Basic Principles of Wound Management

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Basic principles of wound managementAuthorsDavid G Armstrong, DPM, MD, PhD

Andrew J Meyr, DPMSection EditorsHilary Sanfey, MDJohn F Eidt, MDJoseph L Mills, Sr, MDEdardo !rera, MDDeputy Editor"athryn A #ollins, MD, PhD, FA#SDisclosures:David G Armstrong, DPM, MD, PhD $othing to dis%lose& Andrew J Meyr, DPM $othing to dis%lose& ilarySanfey, MD $othing to dis%lose& John ! Eidt, MD $othing to dis%lose&Joseph " Mills, Sr, MD Grant'(esear%h'#lini%al )rialSpport* $+H +nstitte of Aging a-dominal aorti% anerysm stdy.& #onsltant'Advisory !oards* AnGes %riti%al lim-is%hemia./ #es%a )herapeti%s %riti%al lim- is%hemia.& Spea0er* Gore -ypass smmit 1Polytetrafloroethylene2.& 3therfinan%ial interests* Elsevier vas%lar srgery te4t-oo0s.& Eduardo Bruera, MD $othing to dis%lose& #athryn A $ollins, MD,PhD, !A$S $othing to dis%lose&

#ontri-tor dis%losres are reviewed for %onfli%ts of interest -y the editorial grop& 5hen fond, these are addressed -yvetting throgh a mlti6level review pro%ess, and throgh re7irements for referen%es to -e provided to spport the %ontent&

Appropriately referen%ed %ontent is re7ired of all athors and mst %onform to 8p)oDate standards of eviden%e&

$onflict of interest policy

All topi%s are pdated as new eviden%e -e%omes availa-le and orpeer review pro%essis %omplete&"iterature review current through% Sep 9:;


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MED'$A" $A)E

)ole of antiiotics> All wonds are %oloni@ed with mi%ro-es/ however, not all wonds are infe%ted

1, Althogh there is no overwhelming %lini%al eviden%e in spport of short6term

gly%emi% %ontrol as dire%tly affe%ting wond healing potential or preventing infe%tion 1;;,;92, most

%lini%ians ma0e gly%emi% %ontrol a priority when treating wonds and infe%tion& See Ss%epti-ility to

infe%tions in persons with dia-etes mellits&.

Patients at ris0 for the development of %hroni% wonds often have %omor-id %onditions asso%iated with

immno%ompromised states eg dia-etes., and may not have %lassi% systemi% signs of infe%tion s%h asfever and le0o%ytosis on initial presentation 1;?2& +n these patients, hypergly%emia may -e a more

sensitive measre of infe%tion&

-*+(D DEB)'DEME(&> 5onds that have devitali@ed tisse, %ontamination, or residal stre

material re7ire de-ridement prior to frther wond management& A%te tramati% wonds may have

irreglar devitali@ed edges or foreign material within the wond, and srgi%al wonds that have dehis%ed

may have an infe%ted e4date, -owel %ontamination, or ne%roti% ms%le or fas%ia& )hese materials

impede the -odyKs attempt to heal -y stimlating the prod%tion of a-normal metalloproteases and

%onsming the lo%al resor%es ne%essary for healing&

#hara%teristi%s of %hroni% wonds that prevent an ade7ate %elllar response to wond6healing stimli

in%lde a%%mlation of devitali@ed tisse, de%reased angiogenesis, hyper0eratoti% tisse, e4date, and-iofilm formation ie, -a%terial overgrowth on the srfa%e of the wond. 1;2& )hese wonds need planned

serial de-ridement to restore an optimal wond healing environment&

5ond -ed preparation fa%ilitates ordered restoration and regeneration of damaged tisse, and may

enhan%e the fn%tion of spe%iali@ed wond %are prod%ts and advan%ed -iologi% tisse s-stittes

1;


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e4perimental model, high6pressre irrigation de%reased -a%terial levels more than -l- irrigation average

red%tion, C: verss per%ent. with no in%rease in the rate of -a%teremia 19B2& For highly %ontaminated

wonds, the -enefits of red%ing -a%terial load may otweigh the ris0 of spe%lative ada%ent tisse

damage asso%iated with the se of higher irrigating pressres& Althogh higher pressre irrigators may

lead to lo%al tisse damage and in%reased tisse edema, there are no spe%ifi% data availa-le to sggest a

spe%ifi% %toff pressre a-ove whi%h tisse damage or impaired, rather than improved, wond healing willo%%r&

Surgical> Sharp e4%isional de-ridement ses a s%alpel or other sharp instrments eg, s%issors or

%rette. to remove devitali@ed tisse and a%%mlated de-ris -iofilm.& Sharp e4%isional de-ridement of

%hroni% wonds de%reases -a%terial load and stimlates %ontra%tion and wond epitheliali@ation 19C2&

Srgi%al de-ridement is the most appropriate %hoi%e for removing large areas of ne%roti% tisse and is

indi%ated whenever there is any eviden%e of infe%tion %elllitis, sepsis.& Srgi%al de-ridement is also

indi%ated in the management of %hroni% nonhealing wonds to remove infe%tion, handle ndermined

wond edges, or o-tain deep tisse for %ltre and pathology 196?:2& Serial srgi%al de-ridement in a

%lini%al setting, when appropriate, appears to -e asso%iated with an in%reased li0elihood of healing

19,?;2&

+n patients with a%tive infe%tion, anti-ioti% therapy shold -e targeted and determined -y wond %ltre

and sensitivity to de%rease the development of -a%terial resistan%e 1?9,??2& See #elllitis and

erysipelasand #elllitis and erysipelas, se%tion on Anti-ioti%s&.

