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ABC of wound healing: Pressure ulcers

BMJ 2006; 332 doi: (Published 01 June 2006) Cite this as: BMJ 2006;332:0606226
  1. Joseph E Grey, consultant physician1,
  2. Stuart Enoch, research fellow of the Royal College of Surgeons of England2
  1. 1University Hospital of Wales, Cardiff and Vale NHS Trust, Cardiff
  2. 2Keith G Harding director, Wound Healing Research Unit, Cardiff University

A pressure ulcer is defined by the European Pressure Ulcer Advisory Panel (EPUAP) as an area of localised damage to the skin and underlying tissue caused by pressure, shear, or friction, or a combination of these. Pressure ulcers are caused by a local breakdown of soft tissue as a result of compression between a bony prominence and an external surface.

They usually develop on the lower half of the body: two thirds around the pelvis and a third on the lower limbs, with heel ulceration becoming more common. Elderly people are the most likely group to have pressure ulcers; this is especially true for those older than 70 years, up to a third of whom will have had surgery for a hip fracture. Those with spinal injuries form another distinct group, in whom the prevalence is 20-30% one to five years after injury.

Most pressure ulcers arise in hospital, where the prevalence among inpatients is 3-14%, although it can be as high as 70% in elderly inpatients with orthopaedic problems. The incidence of pressure ulcers in hospitals is 1-5%. In patients who are confined to bed or to a chair for more than one week, the incidence rises to almost 8%. In long term healthcare facilities 1.5%-25% of patients develop pressure ulcers. Almost a fifth of pressure ulcers develop at home and a further fifth in nursing homes. The prevalence of pressure ulcers in nursing homes is not much higher than in hospitals. Pressure ulceration in elderly patients is associated with a fivefold increase in mortality, and in-hospital mortality in this group is 25-33%. Estimates of the cost of pressure ulceration to the NHS range from £180m ($318m; a265m) to nearly £2bn a year.


The four main factors implicated are interface pressure, shear, friction, and moisture. When pressure of short …

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