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Wound care

Shruti Tannan and Adam Katz

Wounds

Fundamentals of wound healing

 The wound healing process is like a symphony, requiring many integral components to work together toward a common goal—healing a wound.

 Normal wound healing begins with the initial platelet plug in the inflammatory phase, to a proliferative collagen-producing phase and an ultimate remodeling phase, which can last up to 1 year. Platelets, neutrophils, macrophages, and fibroblasts interact via multiple cytokines and cell signaling pathways to coordinate the transition from one phase to another.

 The arrest of a wound in one of those states, as well as prevention of progress to the next phase, may result in a nonhealing wound. As part of a surgical team, it is helpful to recognize potential challenges to normal wound healing and prepare patients for delayed wound healing or refer them promptly when indicated.

Principles of wound care

History

 Identify any comorbid medical conditions or medications that could delay normal wound healing:

 Medical Conditions

• Diabetes

• Vascular disease

• Smoking

• Malnutrition

• Radiation history (at location of wound)

• Automimmune disorders

 Obtain a history of taking anticoagulants (aspirin, clopidogrel, coumadin) and the reason for taking them.

 Medications

• Immunosuppression (for transplant recipients, autoimmune diseases)

• Prednisone (steroids)

• Chemotherapy

 Clarify the Wound Etiology or Mechanism of Injury

1) Is it acute or chronic?

• If chronic, how long has the wound been there, and what has been tried before?

2) Was the offending agent contaminated or relatively clean?

Physical examination

 Inspect the Wound for Injury to Neurovascular or Tendinous Structures

 Inspect the Wound for Hemostasis, Exposed Bone, or Hardware if Postsurgical

Acute wounds

 Inspect the wound for the degree of contamination (e.g., road rash, grass, dirt).

 Determine if there is actual tissue loss versus the appearance of a “gaping wound” because the wound margins are pulled in opposite directions.

• This helps distinguish wounds with sharply cut margins that can be reapproximated from ones with skin and soft tissue loss that can be treated with local wound care acutely.

 Determine if there is a skin avulsion or a flap of skin detached from underlying structures but attached to intact skin along one margin.

• If so, then assess the viability of the skin by checking for capillary refill in the flap or seeing if it bleeds after a pinprick from an 18-gauge needle.

Chronic wounds

 Is the wound clean or does it have necrotic debris? Is there evidence of infection?

 Is the patient sensate in the anatomic location of the wound (i.e., plantar ulcer with lack of plantar sensation)?

 Does the patient have palpable pulses in the extremity with the wound?

 Is there exposed bone (or tendon)? If so, osteomyelitis must be considered.

Principles of wound care: Treatment

Acute wounds

Irrigation and débridement

1) Irrigate the wound with sterile normal saline with a device producing 7 to 15 pounds per square inch (psi) of pressure. Examples include commercially available pulse lavage devices and a 30-mL syringe attached to an 18-gauge angiocatheter.

2) Débride the wound of any contaminants such as grass and gravel. Minimize actual excision of tissue in the acute setting, and only débride obviously nonviable tissues.

Closure

 To minimize scarring, close acute wounds on extremities (excluding the hand and fingers) in layers.

• Use monofilament suture for contaminated wounds to minimize bacterial seeding of braided suture (see later section on Sutures).

• Avoid tension-creating techniques (vertical and horizontal mattress suture repair) because these are more likely to cause necrosis of the skin edges.

• Approximate muscle with strong absorbable monofilament suture that will last around 90 days (e.g., PDS suture).

• Approximate dermis with absorbable monofilament suture that will last around 40 days (e.g., Monocryl).

• Approximate skin with permanent monofilament suture that will be removed in 1 to 2 weeks (e.g., Prolene, Nylon).

• Wounds on the hand, fingers, and plantar foot should be closed in one layer only, with permanent monofilament suture taking bites through the epidermis and dermis.

Chronic wounds

 Treatment is based on the etiology of the chronicity of the wound. Identify (on the basis of the history) the main etiology for the delayed wound healing.

• Treat contaminated wounds with mechanical débridement in the office or enzymatic débridement or dressings that will débride the wound (normal saline wet-to-dry dressing changes twice daily). Chemicals such as Dakin solution should not be used for more than 48 hours because they can be toxic to healthy tissues.

• Treat pressure ulcers with appropriate orthotics for pressure offloading or total contact casts if the patient is a candidate.

• Treat arterial ulcers with referrals to vascular surgery for evaluation of inflow.

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