The pressure ulcer staging classification is intended to describe the severity of tissue damage. Intact skin with non-blanchable redness of a localised area usually over a bony prominence.
Development of pressure ulcers is a multifactorial process that is not completely understood. Pressure ulcers are thought to be the result of inadequate tissue perfusion, impaired lymphatic function, and mechanical tissue destruction.
Nutritional deficiencies, moisture, and altered skin properties resulting from spinal cord injury increase susceptibility to ischemia.
Ulcers are often not recognised until the ulcer has significantly progressed or has become infected when pressure is of greater intensity and duration.
There is level 3 evidence that 1-2 minutes of pressure relief must be sustained to raise tissue oxygen to unloaded levels. There is level 4 evidence to support position changes to reduce pressure at the ischial tuberosities. For wounds with potential to heal, debride areas with devitalised tissue (except for heel pressure ulcers). For wounds with potential to heal, use wound dressing products that keep ulcer wound bed moist but surrounding skin dry (except for heel pressure ulcers).
A 47-year-old man presented to our emergency department because of progressive swelling of the upper midline neck and dysphagia. Physical examination disclosed bilateral submandibular swelling and protrusion of the tongue. Figure 1 (A) Lateral neck plain radiograph showing swelling of the submandibular region and the presence of free air (arrow). Soft tissue massage is essentially manual therapy specifically targeting soft tissues (muscle, tendons, and fascia) and can be used to treat soft tissue abnormalities such as increased muscle tension, trigger points, and abnormal thickening of connective tissue. Soft tissue massage as an isolated treatment generally will only lead to short term benefit, but when it is used as a component of a holistic treatment approach that identifies and manages the underlying cause of a problem it can be very effective. The soft tissues of our body (muscles, tendons, and fascia) are generally organised in layers that need to slide and glide over one another for movement to occur normally. As well as having an effect on how the body moves soft tissue abnormalities can also be a primary source of pain. Flexor tendon injuries are common, and may result from any insult, often sharp, to the volar aspect of the hand.
Location of injury and assessment of the cascade of the hand [Figure 1] are important initial observations.
If both flexor tendons to a single digit (FDS and FDP) are divided, then that finger will be extended, standing out from the other fingers normally flexed in the cascade [Figure 2]. To test for isolated FDS injury in any of the ulnar three digits, all DIPJs are stabilised in extension except the finger to be examined (1). In the absence of an open wound, inability to flex one or more digits may result from a tendon rupture or nerve palsy. Avulsion of the FDP is a common injury, often occurring in the ring fingers of rugby players.
X ray may show a bony fragment of the distal phalanx [Figure 5] still attached to the ruptured end of the tendon, which may have retracted into the palm. Phalangeal fractures [Figure 8] can occur when one or more digits get trapped in a door or crushed by a similar impact.
A thorough history of the mechanism of injury and a simple examination, as detailed below, should provide a useful indication as to whether a fracture is likely before an X-ray is even performed.
Degloving of tissue results from large shearing forces that pull skin and soft tissue off the hand [Figure 9].
On examination colour of any skin flaps, and evidence of dark, necrotic tissue should be noted. Careful history of the mechanism of injury, and a thorough examination of the function and neurovascular status of the hand will reveal such an injury.
The most common compartment in the upper limb to be effected by compartment syndrome is the anterior compartment of the forearm. Diagnosis is on clinical grounds, but can be confirmed by measuring an intra-compartmental pressure of greater than 30mmHg. Digits can be replanted successfully up to 24 hours after the amputation provided they are stored correctly (11). Relative contraindications to replantation are patient age, severe avulsion injuries, prolonged warm ishaemia time and massive contamination. IV antibiotics (co-amoxiclav) should be prescribed as the wound is presumed to be infected. Hand injuries occur extremely commonly and accurate history, initial assessment and appropriate management assists in maintaining as much hand function as possible.

