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Chronic Wounds in the UC, Part 1

Colin Kaide, MD, Nate Finnerty, MD, and Mike Weinstock, MD
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17:00

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Patients will present to the UC with chronic wounds. Its important to know how to identify acute issues and complications that surround chronic wounds and how to manage these in the UC.

 

Pearls:

  • The common types of wounds are caused by arterial insufficiency, venous insufficiency, pressure and diabetic neuropathy and there is a lot of crossover among these.  

  • Differentiate erythema that is seen with venous stasis from cellulitis by elevating the legs to see if the erythema improves.  If it does, it is not likely an infectious process.  Similarly, if pain worsens with elevation, there is likely an arterial insufficiency component.  If the pain improves with elevation, there is likely a venous insufficiency component.  

  • The most reliable sign of infection in a chronic, non-healing wound is recent increased pain and wound breakdown.

  • A moist wound bed creates the best conditions for healing.  Antibiotic ointment or santyl collagenase can be used to provide moisture in a dry wound.  Venous stasis wounds are often very wet on their own and often require an absorptive dressing rather than an ointment that will make them even more drippy.

 

  • Wounds are often defined by the process that leads to that wound.  The most common are:

    • Arterial insufficiency.  Decreased blood flow leads to friable skin that injures easily and then decreased blood flow to the wound results in poor healing.  These can occur anywhere on the leg, but tend to occur more on the lateral side and appear as punched-out lesions with discrete ulcerations.  There may be associated findings including decreased pulses, dependent rubor, cool skin and chronic pain in the extremity.  Pain caused by arterial insufficiency often decreases with dangling the patient’s legs in a dependent position.  Pain with physical activity is a sign of claudication.

    • Venous insufficiency.  Seen in patients with underlying venous stasis evidenced by chronic edema in their lower extremities.  Ulcers form from within as too much fluid builds up in the skin.  These ulcers typically appear on the medial side of the leg and are accompanied by other signs of venous stasis including hemosiderin staining of the skin, chronic edema and erythema which is often mistaken for cellulitis.  

    • Pressure induced.  Often seen in the sacrum or other areas that are predisposed to sustained pressure such as the backs of the heels.  When the pressure applied to these areas is greater than the capillary pressure, there is decreased blood flow, skin breathdown and wound development that then persists because of the decreased blood flow and all the comorbidities the patients typically have.  Predisposing factors for pressure wounds include spinal injuries, poor nutrition, elderly people who are not as mobile.  

      • Evaluate these wounds by gauging the size and depth.

        • Initially skin is erythematous but blanches with pressure.  This may indicated that there is increased risk for wound development.

        • Stage 1: An area of erythema that does not blanch.  May or may not be tender.

        • Stage 2: Skin is open.  Wound is superficial, partial thickness and involves only the epidermis or the dermis.  There can be some necrosis.

        • Stage 3: Full thickness of the epidermis and dermis and may extend to the fascia, but not through the fascia.  

        • Stage 4: Full thickness wound that often involves necrosis and supporting structures are involved like bone and muscle.  

    • Diabetic neuropathy.  Patients are unable to signs of impending skin damage such as hot spots prior to blister formation or the tip of a nail before stepping completely on it.  Once the injury has a occurred, they are often unaware of it so it goes untreated for days, weeks or months.  

  • History

    • Over what time frame did the wound develop?  Was there an acute injury, or was is gradual in onset because he doesn’t have any sensation in the area?

    • Is there a neuropathic component?  How much sensation does the patient have in the area?  

    • What has been done for the wound previously?

    • What is the patient’s nutritional status?  How bad is the diabetes or is it well-controlled?

    • What are the other comorbidities?  Is there arterial insufficiency?  Has the patient had any bypass surgeries?

    • How has the wound changed recently?  Is it expanding? More painful? Increased drainage? Foul smell? These can indicate to you that the wound might be infected.

      • Gardner SE, et al. The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair Regen. 2001 May-Jun;9(3):178-86. PMID: 11472613

        • Looked at characteristics of wounds that most correlated with infection.  The greatest correlation with infection in a non-healing wound was increased pain and wound breakdown.  

  • Physical exam

    • Pulses

    • Sensation

    • Range-of-motion distal to the wound

    • Touch the wound.  Look for warmth, crepitus, fluctuance.

    • Elevate the patient’s leg and see what changes.  Does the redness drain out?  If yes, you can be more confident that the erythema is more from stasis than cellulitis.  Does the pain get worse?  If yes, then they likely have arterial insufficiency.  If the pain improves, it is probably venous insufficiency.  

  • Treatment.  Prepare your patients that treatment of chronic wounds takes time, commitment and compliance.  The changes they need to make to heal the wounds will likely be lifelong to prevent recurrence.  

    • Off-loading.  Remove the insulting event that created the wound to begin with.  Get pressure off the area.  There are special types of shoes and orthotics that can be used for wounds on the feet.  

    • Topical therapies:

      • If there is no infection, you may not need a topical therapy, but there are some things you can use to treat the symptoms.

      • A moist wound healing bed is best for most patients.  If a wound is really dry and crusty, put something on it that will increase the amount of moisture in the wound.  Bactroban or other antibiotic ointments work well for this, even in the absence of an infection.  If there is a lot of debris, an agent like santyl collagenase that helps break down the debris, slough and exudate.  

      • Venous insufficiency wounds will have a lot of drainage.  There are a lot of topical absorptive agents on the market like calcium alginate pads, but when they have been studied, they are no better than an absorptive dressing from your supply cabinet like an abdominal pad.  

      • Topical NSAIDs can be used to reduce pain in a chronic wound and may reduce your need to prescribe a systemic opioid for pain control.  

    • Wounds with a venous stasis component require reduction in the amount of edema to heal.

      • Compression.  Compression stockings or an ace wrap are typically the first step.  Secondarily, there is a Profore dressing that is a 4-layer compression dressing.  Once the wound begins to heal, the patient has to stay in chronic compression stockings to prevent recurrence.    

      • Elevation.  Patients need to spend a significant amount of time with their legs parallel to or just slightly more than parallel to the ground.  Ankles above the knees, knees above the hips.

      • Walking.  The action of walking engages the calf muscles to help pump the fluid from the distal venous system proximally.  The valves in the veins of patients with venous stasis are usually bad.  Activity is good for these patients, but sitting without elevation is very bad for them.  

    • Referral to a wound center.  It takes a community to heal these wounds over a long period of time.  

  • Indications for transfer to the Emergency Department:

    • A grossly infected wound that requires IV antibiotics.  

    • A patient with systemic symptoms of infection like sepsis.

    • Patients who do not have the ability to care for their own wounds.

    • Patients who have a deeper space infection like osteomyelitis or a necrotic process like wet gas gangrene.  

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