Intended for healthcare professionals

Endgames Picture Quiz

Skin defect in a bedbound patient

BMJ 2011; 342 doi: (Published 18 May 2011) Cite this as: BMJ 2011;342:d874
  1. Alex W N Reid, clinical fellow, plastic surgery1,
  2. Odhran P Shelley, consultant, plastic surgery2
  1. 1Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
  2. 2St Andrew’s Centre for Plastics and Burns, Chelmsford, Essex, UK
  1. Correspondence to: AWN Reid awnr2{at}

A 54 year old man with multiple sclerosis which has rendered him quadriplegic, bedbound, and doubly incontinent was referred to the outpatients department with a non-healing skin defect in the presacral area (figure), which he said had been present for four years. He had no other comorbidities. He previously smoked 20 cigarettes a day for 10 years.

He was otherwise well, pain free, and having silver-alginate dressings applied by the district nurses in the community. He had not had any skin complications in the recent past.

Skin defect in the presacral area of a 54 year old man with multiple sclerosis


  • 1 What is the lesion?

  • 2 How are these lesions graded?

  • 3 How can these lesions be prevented?

  • 4 How would you manage this lesion? When would surgery be indicated?

  • 5 There are no clinical signs of infection but wound swabs grow Escherichia coli. Is this an infection?


1 What is the lesion?

Short answer

This is a sacral pressure ulcer: the photo shows that it is a clean shiny ulcer with undermined edges.

Long answer

Pressure ulcers are soft tissue injuries caused by unrelieved pressure over a bony prominence.1 Ischaemia occurs when external pressure exceeds the capillary pressure (normally 12-32 mm Hg). The higher the external pressure, the shorter the duration needed for soft tissue injury.1 Pressure relief is therefore essential for treatment.2 Shear and friction may cause additional trauma to the skin,2 and excessive moisture is an aggravating factor because it causes maceration of the epidermis.

Some pressure ulcers are known as “decubitus ulcers,” but these ulcers develop over bony prominences while the patient is in the …

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