Wound treatment

Last updated: July 25, 2022

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Wounds are disruptions of the normal structure and function of skin and underlying soft tissue caused by trauma or chronic mechanical stress (e.g., decubitus ulcers). 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.

Acute wound management is covered in detail here. See the articles on decubitus ulcers and venous ulcers for the management of these chronic wounds. Needlestick injuries are also discussed separately.

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
    • 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.

Open vs. closed wounds [3]

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

Initial management [4][5][6]

Hemorrhage control

Assessment of the wound

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

Diagnostics [4][8]

Truncal wounds and/or multisystem complications (potentially life-threatening)

Consider the following tests based on clinical suspicion. See also “Urgent diagnostics for trauma patients.”

Extremity wounds and/or local complications (potentially limb-threatening)

Consider the following tests based on clinical suspicion.

Other investigations

Specialist consults

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

Approach

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

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.

Follow-up

  • Arrange regular follow-up to assess wound healing, especially of complicated wounds.
  • Ensure regular dressing changes.
  • Educate patients on wound care.
  • 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.

Primary wound closure

Secondary wound closure

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

Tertiary wound closure (delayed primary closure)

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][17]

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 [18]
  • Patient characteristics

Antibiotic prophylaxis [19]

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

Antibiotic therapy [19]

Obtain cultures in all patients with infected wounds.

Skin grafting [21]

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 [22]

  • 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 [23][24][25][26]

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
  • Traumatic amputations: Most traumatic amputations are unintentional, resulting from factory, farm, or power tool injuries.
    • Complete fingertip amputation management [24]
      1. Control bleeding by placing direct pressure on the wound and raising the injured area.
      2. Gently clean the amputated part with sterile saline solution.
      3. Cover with gauze dampened with saline.
      4. Place in a watertight bag.
      5. Place the bag in an ice bath in a sealed container.
      6. Go to hospital for urgent assessment.
      7. Reimplantation is more likely to be performed in case of:
        • Short ischemia time
        • Thumb and index finger involvement
        • Children
        • Dominant limb involvement
        • Patients with occupations requiring fine motor skills
        • Upper limb amputations > lower limb amputations (as more prostheses are available for lower limb)

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

Complications

Bite wounds [27]

Bite wounds (caused by animals, e.g., cat bites , or human bites e.g., “fight bite”) are associated with an increased risk of infection, as the bacterial flora of the oral cavity hinders wound healing.

Antibiotic prophylaxis and therapy for bite wounds [28]

Indications [4]

Agents

Use broad‑spectrum antibiotics with activity against aerobic and anaerobic pathogens.

Bite wounds should receive the same treatment as open dirty wounds.

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

Life-threatening and limb-threatening complications [8][9]

See also “Management of trauma.”

Other wound complications

Complications of abdominal surgical incisions

Hematomas and seromas

  • Definition: collection of blood (hematoma) or serum (seroma)
  • Pathophysiology: failure of hemostasis or coagulation
  • Clinical features
    • Usually occurs several days after surgery
    • Either asymptomatic or can have swelling, pain, or drainage
  • Treatment
    • Small or asymptomatic: manage expectantly
    • Large or symptomatic: exploration and drainage, followed by wound packing until granulation tissue is formed, then closed by delayed primary intention or by secondary intention
  • Complications: may lead to wound infections as bacteria have access to deeper layers of fascia and can multiply in the stagnant fluid

Fascial dehiscence [29]

  • Definition: fascial disruption due to abdominal wall tension that overcomes tissue or suture strength, or knot security
  • Clinical features
  • Treatment for early dehiscence
    • Cover wound with moist dressing and perform wound exploration and debridement in the operating room (OR).
    • An abdominal binder can be used to keep organs intact while en route to OR.
    • Reapproximate fascial edge under anesthesia in the OR.
    • Use interrupted sutures to reapproximate the wound edges.
  • Complications
    • Organ evisceration: abdominal organs protrude through the outer abdomen
    • If evisceration has happened, do not use binder, and take to OR immediately.
  • Prevention: : good surgical technique, avoid heavy lifting for 4–6 weeks after abdominal laparotomy

Early fascial dehiscence is a surgical emergency. The mortality rate is 10%.

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

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  10. Maduri P, Akhondi H. Upper Limb Amputation. StatPearls. 2021 .
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  17. Hock MOE, Ooi SBS, Saw SM, Lim SH. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Ann Emerg Med. 2002; 40 (1): p.19-26. doi: 10.1067/mem.2002.125928 . | Open in Read by QxMD
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  21. Diaz JH. Skin and Soft Tissue Infections Following Marine Injuries and Exposures in Travelers. J Travel Med. 2014; 21 (3): p.207-213. doi: 10.1111/jtm.12115 . | Open in Read by QxMD
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  30. BLOODBORNE INFECTIOUS DISEASES: HIV/AIDS, HEPATITIS B, HEPATITIS C. https://www.cdc.gov/niosh/topics/bbp/emergnedl.html. Updated: October 5, 2016. Accessed: June 2, 2020.

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