Approach to non-healing wounds: Clinical sciences

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Introduction0:00–0:50

A non-healing wound refers to a chronic skin and soft tissue wound that fails to heal within the normal healing time frame, which is 4 to 6 weeks.
In the majority of cases, there is an underlying condition or an infection that prevents normal healing. These factors often lead to the loss of normal skin and soft tissue anatomy and function.
In general, non-healing wounds are divided into two main categories: ulcers, which include pressure, neuropathic, venous, and arterial ones; and other non-ulcer related chronic wounds like postoperative wound complications, neoplastic or radiation-induced skin lesions, and infectious or inflammatory wounds.
Alright, when a patient presents with a non-healing wound, your first step is to obtain a focused history and physical exam.

Ulcer0:50–1:25

On history, patients typically have underlying chronic medical conditions such as diabetes or peripheral arterial disease known to prevent proper wound healing by causing inadequate nutritional status or poor blood supply.
They might report first noticing a small wound that progressed to a larger or deeper one over the course of weeks to months.
In this case, consider ulcers.Okay, let’s start with pressure ulcers. These ulcers form when prolonged pressure decreases the blood flow to an area of skin and its underlying soft tissue.

Pressure ulcers1:25–2:31

Typically, patients have a history of immobility, like being bed- or wheelchair-bound, and poor nutrition. Additionally, they might have multiple comorbidities such as stroke or paralysis.
Patients who are hospitalized or reside in nursing homes are at a greater risk of developing pressure ulcers. On exam, you might see partial or complete skin loss with areas of dark ischemic discoloration or necrosis over bony prominences like the sacrum.
Sometimes you might even see the underlying fat, muscle, or bone exposed. With these findings, you can diagnose pressure ulcers.
Here’s a clinical pearl! Although imaging is not needed to make a diagnosis, an MRI is often obtained to evaluate for osteomyelitis if there is exposed bone in the wound bed.Alright, let's move on to neuropathic ulcers.

Neuropathic ulcers2:31–3:36

This type of ulcer occurs in patients with peripheral neuropathy, often from diabetes. Physical exam typically reveals a deep painless “punched out” ulcer with surrounding callus around pressure points, such as plantar metatarsal heads of the feet.
Additionally, patients often have reduced sensation on monofilament testing around the ulcer. In this case, the diagnosis is a neuropathic ulcer.
Here’s another clinical pearl! The management of neuropathic ulcers involves treating the wound and the underlying disease.
Consider checking the patient’s HbA1c to make sure their diabetes is under control to prevent further progression of the neuropathic ulcer.
Additionally, obtain an ankle-brachial index, or ABI, to rule out peripheral arterial disease. Once this is excluded, treatment consists of wound care and reduction of pressure around the wound with appropriate footwear and orthotics.Okay, next let’s talk about venous ulcers.

Venous ulcers3:36–4:35

These patients often have a history of venous insufficiency, and report dull aching pain and swelling of the legs that improves with elevation.
They might also have a history of smoking, prolonged standing, or deep vein thrombosis in the affected leg. On physical exam, ulcers are shallow with irregular borders surrounded by edematous and firm skin with reddish-brown hyperpigmentation.
They are typically located at the medial malleolus. Additionally, patients might have visible dilated and tortuous superficial veins along the same leg above the ulcer.
In this situation, consider a venous stasis ulcer and obtain a venous duplex ultrasound. Venous reflux on ultrasound means that venous valves are incompetent, which causes increased venous pressure in the legs.
With this finding, you can diagnose venous ulcers. Alright, our final type of ulcer is an arterial ulcer.

Arterial Ulcer4:35–5:45

Patients usually report claudication and/or rest pain of the affected extremity and have a history of peripheral arterial disease, atherosclerosis, or smoking.
On physical exam, you might see a punched-out, pale, gray, or yellow ulcer with a dry base often located at the distal ends of digits like the toes.
Additionally, the peripheral pulse proximal to the ulcer might be reduced or absent, and the limb might be cold to touch with shiny skin and hair loss.
With these findings, consider arterial ulcers and obtain an ABI to evaluate for arterial insufficiency. An ABI of less than 0.9 confirms peripheral arterial disease.TIme for a clinical pearl!
Patients with peripheral arterial disease often have other systemic vascular conditions related to atherosclerosis like carotid artery stenosis or coronary artery disease, which should be considered during surgical planning.Okay, now that we’re done with ulcers, let’s talk about different findings.

