ABC of Wound Healing E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: ABC Series
• Sprache: Englisch

Seitenzahl: 241

Veröffentlichungsjahr: 2021

Beschreibung

ABC of Wound Healing, Second Edition

ABC of Wound Healing is a practical, highly illustrated guide to assessment, diagnosis and management of all common types of acute and chronic wounds. This concise yet comprehensive reference covers all essential aspects of wound healing care, including epidemiology, pathophysiology, assessment, treatment, long-term management, and prevention

This revised second edition contains several new chapters on lymphoedema, nutrition, skin care, continence, and scarring. Updated and expanded chapters cover a wider range of devices and therapies, and discuss additional factors that impact wound healing processes, offering new clinical photographs as a visual guide. Applying a multidisciplinary approach to the provision of wound care, ABC of Wound Healing:

• Covers common wounds including traumatic wounds, surgical wounds, diabetic foot ulcers, pressure injuries, and venous and arterial leg ulcers
• Emphasises the importance of reaching a diagnosis, the fundamental step in managing any wound
• Provides up-to-date information on physical, chemical, biological and emerging therapies for patients with various types of wounds
• Contains hundreds of full-colour illustrations and clinical photographs of wounds and treatments

ABC of Wound Healing, Second Edition, remains a must-have guide for junior doctors, specialist registrars in medicine and surgery, specialist nurses, general practitioners and medical students.

Leseprobe

Table of Contents

Cover

Title Page

Copyright Page

List of Contributors

Foreword

CHAPTER 1: Wound Assessment

Approach to patients with wounds

Non‐healing wounds

Further reading

CHAPTER 2: Traumatic Wounds

Mechanisms of injury

Management

Further reading

CHAPTER 3: Surgical Wounds and Surgical Site Infection

Classification

Wound closure

Surgical site infection

Further reading

CHAPTER 4: Burns

Mechanism of burn

Burn assessment

Management of burn injuries

Complications of burns

Further reading

CHAPTER 5: Diabetic Foot Ulcers

Neuropathic foot ulcer

Neuroischaemic foot ulcer

Principles of Management

Charcot osteoarthropathy (Charcot foot)

Acknowledgements

Reference

Further reading

CHAPTER 6: Venous and Arterial Leg Ulcers

Venous ulceration

Arterial ulceration

Mixed ulcers

Further reading

CHAPTER 7: Pressure Injuries

Pathogenesis

Classification

Prevention and treatment

Assessment of risk

Surface selection

Wound care

Safeguarding

Surgery

Complications

References

Further reading

CHAPTER 8: Uncommon Causes of Ulceration

Inflammatory disorders

Cutaneous necrosis

Infection

Malignancy

Drug and iatrogenic causes

Dermatitis artefacta

Reference

Further reading

CHAPTER 9: Infections

Sampling wounds

Treatment

Specific infections

Reference

Further reading

CHAPTER 10: Lymphoedema and Wounds

Defining lymphoedema

Causes of lymphoedema

Staging

Effects of lymphoedema on the skin

Management of lymphoedema

Acknowledgements

References

Further reading

CHAPTER 11: Nutrition, Skin Care and Continence

Nutrition

Skin care

Continence

Acknowledgements

Further reading

CHAPTER 12: Scars

Inflammation

Proliferation

Remodelling

Further reading

CHAPTER 13: Dressings and Devices

Dressings

Devices

Further reading

CHAPTER 14: Drugs and Biological Approaches to Wound Healing

Induced regeneration

Vasodilators in wound healing

Immune modulators

Drugs that reduce matrix degradation

Growth factors

Concerns about biological treatments

Reference

Further reading

Index

End User License Agreement

List of Tables

Chapter 1

Wound edge characteristics.

Chapter 2

Management of bite wounds.

Chapter 3

Timings for removal of non‐absorbable sutures.

Examples of suture materials.

Factors implicated in a higher risk of surgical site infection.

Chapter 4

Burn aetiology by age.

Chapter 6

Features of venous and arterial ulcers.

Risk factors for venous ulceration.

Features of venous eczema and cellulitis.

Compression stockings.

Interpretation of ankle brachial pressure index.

Chapter 7

Key definitions in pressure injury pathogenesis.

Components of three risk assessment scales.

Chapter 8

Connective tissue disorders that can cause and/or exacerbate chronic ulceration.

Causes of vasculitis classified according to the size of vessel affected (Chapel...

Chapter 9

Microbiological analysis.

