11.3 Pressure Injuries & Wound Management

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

11.3 Pressure Injuries & Wound Management

Key Takeaways Explain This Topic AI

NPIAP Staging classifies pressure injuries into Stages 1-4, Unstageable, and DTPI; Stage 3 exposes subcutaneous fat, whereas Stage 4 exposes fascia, muscle, tendon, or bone.

Stable, dry, adherent eschar on heels or ischemic limbs must NOT be debrided, as it functions as a protective biological cover.

Braden Scale scores range from 6 to 23; scores <= 12 indicate high risk requiring aggressive pressure-redistribution and turning protocols.

Dressing selection matches exudate volume: hydrogels/hydrocolloids hydrate dry wounds, whereas calcium alginates/hydrofibers absorb heavy exudate.

Last updated: July 2026

National Pressure Injury Advisory Panel (NPIAP) Staging System

Pressure injuries are localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device, resulting from intense and/or prolonged pressure or pressure in combination with shear. The National Pressure Injury Advisory Panel (NPIAP 2016) classifies pressure injuries into distinct clinical stages: [NPIAP Pressure Injury Staging]

┌─────────────────────────────────────────────────────────────┐
│ Stage 1: Non-blanchable erythema of intact skin │
├─────────────────────────────────────────────────────────────┤
│ Stage 2: Partial-thickness skin loss with exposed dermis │
├─────────────────────────────────────────────────────────────┤
│ Stage 3: Full-thickness skin loss; subQ fat visible │
├─────────────────────────────────────────────────────────────┤
│ Stage 4: Full-thickness skin & tissue loss; exposed bone/ │
│ tendon/muscle/fascia │
├─────────────────────────────────────────────────────────────┤
│ Unstageable: Full-thickness loss obscured by slough/eschar │
├─────────────────────────────────────────────────────────────┤
│ DTPI: Persistent non-blanchable deep red/maroon/purple │
└─────────────────────────────────────────────────────────────┘

NPIAP Stage Clinical Definition & Anatomic Depth Key Visual & Palpable Characteristics

Stage 1 Non-blanchable erythema of intact skin . Localized area of persistent redness; does not turn white when pressed. May differ in temperature, firmness, or sensation compared to adjacent tissue.

Stage 2 Partial-thickness skin loss with exposed dermis . Viable, pink/red, moist wound bed. May present as an intact or ruptured serum-filled blister. No adipose (fat) or deeper tissues visible . No slough or eschar.

Stage 3 Full-thickness skin loss . Adipose (subcutaneous fat) is visible . Granulation tissue and rolled wound margins ( epibole ) often present. Slough/eschar may be visible. No exposed muscle, tendon, ligament, cartilage, or bone .

Stage 4 Full-thickness skin and tissue loss . Directly visible or palpable fascia, muscle, tendon, ligament, cartilage, or bone . Slough and/or eschar may be present. Epibole, undermining, and tunneling common. High osteomyelitis risk .

Unstageable Full-thickness skin and tissue loss in which extent of damage cannot be confirmed . Covered entirely by slough (yellow, tan, gray, green, brown) or eschar (tan, brown, black). Removing slough/eschar reveals Stage 3 or 4. Exception : Stable dry eschar on heels.

Deep Tissue Pressure Injury (DTPI) Persistent non-blanchable deep red, maroon, or purple discoloration . Intact or non-intact skin revealing dark wound bed or blood-filled blister. Results from pressure/shear at bone-muscle interface. May rapidly evolve into Stage 3/4.

Critical Clinical Rules :

Stable, dry, adherent eschar on ischemic limbs or heels should NOT be debrided, softened, or removed. It serves as the body's natural biological cover; removing it risks severe bacterial invasion and limb-threatening osteomyelitis.

Reverse Staging is Prohibited : A healing Stage 4 pressure injury does not become a Stage 3, 2, or 1. It is documented as a "healing Stage 4 pressure injury" because lost muscle and subcutaneous tissue are replaced by granulation/scar tissue, not original dermis/subcutis.

