Visual aids are useful for identifying selected phenomena in healthcare; they are particularly helpful in describing the location of various wounds. I sought to develop a visual aid for accurately assigning location of wounds and lesions in the buttocks area. The need for this was determined based on clinical experience and literature review. My goal was to create a guide that would assist the clinician to accurately identify the anatomic location for skin lesions and/or wounds, to determine the wound etiology and appropriate management, and to track outcomes. I first became aware of the need for the type of visual aid described in this article when I noted that the coding system did not include all possible anatomic locations required for pressure ulcer diagnosis and documentation, forcing nurses to sometimes use inaccurate terminology when describing the location of pressure injuries in the buttocks area. Within the context of this project, I operationally defined the buttocks as the portion of the posterior lower torso from just superior to the posterior iliac crests proximally to the gluteal creases distally. When selecting codes for location of pressure ulcers involving the posterior lower torso, clinicians are limited to the lower back (including coccyx and sacrum), hip, and buttocks (defined within the ICD-10 [International Classification of Disease, 10th Revision] diagnosis manual as encompassing a large soft tissue area, which is a common site for friction injuries but a less common site for pressure ulcers, which usually occur over bony prominences)1 as well as laterality for the practitioner to choose from, but codes still lack specificity and anatomical correctness. Despite 2014 and subsequent updates to the ICD-10, there are still no specific anatomical coding designations for the coccyx, ischial tuberosities, the posterior iliac crests, or the trochanters, all of which are common sites for pressure ulcer development.2 This coding and identification problem became critically important when the Centers for Medicaid & Medicare Services began to deny payment for pressure ulcers (PU) that occur while a patient is hospitalized or being treated in a long-term care facility.3
I became an advanced practice WOC nurse (APRN) in 2008. I noticed that practitioners (nurses, physicians, APRNs, physician assistants) frequently labeled many wounds on the buttocks (the larger general surface area from the lower back to the posterior thighs) as pressure ulcers. I also observed multiple types of lesions on the buttocks, including pressure ulcers, moisture-associated skin damage (MASD), psoriasis, and friction injuries. I became concerned that some wounds being diagnosed as pressure ulcers were caused by factors other than pressure and shear, and that anatomic locations were being incorrectly identified, partially based on limitations in the ICD coding system then in use. After realizing that colleagues and I were not describing and diagnosing many wounds similarly, I decided to look for a visual aid to narrow the communication gap.
Image Search
I initially spoke with WOC nurse colleagues within my facility to determine if they were aware of a visual aid to correctly identify the anatomic location of wounds located on the buttocks and differentiate between bony prominences and soft tissue areas. They were not aware of any such visual aids. They provided support for the idea of creating a visual aid and agreed with my concerns about incorrect diagnoses of buttocks lesions often encountered in clinical practice.
I then completed a Google Image search; I found general anatomical illustrations but nothing specific to my objectives. Most of the images identified via the Google search engine had been developed for describing surgical procedures or basic anatomical education for various healthcare and/or science students. I also searched Netter Images4 but did not find a detailed surface anatomy of the buttocks. Finally, I searched scholarly articles, using the CINAHL and MEDLINE databases. This search was based on the key terms "surface anatomy," "skin," "buttocks," and "gluteal area." This search did not retrieve useful visual aids.
Creation of an Original Image
When these searches failed to produce a useful visual aid, I revisited an article I published in the Journal that described a case series of patients with friction injuries.5 While formulating that clinical case series, I developed a visual aid that is the focus of this View From Here feature column. I began by locating photos of several patients' buttocks areas; all identifying markers and dates were removed. Using verbal descriptors from Gray's Anatomy,6 I drew markings to indicate the different areas of the buttocks based on the location of bony prominences, and I added soft tissue and skin crease locations to complete the initial aid (Figure 1). My daughter, who is a graphic designer, provided substantial assistance in the development of this image. I sent the initial draft to a member of our Department of Anatomy at the University of Nebraska College of Medicine, who kindly responded with suggestions that were used to improve the visual aid, including terminology changes for anatomic accuracy and consistency. The figure was then shown to 2 prominent plastic surgeons in the community who are wound experts; they agreed with the anatomical markings and labels and offered some aesthetic suggestions, which were used to further improve the visual aid. Lastly, the image was shown to my WOC colleagues and internationally known wound experts on pressure ulcer. Their comments were favorable with only a few minor additional aesthetic changes; no significant changes were made to the anatomical designations or labeling. The final aesthetic edits were made and a PDF file was created and submitted to our skin wound advisory team, who agreed to place the image in our electronic record to be used by all staff for documentation of wounds on the buttocks surface area.
Next Steps
I plan to take this visual aid to the American Medical Association and the Centers for Medicare & Medicaid Services, and to ask that it be used to expand the codes for designation of wound location. I believe that its incorporation into their documents enables more accurate identification and classification of multiple injuries of the buttocks such as pressure ulcers, friction injuries, and MASD.
I have discussed this issue with many clinicians and found that many providers code based on their personal beliefs or preferences since specific locations are not available in the current coding system. Because of this limitation, it is not possible to accurately identify how many pressure ulcers occur on the sacrum versus the coccyx, versus the posterior iliac crests, versus the ischia, versus the gluteal areas. Accurate identification of wound location also influences the assessment of wound etiology. For example, suspicion of a pressure ulcer is heightened when it occurs over a bony prominence, while MASD is considered more likely when skin damage follows the path taken by urine or stool in the incontinent person. Therefore, the ability to accurately identify anatomical location would be helpful to all clinicians in making appropriate diagnoses and implementing appropriate management plans. Accurate determination of location and etiology also may reduce the risk of withheld reimbursement due to inaccurate labeling of a moisture or friction wound as a pressure ulcer.
Summary
Accurate description of wound location is an important element of wound assessment, and a contributing factor to correct determination of wound etiology. Wounds located in the buttocks area may be caused by pressure, moisture, friction, or other etiologic factors, and correct determination of wound location is of particular importance in determining etiology of these wounds. Accurate description of location has been compromised by the lack of a visual aid that provides clear definition of all key anatomic locations, including bony prominences, soft tissue areas, and body folds. This article introduces a visual aid designed to promote accurate description of the location of buttock wounds.
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