Wound treatment

Wounds are disruptions of the normal structure and function of skin and underlying soft tissue caused by trauma or chronic mechanical stress. Wounds can be acute or chronic and open or closed. All wounds should be assessed for the extent of injury, degree of contamination, and injury to adjacent neurovascular structures and bones. Patients with multiple wounds should be screened for concurrent injuries to deeper structures or organs, as well as complications such as rhabdomyolysis, compartment syndrome, and venous thromboembolism. Open wounds are managed with cleaning, removal of devitalized tissue, and, if feasible, wound closure. The type and timing of wound closure depend on the degree of contamination and how much time has passed since the injury. Options for wound closure range from glue, wound closure strips, and suturing to complex plastic surgery repairs such as skin grafting. Closed musculoskeletal wounds are managed according to the POLICE principle. Chronic wounds and ulcers can often be treated conservatively; however, in severe or nonhealing wounds, surgical intervention, including debridement and skin grafting, may be necessary. Management of the underlying cause (e.g., diabetes, chronic venous disease) is imperative to enable healing of chronic wounds. Wound complications include hematomas, seromas, infection, and delayed healing. Complications of abdominal surgical wounds additionally include wound dehiscence and evisceration, and fistulas of the GI tract.

See also “Decubitus ulcers,” “Venous ulcers,” “Needlestick injuries,” and “Bite wounds.”

Acute vs. chronic wounds ^[1]

• Acute wound: a disruption of the skin and/or underlying soft tissue that has a well-organized healing process with predictable tissue repair
  • Stab wounds
  • Abrasions: superficial skin injuries caused by rubbing, scraping, and/or irritation
  • Lacerations: skin compression and splitting with irregular and macerated edges
  • Avulsion injury ^[2]
    • Traumatic detachment of the skin and subcutaneous fat caused by a shearing force
    • Can range from the detachment of small skin flaps to complete degloving of an extremity
  • Bruises
    • Rupture of blood vessels within the skin as a result of direct trauma, with the surface of the skin remaining intact
    • Can also occur in muscles, bones, and internal organs
• Chronic wound: a wound with an impaired healing process, usually involving a prolonged or excessive inflammatory phase, persistent infections, formation of drug-resistant microbial biofilms, and the inability of cells to respond to reparative stimuli. All chronic wounds begin as acute wounds.
  • Vascular ulcers (venous ulcers and arterial ulcers)
  • Diabetic ulcers
  • Decubitus ulcers

Open vs. closed wounds ^[3]

• Open wound: a wound with skin breakage and exposure of underlying tissue to the outside environment
  • Lacerations
  • Gunshot wounds
  • Punctures
• Closed wound: a wound with intact skin, and underlying tissue not directly exposed to the outside environment
  • Contusions
  • Hematomas
  • Crush injuries
  • Blunt trauma

This section covers the basics of wound management. See “Management of trauma patients,” “Blunt trauma,” and “Penetrating trauma” for further details.

Approach ^[4][5][6]

• Identify severe and concealed injuries on the primary survey.
  • Consider hemostatic measures for active bleeding.
  • Screen for life-threatening or limb-threatening complications.
• Assess the wound for associated musculoskeletal or neurovascular injuries and degree of contamination.
• Consider additional diagnostics, specialty consults, and definitive management depending on the type of wound and associated injuries.
  • See “Management of open wounds” and “Management of closed wounds.”
  • Suspected open fracture or wound overlying a joint line
    • Splint the affected joint or bone
    • Begin general management of fractures and antibiotics for open fractures as needed.
• Evaluate at-risk patients for nonaccidental trauma (See “Sexual violence,” “Intimate partner violence,” “Older adult abuse,” and “Child abuse.”)

Hemorrhage control

• Actively hemorrhaging wounds: Perform hemostatic measures.
  • Mechanical hemostasis: local pressure over the wound, packing the wound, or application of a tourniquet proximal to the site of bleeding
  • Pharmacological hemostasis: local hemostatic agents (e.g., epinephrine or fibrin) or systemic antifibrinolytics (e.g., tranexamic acid)
  • Surgical hemostasis: thermal coagulation (e.g., electrocautery) or ligation (e.g., sutures or hemostatic clips) of the bleeding vessel(s)
  • Interventional radiology: angiographic embolization
• Hemorrhagic shock: Resuscitate with blood products. ^[7]
• Coagulopathy
  • Obtain coagulation studies in patients with suspected or known coagulation disorders.
  • Administer anticoagulant reversal in patients with ongoing or severe hemorrhage.
  • In severe wound(s), consider withholding further doses of antithrombotics in consultation with specialists.