+n patients with %hroni% %riti%al lim- is%hemia, srgi%al de-ridement mst -e %opled with

revas%lari@ation in order to -e s%%essfl 1?2& See )reatment of %hroni% lower e4tremity %riti%al lim-

is%hemia&.

En.ymatic> En@ymati% de-ridement involves applying e4ogenos en@ymati% agents to the wond&

Many prod%ts are %ommer%ially availa-le ta-le ;., -t reslts of %lini%al stdies are mi4ed and their se

remains %ontroversial 1? An additional method of wond de-ridement ses the larvae of the Astralian sheep -low fly

Lucilia [Phaenicia] cuprina. or green -ottle fly Lucilia [Phaenicia] sericata, Medi%al Maggots, Monar%h

La-s, +rvine, #A. 1?,?2& Maggot therapy %an -e sed as a -ridge -etween de-ridement pro%edres, or

for de-ridement of %hroni% wonds when srgi%al de-ridement is not availa-le or %annot -e performed&

Maggot therapy may also red%e the dration of anti-ioti% therapy in some patients 1:2&

Maggot therapy has -een sed in the treatment of pressre l%ers 1;,92, %hroni% venos l%eration

1?,2, dia-eti% l%ers 1?2, and other a%te and %hroni% wonds 1


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Dressing %hanges in%lde the appli%ation of a perimeter dressing and a %over dressing of mesh %hiffon.

that helps dire%t the larvae into the wond and limits their migration movie ;.& Larvae are generally

%hanged every to C9 hors& 3ne stdy that evalated maggot therapy in %hroni% venos wonds fond

no advantage to %ontining maggot therapy -eyond one wee0 12& Patients were randomly assigned to

maggot therapy n N


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ine%tions with GM6#SF 9:: m%g, :: m%g, or pla%e-o fond signifi%antly higher rates of healing at

;? wee0s in the GM6#SF grop Most topi%ally6applied antisepti% and antimi%ro-ial prod%ts are

irritating, partially %ytoto4i% leading to delayed healing, and %an %ase %onta%t sensiti@ation& However, two

of these agents may -e asso%iated with potential -enefits in sele%t poplations*

'odine0ased> #ade4omer iodine eg, +odosor-. is an antimi%ro-ial that red%es -a%terial load within

the wond and stimlates healing -y providing a moist wond environment 1B Althogh silver is to4i% to -a%teria, silver6%ontaining dressingshave not demonstrated

signifi%ant -enefits 1BB6B2& A systemati% review evalating topi%al silver in infe%ted wonds identified

three trials that treated C parti%ipants with varios silver6%ontaining dressings 1B2& 3ne trial %ompared

silver6%ontaining foam #ontreet. with hydro%elllar foam Allevyn. in patients with leg l%ers& )he se%ond%ompared a silver6%ontaining alginate Silver%el. with an alginate alone Algosteril.& )he third trial

%ompared a silver6%ontaining foam dressing #ontreet. with -est lo%al pra%ti%e in patients with %hroni%

wonds& Silver6%ontaining foam dressings were not fond to signifi%antly improve l%er healing at for

wee0s %ompared with non6silver6%ontaining dressings for -est lo%al pra%ti%es& $evertheless, silver

dressings are sed -y many %lini%ians to de%rease the heavy -a%terial srfa%e %ontamination 1C:2&

oney> Honey has -een sed sin%e an%ient times for the management of wonds& Honey has -road

spe%trm antimi%ro-ial a%tivity de to its high osmolarity, and high %on%entration ofhydrogen

pero4ide 1C;2& Medi%al grade honey prod%ts are now availa-le as a gel, paste, and impregnated into

adhesive, alginate, and %olloid dressings 1C9,C?2& !ased pon the reslts of systemati% reviews evalating

honey to aid healing in a variety of wonds, there are insffi%ient data to provide any re%ommendations

for the rotine se of honey for all wond types/ spe%ifi% wond types, s%h as -rns, may -enefit,

whereas others, s%h as %hroni% venos l%ers, may not 1C6:2&

Beta loc1ers> "eratino%ytes have -eta6adrenergi% re%eptors, and -eta -lo%0ers may inflen%e their

a%tivity and in%rease the rate of matration and migration& )he se of systemi% -eta -lo%0ers has -een

stdied in -rn patients 1;2, and several %ase stdies have presented the se of topi%al timololin %hroni%

wonds 1962&

)imololis a topi%ally applied -eta -lo%0er with some limited eviden%e that it promotes 0eratino%yte

migration and epitheliali@ation of %hroni% wonds, whi%h have -een nresponsive to standard wond

interventions&

-*+(D D)ESS'(GS> 5hen a sita-le dressing is applied to a wond and %hanged appropriately, thedressing %an have a signifi%ant impa%t on the speed of wond healing, wond strength and fn%tion of the

repaired s0in, and %osmeti% appearan%e of the reslting s%ar& $o single dressing is perfe%t for all wonds/

rather, a %lini%ian shold evalate individal wonds and %hoose the -est dressing on a %ase -y %ase

