TASA ID: 694

Wounds to the skin and deeper structures are among the most common of acute medical conditions.  Fortunately, most of these are minor injuries, and most of them resolve uneventfully when managed appropriately.  Many wounds; however, involve injuries that require skillful assessment to properly appreciate their magnitude, and many must be repaired skillfully to avoid long-term sequelae.

Not all wounds are acute; however, and a surprising number of them do not heal without intervention and remain chronic for weeks to years.  Many of these chronic wounds evolve even without a specific injury, being the result of other chronic or systemic illnesses.

Acute wounds may be caused by blunt force or by an object penetrating through the skin.  Both blunt and penetrating injuries obviously can damage the skin with plainly visible consequences, but both may also cause injury to deep tissues and structures hidden from observation, requiring careful inspection and indirect diagnostic techniques.  

Management of acute uncomplicated superficial wounds is straightforward.  Ideally, they are addressed within the first six hours of injury, after which time they are considered to be more prone to infection and thereafter progressively less likely to heal spontaneously.  Bleeding must be controlled to allow proper inspection and safe wound closure.  The most critical steps to minimize infection are to remove any foreign debris, debride or excise tissues deemed to be crushed or tattered so as to be nonviable, and thorough irrigation with any suitable fluid such as saline or even tap water. 

All open wounds should be explored to rule out injury to critical deep structures.  This would in particular include damage to nerves, arteries, tendons, muscles, joint spaces, and any underlying organs.  Damage to thread-like nerves or blood vessels cannot be repaired, but the other structures often do require specific repair, or there is risk of further damage and/or long-term disability.  Deep structure damage can often be recognized with very careful direct inspection, but a thorough assessment of nerve function, blood flow, and motor function distal to the wound is necessary to more accurately rule out injury to structures not directly visible.

Wounds may be closed with suture material, tissue glue, or tape, but proper choice of technique and material depends on the size and location of the wound and the desired cosmetic appearance of the wound, both during and after healing.  Even without deep structure injury, a multi-later closure of the skin is sometimes used, with subcutaneous stitches placed below the outer layers of skin to provide additional and/or permanent supporting strength.  Dressings are often used to protect the area but are generally not required, nor are antibiotics.  Even with optimal care, about 3% of wounds become infected.

Foreign bodies can be difficult to find, and even when located they can be surprisingly difficult to remove.  X-rays do not always show foreign material, as some of it is isodense with the surrounding tissue.  Metallic objects and small gravel or sand generally can be visualized on x-rays, while glass and heavier plastics remain hard to see.  Ultrasound can often help locate larger pieces of solid materials, and, rarely, magnetic resonance imaging (MRI) is employed.  Generally, it is important to remove these objects, as leaving them in place may add to infection risk, become tender or painful, or shift position so as to impinge on critical structures such as nerves or blood vessels.  Failure to remove unidentified foreign bodies remains one of the top ten categories for litigation in the acute care field.  Occasionally, a foreign body is intentionally left in place when the risk of an attempted retrieval outweighs the expected benefits.  

In otherwise healthy individuals, wound healing progresses uneventfully, but the healed skin remains fragile for weeks and the healing process may not reach a final plateau for as much as six months to a year.  If a wound should happen to reopen, termed dehiscence, the resulting open wound generally is far more difficult to heal and may become chronic.

Chronic wounds often require specialized care and months to heal.  The average cost of medical care required to heal a chronic wound in 2016 was around $52,000.  These wounds are bothersome to patients due to pain, drainage, bleeding, odor, unsightliness, limited use of the involved part, possible loss of time from work, and the need for multiple clinic visits.  Open wounds are more prone to infection, can potentially expand rather than heal, and often leave unsightly firm scars.  

The majority of chronic wounds are not the result of dehiscence, but rather they are a complication of other injury or, more commonly, are associated with other illnesses and pre-existing conditions.  A key point is that chronic wounds remain chronic for one or more reasons unrelated to the wound itself, and the underlying causes must be identified and addressed to heal these wounds and prevent recurrences.
An example of this is where wounds develop and then fail to heal due to inadequate blood flow.  Poor tissue perfusion leads to inadequate cell function and death of skin cells, resulting in an open wound.  Efforts to heal these wounds with cleaning, debridement, ointments, special dressings and the like are fruitless without addressing the primary cause and doing something to improve blood flow.  

The list of chronic wound etiologies is long.  Pressure ulcers remain a major category of chronic wounds, including "bed sores" and other areas of skin breakdown related to frequent prolonged periods of pressure, such as in persons who are bedridden or otherwise unable to reposition themselves well.  Here, the skin typically breaks down over areas of bony prominence such as the coccyx, heels, buttocks, and elbows.  Healing may be complicated by decreased sensory perception, inactivity, moisture, improper seat cushions and mattresses, friction, hygiene issues, infection, and inattentive caregivers, to name just a few of the many factors.  Smoking, deteriorating general health, medications, dementia, and poor nutrition are some of the many patient-related factors, some of which are modifiable and some not.  When conditions are adverse enough to cause pressure ulcers, reversing the process and achieving healing can be frustratingly slow and labor-intensive, at times to no avail.  

Venous leg ulcer is another common type of chronic wound.  Here, edema builds up in the lower leg, causing decreased tissue perfusion, stretching and thinning of the skin, development of poor tissue quality, and eventual breakdown of the skin.  The edema may be the result of incompetent veins, capillary dysfunction, prolonged standing, inflammatory changes, obesity, pregnancy, sedentary lifestyle, low blood protein levels, medications, and other factors.  Again, the offending factors must be addressed to gain control of the wound.  Recurrences are common.  

Other causes of chronic wounds include, diabetes, burns, malignancy, osteomyelitis, cellulitis, radiation tissue necrosis, lymphedema, primary dermatologic conditions, such as pyoderma and calciphylaxis, various medications, and many other etiologies.  There may be underlying structural concerns, congential issues, ongoing trauma, post-operative complications, and other issues to complicate the situation.  Very commonly, there are multiple factors in play.  Further, wounds often involve not just the skin, but also extend down into critical deep structures, disruption of which can lead to long term disability.

Standard wound care involves addressing the causative issues, plus cleaning of the wound, excising nonviable tissue, creating a healing wound environment by controlling moisture, temperature, and pressure, periodic dressing changes, and ongoing monitoring so as to modify care as healing progresses, or fails to progress.  More advanced strategies include tissue grafting, use of bioengineered tissue, hyperbaric oxygen, and newer techniques including the use of stem cells and placental tissue.  As with most medical interventions, the correct treatment depends on the specific situation.  

Healing may not be realistic in some situations.  In certain settings, the goal of care may be to arrest further development of the wounds rather than to achieve healing.  In terminally ill patients, the very elderly with shorter life expectancy, patients who have obstacles to obtaining proper care, those who are persistently non-compliant, etc., it may be more realistic to primarily address issues, such as pain or drainage, and not have an unrealistic expectation that the wound will heal.  

Humans have lived through the millenia with a remarkable ability to bounce back from acute and chronic wounds.  Modern medicine has improved even those high odds of recovery.  But even with the best of care, some wounds will not heal, and some persons will have setbacks.  Fortunately; however, the vast majority of wounds heal satisfactorily when managed appropriately.  

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

This article may not be duplicated, altered, distributed, saved, incorporated into another document or website, or otherwise modified without the permission of TASA. Contact for any questions.


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