Wound assessment

• Consider local or regional anesthesia or systemic analgesia before wound exploration (see “Pain Management” for drugs and dosages).
• Assess location, age, depth, width, length of the wound(s), and extent of devitalized tissue.
• Assess for degree of contamination (i.e., clean wounds or dirty wounds) and for signs of infection.
• Assess for concurrent injuries.
  • Perform neurovascular examination prior to administering anesthesia to identify neurovascular injury.
  • Assess for signs of fracture and joint injury.
  • Assess for tendon injuries. (see “Finger tendon integrity testing,” “Biceps tendinopathy and biceps tendon rupture,” “Achilles tendon rupture,” and “Patellar tendon rupture” for details).

Penetrating wounds, open fractures, and wounds with extensive devitalized tissue are risk factors for tetanus.

Diagnostics ^[4][8]

The diagnostic approach depends on the patient's hemodynamic status and the pretest probability of the suspected injury and associated complications.

• Identify and treat life- or limb-threatening complications (e.g., compartment syndrome, cardiac tamponade, crush syndrome).
• Truncal wounds and/or polytrauma: Obtain urgent diagnostics for trauma patients, e.g., coagulation panel, type and screen, eFAST, CT imaging for trauma, diagnostics for rhabdomyolysis.
• Extremity wounds
  • Neurovascular injury: Consider CTA extremity, duplex US, EMG, or nerve conduction studies depending on the injury.
  • Obtain X-rays if fractures, dislocations, or radiopaque foreign bodies are suspected.
  • If indicated, measure compartment pressures.
• Infected wounds: Consider wound cultures.
• Consider screening for risk factors that impact wound healing (e.g., diabetes mellitus, anemia).

Specialist consults for wounds

Consultation protocols vary among hospitals depending on the available specialist expertise and the agreements between specialties.

• General surgery for:
  • Trauma (including polytrauma)
  • Large or multiple wounds
  • Blunt or penetrating abdominal injury
  • Wounds potentially involving the anal sphincter (perineal injury)
• Orthopedic surgery for:
  • Wounds overlying a fracture or dislocation
  • Damage to underlying structures (such as vessels, nerves, tendons, or joint capsule)
• Plastic surgery for:
  • Multiple or complex facial wounds (e.g., involving the lips or eyelids)
  • Extensive injuries to the hands (may also be managed by orthopedics)
• Cardiothoracic surgery for blunt or penetrating chest injury
• Vascular surgery for suspected or confirmed vascular injury (transection, aneurysm, thrombosis)
• Neurosurgery for suspected TBI
• Urology and/or gynecology for genitourinary trauma

• Determine if the patient requires a full trauma workup (see “Management of trauma patients”).
• Active bleeding: Perform hemostatic measures.
• Provide adequate analgesia.
• Screen for life-threatening or limb-threatening complications (e.g., pneumothorax, rhabdomyolysis, compartment syndrome).
• Assess for concurrent injuries.
• Assess wound characteristics and age.
• Administer tetanus prophylaxis if necessary.
• Obtain laboratory studies and imaging as needed.
• Order specialist consults as needed; consider management in the OR.
• Clean the wound.
• Treat as appropriate.
  • Clean, recent open wounds: primary closure
  • Older, contaminated open wounds: secondary closure
  • Closed musculoskeletal wounds: POLICE principle
• Immobilize fractures and wounds over joints.
• Screen for risk factors for delayed wound healing.

Approach

See “Acute wound management” for initial assessment and emergency measures.

• Perform wound irrigation and debridement for all open wounds.
• Consider closure of acute open wounds depending on wound characteristics.
  • Primary wound closure is indicated for recently sustained, clean, uninfected wounds that have edges that can be easily approximated.
  • Consider secondary wound closure or tertiary wound closure for all other wounds (e.g., infected, contaminated, wide or irregular edges, delayed presentation).
  • Identify if the wound should be repaired by a specialist (see “Specialist consults”).
  • Consider referral to plastic surgery for skin grafting for wounds with extensive tissue loss.
• Consider antibiotics for acute open wounds depending on the wound and patient characteristics.
  • Consider prophylaxis for wounds at high risk of infection including certain bite wounds.
  • Treat infected wounds.
  • Select antibiotics based on the likely pathogens and local resistance patterns.
• Consider tetanus prophylaxis (tetanus toxoid ± human tetanus immunoglobulin ). ^[4][9]

When evaluating a wound for primary or secondary closure, consider the length of time that has elapsed since injury, wound characteristics, and comorbidities.

