Orthopedics - Non Healing Wound

Non Healing Wound

Diagnosis/Definition

Chronic Wound: any non-healing wound and/or ulcer that has been present for 3-4 week duration and has not responded to conventional therapies.

Initial Diagnosis and Management

• Pressure Ulcers: Management involves assessment of systems, wound management, and evaluation by a plastic surgeon.
  • Stage III - full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through, fascia.
  • Stage IV - full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (tendon, joint capsule).
• Non-Healing Surgical Wounds: Wounds that are taking longer to heal because of underlying problems such as diabetes, poor nutritional status, immune compromised, or infection. Any surgical wound of 3-4 week duration that is not responding to conventional therapies. Management includes assessment of systems, wound management, and evaluation of a general surgeon.
• Lower Extremity Ulcerations: Any non-healing ulcer of a lower extremity that has been present for 3-4 week duration and has not responded to conventional therapies.
  • ARTERIAL ULCER - caused by ischemia; related to the presence of arterial occlusive disease; generally present on the foot, typically the distal appendages and lateral malleolus; very painful; onset can be precipitated by trauma. Management involves assessment of blood flow to the extremity, wound management, and evaluation by a vascular surgeon.
  • VENOUS STASIS ULCER - result of edema and impaired venous return; loss of epidermis and various levels of dermis and subcutaneous tissue occurring on the medial aspect of the distal 1/3 of the lower extremity. Often found in combination with an edematous and indurated lower extremity. Management involves assessment of blood flow to the extremity, wound management, compression stockings and/or wraps, and evaluation from a vascular surgeon. A dermatologist consult may be obtained if chronic dermatitis is present.
  • MIXED VESSSEL (ARTERIAL AND VENOUS ULCER) - presence of arterial insufficiency and venous disease. Typically, ulcers are found on the lower extremity including the foot. Management includes assessment of blood flow to the lower extremity, wound management, and evaluation by a vascular surgeon.
• All patients should be encouraged to decrease their risk factors (e.g., smoking, etc.) and to manage co-existing conditions such as diabetes.
• All other ulcerations assessed individually and treated according to the underlying etiology.

Ongoing Management and Objectives

Allow healing of all wound and/or ulcers; management is tailored to the specific wound and etiology.

Indications for Specialty Care Referral

Any non-healing wound and/or ulcer that has been present for 3-4 week duration and has not responded to conventional therapies should be referred to the wound clinic.

Criteria for Return to Primary Care

Once the wound-care plan is effective, follow-up can be done by primary care for risk factor reduction.

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