Risk Assessment: The Braden Scale

The Braden Scale for Predicting Pressure Sore Risk is a validated tool evaluated routinely in rehabilitation units. It consists of 6 subscales :

Sensory Perception (1–4): Ability to respond meaningfully to pressure-related discomfort.

Moisture (1–4): Degree to which skin is exposed to moisture (diaphoresis, incontinence).

Activity (1–4): Degree of physical activity (bedfast, chairfast, walks occasionally/frequently).

Mobility (1–4): Ability to change and control body position.

Nutrition (1–4): Usual food consumption pattern.

Friction & Shear (1–3): Assistance required for moving in bed/chair.

Scoring Range : Total score ranges from 6 to 23 .

Risk Stratification :

No Risk : 19–23
Mild Risk : 15–18
Moderate Risk : 13–14
High Risk : 10–12

Very High Risk : ≤ 9 \le 9 ≤ 9 Clinical Utility : A lower Braden score indicates higher risk and mandates immediate implementation of preventive interventions (e.g., Q2H turning schedules, specialized pressure-redistribution mattresses/cushions, moisture barrier creams).

Wound Debridement Strategies

Debridement removes necrotic, devitalized tissue and bacterial biofilm to convert a chronic wound into an active healing wound.

Debridement Type Mechanism of Action Clinical Indications & Advantages Contraindications & Limitations

Surgical / Sharp Removal of devitalized tissue using scalpel, scissors, or curette by a clinician. Fastest, most efficient method. Essential for severe infection, sepsis, or extensive necrosis. Contraindicated in severe arterial insufficiency or dry stable heel eschar. Painful; requires analgesia.

Enzymatic Topical application of exogenous proteolytic enzymes ( Collagenase / Santyl ). Selective; digests collagen fibers anchoring devitalized tissue to wound bed. Slower than sharp; requires daily application; deactivated by silver/heavy metals.

Autolytic Body's own endogenous enzymes (macrophages/neutrophils) digest necrotic tissue under moist dressings. Highly selective , painless, easy to apply. Uses hydrocolloids, hydrogels, or transparent films. Slowest method; contraindicated in actively infected or grossly purulent wounds.

Mechanical Physical force to detach necrotic tissue (e.g., wet-to-dry dressings, pulsed lavage, whirlpool). Widely available; effective for large slough volumes. Non-selective ; can tear viable granulation tissue and cause significant pain.

Biological Medical maggots ( Lucilia sericata larvae) secrete digestive enzymes. Selective; rapid liquefaction of necrotic tissue and bacterial ingestion. Patient psychological aversion; specialized dressing required.

Dressing Selection Matrix

Selecting the appropriate wound dressing depends primarily on exudate volume , wound bed depth , and presence of infection .

Wound Characteristics Primary Dressing Goal Recommended Dressing Categories Examples & Mechanism

Dry Wound / Minimal Exudate (e.g., Stage 2/3 with dry bed) Rehydrate and provide moisture balance. Hydrogels , Hydrocolloids , Transparent Films . Hydrogels donate water to dry wound beds; Hydrocolloids maintain moist autolytic environment.

Moderate to Heavy Exudate (e.g., Stage 3/4 exuding ulcer) Absorb excess moisture and prevent maceration. Calcium Alginates , Hydrofibers , Polyurethane Foams . Alginates (seaweed extract) & Hydrofibers absorb up to 20x weight, turning into gel; Foams absorb and cushion.

Infected / Malodorous Wounds Reduce bacterial load and manage bioburden. Silver-Impregnated Dressings , Cadexomer Iodine , Honey . Sustained release of antimicrobial silver ions or iodine to destroy bacterial membranes.

Deep Cavity / Tunneling Wounds Eliminate dead space and absorb exudate. Alginate / Hydrofiber Ropes , Gauge Packing . Loosely pack ropes into cavities to prevent superficial bridging and abscess formation.