Wound

A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying disease processes such as diabetes mellitus, venous/arterial insufficiency, or immunologic disease. Wounds can vary greatly in their appearance depending on wound location, injury mechanism, depth of injury, timing of onset (acute vs chronic), and wound sterility, among other factors. Treatment strategies for wounds will vary based on the classification of the wound, therefore it is essential that wounds be thoroughly evaluated by a healthcare professional for proper management. In normal physiology, all wounds will undergo a series of steps collectively known as the wound healing process, which include hemostasis, inflammation, proliferation, and tissue remodeling. Age, tissue oxygenation, stress, underlying medical conditions, and certain medications are just a few of the many factors known to affect the rate of wound healing.
Wounds can be broadly classified as either acute or chronic based on time from initial injury and progression through normal stages of wound healing. Both wound types can further be categorized by cause of injury, wound severity/depth, and sterility of the wound bed. Several classification systems have been developed to describe wounds and guide their management. Some notable classification systems include the CDC's Surgical Wound Classification, the International Red Cross Wound Classification, the Tscherne classification, the Gustilo-Anderson classification of open fractures, and the AO soft tissue grading system.
An acute wound is any wound which results from direct trauma and progresses through the four stages of wound healing along an expected timeline. The first stage, hemostasis, lasts from minutes to hours after initial injury. This stage is followed by the inflammatory phase which typically lasts 1 to 3 days. Proliferation is the third stage of wound healing and lasts from a few days up to a month. The fourth and final phase of wound healing, remodeling/scar formation, typically lasts 12 months but can continue as long as 2 years after the initial injury. Acute wounds can further be classified as either open or closed. An open wound is any injury whereby the integrity of the skin has been disrupted and the underlying tissue is exposed. A closed wound, on the other hand, is any injury in which underlying tissue has been damaged but the overlying skin is still intact.
Fractures can be classified as either open or closed, depending on whether the integrity of the overlying skin has been disrupted or preserved, respectively. Several classification systems have been developed to further characterize soft tissue injuries in the setting of an underlying fracture:
Any wound which is arrested or delayed during any of the normal stages of wound healing is considered to be a chronic wound. Most commonly, these are wounds which develop due to an underlying disease process such as diabetes mellitus or arterial/venous insufficiency. However, it is important to note that any acute wound has the potential to become a chronic wound if any of the normal stages of wound healing are interrupted. Chronic wounds are most commonly a result of disruption of the inflammatory phase of wound healing, however errors in any phase can result in a chronic wound. The exact duration of time which distinguishes a chronic wound from an acute wound is not clearly defined, although many clinicians agree that wounds which have not progressed for over three months are considered chronic wounds.
Wound sterility, or degree of contamination of a wound, is a critical consideration when evaluating a wound. In the United States, the CDC's Surgical Wound Classification System is most commonly used for classification of a wound's sterility, specifically within a surgical setting. According to this classification system, four different classes of wound exist, each with their own postoperative risk of surgical site infection:
Wound presentation will vary greatly based on a number of factors, each of which is important to consider in order to establish a proper diagnosis and treatment plan. In addition to collecting a thorough history, the following factors should be considered when evaluating any wound:
A thorough wound evaluation, particularly evaluation of wound depth and removal of necrotic tissue, should be performed only by a licensed healthcare professional in order to avoid damage to nearby structures, infection, or worsening pain.
Additional diagnostic tests may be needed during wound evaluation based on the cause, appearance, and age of a wound.
The goal of wound care is to promote an environment that allows a wound to heal as quickly as possible, with emphasis on restoring both form and function of the wounded area. Although optimal treatment strategies vary greatly depending on the specific cause, size, and age of a particular wound, there are universal principles of wound management that apply to all wounds. After a thorough evaluation is performed, all wounds should be properly irrigated and debrided. Proper cleansing of a wound is critical to prevent infection and promote re-epithelialization. Further efforts should be made to eliminate/limit any contributing factors to the wound (e.g. diabetes, pressure, etc.) and optimize the wound's healing ability (i.e. optimize nutritional status). The end goal of wound management is closure of the wound which can be achieved by primary closure, delayed primary closure, or healing by secondary intention, each of which is discussed below. Pain control is a mainstay of wound management, as wound evaluation, wound cleansing, and dressing changes can be a painful process.
Proper cleansing of a wound is critical in preventing infection and promoting healing of any wound. Irrigation is defined as constant flow of a solution over the surface of a wound. The goal of irrigation is not only to remove debris and potential contaminants from a wound, but also to assist in visual inspection of a wound and hydrate the wound. Irrigation is typically achieved with either a bulb or syringe and needle/catheter. The preferred solution for irrigation is normal saline which is readily accessible in the emergency department, although recent studies have shown no difference in emergency department infection rates when comparing normal saline to potable tap water. Irrigation can also be achieved with a diluted 1% povidone iodine solution, but studies have again shown no difference in infection rates when compared to normal saline. Irrigation with antiseptic solutions, such as non-diluted povidone iodine, chlorhexidine, and hydrogen peroxide is not preferred since these solutions are toxic to tissue and inhibit wound healing. The exact volume of irrigation used will vary depending on the appearance of the wound, although some sources have reported 50–100 mL of irrigation per 1 cm of wound length as a guideline.
