Treating pressure ulcers

The case shown here in this picture was noted associated with an 89-year-old debilitated nursing home resident. He has no evidence of bacteremia or osteomyelitis. Which of the following is an acceptable treatment?

• A) application of povidone-iodine gauze two times per day
• B) application of hydrogen peroxide 3 times per day
• C) systemic antibiotics for 7 to 10 days
• D) keeping the area clean and dry until granulation tissue forms
• E) surgical debridement

 The answer is E. (Surgical débridement)

When treating this pressure ulcer, it is important to maintain a moist environment while keeping the surrounding skin dry. This can be accomplished by loosely packing the ulcer with saline-moistened gauze. Topical antimicrobials such as silver sulfadiazine cream may be helpful in ulcers that appear infected. Topical antiseptics such as povidone-iodine or hydrogen peroxide should be not be used in the treatment of pressure ulcers. Systemic antibiotics should be reserved for serious infections (e.g., bacteremia, osteomyelitis). A 2-week trial of topical antimicrobials may be considered for ulcers that do not appear infected but are not improving. Although most patients are successfully managed without surgery, procedures may be appropriate in patients whose quality of life would be markedly improved by rapid wound closure. Stage 3 and 4 ulcers with necrotic tissue should be débrided. Ulcers with minimal exudate that are not infected can be covered with an occlusive dressing to promote autolytic débridement. Ulcers with thick exudate, slough, or loose necrotic tissue should undergo mechanical débridement. Options include wet-to-dry dressings, hydrotherapy, wound irrigation, and scrubbing the wound with gauze. Ulcers with evidence of cellulitis or deep infection should undergo sharp débridement with a scalpel or scissors. Ulcers with a thick eschar or extensive necrotic tissue should undergo sharp débridement as well. However, a thick, dry eschar covering a heel ulcer should generally be left intact. Patients without access to surgical inter-ventions (such as in a long-term care setting) or those who may not be acceptable surgery candidates can be treated with enzymatic débriding agents. Wound débridement should stop once necrotic tissue has been removed and granulation tissue is present.

Illustration of Lumbar Hernia

Lumbar hernia "hernia in the lumbar region" or may be called Bleichner's Hernia is quite uncommon as compared to other ventral abdominal wall hernias, 1.5% of all abdominal hernias. note that 25% of all lumbar hernias have a traumatic etiology.
These occur more commonly in males and are twice as common on the left than the right side. Patients are usually between 50 to 70 years old. These hernias can occur anywhere within the lumbar region but are more common through the superior lumbar triangle (of Grynfeltt-Lesshaft)

So, Lumbar hernia has 2 anatomical types:
1-Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It is named after French surgeon Jean Louis Petit (1674–1750).
2-Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840–1913).

**Patients with lumbar hernia are usually asymptomatic but may complain of backache, flank pain or a dragging sensation. These hernias have a natural history of a gradual increase in size over time.

Left lumbar hernia .

The differential considerations :
At this stage include the differential considerations includes lipoma, soft tissue tumors, hematoma or abscess.