Refer patients with the following wounds for repair by a specialist: multiple, large, and/or complex wounds (e.g., facial wounds involving the eyelids, extensive hand injuries); wounds with damage to underlying structures (e.g., vessels, nerves, tendons); and wounds in the genitourinary tract.

Wound irrigation and debridement ^[10]

• Consider local anesthesia prior to irrigation in sensitive areas. ^[6]
• Wash the wound with soap and water.
• If there is risk of viral transmission (e.g., rabies, B-virus), rinse the wound with povidone-iodine or chlorhexadine. ^[6][11][12]
• Irrigate wounds with pressurized tap water or saline.
• Avoid irrigation of open wounds with disinfectant solutions (e.g., peroxide) as these can impair wound healing. ^[6]
• Debride devitalized tissue. ^[13]

In general, irrigate with 50–100 mL of tap water or saline per centimeter of wound length. ^[6]

Follow-up for open wounds

• Arrange regular follow-up to assess wound healing, especially of complicated wounds.
• Ensure regular dressing changes.
• Educate patients on wound care.
  • Keep the wound clean and dry.
  • Check regularly for signs of wound infection.
  • Seek medical attention if the wound deteriorates.
• Schedule suture/staple removal as needed; always assess wound healing before removing sutures/staples. ^[4]
  • In otherwise healthy individuals, the timing of suture/staple removal depends on the location of the wound.
    • Face: after 3–5 days
    • Scalp and trunk: after 7–10 days
    • Extremities: after 10–14 days
  • Timing of suture/staple removal may be longer for complex wounds or if there are risk factors for delayed wound healing.

See “Wound closure of bite wounds” for guidance specific to bite wounds.

Primary wound closure

• Definition: closure of recent wounds by approximation of the wound edges, allowing for healing by primary intention
• Indications
  • Recent, clean wounds that have a low risk of infection
  • For details, see “Indications for primary wound closure.”
• Procedure: : See “Wound closure techniques.”
• Antibiotics ^[14]
  • Minor, uncontaminated injuries: Antibiotic prophylaxis is not routinely required.
  • Wounds at high risk of infection: Consider antibiotic prophylaxis.
• Wound healing
  • Occurs by primary intention
  • Wound healing occurs with minimal inflammation and minimal to no granulation tissue formation.
  • Organ-specific tissue forms at the site of healing
  • Minimal (hairline) scar formation

Secondary wound closure

• Definition: leaving a wound to heal by secondary intention (i.e., without approximating the wound edges)
• Indications
  • Infected wounds, e.g., surgical site infection ^[15]
  • Wounds at high risk of infection, e.g., wounds with implanted foreign bodies ^[6]
  • Bite wounds that do not meet the criteria for primary closure (see “Bite wounds” for details)
  • Wounds older than the time frame within which primary closure can be safely performed.
  • Large wounds with irregular edges that cannot be approximated without tension
• Goal: debridement to remove devitalized tissue; removal of contaminants and foreign bodies that may disrupt healing. ^[6]
• Procedure ^[6]
  1. Administer; local, regional, or general anesthesia.
  2. Clean via pressured irrigation using warm, isotonic saline. ^[6][16]
  3. Perform surgical (sharp) debridement: removal of devitalized tissue and debris to allow for wound healing
  4. Ensure drainage (e.g., silicone/rubber drains, strip of gauze) of deep wounds.
  5. Apply moist dressing.
  6. Immobilize the affected extremity, if necessary.
• Further treatment
  • Wounds at high risk of infection: Consider antibiotic prophylaxis.
  • Infected wounds: Administer antibiotics (see “Empiric antibiotic therapy for skin and soft tissue infections”).
  • Regular dressing changes
  • Reevaluation for delayed primary closure (if needed) after ∼ 3 days
  • Consider negative pressure wound therapy (NPWT) as an adjunct to stimulate the healing process for large wounds. ^[14][17]
• Wound healing
  • Occurs by secondary intention
  • Usually accompanied with pronounced inflammation
  • Takes longer than wounds that have been repaired with primary closure
  • Requires the formation of granulation tissue
  • The wound bed is replaced with increased proliferation of fibroblasts.
  • Pronounced scar formation

Tetanus prophylaxis is usually required for most wounds that need secondary closure.