-asis& E4amples of differing types of wonds and potential dressings are given in the ta-le ta-le 9.& +n

addition, wonds mst -e %ontinally monitored, as their %hara%teristi%s and dressing re7irements

%hange over time 1


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)here is little %lini%al eviden%e to aid in the %hoi%e -etween the different types of wond dressings&

#onsenss opinion spports the following general prin%iples for %hroni% wond management 1B2*

Hydrogels for the de-ridement stage

Foam and low6adheren%e dressings for the granlation stage

Hydro%olloid and low6adheren%e dressings for the epitheliali@ation stage&

For all intents and prposes, dressings are -est sited to manage the moistre level in and arond the

wond& Althogh some may have additional -enefits in terms of lo%al antimi%ro-ial effe%ts, red%ed pain

on %hange, odor %ontrol, anti6inflammatory or mild de-ridement a-ility, these are se%ondary -enefits 1C2&

Dressings are typi%ally %hanged on%e a day or every other day to avoid distr-ing the wond healing

environment& !e%ase some dressings may impede some aspe%ts of wond healing, they shold -e sed

with %ation& As e4amples, alginate dressings with high %al%im %ontent may impede epitheliali@ation -y

triggering prematre terminal differentiation of 0eratino%ytes 1B2, and silver6%ontaining dressingsare

%ytoto4i% and shold not -e sed in the a-sen%e of signifi%ant infe%tion& See Antisepti%s and

antimi%ro-ial agentsa-ove and Alginates-elow&.

)he advantages and disadvantages of the varios dressing types are dis%ssed -elow& See #ommon

dressings-elow&.

'mportance of moisture> For m%h of the history of medi%ine, it was -elieved that wonds shold not

-e o%%lded -t left e4posed to the air& However, an important stdy in a pig model showed that moist

wonds healed more rapidly %ompared with wonds that dried ot 12& Similar reslts have -een

o-tained in hmans 16;2&

3%%lded wonds heal p to : per%ent more rapidly than non6o%%lded wonds 12& )his is thoght to

-e de, in part, to easier migration of epidermal %ells in the moist environment %reated -y the dressing

1:2& Another me%hanism for improved wond healing may -e the e4posre of the wond to its own flid

192& A%te wond flid is ri%h in platelet6derived growth fa%tor, -asi% fi-ro-last growth fa%tor, and has a-alan%e of metalloproteases serving a matri4 %stodial fn%tion 1?2& )hese intera%t with one another and

with other %yto0ines to stimlate healing 12& 3n the other hand, the effe%t of %hroni% wond flid on

healing may not -e -enefi%ial& #hroni% wond flid is very different from a%te wond flid and %ontains

persistently elevated levels of inflammatory %yto0ines whi%h may inhi-it proliferation of fi-ro-lasts 1


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Prote%ts the wond from frther me%hani%al or %asti% damage

Prevents -a%terial invasion or proliferation

#onforms to the wond shape and eliminates dead spa%e

De-rides ne%roti% tisse

Does not ma%erate the srronding via-le tisse

A%hieves hemostasis and minimi@es edema throgh %ompression

Does not shed fi-ers or %omponds that %old %ase a foreign -ody or hypersensitivity rea%tion

Eliminates pain dring and -etween dressing %hanges

Minimi@es dressing %hanges

+s ine4pensive, readily availa-le, and has a long shelf life

+s transparent in order to monitor wond appearan%e withot disrpting dressing

+n most %ases, a dressing with all of these %hara%teristi%s is not availa-le, and a %lini%ian mst de%ide

whi%h of these is most important in the %ase of a parti%lar wond& )he moistre %ontent of a wond -ed

mst -e 0ept in -alan%e for -oth a%te and %hroni% wonds& )he area shold -e moist enogh to promote

healing, -t e4%ess e4date mst -e a-sor-ed away from the wond to prevent ma%eration of the healthytisse&

$ommon dressings> Althogh dressings %an -e %ategori@ed -ased pon many %hara%teristi%s, it is

most sefl to %lassify dressings -y their water6retaining a-ilities -e%ase the primary goal of a dressing

is the maintenan%e of moistre in the wond environment& As s%h, dressings are %lassified as open,

semi6open or semi6o%%lsive&

3pen dressings in%lde, primarily, ga@e, whi%h is typi%ally moistened with saline -efore pla%ing it into the

wond& Ga@e -andages are availa-le in mltiple si@es, in%lding 9 4 9 in%h and 4 in%h s7are

dressings and in ? or in%h rolls eg, "erli4.& )hi%0er a-sor-ent pads eg, A!D pads. are sed to %over

the ga@e dressings& For managing large wonds, self adhesive straps Montgomery straps. %an -e sed

to hold a -l0y dressing in pla%e& As dis%ssed a-ove, dried ga@e dressings are dis%oraged& 5et6to6moist ga@e dressings are sefl for pa%0ing large soft6tisse defe%ts ntil wond %losre or %overage