Clinical features of necrotising fasciitis.

Chapter 10

Stages of lymphoedema.

Examples of wounds associated with lymphoedema and chronic oedema.

Chapter 11

Assessment of nutritional status.

Common skin problems associated with chronic wounds.

Chapter 14

Drugs that can impair wound healing.

Vasodilator drugs used in wound healing.

Immune‐modulating drugs used in wound healing.

Major growth factors that play important roles in normal wound healing.

Examples of tissue engineered skin substitutes.

List of Illustrations

Chapter 1

Methods of wound measurement. (a) Wound measurement using a ruler. (b) Wound...

The importance of probing a wound. (a) A small abdominal wound. (b) On exami...

Communication between pilonidal sinus wounds.

Healing edge of an abdominal wound. The size of the original wound is eviden...

Squamous cell carcinoma with raised edges.

Dead tendon in the base of the wound (indicated by arrow).

Examination of the wound bed. (a) Healthy granulation tissue in a hidradenit...

Examination of the wound bed. (a) Necrotic tissue. (b) Slough. (c) Fibrin (s...

(a) Pressure injury with extensive callus build‐up before debridement. (b) S...

Larval debridement of a pressure injury.

Maceration of surrounding skin.

A non‐healing wound; this venous leg ulcer has been present for over 10 year...

Chapter 2

Pretibial laceration closed with adhesive strips.

Fasciotomy wound.

Degloving injury – avulsion of the skin from underlying tissue.

Heavily contaminated traumatic wound.

Arm wound with tourniquet in place prior to debridement.

Dirt identified in bloodless field.

Hydrosurgical debridement.

‘The solution to pollution is dilution’ – following debridement, wounds shou...

Debrided wound ready for dressing application.

The reconstructive ladder.

Failed healing of donor site after harvesting of split‐thickness skin graft....

Chapter 3

Primary closure using interrupted sutures.

Groin wound left open to heal by secondary intention.

Sizes of suture thread, classified as a fraction of gauge 0.

Types of needles used for different surgical procedures. Straight needles an...

Shapes of needles used in wound closure.

A healed laparotomy wound closed with subcuticular sutures.

Dehiscence of an abdominal wound closed with staples.

Postoperative wound dehiscence caused by surgical site infection. The result...

Chapter 4

(a) Full thickness flame burn to lower limbs. (b) 'Pull over' scald (hot tea...

Electrical burn.

Chemical burns. (a) Acid burns to the hands. (b) Alkali burns to the knees....

A Lund and Browder chart is useful for assessing the extent of burn injury (...

A Biobrane suit for a child with superficial partial‐thickness burns.

(a) A full thickness torso burn which is restricting ventilation. (b) Chest ...

Hypertrophic scarring.

Chapter 5

(a) Neuropathic diabetic foot ulcer. (b) Neuroischaemic diabetic foot ulcers...

Doppler waveforms. (a) Triphasic waveforms (normal). (b) Biphasic waveforms ...

(a) Measurement of ankle pressure. (b) Measurement of toe pressure. Source: ...

Areas of abnormal pressure distribution in the diabetic foot. Plantar ulcers...

Examination of an ulcer with a probe.

(a) Ulcers seen on plantar aspect of foot following debridement of callus. (...

Pressure redistribution. (a) Walking boot. (b) Custom made shoe. (c) Half sh...

A below‐knee plaster cast with a frame that reduces forces through the foot....

(a) A necrotic toe. (b) The necrotic toe has been amputated.

Overgranulation in a diabetic foot ulcer, which can be a sign of chronic inf...

Exposed bone (arrow) can suggest the presence of osteomyelitis.

Forefoot amputation due to wet gangrene.

A pin discovered in a neuropathic foot.

X‐ray showing Charcot osteoarthropathy. There are multiple fractures and des...

Chapter 6

Typical venous ulcer with an irregular border and sloping edges located in t...

Typical arterial ulcer with exposed tendon and well-defined edges.

Brown skin pigmentation caused by haemosiderin deposition.

Atrophie blanche.

Severe eczema.

Treatment algorithm for venous eczema.

Types of compression. (a) Single‐layer elastic bandage. (b) Two‐layer hosier...

Sharp debridement at the bedside. (a) Before debridement. (b) After debridem...

Arterial ulcers with typical skin changes (hairless, shiny and thin).

An angiogram showing multilevel arterial disease. The arrow indicates a sten...