Tertiary wound closure (delayed primary closure)

• Definition: surgical closure of a wound after healing by secondary intention has already begun; also known as healing by tertiary intention
• Indications
  • Clean wounds with healthy edges in patients presenting after the time frame within which primary closure can be safely performed.
  • Contaminated wounds left to heal by secondary intention and with no signs of infection after 3–5 days ^[6]
• Procedure
  1. Clean the wound and debride any areas of devitalized tissue.
  2. Close the wound using an appropriate wound closure technique (e.g., simple interrupted sutures).
• Wound healing
  • Occurs by tertiary intention
  • Results in a larger scar than with primary or secondary closure due to an interruption in normal wound healing

Contaminated wounds can be closed (i.e., by delayed primary closure) if there are no signs of infection after a few days of observation.

Wounds at high risk of infection ^[4][6][18]

If one or more of the following high-risk features are present, antibiotic prophylaxis should be considered.

• Wound characteristics
  • Complicated wounds, e.g., crush injuries, deep puncture wounds
  • Significant contamination, e.g., with feces, saliva, or dirt
  • Implanted foreign bodies
• Wound location
  • Poorly vascularized areas, e.g., feet, hands
  • Suspected extension to bones and joints, e.g., open fractures
  • Areas with significant bacterial colonization, e.g., armpits, genitals, intraoral wounds ^[19]
• Patient characteristics
  • Advanced age
  • Immunosuppression
  • Significant comorbidities, e.g., diabetes mellitus

Antibiotic prophylaxis ^[20]

• A single dose is usually sufficient for superficial wounds, while deep wounds and open fractures may require longer regimens.
• Specific regimes depend on the type and location of the wound, e.g:
  • Bite wounds: See “Antibiotics for bite wounds.”
  • Gaping intraoral lacerations: Antibiotics should cover oral flora, topical antibiotics (e.g., bacitracin) may be considered. ^[4][19]
  • Puncture wounds of the foot: Consider adding agents that cover Pseudomonas aeruginosa and/or MRSA. ^[4]

Most wounds that can undergo primary closure do not require antibiotic prophylaxis, except wounds at high risk of infection.

Antibiotic therapy ^[20]

• In general, infected wounds are treated with empiric antibiotic therapy for skin and soft tissue infections.
• Specific regimes may be necessary for certain types of wounds, including:
  • Infected marine wounds ^[4][9]
    • Superficial infections (e.g., erysipelas): Consider penicillins or macrolides.
    • Purulent infections (e.g., abscess): Consider penicillinase-resistant penicillins or 1^st generation cephalosporins
    • Necrotizing infections, patients with chronic wounds or immunocompromise: broad-spectrum antibiotics with activity against anaerobes, gram-positive aerobes, and gram-negative bacteria
  • Infected bite wounds: See “Antibiotic prophylaxis and therapy for bite wounds.”

Obtain cultures in all patients with infected wounds.

• See “Acute wound management” for initial assessment, emergency measures, and diagnostics.
• Ensure proper analgesia (see “Pain management” for drugs and dosages).
• Treat concomitant injuries.
• Screen for and manage complications (e.g., compartment syndrome, deep vein thrombosis, rhabdomyolysis) ^[8][21]
• Minimize further inflammation: POLICE principle for acute musculoskeletal injuries (e.g., injuries to bones, tendons, or ligaments) ^[22]
  • Protection
  • Optimal Loading
  • Ice
  • Compression
  • Elevation

Skin grafting ^[23]

Skin grafts may be used to close wounds, prevent fluid and electrolyte loss, and reduce bacterial burden and infection.

Full thickness skin graft (FTSG)

• Graft: epidermis and dermis (including dermal appendages), usually obtained from areas of redundant and pliable skin (e.g., groin, lateral thigh, lower abdomen, lateral chest)
• Indications: small, uncontaminated, well-vascularized wounds
• Advantages: good postoperative cosmetic outcome
• Disadvantages: high risk of necrosis, secondary injury to the donor area

Split-thickness skin graft (STSG)

• Graft: epidermis and upper part (¼–¾) of the dermis (without dermal appendages)
• Indications: many uses; resurface large wounds and mucosal deficits, line cavities, close donor sites of flaps, treat large chronic wounds
• Advantages: heals well, only superficial secondary defect in donor area, which does not have to be covered
• Disadvantages: scar formation when graft heals, skin pigmentation change, tendency to contract, more fragile
• Subtype: mesh graft
  • Graft can be stretched 3–6 times its original size by grid‑like incisions.
  • Suitable for large skin defects

Skin grafts are contraindicated in the case of contaminated wounds or insufficient blood supply.