%an -e performed& Ga@e dressings are ine4pensive -t often re7ire fre7ent dressing %hanges&

Semi6open dressings typi%ally %onsist of fine mesh ga@e impregnated with petrolem, paraffin wa4, or

other ointment, and have prod%t names s%h as eroform, Adapti%, Jelonet, and Sofra )lle& )his initial

layer is %overed -y a se%ondary dressing of a-sor-ent ga@e and padding, then finally a third layer of

tape or other method of adhesive& !enefits of semi6open dressings in%lde their minimm e4pense and

their ease of appli%ation& )he main disadvantage of this type of dressing is that itdoes not maintain a

moistre6ri%h environment or provide good e4date %ontrol& Flid is permitted to seep throgh the first

layer and is %olle%ted in the se%ond layer, allowing for -oth desi%%ation of the wond -ed and ma%eration

of the srronding tisse in %onta%t with the se%ondary layer& 3ther disadvantages in%lde the -l0 of the

dressing, its aw0wardness when applied to %ertain areas, and the need for fre7ent %hanging&

Semi6o%%lsive dressings %ome in a wide variety of o%%lsive properties, a-sorptive %apa%ities,

%onforma-ility, and -a%teriostati% a%tivity& Semi6o%%lsive dressings in%lde films, foams, alginates,

hydro%olloids, and hydrogels, and are dis%ssed -elow&

!ilms> Polymer films are transparent sheets of syntheti% self6adhesive dressing that are permea-le to

gases s%h as water vapor and o4ygen -t impermea-le to larger mole%les in%lding proteins and

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-a%teria& )his property ena-les insensi-le water loss to evaporate, traps wond flid en@ymes within the

dressing, and prevents -a%terial invasion& )hese dressings are sometimes 0nown as syntheti% adhesive

moistre6vapor6permea-le dressings, and in%lde )egaderm, #tifilm, !listerfilm, and !io%lsive&

)ransparent film dressings were fond to provide the fastest healing rates, lowest infe%tion rates, and to

-e the most %ost6effe%tive method for dressing split6thi%0ness s0in graft donor sites in a review of ??

p-lished stdies 1;::2&

Advantages of these dressings in%lde their a-ility to maintain moistre, en%orage rapid re6

epitheli@ation, and their transparen%y and self6adhesive properties& Disadvantages of film dressings

in%lde limited a-sorptive %apa%ity, and they are not appropriate for moderately to heavily e4dative

wonds& +f they are allowed to remain in pla%e over a wond with heavy e4dates, the srronding s0in is

li0ely to -e%ome ma%erated& +n addition, if the wond dries ot, film dressings may adhere to the wond

and -e painfl and damaging to remove&

!oams> Foam dressings %an -e thoght of as film dressings with the addition of a-sor-en%y& )hey

%onsist of two layers, a hydrophili% sili%one or polyrethane6-ased foam that lies against the wond

srfa%e, and a hydropho-i%, gas permea-le -a%0ing to prevent lea0age and -a%terial %ontamination&

Some foams re7ire a se%ondary adhesive dressing& Foams are mar0eted nder names s%h as Allevyn,

Adhesive, Lyofoam, and Spyrosor-&

Advantages of foams in%lde their high a-sorptive %apa%ity and the fa%t that they %onform to the shape of

the wond and %an -e sed to pa%0 %avities& Disadvantages of foams in%lde the opa%ity of the dressings

and the fa%t that they may need to -e %hanged ea%h day& Foam dressings may not -e appropriate on

minimally e4dative wonds, as they may %ase desi%%ation&

3ne small trial %ompared foams to films as dressings for s0in tears in instittionali@ed adlts and fond

that more %omplete healing o%%rred in the grop sing foams 1;:;2&

Alginates> $atral %omple4 polysa%%harides from varios types of algae form the -asis of alginate

dressings& )heir a%tivity as dressings is ni7e -e%ase they are insol-le in water, -t in the sodim6ri%h

wond flid environment these %omple4es e4%hange %al%im ions for sodim ions and form an

amorphos gel that pa%0s and %overs the wond& Alginates %ome in varios forms in%lding ri--ons,

-eads, and pads& )heir a-sorptive %apa%ity ranges depending pon the type of polysa%%haride sed& +n

general, these dressings are more appropriate for moderately to heavily e4dative wonds&

Advantages of alginates in%lde agmentation of hemostasis 1;:9,;:?2, they %an -e sed for wond

pa%0ing, most %an -e washed away with normal saline in order to minimi@e pain dring dressing %hanges,

and they %an stay in pla%e for several days& Disadvantages of alginates are that they re7ire a se%ondary

dressing that mst -e removed in order to monitor the wond, they %an -e too drying on a minimally

e4dative wond, and they have an npleasant odor&

+n a trial of CC patients, patients with dia-eti% foot wonds were randomly assigned to alginate or

petrolem ga@e dressings 1;:2& Patients treated with alginates were fond to have signifi%antly sperior

granlation tisse %overage at for wee0s of treatment, signifi%antly less pain, and fewer dressing

