Trusted medical expertise in seconds.

Access 1,000+ clinical and preclinical articles. Find answers fast with the high-powered search feature and clinical tools.

Try free for 5 days
Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer.

Wound treatment

Last updated: August 9, 2021

Summarytoggle arrow icon

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.

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
    • 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 [2]

  • 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

Amputations [3][4]

An amputation is the surgical or traumatic separation of a body part from the rest of the body.

  • Complete amputation: the body part is totally severed
  • Partial amputation: some soft tissue remains connected to the affected body part and the rest of the body
  • Surgical amputations: careful, controlled removal of a body part in the operating room
  • Traumatic amputations: Most traumatic amputations are accidental, and usually result from factory, farm, or power tool accidents. Motor vehicle accidents may also cause traumatic amputations. The tips of longer fingers tend to be injured more often because they are more exposed to harm.
    • Complete fingertip amputation management [4]
      1. Control bleeding by placing direct pressure on the wound and raise 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. Head to hospital for urgent assessment.
    • Reimplantation is more likely to be performed for:
      • Short ischemia time
      • Thumb and index fingers
      • Children
      • Dominant limb involved
      • Patients whose occupation depends on motor skills
      • Upper limb amputations > lower limb amputations (as more prostheses are available for lower limb)
  • Complications

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

Bite wounds [5]

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

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

This section covers the basics of wound management. See “Management of trauma patients,” “Blunt trauma,” and “Penetrating trauma” as needed.

Approach [6][7][8]

  • Determine the likelihood of systemic injury or complications.
  • Severe injuries or potential for multiple concealed injuries: ABCDE assessment (see “Primary survey” for details)
  • Control active bleeding.
  • Screen for life-threatening or limb-threatening complications.
  • Assess the wound for associated neurovascular or musculoskeletal injuries and degree of contamination.
  • Consider the need for specialty consults.
  • If specialist input is not required, manage the wound as appropriate.

Hemorrhage control

Screening for life-threatening and limb-threatening complications [10][11]

Assessment of the wound

Penetrating wounds, open fractures, and wounds with extensive devitalized tissue are risk factors for Clostridium tetani infection (see “Risk factors for tetanus” for further details).

Diagnostics [6]

Specialist consults

  • 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:
  • 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

Wound management

Approach

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

Closure of acute open wounds

Primary wound closure

  • Definition: closure of recent wounds by approximation of the wound edges, allowing for healing by primary intention
  • Indications
    • Clean wounds that have a low risk of infection and edges that can be approximated without tension
    • Recent wounds, typically described as: [8][14]
      • Within 6–10 hours of injury on the extremities
      • Within 10–12 hours of injury on the scalp and face
  • Procedure [8]
    1. Assemble equipment, e.g., cleaning supplies, local anesthesia, sterile drapes.
    2. Clean the wound and create a sterile field around it. [8]
    3. Consider administering local anesthesia depending on the planned method of closure.
    4. Inspect the wound.
    5. Excise wound edges (if necessary) and irrigate the wound.
    6. Perform tension-free approximation of the wound edges using any of the following:
    7. Apply sterile dressing.
    8. Immobilize the affected extremity, if necessary.
  • Antibiotics [16]
  • Wound healing

Secondary wound closure

  • Definition: leaving a wound to heal by secondary intention (i.e., without approximating the wound edges)
  • Indications
    • Infected wounds or wounds at high risk of infection
      • Contaminated wounds: contact with dirt, soil, bodily fluids (including bite wounds not meeting the criteria for primary closure; see “Bite wounds” for details) [8]
      • Wounds with foreign bodies (e.g., bullets, glass shards, shrapnel)
      • Wounds with extensive tissue loss or necrotic tissue
      • Surgical site infection [17]
      • 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. [8]
  • Procedure [8]
    1. Administer; local, regional, or general anesthesia.
    2. Clean via pressured irrigation using warm, isotonic saline. [8][12]
    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
  • 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)

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

Follow-up

  • Regular follow-ups 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. [6]
    • 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.

Skin grafting [20]

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 [21]

  • 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

Hematomas and seromas [22]

  • 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

Skin and soft tissue infections

Fascial dehiscence [22]

  • 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%.

