Paul M. Graham, DO
In this article, we will describe the most common types of wounds typically encountered by physicians and discuss in detail the characteristics of varying wound etiologies and treatment options available for each.
Without an appropriate wound care treatment regimen, chronic wounds may develop. One of the most important aspects of wound care is preventing the development of an infection. A wound infection will decrease the vital nutrients and oxygen available to the wound tissue, thus preventing adequate healing from taking place. Use this article as a tool for which direction you need to take in the event that you develop the following wounds.
Traumatic Wounds – Trauma is a very common cause of wounds and should be handled in a serious manner to prevent infection and increased severity. Many factors influence how easily and rapidly a wound will heal including adequate perfusion, immune status, infection, underlying diabetes or vascular disease, and type of wound care regimen. Traumatic wounds should be cleaned thoroughly with sterile saline and covered with a bandaid or sterile dressing. Seek medical attention for an appropriate wound care regimen.
Surgical Wounds – Surgical wounds are most commonly allowed to heal by a process termed primary intention, in which the wound edges are approximated and closed with sutures or staples. Surgical site infections are a major cause of failed progression through the normal stages of healing. When this occurs, redness, swelling, drainage, and pain may be present at the surgical site. It is very important to recognize these changes, as it could potentially prevent adequate closure of the wound. If this occurs, the wound may have to be reopened with closure by secondary intention (healing of an open wound from inside to outside), increasing the risk for a more pronounced scar.
Burn Injuries – Burns are very common cause of wound formation. Burns result in the loss of skin integrity, increasing the risk of infection and fluid loss. There are three types of burns than may occur: thermal burns, chemical burns, and electrical burn. Following an appropriate skin assessment and classification of burn depth, treatment should be initiated. The burn should be cooled with cool water for at least 20 minutes. Avoid very cold water or ice as it may cause blood vessel constriction and reduce blood flow to the affected area. Mild burn injuries should be debrided (removal of tissue) of dead skin and debris with an appropriate sterile dressing applied. Deep burns make the skin inelastic and may act as a tourniquet, decreasing the blood flow to the surrounding tissues. Excision of this dead tissue may be required and reconstruction often includes the application of skin grafts for proper healing to take place. Assessing and maintaining the patients fluid status is very important in deep wounds. All burns are susceptible to infection and proper treatment with silver-based products should be applied. Silver dressings work by decreasing the colonization of bacterial within the wound, thus encouraging wound healing to take place. During the healing process, the burn injury should be kept moist with healing ointment and should be protected from the sun.
Pressure Ulcers – Pressure ulcers are a very serious problem occurring in many immobile and bed-ridden patients. These ulcers typically develop as a result of an area of skin being compressed between a bony prominence and an external surface such as a bed or chair, for a prolonged period of time. This compression limits circulation and waste product removal from the involved tissue, causing breakdown of the skin to occur. Scheduled repositioning is one of the most important preventative factors that should be implemented in anyone that may be prone to developing a pressure ulcer from prolonged immobility.
Vascular Ulcers – Vascular ulcers are a leading cause of morbidity in patients with a history of peripheral vascular disease or venous insufficiency. A majority of these ulcers become chronic and recurrent, increasing the risk for lower extremity amputation. It is imperative that a full vascular workup be completed prior to treatment of any lower extremity wound. Treatment could pose great risk if there is not enough perfusion to the wound, thus increasing the severity.
There are two types of vascular ulcers. The first type involves arterial supply (arteries) and the second type involves venous drainage (veins). Disruption in arterial blood supply, deprives the tissue of the required oxygen and nutrients, causing cell death and ulcer formation. Venous insufficiency is a growing problem in today’s society and is responsible for many detrimental changes that take place in the lower legs. As the valves within the veins fail, the pressure increases, causing edema and varicosities to form. Without compression therapy and elevation of the lower legs, chronic skin changes may occur. In patients with venous insufficiency, a common condition known as lipodermatosclerosis may occur in the lower legs. Lipodermatosclerosis causes harding and darkening of the skin, giving it a “woody, bark like texture and appearance”. Compression stockings and elevation are the mainstay of treatment and act to increase the blood flow back to the heart.
Neuropathic Ulcers – Diabetes is the leading cause of peripheral neuropathy in the United States. Nearly 194 million people worldwide have been diagnosed with diabetes. Peripheral neuropathy is a condition characterized by degeneration of nerve cells, usually affecting the lower extremities in diabetic patients. Damage occurs in sensory and motor nerves, thus diminishing the sensation and movement of the lower legs. Neuropathic ulcers are initiated by trauma, usually by repetitive pressure, trauma, and/or heat. Due to the lack of sensation from peripheral neuropathy, the skin injury is not felt, leading to further damage and ulcer formation.
A condition know as Charcot joint is caused by repetitive trauma to single or multiple joints, leading to the joint destruction and deformation. This is caused by the loss of protective sensation that is responsible for the prevention of repetitive injuries. Offloading is key to the prevention of these ulcers and should be an essential part of diabetic wound care. Offloading is the reduction of pressure on ulcer-prone areas of the foot and include appropriately fitted shoes or orthotic devices designed to prevent ulcer formation. Once a neuropathic ulcer develops, routine debridement of the wound along with various dressing applications, and offloading must be initiated as part of the wound care regimen. If proper wound care is not implemented, osteomyelitis (bone infection) may ensue. Protective footwear, patient education, and frequent followup are three interventions that have been proven to reduce the occurrence of ulceration. Always make sure to examine your feet on a daily basis for early recognition and prevention of these ulcers.
Malignant Skin Wounds – Malignant wounds develop secondary to cancerous cells invading the skin and vessels, causing loss of skin perfusion and resulting in tissue death and ulceration. These lesions may be a primary cancer or secondary to metastatic spread to the skin from a tumor at a distant site. These wounds may present with bleeding, serous drainage, pain, and a foul odor. Treatment is aimed at three core principles: treatment of the underlying tumor, management of preexisting medical conditions, and local wound care. Depending on the stage of the tumor, various wound care procedure can be initiated. The most common treatment used in the management of malignant lesions include excision, but autolytic debridement can be done prior to removal. Autolytic debridement uses the body’s own enzymes and moisture to soften and liquefy hard scabs and slough that may be present in the wound. This debridement is virtually painless and well tolerated. Depending on the severity of the wound, your doctor will decide the most appropriate course of treatment including excision or chemotherapy.
Photo Credit: Home Remedy
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