%hanges than the petrolem ga@e grop&

ydrocolloids> Hydro%olloid dressings sally %onsist of a gel or foam on a %arrier of self6adhesive

polyrethane film& )he %olloid %omposition of this dressing traps e4date and %reates a moist

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environment& !a%teria and de-ris are also trapped, and washed away with dressing %hanges in a gentle,

painless form of me%hani%al de-ridement& Another advantage of hydro%olloids is the a-ility to se them

for pa%0ing wonds& Disadvantages in%lde malodor and the potential need for daily dressing %hanges,

and allergi% %onta%t dermatitis has -een reported 1;: Hydrogels are a matri4 of varios types of syntheti% polymers with Q< per%ent water

formed into sheets, gels, or foams that are sally sandwi%hed -etween two sheets of remova-le film&

)he inner layer is pla%ed against the wond, and the oter layer %an -e removed to ma0e the dressing

permea-le to flid& Sometimes a se%ondary adhesive dressing is needed& )hese ni7e matri%es %an

a-sor- or donate water depending pon the hydration state of the tisse that srronds them& Hydrogel

prod%ts in%lde +ntrasite Gel, Rigilon, #arrington Gel, and Elastogel&

Hydrogels are most sefl for dry wonds& )hey initially lower the temperatre of the wond environment

they %over, whi%h provides %ooling pain relief for some patients 1;:2& As a disadvantage, althogh there

have -een no reports of in%reased wond infe%tion, hydrogels have -een fond to sele%tively permit

gram6negative -a%teria to proliferate 1;;:2&

ydroactive> Hydroa%tive, the most re%ently developed syntheti% dressing, is a polyrethane matri4

that %om-ines the properties of a gel and a foam& Hydroa%tive sele%tively a-sor-s e4%ess water while

leaving growth fa%tors and other proteins -ehind 1;;;2&

A randomi@ed trial %ompared hydroa%tive dressings with two different hydro%olloids and fond the

hydroa%tive dressing to -e e7ally effe%tive at promoting l%er healing and alleviating l%er6asso%iated

pain after ;9 wee0s of treatment 1;;92& Another stdy fond hydroa%tive dressings %om-ined with

en@ymati% de-ridement to -e more %ost6effi%ient than ga@e alone in dressing pressre l%ers and

venos stasis l%ers 1;;?2&

-*+(D PA$#'(G> 5onds with large soft6tisse defe%ts may have an area of dead spa%e -etweenthe srfa%e of inta%t healthy s0in and the wond -ase& )hese wonds are des%ri-ed as tnneled or

ndermined& 8ndermining is defined as e4tension of the wond nder inta%t s0in edges s%h that the

wond measres larger at its -ase than is appre%iated at the s0in srfa%e&

5hen des%ri-ing and do%menting ndermined wonds, it is important to a%%rately measre the depth

of ndermining in %entimeters and lo%ation of ndermining sing %lo%0 formation as a gide ;9*::, B*::,

9
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et%&.& )he presen%e of ne%roti% tisse indi%ates the need for srgi%al de-ridement to de%rease -a%terial

-rden and prevent se7elae of infe%tion 1?92&

Althogh there have -een no spe%ifi% trials %omparing pa%0ed verss npa%0ed wonds, wond pa%0ing

is %onsidered standard %are 1;;2& )raditional ga@e dressings are often sed to pa%0 wonds asso%iated

with signifi%ant dead spa%e or ndermining to aid in %ontining de-ridement of devitali@ed tisse from the

wond -ed& )he ga@e is moistened with normal saline or tap water and pla%ed into the wond and

%overed with dry layers of ga@e& As the moistened ga@e dries, it adheres to srfa%e tisses, whi%h are

then removed when the dressing is %hanged& Dressing %hanges shold -e fre7ent enogh that the

ga@e does not dry ot %ompletely, whi%h %an -e two to three times daily& A disadvantage of ga@e

dressings is that they %an also remove developing granlation tisse, reslting in reinry& )hs, these

dressings are dis%ontined when the ne%roti% tisse has -een removed and granlation is o%%rring& An

alternative to ga@e dressing for managing wonds with signifi%ant dead spa%e is negative pressre

wond therapy& See $egative pressre wond therapy-elow&.

Many of the materials that are sed as topi%al dressings for wonds foams, alginates, hydrogels. %an -e

molded into the shape of the wond and are sefl for wond pa%0ing& As with their se in dressing

wonds, there is little %onsenss over what %onstittes the -est material for wond pa%0ing& See5onddressingsa-ove&.

5ond dressing %hanges asso%iated with large defe%ts %an -e managed withot repeated appli%ations of

tape to the s0in -y sing Montgomery straps pi%tre 9.&

-*+(D $"*S+)E> Primary %losre refers to the stre or staple %losre of a%te srgi%al or

tramati% wonds after appropriate wond preparation figre ; andfigre 9.& See Minor wond

preparation and irrigationand #losre of s0in wonds with stresand #losre of minor s0in wonds

with staples&.

