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Clinical manifestations and diagnosis
Pressure ulcers are usually easy to identify by their appearance and location overlying a bony prominence. The exception may be stage 1 ulcers which can be difficult to recognize, particularly in patients with darkly pigmented skin. They also may be confused with other conditions that cause erythema such as cellulitis.
Eschar often covers deep ulcers, making it difficult to determine whether lesions are stage 3 or 4. In addition, the extent of stage 4 ulcers is often underestimated due to undermining and fistula formation; a relatively small superficial skin defect may mask extensive deep tissue necrosis.Pressure ulcers may be associated with both medical and psychosocial complications. The medical complications can be life threatening and are more common with stage 3 and 4 ulcers.
Psychosocial consequences are not often considered. However, patients with pressure ulcers may suffer pain and feel stigmatized by the development of a chronic skin ulcer. This could result in depression, social isolation, and decrements in overall health-related quality of life. The extent and magnitude of psychosocial complications have not been well defined in the literature.



Infection
Infection is common among patients with pressure ulcers; on the other hand, pressure ulcers are an uncommon cause of fever. When pressure ulcers do cause bacteremia, they have been associated with high mortality rates (up to 50
percent in one small study). Osteomyelitis can occur via direct extension from the wound. Radiography often is unable to differentiate osteomyelitis from reactive changes in bone due to the overlying ulcer. Technetium bone scans are sensitive but nonspecific.
Indium 111- labeled leukocyte scanning may be considered, but is difficult to interpret in the presence of surrounding soft tissue inflammation. Computed tomography has a low sensitivity but high specificity for the diagnosis of osteomyelitis. Bone biopsy with culture may be necessary to confirm the diagnosis.
Other rare infectious complications of pressure ulcers include septic arthritis, endocarditis, and meningitis. Pressure ulcers may also pose a risk to other hospitalized patients by serving as a reservoir for resistant organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and multiply-resistant gram negative bacilli.