Composite graft ^[24]

• Graft: a graft containing multiple structures, such as skin and other structures like muscles, bones, or cartilage
• Indications: distal fingertip amputations, nasal reconstructions, ear reconstructions
• Advantages: heals well, usually includes pedicle containing blood supply, aesthetically pleasing
• Disadvantages: higher infection rate, increased risk that graft does not take compared to local flaps

Amputations ^{[25][26][27][28]}

An amputation is the surgical or traumatic severance of a body part.

Types

• Complete amputation: the body part is totally severed
• Partial amputation: some soft tissue remains connected to the affected body part and to the rest of the body
• Surgical amputation: the surgical removal of a body part
  • Indications
    • Gangrene (e.g., due to diabetes mellitus, bacterial infection such as Clostridium perfringens, or peripheral arterial disease)
    • Infection (e.g., osteomyelitis)
    • Malignancy (e.g., osteosarcoma)
    • Irreparable trauma injury (e.g., comminuted fracture of a limb)
    • Severely burned limbs
    • Compartment syndrome
    • Severe contractures
    • Congenital anomalies
    • Severe thermal and/or electrical injury
  • Procedure
    1. Preparation and disinfection of the limb
    2. Preparation of skin flaps (for closing the wound)
    3. Dissection of the fascia, muscles, vessels, and nerves
    4. Transsection of the bone (if necessary)
    5. Smoothing of the edges of the bone
    6. Fixation of the remaining muscles along the bone
    7. Suturing and closing of the fascia, subcutaneous tissue, and the skin (see “Acute wound treatment”)
• Traumatic amputations: Most traumatic amputations are unintentional, resulting from factory, farm, or power tool injuries.
• Fingers: See “Finger amputations.”

Do not allow the amputated part to be in direct contact with ice, because this can cause further damage.

Complications

• Wound infection: stump pain, erythema, fever, and wound drainage
• Deep vein thrombosis
• Stump hematoma
• Stump ulcer
  • Etiology: most commonly due to friction and repetitive pressure from a prosthesis with a suboptimal fit
  • Risk factors: conditions associated with poor wound healing (e.g., diabetes, peripheral neuropathy, vasoconstriction)
  • Management of noninfected stump ulcer: pressure relief, skin care, frequent wound checks, and maintaining an optimal fit between prosthetic socket and residual limb
• Edema
• Contractures leading to deformities and diminished function in the joint adjacent to the stump
• Skin necrosis around the vital stump
• Phantom limb pain: the sensation of a lost limb after amputation, which often feels painful
• Phantom limb sensation: the sensation that an amputated or lost limb is still intact, often involving pain (phantom limb pain)
• Residual limb pain: stump pain following an amputation

Bite wounds

See “Bite wound management” in “Animal bites” for details.

• Infection risk and transmitted organisms depend on the animal (e.g., human bites, dog bites, cat bites).
• Perform thorough wound irrigation and debridement for all patients.
• Provide tetanus prophylaxis for all patients with outdated or unknown tetanus immunization.
• Wound closure strategy, rabies postexposure prophylaxis, indications for antibiotics for bite wounds, and depend on animal and wound characteristics (see “Overview of bite wound management”).
• Manage envenomation, if present.

Stab wounds

• When performing first aid, do not remove the foreign body from the wound, as this could stop the object's sealing and tamponading effect, which could result in bleeding.
• Removal in a hospital setting with staff prepared for immediate surgical intervention
• Treatment: see “Penetrating trauma”

Miscellaneous

• Needlestick injuries
• Decubitus ulcers

Life-threatening and limb-threatening complications ^[8][21]

See also “Management of trauma.”

• Severe hemorrhage: consumptive coagulopathy, hypothermia
• Extremity trauma: vascular injury, compartment syndrome, VTE
• Crush injury: compartment syndrome, rhabdomyolysis
• Internal injuries: e.g., pneumothorax, cardiac tamponade, hemoperitoneum, pneumoperitoneum, traumatic brain injury
• Open fractures

Other wound complications

• Bacterial wound infections
• Tetanus
• Associated tendon, nerve, or vascular injury
• Scarring, fibrosis, and contractures
• Retained foreign bodies

Complications of surgical incisions

• Surgical site infection
• Intestinal fistulas
• Wound dehiscence: the spontaneous separation of wound edges following surgical wound repair
  • Can be superficial (skin and subcutaneous tissue) or deep (fascial)
  • Common after abdominal surgery; see “Fascial dehiscence.”
  • Consult surgery for treatment, e.g., secondary wound closure.
• Hematomas and seromas

We list the most important complications. The selection is not exhaustive.

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