Wound presentation

Pedal Wounds and

Treatment Principles

Michael Gruse Jr. DPM/PGY-1

Wound Healing

Wound repair requires an environment which is conducive to

epithelialization, collagen formation, angiogenesis, and

wound contracture

Cleveland VA Medical Center


Establish Etiology or Pathology

of Ulcer



Arterial Ulcers


No flow - No go

Must Establish Flow


Arterial UlcersEstablish flow

• Anti Platelet Medication • Pletal (cilostazol)• Plavix (clopidogrel)

• Referral to Vascular Surgeon


Next Step?


Prevention

Do not allow Chronic Venous Insufficiency to progress to ulceration

Venous Ulcers


Venous Insufficiency


Prevent edema• Elevation•Compression•Support Hose• Intermittent Compression Pump

Venous Ulcers



Skin Care• Maintain moisture• Treat stasis dermatitis

Venous Ulcers



Venous Ulcers


Trauma


Prevention

Neuropathic Ulcers



Prevention• Good glycemic control• Daily foot inspections• "Diabetic" socks• Change shoes in middle of day• Weight distributing insoles q6months• Regular professional care

Neuropathic Ulcers



REMOVE EXCESSIVE PRESSURE or

DISTRIBUTE PRESSURE EVENLY

Neuropathic Ulcers



Methods of Reducing Pressure•Total Contact Cast•Felted foam dressings•Firm but moldable insoles•Rocker bottom soles•Metatarsal bars•Non-weight bearing

Neuropathic Ulcers



After etiology is addressedProvide Normal Wound Care

Must Understand Eiology of Wound



Diagnose and Control Infection• signs and symptoms• radiographs• wound cultures and sensitivities• antibiosis

Treatment of Dermal Wounds


Is it infected?


Diagnose and Control InfectionSigns and Symptoms

• Fever• Cellulitis - Lymphangitis• Drainage• Foul odor• Palpable - tender lymph nodes




Diagnose and Control InfectionRadiographs

• baseline• soft tissue swelling & density• soft tissue planes• gas• bone involvement




Diagnose and Control InfectionWound cultures and Sensitivities

• Curette base of wound• aerobic and anaerobic if indicated• If wound probes to bone – it is infected until proven otherwise




Diagnose and Control InfectionAntibiosis

• begin broad spectrum coverage• Cover MRSA if recent antibiotics or hx of MRSA• reassess after culture is returned




Debridement should be

aggressive and thorough




Debridement • sharp debridement if applicable• wet to dry dressings

• saline preferred• Dakin's-Betadine-Peroxide-Acetic acid ?

• enzymatic debridement if ischemic• autolysis




AUTOLYSIS

the body's wound fluid hydrates and lyses the wound by mobilizing the body's own

enzymes




Wound Dressings

A moist wound environment is physiologic and speeds

epithelialization




Wound Dressings• Epithelialization occurs up to 50% faster in a moist environment than in a dry environment.• Wound fluid possesses growth factors that stimulate angiogenesis and epithelialization




Wound Dressings

There is no evidence that anything stimulates granulation tissue with the possible exception of growth

factors




Phases of Healing


I. Inflammatory PhaseErythema, warmth, edema, pain

A) VasoconstrictionB) VasodilationC) Leukocyte migrationD) Monocytes > macrophages


Phases of Healing


II. Proliferative Phase• Beefy red granulation tissue

MacrophagesCollagen synthesisAngiogenesis

• Thin, silvery epithelial layerEpithelialization

• Wound shrinkageContraction


Phases of Healing


III. Maturation PhaseShrinkage, thinning, paling of scarCollagen remodeling

Capillary regressionTensile strength increases


Ask yourself the following questionsIs it arterial?Is it venous?Is it neuropathic?Is it infected?Is there osteomyelitis?

SUMMARY


Wound presentation

Art & Photos

Transcript of Wound presentation