with 23% of the reported cases being heel pressure ulcers. Mortality rates are higher among patients with pressure ulcers, especially elderly patients.

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WHY IS the HEEL at RISK of ULCERATION?

Bony prominences — of which the heel is one — are particularly prone to pressure ulcers (heels are the second most common location for ulcers)

The foot is load-bearing, and the heel is the focal point of the weight borne by the foot

The calcaneus heel bone is not well-protected; there are just 3.8mm between the bone and the skin

When mobilising, the heel region is subject to both internal and external forces

The Achilles tendon has little blood supply, making the area vulnerable particularly in the vascularly compromised (eg peripheral arterial disease).

Arterial blood flow to the heel is supplied by the lateral and medial plantar artery and the medial calcaneal branch of the posterior tibial artery . Differences in blood flow to the heel is seen in patients with ankle-brachial indices lower than 0.8. Blood flow, via transcutaneous oxygen levels to the heels, was tested in patients who underwent hip-replacement surgery and had elastic support stocking and sequential compression devices on the legs. Transcutaneous oxygen levels were lower in both heels, and more so in the operative limb during periods of pressure loading and when pressure was removed (unloading)

Heel Ulcer

WHO IS at RISK of ULCERATION?

Patients with:

Diabetes, which makes fat pads less pliable and less able to regain shape and position after impact.

Reduced mobility, or who are immobile.

Poor perfusion/vascular compromise and/or renal disease n Fragile skin (eg the elderly)

Neuropathy or conditions that cause involuntary movements (eg Parkinson’s disease), which can result in not being aware of damage to the heel .

Large, oedematous limbs and/or thin, bony feet

Abnormal foot anatomy (eg high plantar arches or amputated toes).

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WHY ARE HEEL ULCER DIFFICULT to MANAGE?

Pain makes mobility and even bed rest difficult due to ulcer location

Poor perfusion is inherent in the anatomy

Moderate to high levels of exudate mean leakage is a common problem requiring management with an absorbent dressing to prevent maceration

The wound is awkwardly positioned and often irregularly shaped and Dressings might not stay in place due to ulcer location and exudate levels.

 

Management of heel ulcer 

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Heel ulcer

Due to the risk of ulceration to the heel, the high number of cases of heel ulcer and the poor chance of recovery, precautions need to be taken for all patients at bedrest. Effective Heel Ulcer Prevention The most effective way to prevent and treat heel pressure ulcers is to reduce the direct pressure applied to the heel when a patient is lying in a prone position. This is typically achieved with a heel offloading boot, also known as a suspension boot. Using a heel offloading booth affords the following advantages:

  • Heel elevation in a zero pressure environment
  • Forefoot support to prevent heel cord contracture
  • Ventilation holes and an open leg and forefoot promote air circulation and increase patient comfort
  • Proper positioning to avoid hip rotation

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Treating Heel  Ulcer

Treatment of existing heel pressure ulcers may also include the following:

• Cleansing with saline or potable water; surfactants and/or antibacterial agents of low tissue toxicity can be appropriate where debris or bacterial colonization is present.

  • Debridement of devitalized tissue should be followed by maintenance debridements.
  • Dressing to keep the wound bed moist and the peripheral skin dry.
  • Topical antibiotics may be appropriate for tissue infections or bioburdens. Systemic antibiotics are indicated for patients with systemic infection or osteomyelitis
  • Surgery to apply skin grafts may be an appropriate choice to speed closure/epithelialization of clean granulating heel pressure sores.

Heel-with-stable-eschar

” Do Not debride Heel eschar till limb arterial status is investigated. If Ankle brachial pressure index less than 0.5 DO NOT DEBRIDE unless infected and draining pus or underlying abscess” 

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“Use Heal conforming Foam dressing for  Heal ulcer to manage exudate and also provide offloading”

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