Delayed primary %losre a%hieves s0in edge apposition following an interval of wond management&

Delayed %losre in a-dominal wonds, %hest wonds, and srgi%al wonds withot eviden%e of infe%tionis widely a%%epted figre ;. 1;; $egative pressre wond therapy enhan%es wond healing -y

red%ing edema srronding the wond, stimlating %ir%lation, and in%reasing the rate of granlation

tisse formation 1;;B6;;2& )he te%hni7e involves the appli%ation of a %ontrolled s-atmospheri%

pressre to a wond %overed with a foam dressing& $egative pressre wond therapy is sefl to manage

large defe%ts ntil %losre %an -e performed& +t has also -een sed with modest s%%ess in the treatment

of pressre l%ers 1;9:6;992, and dia-eti% wonds 1;;,;9?2& See$egative pressre wond therapy&.

-*+(D $*2E)AGE

S1in grafts> Split6thi%0ness and fll6thi%0ness s0in grafts are the most -asi% -iologi% dressings and

%onsist of s0in ta0en from a donor site and grafted onto a wond on the same patient& S0in grafts are

sed for wond %losre, to prevent flid and ele%trolyte loss, and red%e -a%terial -rden and infe%tion&

S0in transplanted from one lo%ation to another on the same individal is termed an atogenos graft or

atograft&

S0in grafts are %lassified as either split6thi%0ness or fll6thi%0ness, depending pon the amont of dermis

in%lded in the graft& A partial or split6thi%0ness s0in graft %ontains a varia-le thi%0ness of dermis, while a

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fll6thi%0ness s0in graft %ontains the entire dermis& )he %hara%teristi%s of normal s0in are maintained with

a thi%0er dermal %omponent& However, thi%0er grafts re7ire a more ro-st wond -ed de to the greater

amont of tisse that needs to -e revas%lari@ed& )he %hoi%e -etween fll6 and split6thi%0ness s0in

grafting depends pon the %ondition of the wond, lo%ation, si@e, and need for %osmesis 1;9,;9 Fll6thi%0ness grafts %ontain the epidermis and dermis, and ths retainmore of the %hara%teristi%s of normal s0in, in%lding %olor, te4tre, and thi%0ness, when %ompared with

split6thi%0ness grafts& Fll6thi%0ness s0in grafts are limited to relatively small, n%ontaminated, well6

vas%lari@ed wonds& )he s0in sed for fll6thi%0ness s0in grafts is o-tained from areas of redndant and

plia-le s0in s%h as the groin, lateral thigh, lower a-domen, or lateral %hest& Donor sites are sally

%losed primarily& )he main disadvantages of fll6thi%0ness grafts in%lde limited availa-ility of donor s0in

and the potential for flid a%%mlation -eneath the graft&

Split0thic1ness s1in grafts> Split6thi%0ness s0in grafts are %ommonly sed tisse for wond %overage&

A split6thi%0ness s0in graft in%ldes the epidermis and a varia-le amont of dermis ranging -etween :&::

to :&:;9 in%hes pi%tre ?.& Split6thi%0ness s0in grafts are frther %ategori@ed as thin :&::< to :&:;9

in%hes., intermediate :&:;9 to :&:; in%hes., or thi%0 :&:; to :&:?: in%hes. -ased pon the thi%0ness ofgraft harvested&

#ompared with fll6thi%0ness s0in grafts, split6thi%0ness s0in grafts tolerate a less6than6ideal wond -ed

and have a -roader range of appli%ations& )hey %an -e sed to resrfa%e large wonds, line %avities,

resrfa%e m%osal defi%its, %lose donor sites of flaps, and resrfa%e ms%le flaps& )hey also are sed to

a%hieve temporary %losre of wonds %reated -y the removal of lesions that re7ire pathologi%

e4amination prior to definitive re%onstr%tion& Split6thi%0ness s0in grafts have -een sed s%%essflly in

treating large %hroni% wonds, in%lding those on the leg and sole of the foot, provided the area %an -e

prote%ted against %hroni% verti%al and shear stresses&

Split6thi%0ness s0in grafts %an -e meshed to provide %overage of a greater srfa%e area at the re%ipient

site, with e4pansion ratios generally ranging from ;*; to B*;& Split6thi%0ness s0in graft donor sites healspontaneosly with %ells spplied -y the remaining epidermal appendages& Donor sites %an -e re6

harvested on%e healing is %omplete&

Split6thi%0ness grafts have disadvantages that need to -e %onsidered& Split6thi%0ness grafts are more

fragile, espe%ially when pla%ed over areas with little nderlying soft tisse -l0 for spport& )hey %ontra%t

more dring healing, do not grow with the individal, and tend to -e smoother and shinier than normal

s0in -e%ase of the a-sen%e of s0in appendages in the graft& )hey also tend to -e a-normally pigmented,

either pale or white, or alternatively, hyperpigmented, parti%larly in dar0er6s0inned individals& For these

reasons, split6thi%0ness s0in grafts are more widely sed for %ontrol of infe%tion and prevention

of flid'ele%trolyte loss rather than %osmesis 1;9,;9B2&

Biologic 3cell0ased dressings4> !iologi% %ell6-ased dressings are %omposed of a live6%ell %onstr%t

that %ontains at least one layerof live allogeni% %ells&

#ell6-ased dressings %an -e sed when traditional dressings have failed or are deemed inappropriate

