Etiology and Pathology of Pressure Ulcers

  • Salah Rubayi


It has been observed that the application of constant pressure of 70 mmHg for more than 2 h produced irreversible tissue damage [1]. Minimal tissue damage was observed when the pressure exceeded 240 mmHg, providing there was intermittent pressure relief [2]. Histopathological changes secondary to pressure on the tissues include occluding of the blood flow to the tissues. If occluding occurs for short periods of time, the result is anoxia of the cells. If the pressure continues for longer periods of time, complete occlusion of the blood flow results in ischemia of the cells and then necrosis and, consequently, irreversible tissue damage. Muscle fibers are more sensitive to the ischemia effect of prolonged pressure than the skin [3, 4]. Shear forces are an etiologic factor in development of pressure, and ulcers [5, 6] are caused by movement of boney prominence against the subcutaneous tissues. This occurs when the position of the patient, for example, in bed, is shifted in a way that the skin remains stationary in relation to the support of the body and, as a result of the movement, the subepidermal vessels are bent at a right angle. Shear alone does not cause tissue necrosis; however, it is a predisposing factor in causing pressure ulcers. Shear forces are seen more frequently in clinical practice when a patient loses weight and tissue sliding can occur over the boney prominences. Friction forces relate to rubbing of the skin against linen or clothing, or even when lifting a patient on a sling. Most abrasion injuries are caused by friction, although friction does not lead to all pressure ulcers; it can damage the epidermis and make the skin susceptible to pressure ulcers [1].


Heterotopic Ossification Pressure Ulcer Necrotizing Fasciitis Spinal Cord Injury Patient Pressure Relief 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Dinsdale SM (1974) Decubitus ulcers: role of pressure and friction in causation. Arch Phys Med Rehabil 55:147–155PubMedGoogle Scholar
  2. 2.
    Brooks B, Duncan GW (1940) Effects of pressure on tissues. Arch Surg 40:696CrossRefGoogle Scholar
  3. 3.
    Lindan O (1961) Etiology of decubitus ulcers. Arch Phys Med Rehabil 2:774–783Google Scholar
  4. 4.
    Nola GT, Vistnes LM (1980) Differential response of skin and muscle in the experimental production of pressure sores. Plast Reconstr Surg 66:728CrossRefPubMedGoogle Scholar
  5. 5.
    Reichel S (1958) Shearing forces as a factor in decubitus ulcers in paraplegics. JAMA 166:762–763CrossRefGoogle Scholar
  6. 6.
    Guttman L (1958) Problem of treatment of pressure sores in spinal paraplegics. Br J Plast Surg 8:196–213CrossRefGoogle Scholar
  7. 7.
    Allman RA, Desforges JF (1989) Pressure ulcers among the elderly. N Engl J Med 320:850–853CrossRefPubMedGoogle Scholar
  8. 8.
    Pinchafsky-Devin GD, Kaminski MV (1986) Correlation of pressure sore and nutrition. J Am Geriatr Soc 34:435–440Google Scholar
  9. 9.
    Allman RM, Lapraede CA, Noel LB et al (1986) Pressure sores among hospitalized patients. Ann Intern Med 105:337–342CrossRefPubMedGoogle Scholar
  10. 10.
    Levine J, Simpson M, McDonald R (1989) Pressure sores: a plan for primary care prevention. Geriatrics 44:75–90PubMedGoogle Scholar
  11. 11.
    Sacks AH, O’Neill H, Perkash I (1985) Skin blood flow changes and tissue deformations produced by cylindrical indentors. J Rehabil Res Dev 22:1–6CrossRefPubMedGoogle Scholar
  12. 12.
    Kennedy EJ (1986) The facts and figures: spinal cord injury. University of Alabama, BirminghamGoogle Scholar
  13. 13.
    Mawson AR, Neville P, Winchester Y (1988) Risk factors for early occurring pressure ulcers following spinal cord injury. Am J Phys Med Rehabil 67:123–127CrossRefPubMedGoogle Scholar
  14. 14.
    Ganong WF (1989) Review of medical physiology. Appleton & Lange, San MateoGoogle Scholar
  15. 15.
    Rodriguez GP, Claus-Walker J, Kent MC, Stal S (1986) Adrenergic receptors in insensitive skin of spinal cord injured patients. Arch Phys Med Rehabil 67:177–180CrossRefPubMedGoogle Scholar
  16. 16.
    Vidal J, Sarrias M (1991) An analysis of the diverse factors concerned with the development of pressure sores in spinal cord injured patients. Paraplegia 29:261–267CrossRefPubMedGoogle Scholar
  17. 17.
    Hawkins DA, Heinemann AW (1998) Substance abuse and medical complications following spinal cord injury. Rehabil Psychol 43:219–231, {Scientific evidence-V}CrossRefGoogle Scholar
  18. 18.
    Salzberg CA, Byrne CG, Cayten CG et al (1996) A new pressure ulcer risk assessment scale for individuals with spinal cord injury. Am J Phys Med Rehabil 75:96–104CrossRefPubMedGoogle Scholar
  19. 19.
    Salzberg CA, Byrne DW, Cayten CG (1998) Predicting and preventing pressure ulcers in adults with paralysis. Adv Wound Care 11:237–246PubMedGoogle Scholar
  20. 20.
    Reuler JB, Cooney TG (1981) The pressure sore: pathophysiology and principles of management. Ann Intern Med 94(5):661–666CrossRefPubMedGoogle Scholar
  21. 21.
    Stover SL, DeLisa JA, Whiteneck GG (1995) Spinal cord injury: clinical outcomes from the model systems. Aspen Publication, GaithersburgGoogle Scholar
  22. 22.
    Rubayi S, Montgomerie JC (1992) Septic ischial bursitis in patients with spinal cord injury. Paraplegia 30:200–203CrossRefPubMedGoogle Scholar
  23. 23.
    Shea JD (1975) Pressure sores. Clin Orthop 112:89PubMedGoogle Scholar
  24. 24.
    Comarr AE (1950) Ischial decubitus ulcer with atypical features. J Int Coll Surg 13:232Google Scholar
  25. 25.
    Schneider M, Krug AJ (1960) Dislocation of the hip secondary to trochanteric decubitus, a complication of multiple sclerosis. J Bone Joint Surg Am 42-A:1165Google Scholar
  26. 26.
    Firooznia H, Rafii M, Golimbu C, Cam S, Sokolow J (1982) Computed tomography of pressure sores, pelvic abscesses and osteomyelitis in patients with spinal cord injury. Arch Phys Med Rehabil 63:545–548PubMedGoogle Scholar
  27. 27.
    Rubayi S, Soma C, Wang A (1993) Diagnosis and treatment of illopsoas abscess in spinal cord injury patients. Arch Phys Med Rehabil 74:1186–1191PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  1. 1.Department of SurgeryRancho Los Amigos National Rehabilitation CenterDowneyUSA
  2. 2.Division of Plastic Surgery, Department of Surgery, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesUSA

Personalised recommendations