Debridement is defined as removal of devitalized or dead tissue, particularly necrotic tissue, eschar, or slough. Debridement is a critical aspect of wound care because devitalized tissue, particularly necrotic tissue, serves as nutrients for bacteria thereby promoting infection. Additionally, devitalized tissue creates a physical barrier over a wound which limits the effectiveness of any applied topical compounds and prevents re-epithelialization. Lastly, devitalized tissue, especially eschar, prevents accurate assessment of underlying tissue, making appropriate assessment of a wound impossible without adequate debridement. Debridement can be achieved in several ways:
The end goal of wound care is to re-establish the integrity of the skin, a structure which serves as a barrier to the external environment. The preferred method of closure is to reattach/reapproximate the wound edges together, a process known as primary closure/healing by primary intention. Wounds that have not been closed within several hours of the initial injury or wounds that are concerning for infection will often be left open and treated with dressings for several days before being closed 3–5 days later, a process known as delayed primary closure. The exact duration of time from initial injury in which delayed primary closure is preferred over primary closure is not clearly defined. Wounds that cannot be closed primarily due to substantial tissue loss can be healed by secondary intention, a process in which the wound is allowed to fill-in over time through natural physiologic processes. When healing by secondary intention, granulation tissue grows in from the wound edges slowly over time to restore integrity of the skin. Healing by secondary intention can take up to months, requires daily wound care, and leaves an unfavorable scar, thus primary closure is always preferred when possible. As an alternative, wounds that cannot be closed primarily can be addressed with skin grafting or flap reconstruction, typically done by a plastic surgeon. There are several methods that can be implemented to achieve primary closure of a wound, including suture, staples, skin adhesive, and surgical strips. Suture is the most frequently used for closure. There are many types of suture, but broadly they can be categorized as absorbable vs non-absorbable and synthetic vs natural. Absorbable sutures have the added benefit of not requiring removal and are often preferred in children for this reason. Staples are less time-consuming and more cost effective than suture but have a risk of worse scarring if left in place for too long. Adhesive glue and sutures have comparable cosmetic outcomes for minor lacerations <5 cm in adults and children. The use of adhesive glue involves considerably less time for the doctor and less pain for the person. The wound opens at a slightly higher rate but there is less redness. The risk for infections (1.1%) is the same for both. Adhesive glue should not be used in areas of high tension or repetitive movements, such as joints or the posterior trunk.
After a wound is irrigated, debrided, and, if possible, closed, it should be dressed appropriately. The goals of a wound dressing are to act as a barrier to the outside environment, facilitate wound healing, promote hemostasis, and act as a form of mechanical debridement during dressing changes. The ideal wound dressing maintains a moist environment to optimize wound healing but is also capable of absorbing excess fluid as to avoid skin maceration or bacterial growth. Several wound dressing options are available, each tailored to different kinds of wounds:
Ideally, wound dressings should be changed daily to promote a clean environment and allow for daily evaluation of wound progression. Highly exudative wounds and infected wounds should be monitored closely and may require more frequent dressing changes. Negative pressure wound dressings can be changed less frequently, every 2–3 days. Wound progression over time can be monitored with transparent sheet tracings or photographs, each of which produce reliable measurements of wound surface area.
There is moderate evidence that honey is more effective than antiseptic followed by gauze for healing wounds infected after surgical operations. There is a lack of quality evidence relating to the use of honey on other types of wounds, such as minor acute wounds, mixed acute and chronic wounds, pressure ulcers, Fournier's gangrene, venous leg ulcers, diabetic foot ulcers and Leishmaniasis.
Therapeutic touch has been implicated as a complementary therapy in wound healing; however, there is no high quality research supporting its use as an evidence based clinical intervention. More than 400 species of plants are identified as potentially useful for wound healing. Only three randomized controlled trials, however, have been done for the treatment of burns.
From the Classical Period to the Medieval Period, the body and the soul were believed to be intimately connected, based on several theories put forth by the philosopher Plato. Wounds on the body were believed to correlate with wounds to the soul and vice versa; wounds were seen as an outward sign of an inward illness. Thus, a man who was wounded physically in a serious way was said to be hindered not only physically but spiritually as well. If the soul was wounded, that wound may also eventually become physically manifest, revealing the true state of the soul. Wounds were also seen as writing on the "tablet" of the body. Wounds acquired in war, for example, told the story of a soldier in a form which all could see and understand, and the wounds of a martyr told the story of their faith.
In humans and mice it has been shown that estrogen might positively affect the speed and quality of wound healing.