Intestinal fistulas

  • Etiology
    • A complication of open abdominal surgery, especially when the bowel is frequently manipulated, with possible disruption of bowel anastomosis, inadvertent enterotomy, or small bowel injury.
    • Can occur as early as 8 days from initial laparotomy [23]
    • Other causes: IBD, cancer, irradiation
  • Types
  • Complications: sepsis, fluid and electrolyte abnormalities, malnutrition
  • Treatment [24]
    • Spontaneous closure occurs in at least 30% of patients [25][26]
    • Conservative therapy: rehydration and electrolyte repletion, antibiotics (in case of infections), nutritional support, control of fistula drainage (e.g., ostomy pouch), skin protection
    • Surgical therapy: attempted 1–4 months after trial of conservative therapy if no signs of spontaneous closure are present
      • Lysis of adhesions
      • Resection of abnormal or diseased bowel
      • Reanastamosis of healthy bowel
  1. Demidova-Rice TN, Hamblin MR, Herman IM. Acute and Impaired Wound Healing: Pathophysiology and Current Methods for Drug Delivery, Part 1: Normal and Chronic Wounds: Biology, Causes, and Approaches to Care. Adv Skin Wound Care. 2012; 25 (7): p.304-314. doi: 10.1097/01.ASW.0000416006.55218.d0 . | Open in Read by QxMD
  2. Closed Wound Basics. http://www.woundcarecenters.org/article/wound-basics/closed-wound-basics. Updated: February 14, 2017. Accessed: February 14, 2017.
  3. Alessandrino F, Balconi G. Complications of muscle injuries. J Ultrasound. 2013; 16 (4): p.215-222. doi: 10.1007/s40477-013-0010-4 . | Open in Read by QxMD
  4. Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin. 2004; 20 (1): p.171-192. doi: 10.1016/s0749-0704(03)00091-5 . | Open in Read by QxMD
  5. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE?. Br J Sports Med. 2011; 46 (4): p.220-221. doi: 10.1136/bjsports-2011-090297 . | Open in Read by QxMD
  6. Tramautic Amputations. http://www.emsworld.com/article/10322826/tramautic-amputations. Updated: June 1, 2006. Accessed: February 14, 2017.
  7. Amputation: traumatic. https://medlineplus.gov/ency/article/000006.htm. Updated: September 22, 2016. Accessed: February 14, 2017.
  8. Endom EE. Initial management of animal and human bites. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/initial-management-of-animal-and-human-bites.Last updated: August 11, 2016. Accessed: February 14, 2017.
  9. Nicks BA, Ayello EA, Woo K, Nitzki-George D, Sibbald RG. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med. 2010; 3 (4): p.399-407. doi: 10.1007/s12245-010-0217-5 . | Open in Read by QxMD
  10. Childs DR, Murthy AS. Overview of Wound Healing and Management. Surg Clin North Am. 2017; 97 (1): p.189-207. doi: 10.1016/j.suc.2016.08.013 . | Open in Read by QxMD
  11. 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
  12. Franz MG, Robson MC, Steed DL, et al. Guidelines to aid healing of acute wounds by decreasing impediments of healing. Wound Repair Regen. 2008; 16 (6): p.723-748. doi: 10.1111/j.1524-475x.2008.00427.x . | Open in Read by QxMD
  13. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Infect Control Hosp Epidemiol. 1999; 20 (4): p.247-280. doi: 10.1086/501620 . | Open in Read by QxMD
  14. Pfaff JA, Moore GP. Reducing Risk in Emergency Department Wound Management. Emerg Med Clin North Am. 2007; 25 (1): p.189-201. doi: 10.1016/j.emc.2007.01.009 . | Open in Read by QxMD
  15. Prevaldi C, Paolillo C, Locatelli C, et al. Management of traumatic wounds in the Emergency Department: position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES). World J Emerg Surg. 2016; 11 (1). doi: 10.1186/s13017-016-0084-3 . | Open in Read by QxMD
  16. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  17. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  18. Kalkwarf KJ, Cotton BA. Resuscitation for Hypovolemic Shock. Surg Clin North Am. 2017; 97 (6): p.1307-1321. doi: 10.1016/j.suc.2017.07.011 . | Open in Read by QxMD
  19. Robinson LR. Traumatic injury to peripheral nerves. Muscle Nerve. 2000; 23 (6): p.863-873. doi: 10.1002/(sici)1097-4598(200006)23:6<863::aid-mus4>3.0.co;2-0 . | Open in Read by QxMD
  20. Armstrong DG, Meyr AJ. Basic principles of wound management. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/basic-principles-of-wound-management.Last updated: December 4, 2016. Accessed: February 14, 2017.
  21. Alper N, Sood A, Granick MS. Composite graft repair for distal fingertip amputation.. Eplasty. 2013; 13 : p.ic32.
  22. Mizell JS. Complications of abdominal surgical incisions. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.emsworld.com/article/10322826/tramautic-amputations.Last updated: March 30, 2016. Accessed: February 28, 2017.
  23. Martin N, Sarani B. Management of the open abdomen in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-the-open-abdomen-in-adults?source=search_result&search=intestinal%20fistula&selectedTitle=2~94#H632146279.Last updated: August 8, 2016. Accessed: February 28, 2017.
  24. Stein SL. Overview of enteric fistulas. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-enteric-fistulas.Last updated: January 23, 2015. Accessed: February 28, 2017.
  25. Haack CI, Galloway JR, Srinivasan J. Enterocutaneous Fistulas: A Look at Causes and Management. Current Surgery Reports. 2014; 2 (10). doi: 10.1007/s40137-014-0071-0 . | Open in Read by QxMD
  26. Ramirez PT, Frumovitz M, Abu-Rustum NR. Principles of Gynecologic Oncology Surgery. Elsevier B.V. ; 2018
  27. 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.