Technology and product reviews T E C H N O L O G Y U P D A T E :


Preventing pressure ulcers occurring on the heel


Author: Joyce Black


Pressure ulcers are defined as localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in conjunction with shear. An important change to this definition is the elimination of friction as a cause of pressure ulcers. Patients can develop friction injury to the heel from the constant movement of the heel on their bed linen. The change to this definition stems from an understanding that frictional forces are superficial and lead to heat in the tissues, producing serum-filled blisters; friction does not involve pressure. Shear forces — the combination of pressure and movement — can and do lead to pressure ulcers.


INTRODUCTION In a large, cross-sectional survey focusing on pressure ulcer prevalence (104,266 patients), heel pressure ulcers were found to occur in 18.2% of cases[1]


. This number References


1. Van Gilder C, Lachenbruch C, Harrison P, Davis D. Overall results from the 2011


International Pressure Ulcer


Prevalence Survey. Presented at the Wound Ostomy and


Conticence Nursing Conference, 2012


2. Van Gilder C, Macfarlane GD, Meyer S. Results of nine


international pressure ulcer prevalence surveys: 1989 to


2005. Ostomy Wound Manage 2008; 54(2): 40–54.


3. Salcido R, Lee A, Ahn C. Heel pressure ulcers: Purple heel and deep tissue injury. Adv Skin Wound Care 2010; 24(8): 374–80.


4. Padula W, Mishra M, Makic M, Sullivan P. Improving quality of pressure ulcer care with prevention: A cost effective


analysis. Med Care 2011; 49(4): 385–92.


5. Brown G. Long-term outcomes of full-thickness pressure ulcers: healing and mortality. Ostomy Wound Manage 2003; 49(10): 42–50.


may seem lower than past estimates of heel ulcer prevalence — however, in this study pressure ulcers in 25 anatomical sites were recordedand ulcers that in the past were attributed to the heel were in fact shown to be located on other sites on the lower limb. Earlier data from a similar cross-sectional


survey on heel ulcers, this time with fewer patients (85,838), recorded prevalence ranging from 23–28.9% and incidence ranging from 23.6–26.1%[2]


most common site for deep tissue injury (DTI)[3]


41% of all DTIs[2]


comprised 394,699 cases of pressure ulcers that were treated at a cost of $8,730 per case, totalling $3.5bn. It is important to note that these costs related only to treatment submitted for payment. Mortality data on patients with pressure


ulcers on the heels are also not reported separately. Brown[5]


reported on 74 patients


at end of life with full thickness pressure ulcers (16.2% were on the heel). The 180-day mortality rate for these patients was 68.9%, with an average of 47 days from the ulcer onset to death. Healing times for heel ulcers are long, in many cases over a year[6]


. Some of the delays . The heel is the


and this area of the foot accounts for .


COST AND SIGNIFICANCE The cost of pressure ulcers is thought to be high, although no specific data on the cost of heel pressure ulcers could be found. General pressure ulcer prevention was estimated to cost $54.66 per day in acute care settings[4]


in the US. The model used by


Padula did not include specific prevention methods or devices for heel pressure ulcers. The cost of pressure ulcer treatment in the UK was estimated at £1.4bn to £2.1bn[5] In 2012, US medical insurance claims


. 58 Wounds International Vol 3 | Issue 3 | ©Wounds International 2012


in healing can be attributed to underlying comorbid problems including poor arterial flow to the leg, diabetic neuropathy, continued use of tobacco and difficulty maintaining pressure relief on the heel for the length of time needed to heal the ulcer. Morbidity, that is to say amputation, for heel ulcers with osteomyelitis or critical limb ischaemia is also common. In one study, 11% of patients with ischaemic heel ulcers and gangrene required amputation, compared with a group of patients with ulcers on other aspects of the foot[7]


. Similarly, Han and Ezquerro[8] reported


that 42% of 43 patients (18 patients) with heel ulcers required leg amputation due to persistent infection or non-healing wounds.


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