Wound treatment

Last updated: November 28, 2023

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. 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.”

Classificationtoggle arrow icon

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.

Open vs. closed wounds [3]

Acute wound managementtoggle arrow icon

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]

Hemorrhage control

Wound assessment

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.

Specialist consults for wounds

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

Acute management checklisttoggle arrow icon

Open woundstoggle arrow icon


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.

Wound irrigation and debridement [10]

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.

Wound closuretoggle arrow icon

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

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.

Antibioticstoggle arrow icon

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

Antibiotic prophylaxis [20]

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

Antibiotic therapy [20]

Obtain cultures in all patients with infected wounds.

Closed woundstoggle arrow icon

Plastic and reconstructive surgerytoggle arrow icon

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

Special woundstoggle arrow icon

Amputations [25][26][27][28]

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


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


Bite wounds

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

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


Complicationstoggle arrow icon

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

See also “Management of trauma.”

Other wound complications

Complications of surgical incisions

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

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Referencestoggle arrow icon

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  2. Boettcher-Haberzeth S, Schiestl C. Management of Avulsion Injuries. Eur J Pediatr Surg. 2013; 23 (05): p.359-364.doi: 10.1055/s-0033-1353493 . | Open in Read by QxMD
  3. Closed Wound Basics. Updated: February 14, 2017. Accessed: February 14, 2017.
  4. 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
  5. 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
  6. 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
  7. Tramautic Amputations. Updated: June 1, 2006. Accessed: February 14, 2017.
  8. Amputation: traumatic. Updated: September 22, 2016. Accessed: February 14, 2017.
  9. Maduri P, Akhondi H. Upper Limb Amputation. StatPearls. 2021.
  10. Molina CS, Faulk JB. Lower Extremity Amputation. StatPearls. 2020.
  11. 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
  12. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999; 20 (4): p.247-280.doi: 10.1086/501620 . | Open in Read by QxMD
  13. 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
  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. 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
  16. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  17. 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
  18. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  19. Holmes GP, Chapman LE, Stewart JA, et al. Guidelines for the Prevention and Treatment of B-Virus Infections in Exposed Persons. Clin Infect Dis. 1995; 20 (2): p.421-439.doi: 10.1093/clinids/20.2.421 . | Open in Read by QxMD
  20. Pounder D. Avoiding rabies. BMJ. 2005; 331 (7515): p.469-470.doi: 10.1136/bmj.331.7515.469 . | Open in Read by QxMD
  21. Brook I. Management of human and animal bite wound infection: An overview. Curr Infect Dis Rep. 2009; 11 (5): p.389-395.doi: 10.1007/s11908-009-0055-x . | Open in Read by QxMD
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  25. Alper N, Sood A, Granick MS. Composite graft repair for distal fingertip amputation.. Eplasty. 2013; 13: p.ic32.
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  27. Katsetos SL, Nagurka R, Caffrey J, Keller SE, Murano T. Antibiotic prophylaxis for oral lacerations: our emergency department’s experience. J Emerg Med. 2016; 9 (1).doi: 10.1186/s12245-016-0122-7 . | Open in Read by QxMD
  28. Worster B, Zawora MQ, Hsieh C. Common questions about wound care. Am Fam Physician. 2015; 91 (2): p.86-92.
  29. BLOODBORNE INFECTIOUS DISEASES: HIV/AIDS, HEPATITIS B, HEPATITIS C. Updated: October 5, 2016. Accessed: June 2, 2020.

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