1;9C2& 3ne stdy sggested that advan%ed -iologi%s shold -e sed when %hroni% wonds fail to heal at

an appropriate rate of %losre, ie,


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growth fa%tors are added to a defi%ient wond6healing environment&A%%elerated wond healing red%es

the ris0 of wond infe%tion&

#ell6-ased therapies may se epidermal and dermal elements& 3ther therapies fo%s on dermal elements

s%h as %ollagen and fi-ro-lasts, whi%h prevent wond %ontra%tion and provide greater sta-ility 1;92&

Apligraf %om-ined with %ompression therapy has -een fond to improve healing of venos stasis l%ers

%ompared with %ompression therapy 1;?:2& #lini%al ree%tion has not -een reported& #ell6-ased therapies

have also -een stdied in patients with dia-etes 1;?;6;?2& +n one stdy of 9: patients with noninfe%ted

neropathi% l%ers, wee0ly appli%ation of Grafts0in for for wee0s improved the rate of %omplete wond

healing %ompared with sal %are


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Fas%iotomy wonds O Animal models of reperfsion following release of a%te e4tremity

%ompartment syndromes sggest that the H!3) may -e -enefi%ial& SeePatient management

following e4tremity fas%iotomy, se%tion on Hyper-ari% o4ygen&.

)hermal inry O A systemati% review of H!3) in -rn wonds fond only two high 7ality trials and

%on%lded that there was insffi%ient eviden%e to spport the se of H!3 following thermal inry

1; A variety of other therapies, s%h as low fre7en%y ltrasond 1;


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Pressure ulcers> )he treatment of pressre l%ers depends pon the stage of the l%er& See #lini%al

staging and management of pressre l%ers, se%tion on 8l%er management&.

Diaetic foot ulcer> )he management of dia-eti% foot l%ers varies depending on the grade of l%er

1;C;2& See Management of dia-eti% foot l%ers&.

2enous ulcer> )he mainstay of treatment for venos l%erations is %ompression& SeeMedi%almanagement of lower e4tremity %hroni% venos disease, se%tion on 8l%er %are&.

'schemic ulcerations and gangrene> )he presen%e of is%hemia inflen%es the timing of de-ridement

and definitive intervention&

For patients with wet gangrene or a-s%ess, the wond shold -e de-rided immediately regardless of the

need for revas%lari@ation& )he dressing %hoi%e depends pon the level of anti%ipated drainage and the

si@e of the wond& Dead spa%e is sally managed with ga@e pa%0ing& )he e4tremity shold -e

revas%lari@ed as soon as possi-le, if needed, after drainage'de-ridement and %ontrol of the infe%tion&

For patients with dry gangrene withot %elllitis, the lim- shold -e revas%lari@ed first& )he wond

dressing is prote%tive, red%ing the ris0 for trama or infe%tion& )he wond shold -e lightly wrapped witha -l0y dry ga@e -andage, avoiding e4%ess pressre that %old aggravate is%hemia& Following

revas%lari@ation, the wond shold -e monitored %losely for signs of healing, or for

tisse ne%rosis'drainage that may indi%ate a need for frther de-ridement&

+lcerated and fungating malignant wounds> )he palliative treatment of l%erating and fngating

wonds se%ondary to malignan%y represents a %lini%al %hallenge withot eviden%e6-ased gidelines or

esta-lished proto%ols& )he pra%titioner shold esta-lish goals for wond management with the patient,

sin%e the sal goal of wond %losre will generally not -e realisti%& )opi%al wond %are and spe%ifi%

dressings shold -e tailored to the individal wond and patient needs, and the physi%ian shold

appre%iate that proper wond management %an ma0e a great deal of differen%e to the patient, and

inflen%e his or her a-ility to %omforta-ly re%eive gests, parti%ipate in p-li% events, and assist with

a%tivities of daily living 1;C96;C


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3o@ing from the l%er -ed %an -e %ontrolled with topi%al hemostati% agents ors%ralfate1;C2, and

gentle pressre in the form of elasti% -andages, with fo%al points of -leeding managed with silver

nitrate, hand6held %atery, or lo%al anestheti% with epinephrine&See 3verview of topi%al hemostati%

agents and tisses adhesives sed in the operating room and +nfiltration of lo%al anestheti%s&.

S+MMA)/ A(D )E$*MME(DA&'*(S

For optimal wond healing, the wond -ed needs to -e well vas%lari@ed, free of devitali@ed tisse,

%lear of infe%tion, and moist& See +ntrod%tion a-ove&.

5ond dressings shold -e %hosen -ased pon their a-ility to manage dead spa%e, %ontrol

e4date, red%e pain dring dressing %hanges as appli%a-le., prevent -a%terial overgrowth, ensre

proper flid -alan%e, -e %ost6effi%ient, and -e managea-le for the patient or nrsing staff&

See 5ond pa%0ing a-ove and 5ond dressingsa-ove&.

