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CHAPTER 30
trochanterics can best be safeguarded by placing the patient on pillow packs or, even
better, on sorbo rubber packs (Figs. 73 and 74). Pressure to the heels can easily be pre
vented by placing pillows underneath the calves (Fig. 73b) avoiding those popular rings
placed around the heels, whether made of cotton-wool, rubber, or other material. These
were found to produce pressure sores, especially over the Achilles tendon, by shearing
stress, rather than to prevent them. This is understandable if one remembers the course
taken by the vascular supply to the heels, which can easily be interfered with by a
constricting ring around the heels. It is unfortunate that, in the training courses of nurses,
these 'halos' around the heels are still taught as the method of choice in preventing sores
over the heels while their potential dangers are not considered.
As mentioned previously, in recent years the introduction of the Stoke Mandeville-
Egerton electrically controlled turning bed has greatly facilitated the regular turning to
prevent pressure sores and relieve pressure from established sores and thus promote
healing. It may be stated that this is more difficult if not impossible to achieve with the
Stryker frame, as the turning is only possible from the supine to prone position, in
particular if a patient with a broken spine has sustained associated injuries such as
fracture of ribs, haemothorax, etc., and has to lie in supine position for longer periods.
The same can be said of the sheep-skin or the so-called ripple mattress (Gardner,
1948), where the pressure of the sets of compartments can be alternately inflated and
deflated by a pump. Prevention or healing of a pressure sore will be best accomplished
if the patient's position is changed from the supine into lateral position. To let the patient
lie continuously or for periods longer than 2 hr in recumbent or lateral position will
neither prevent nor heal sores penetrating into deeper tissues. Moreover, as already
pointed out, the recumbent position is contrary to the principles of preventing stagnation
and ascending infection of the urinary tract. Air and water mattresses have been aban
doned, as they have not proved successful in preventing pressure on the bony parts.
As soon as possible, the paraplegic patient should be fully instructed in details about
the dangers of pressure; indeed he should be indoctrinated with the idea that, as soon as
he is transferred from a bedridden patient to the use of a wheelchair, prevention of sores
or the break-down of a healed sore depends largely on his own alertness and watchfulness
in frequently lifting himself, or, in the case of a tetraplegic, in shifting his position in the
wheelchair from one side to the other.
Paraplegics with marked adductor spasticity should have a soft pad between the
knees, the width of which must be adjusted to the degree of spasticity to prevent shear-
stress between the knees.
Every evening before going to bed, paraplegics and tetraplegics should examine
their buttocks for pressure damage with the aid of a hand mirror, or they should be
examined by their attendants. To promote good circulation, gentle massage to the sacrum,
buttocks and trochanter should be given. If the skin is harsh and dry it is well to use a
mixture of olive oil and 50-60 per cent alcohol.
(b) Treatment of established sores.
Once sores have developed, the principle of
preventing pressure has to be enforced, and this represents the cardinal local treatment of
sores. Furthermore, having regard to the fact that sores are always infected, early excision