Around 1% of the Australian population suffer from leg ulcers - they are more common in older people (over 65) and three times more likely to affect women than men. Arterial Leg Ucers Arterial leg ulcers arise as a result of arterial disease whereby perfusion through the lower limb results in a cycle of tissue damage (ischaemia, hypoxia, necrosis) and the development of an ulcer. Unlike venous leg ulcers, compression therapy is NOT appropriate for treatment of arterial ulcers and referral is required to a vascular specialist.
Mixed Aetiology Leg Ulcers A mixed ulcer has its origin primarily in the chronic venous insufficiency in the patient's leg and its ability to heal is determined by the severity of the coexisting arterial insufficiency.
Compression to the lower limb is the single most important factor in the conservative treatment of venous leg ulcers. While compression is the most important component for venous leg ulcers, some ulcers produce very high amounts of exudate, especially during the first 1-2 weeks of treatment. Arterial Leg Ulcer Following assessment by a vascular specialist these ulcers may require debridement of dead, necrotic tissue, in which case gel dressings such as IntraSite* Gel are suggested. Multi-Layer bandage systems are the recommended first-line therapy for treatment of venous leg ulcers (ILUAB). Compression Therapy is NOT SUITABLE for Treatment of Arterial Ulcers - Patients with suspected arterial ulcers should be referred to a vascular specialist. Fractures of the lateral talar dome usually occur due to trauma, whereas medial talar dome fractures are caused by repetitive stress and may be chronic.
Treatment involves a below knee cast, non-weight bearing crutches, and a referral to an orthopaedician. This entry was posted in Advanced EM Cases, Imaging Case of the Week, Orthopaedic by Prathibha. Plantar Warts (Verruca Plantaris) are one of several soft tissue conditions of the foot that can be quite painful. If left untreated, a wart can increase in size or one would notice increasing number of warts on the foot over time.
Plantar warts are often contracted by walking barefoot on dirty surfaces or littered ground where the virus is lurking.
Like any other infectious lesion, plantar warts are spread by touching, scratching, or even by contact with skin shed from another wart. You should seek medical evaluation and treatment if you believe you have a wart to obtain proper care and prevent worsening of the condition. Don’t let your foot and ankle pain or discomfort prevent you from having a healthy lifestyle.
They usually occur over bony prominences and in North America are classified by stages according to the degree of tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. As muscle cells require more oxygen, cell death happens quicker in muscle tissue and damage is not initially seen on the surface. Cell death happens quicker in muscle cells than skin cells so frequent skin checks are important to identify subtle underlying tissue changes. The typical redness or other colour changes associated with pressure ulcers are less visible.
The result the pressure has on the skin is influenced by its intensity and duration, as well as the tissue tolerance to the pressure. In fact Physiotherapy as a profession has it’s origins in massage, and today massage techniques continue to form a part of many physiotherapy treatments. Lack of this ‘sliding and gliding’ can lead to restriction of movement in a body region, with the development of harmful altered movement patterns to compensate for this restriction. Each digit has a flexor digitorum superficialis (FDS) and a flexor digitorum profundus (FDP). This knowledge helps to diagnose an FDS division when FDP to the same digit remains intact. With isolated FDS division, there will be no postural change in the cascade of the hand, as an intact FDP will produce the flexion normally seen in the cascade.
Application of pressure on the flexor muscle mass in the anterior forearm will lead to passive finger flexion if the tendons are intact.
The tendon detaches from the distal phalanx and sometimes avulses a segment of bone with it.
4th and 5th metacarpals commonly break as a result of throwing a punch (surprisingly often the target is a wall!). Patients complain of excessive pain, often out of proportion to the appearance of the limb, or worsening pain despite splinting of an arm with a fracture (10).
Author: Michael E Robinson, MD, Consulting Staff, Department of Orthopedics, Division of Primary Care Sports Medicine, Permanente Medical Group and Kaiser Hospital.

A venous leg ulcer occurs secondary to underlying venous disease whereby damage to the superficial, deep or perforating veins leads to venous hypertension. Graduated compression reduces the abnormally high pressures in the superficial veins and may improve the competence of the valves. For these cases Allevyn* Non-Adhesive can be used - a "state of the art" hydrocellular foam dressing which absorbs large amounts of exudate and also helps to create a moist wound environment. Allevyn Non-Adhesive is particularly useful for arterial ulcers to protect and assist to maintain a moist wound environment. They usually occur on the bottom of the foot although occasionally around the sides of digits.
However, warts in children have a higher tendency to spontaneously resolve on its own without any treatment where as they tend to linger around adults if left untreated. The causative virus thrives in warm, moist environments, making infection a common occurrence in communal bathing facilities.
It can be a single lesion on the foot or a cluster of lesions, varying in size and tenderness. Corns and calluses are layers of dead skin that build up to protect an area in which there is increased pressure. Over-the-counter preparations contain acids or chemicals that destroy skin cells, and it takes an expert to destroy abnormal skin cells (warts) without also destroying surrounding healthy tissue. Our doctor has a variety of treatment options available for our patients including topical and oral treatments.
An appointment is required to ensure we give each patient sufficient amount of time to address their concerns and needs.
A pressure ulcer can progress to a greater stage but reverse staging (describing a healing pressure ulcer as a lesser stage) is incorrect practice. Therefore, compare the area of skin alteration with an adjacent or opposite area of the body. Soft tissue massage techniques can ‘loosen up’ these restrictions, lessening the need for the compensatory movements, while also making retraining of the correct movement patterns more achievable.
Elimination of these trigger points can significantly reduce pain and additionally may assist rehabilitation of specific muscles. The injury results from forced extension whilst the FDP is maximally contracted, as happens with a finger getting caught in a rugby jersey. As the syndrome progresses, signs may include swelling of the limb, reduced radial pulse, pallor of the fingers, and increased capillary return time, however these are late signs! The ulcer usually presents within the gaiter region of the leg and is superficial with irregular edges. Arterial leg ulcers are usually located from the malleolus (ankle) level down throughout the foot.
Warts are caused by a type of Human Papilloma Virus (unrelated to oral or genital warts), which generally invades the skin through small or invisible cuts and abrasions. Warts often has a center with brownish pinpoint discolorations and skin lines on the bottom of the foot usually diverge around the area.
It is also possible for a variety of more serious lesions to appear on the foot, including malignant lesions such as carcinomas and melanomas. Self treatment with such medications especially should be avoided by people with diabetes and those with cardiovascular or circulatory disorders. Very rarely and in severe cases in which the wart is resistant and has failed multiple therapies, the doctor may consider surgical excision of the wart. She enjoys treating all aspects of foot and ankle pathologies with a special interest in pediatrics, sports medicine, and reconstructive surgery.
Adequate protein and hydration, unless contraindicated, are also necessary for wound healing. Although rare, these conditions can sometimes be misidentified as a wart and require urgent workup and treatment. Selection of treatment depends on the doctor’s thorough assessment of you overall medical health, nature of the wart such as size and location, and how many lesions are involved. Exudate volumes tend to be moderate to high until the generalised oedema throughout the limb is controlled through sustained graduated compression therapy.
It is important to consult a doctor when any suspicious growth or eruption is detected on the skin on the foot in order to ensure a correct diagnosis.

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