5e sggest sharp srgi%al de-ridement over nonsrgi%al methods for the initial de-ridement of

devitali@ed tisse asso%iated with a%te and %hroni% wonds or l%ers when possi-le Grade 6$.&

See 5ond de-ridementa-ove&.

)opi%al agents s%h as antisepti%s and antimi%ro-ial agents %an -e sed to %ontrol lo%ally heavy

%ontamination& Signifi%ant improvements in rates of wond healing have not -een fond and tisse

to4i%ity may -e a signifi%ant disadvantage& SeeAntisepti%s and antimi%ro-ial agentsa-ove&.

For deep wonds, negative pressre wond therapy may prote%t the wond and red%e the

%omple4ity and depth of the defe%t& $egative pressre wond therapy is fre7ently sed to manage

%omple4 wonds prior to definitive %losre& See $egative pressre wond therapy a-ove&.

Following wond -ed preparation, a%te wonds %an often -e %losed primarily& #hroni% wonds

that demonstrate progressive healing as eviden%ed -y granlation tisse and epitheliali@ation along

the wond edges %an ndergo delayed %losre or %overage with s0in grafts or -ioengineered

tisses& See5ond %losrea-ove and 5ond %overage a-ove&.

Many other therapies have -een sed with the aim of enhan%ing wond healing and in%lde

hyper-ari% o4ygen therapy, and wond stimlation sing ltrasond, ele%tri%al, and ele%tromagneti%energy& Some of these therapies have shown a marginal -enefit in randomi@ed stdies, and may -e

sefl as adn%ts for wond healing& See Adn%tive therapiesa-ove&.

A$#(*-"EDGME(&> 5e are saddened -y the death of J Andrew !illings, MD, who passed away in

Septem-er 9:;


16/26

?& Golin0o MS, #lar0 S, (ennert (, et al& 5ond emergen%ies* the importan%e of assessment,do%mentation, and early treatment sing a wond ele%troni% medi%al re%ord& 3stomy 5ond Manage9::/


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9:& Moore E, #owman S& 5ond %leansing for pressre l%ers& #o%hrane Data-ase Syst (ev 9:;?/?*#D::?&

9;& Hollander JE, Singer AJ& La%eration management& Ann Emerg Med ;/ ?*?


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?& Pal AG, Ahmad $5, Lee HL, et al& Maggot de-ridement therapy with L%ilia %prina* a%omparison with %onventional de-ridement in dia-eti% foot l%ers& +nt 5ond J 9::/ B*?&

?& Andersen AS, Sandvang D, S%hnorr "M, et al& A novel approa%h to the antimi%ro-ial a%tivity ofmaggot de-ridement therapy& J Antimi%ro- #hemother 9:;:/ B


19/26


20/26

C9& http*''www&dermas%ien%es&%om'medihoney6prod%ts A%%essed on April 9, 9:;


21/26

:& SvensZ ), Pomaha% !, Tao F, et al& A%%elerated healing of fll6thi%0ness s0in wonds in a wetenvironment& Plast (e%onstr Srg 9:::/ ;:B*B:9&

;& Rogt PM, Andree #, !reing ", et al& Dry, moist, and wet s0in wond repair& Ann Plast Srg ;


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;:C& Hansson #& )he effe%ts of %ade4omer iodine paste in the treatment of venos leg l%ers%ompared with hydro%olloid dressing and paraffin ga@e dressing& #ade4omer +odine Stdy Grop& +nt JDermatol ;/ ?C*?:&

;:& Mi%hane0 A, Hansson #, !erg G, M[nes0Zld6#laes A& 1+odine6ind%ed hyperthyroidism after%ade4omer iodine treatment of leg l%ers2& La0artidningen ;/


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;9


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;:& (ey@elman A, #rews (), Moore J#, et al& #lini%al effe%tiveness of an a%elllar dermalregenerative tisse matri4 %ompared to standard wond management in healing dia-eti% foot l%ers* aprospe%tive, randomised, mlti%entre stdy& +nt 5ond J 9::/ B*;B&

;;& )hom S(& Hyper-ari% o4ygen* its me%hanisms and effi%a%y& Plast (e%onstr Srg 9:;;/ ;9C Sppl;*;?;S&

;9& !rem H, )omi%6#ani% M& #elllar and mole%lar -asis of wond healing in dia-etes& J #lin +nvest9::C/ ;;C*;9;&

;?& )i--les PM, Edels-erg JS& Hyper-ari%6o4ygen therapy& $ Engl J Med ;B/ ??*;B9&

;& 5attel F, Mathie D, $evi\re (, !o%7illon $& A%te peripheral is%haemia and %ompartmentsyndromes* a role for hyper-ari% o4ygenation& Anaesthesia ;/


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;


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;C?& Mer@ ), "lein #, 8e-a%h !, et al& Fngating 5onds 6 Mltidimensional #hallenge in Palliative#are& !reast #are !asel. 9:;;/ B*9;&

;C& e%h DF, Grond S, Lyn%h J, et al& Ralidation of 5orld Health 3rgani@ation Gidelines for %an%erpain relief* a ;:6year prospe%tive stdy& Pain ;

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