Lower limb for FRCS (Plast)

This is a deep tissue pressure injury. Prolonged loading against the sacrum generates the highest pressure and shear at the bone-muscle interface, and muscle, with its high metabolic rate, is the tissue least tolerant of ischaemia; a pressure injury therefore begins deep and extends outwards in a cone whose apex is at the skin, so intact purple, boggy skin signals a large volume of necrotic muscle and fat beneath that will declare itself as a category 3 or 4 ulcer over days to weeks. The epidermis and dermis are the most resistant and are damaged last; subcutaneous fat is involved but less than muscle; and periosteum is affected only in the deepest established ulcers. Management is complete offloading and observation without early debridement. Reference: EPUAP/NPIAP pressure injury classification; Key Notes on Plastic Surgery 2e (pressure sores).

This is an open fracture awaiting primary debridement. The BOA/BAPRAS standards limit emergency department wound handling to removing gross contamination, photographing the wound and covering it with saline-soaked gauze under an occlusive film; the photograph lets every later reviewer see the wound without exposing it again, as repeated inspection adds hospital-acquired contamination. Irrigation belongs in theatre alongside formal excision, not in the resuscitation room. Negative pressure dressings are applied only after surgical debridement. Pre-debridement swabs correlate poorly with the organisms that cause later infection, and antiseptic packing adds nothing and damages tissue. A loose dressing lifted at each review defeats the purpose of the photograph. Reference: BOAST Open Fractures (BOA/BAPRAS); Standards for the Management of Open Fractures (BOA/BAPRAS).