Chronic nonhealing wounds5:45–6:23

History often reveals external forces of injury like trauma or surgery, or other underlying diseases like cancer or inflammatory conditions.
These conditions can contribute to the patient’s inadequate nutritional status or impaired blood circulation impeding their wound healing.
Patients report these wounds starting as minor ones that progress or do not get better. In this situation, consider other chronic non-healing wounds that are not related to ulcers.Let’s start with postoperative wound complications.

Post-operative wound complications6:23–7:46

Patients usually have a history of a recent surgical procedure, possibly followed by a complication such as wound disruption, dehiscence, evisceration, infection, or drainage.
On physical exam, you might find fever, tachycardia, or partial or complete incisional disruption with drainage ranging from serosanguinous to frank pus or even GI contents, and foul smell.
If any of these findings are present, consider post-op wound complications. Next, order labs including CBC, ESR, CRP, and albumin to assess for infection and nutritional status, in addition to an ultrasound or CT scan to further evaluate the wound.
On labs, you might see anemia, leukocytosis, elevated ESR and CRP, and hypoalbuminemia. Imaging can show disrupted tissue layers, air within the soft tissue, or fluid collections.
Consider obtaining wound and blood cultures if there is a high suspicion of an infection. Depending on your findings, you can confirm the diagnosis of postoperative wound complications such as dehiscence, fistula, or infection.Moving on, let’s talk about neoplastic lesions and radiation-induced skin changes.

Neoplastic lesions or radiation-induced skin changes7:46–9:07

Patients with these conditions often have a personal or family history of malignancy and might have received radiation treatment.
In some patients, history might include risk factors like prolonged exposure to UV rays, exposure to chemicals, or heavy metals.
They might report rapid growth of a lesion in preexisting wounds or scars that did not improve with standard care. On exam, neoplastic lesions can appear as hypo or hyperpigmented nodules, ulcers resembling a crater, or hard fixed raised nodules known as cauliflower lesions.
They might also have erythema or desquamation. Radiation-induced skin changes, on the other hand, can look like a rash that later turns into white shiny taut skin.
If you are considering neoplastic lesions or radiation-induced skin change as your diagnosis, your next step is to obtain a wound biopsy.
Biopsy showing malignant cells confirms your diagnosis of a neoplasm, while epidermal necrosis with dermal inflammatory changes supports radiation-induced skin changes.
Finally, let's discuss infectious and inflammatory wounds. These wounds form as a result of inflammatory destruction of the skin and soft tissue.

Infectious wound9:07–10:11

The inflammation can be triggered by an infection or underlying inflammatory conditions like vasculitis or autoimmune skin disease.
Patients with chronic infectious wounds typically have a history of multiple treatments like incision and drainage, debridement, and antibiotics with inadequate response.
They might experience pain and fevers. On exam, infectious wounds look like an open sore with necrotic debris called fibrinous exudate and purulent discharge, and in some cases an area of fluctuance indicating an abscess.
If you see any of these findings, consider an infectious wound. To confirm the diagnosis, order a wound swab.
Cultures grown from the wound swab confirm your diagnosis, and can also help identify the causative organism of the wound.
When it comes to inflammatory wounds, patients usually have some inflammatory condition in their history. They often report a rash-like wound that hasn’t improved despite treatment, pain, and itchiness.

Inflammatory wound10:11–11:07

They might also tell you that they had flare-ups of similar lesions in the past. On examination, inflammatory wounds can resemble a dry rash with atopic skin, erythema, or dark discoloration appearing in multiple parts of the body.
If this is the case, consider an inflammatory wound and order a biopsy. If it shows inflammatory changes, vasculitis, and atrophic skin, you’re dealing with an inflammatory wound.
Okay, if you’ve ruled out all of these causes of chronic non-healing wounds, consider and assess for some other less-common causes of non-healing wounds like vasculitis or lymphoma.Alright, as a quick recap… When assessing non-healing wounds you should think about ulcers such as pressure, neuropathic, venous, and arterial ulcers, as well as other chronic wounds like postoperative wound complications, neoplastic or radiation-included skin changes,

Review11:07–11:23

Approach to non-healing wounds: Video, Steps, Uses | Osmosis