Management of Bone Exposure Skin Ulcers
The best approach for managing bone exposure skin ulcers is a comprehensive treatment protocol that includes debridement of necrotic tissue, appropriate wound dressings, offloading of pressure, assessment for infection, and consideration of advanced wound therapies including negative pressure wound therapy or surgical intervention for non-healing ulcers. 1, 2
Initial Assessment and Classification
- Evaluate for signs of infection (erythema, warmth, purulence, pain)
- Assess vascular status (palpate pulses, consider ABI if diminished)
- Determine ulcer depth and extent of bone exposure
- Classify ulcer severity:
- Uncomplicated: Superficial, not infected, not ischemic
- Complicated: Deep with bone exposure, infected, or ischemic
- Severely complicated: Wet gangrene, abscess, or systemic infection 1
Core Treatment Principles
1. Debridement
- Remove all necrotic tissue and surrounding callus to fully visualize the wound 1
- Consider bone biopsy if osteomyelitis is suspected 1
- Debride regularly to maintain a clean wound bed 2
2. Infection Management
- For suspected bone infection:
3. Offloading and Pressure Relief
- For plantar ulcers: Use non-removable knee-high offloading device (total contact cast or irremovable walker) 1
- For non-plantar ulcers: Consider shoe modifications, temporary footwear, or orthoses 1
- Instruct patient to limit standing/walking and use crutches if necessary 1
4. Wound Dressing Selection
- Select dressings based on exudate level:
- Minimal exudate: Hydrocolloid dressings
- Moderate exudate: Foam dressings
- Heavy exudate: Alginate or hydrofiber dressings 2
- Change dressings regularly and inspect the wound at each change
5. Vascular Assessment
- For patients with ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularization 1
- If wound fails to heal within 6 weeks despite optimal management, consider revascularization 1
Advanced Therapies for Non-Healing Ulcers
1. Negative Pressure Wound Therapy (NPWT)
- Consider NPWT for post-operative wounds or wounds with significant depth 1, 3
- NPWT combined with flap transfer has shown good results for lower-limb wounds with bone exposure 3
2. Artificial Dermis and Skin Grafting
- For large defects with exposed bone, consider staged approach using artificial dermis followed by skin grafting 4, 5
- This technique has shown complete wound healing in 15 out of 17 cases with minimal donor-site morbidity 4
3. Surgical Options
- Consider surgical intervention for ulcers that fail to respond to conservative management 2
- Options include:
- Flap coverage for large defects
- Minor amputation for non-salvageable tissue
4. Other Adjunctive Therapies
- Consider hyperbaric oxygen treatment for poorly healing wounds 1
- CO2 laser treatment has shown promise in diabetic foot ulcers with exposed bone by creating discontinuities in periosteum to promote healing 6
Monitoring and Follow-up
- Document wound characteristics and healing progress at each assessment
- If evidence of infection has not resolved after 4 weeks of appropriate therapy, re-evaluate and consider alternative treatments 1
- Once healed, include patient in an integrated foot-care program with ongoing observation and education 1
Pitfalls and Caveats
- Avoid footbaths as they can induce skin maceration 1
- Don't delay treatment of ischemic or infected ulcers as this increases risk of amputation 1
- Don't rely solely on soft tissue cultures when osteomyelitis is suspected; bone cultures are more accurate 1
- Don't use silver or antimicrobial dressings routinely as they are not well-supported for wound management 1
- Don't use biologically active products (collagen, growth factors) routinely for neuropathic ulcers 1
By following this structured approach to bone exposure skin ulcers, clinicians can optimize healing outcomes and reduce the risk of complications including amputation.