Chapter 7

Examples of common pressure injury sites. (a) Pressure injury over elbow joi...

Potential sites for pressure injury development in those at risk. The most c...

Shear force, e.g. from sliding down a bed.

Friction forces, e.g. repositioning a patient on a bed sheet.

Definition of Category/Stage I to IV pressure injuries from the Internationa...

Definition of unstageable pressure injuries from the International NPIAP/EPU...

Definition of suspected deep tissue injury, from the International NPIAP/EPU...

Reactive support surfaces. (a) An inflatable cushion. (b) An inflatable boot...

Types of support surface. (a) Mattress made from pressure‐redistributing foa...

(a) Large unstageable pressure injury (covered in eschar) on the lower back....

Category/Stage IV pressure injury with necrotic muscle and bone in the wound...

Chapter 8

Uncommon causes of ulceration.

Examples of uncommon causes of ulceration. (a) Acroangiodermatitis or pseudo...

Pyoderma gangrenosum. The wound bed is purulent and the edge is inflamed/vio...

Peristomal pyoderma gangrenosum.

Necrobiosis lipoidica diabeticorum.

Virchow's triad of thrombosis.

Sclerodactyly caused by systemic sclerosis. The patient also suffers from Ra...

(a) Cutaneous calcinosis (calcium deposits in the skin). (b) Calciphylaxis (...

(a) Purpuric rash associated with cutaneous vasculitis. (b) Cutaneous leucoc...

Skin malignancies. (a) Basal cell carcinoma. (b) Squamous cell carcinoma. (c...

Punch biopsy taken from a chronic leg ulcer for histopathological analysis. ...

Chapter 9

Spectrum of bioburden in chronic wounds.

(a) A clean, healing wound. (b) A leg ulcer with heavy slough, likely coloni...

Change in exudate can indicate wound infection. (a) Purulent exudate. (b) Gr...

Changes in the wound bed can indicate wound infection. (a) Unhealthy granula...

Charcoal swab used to perform a superficial wound swab.

Surgery for necrotising fasciitis. (a) Necrotising fasciitis of the groin ‐ ...

Chronic osteomyelitis of the tibia associated with multiple wounds on the an...

X‐ray showing osteomyelitis of the fourth metatarsal, associated with a diab...

Algorithm for management of suspected osteomyelitis.

Chest sinuses caused by chronic mediastinitis following cardiac surgery.

Chapter 10

Lymphoedema resulting from cancer treatment. (a) Unilateral upper limb lymph...

(a) Lymphoedema caused by trauma to the lower limb. (b) Lymphovenous oedema....

Primary lymphoedema.

Hyperkeratosis.

Papillomatosis.

Cellulitis – the right lower limb is swollen and erythematous.

Ulceration caused by compression bandaging.

Lower limb ulcers caused by lymphoedema.

Chapter 11

(a) A standard adult nasogastric tube. (b) A nasogatric tube inserted throug...

(a) Hyperkeratosis in a patient with chronic venous leg ulcers. (b) Severe s...

(a) Irritation caused by an adhesive dressing; note the redness is in the di...

Urisheaths – an option for managing urinary incontinence in men. The sheath ...

Erosion of the urethra caused by an indwelling urethral catheter – a rare bu...

Options for managing incontinence.

Moisture lesions on the buttock.

Chapter 12

Examples of skin scarring. (a) Laparotomy wound healed by primary intention....

Abnormal scarring caused by skin diseases. (a) Hidradenitis suppurativa. (b)...

Surgical revision of a stretched scar. (a) The anterior end of the scar (arr...

Early changes in scar morphology – hypertrophy. (a) One month after wound cl...

A keloid scar following ear piercing.

Hypertrophy or keloid? (a) A lesion has been excised from the left shoulder ...

Later changes – scar maturation. (a) A facial wound has been sutured but due...

Chapter 13

A clean, granulating postoperative wound suitable for covering with a low ad...

A wound with high exudate levels (seen dripping down the leg) suitable for a...

(a) A dry, necrotic wound. (b) A wound with adherent, thick slough. Rehydrat...

A cavity wound suitable for packing with an alginate dressing.

Some alginates have haemostatic properties so are useful for wounds that are...

A granulating abdominal wound suitable for a foam dressing.

An infected wound (indicated by presence of purulent exudate and dark, unhea...

Prolonged use of silver dressings can cause staining of the skin and the wou...

Failure to adequately control exudate levels may result in maceration of the...

Occasionally, even the most absorptive dressings cannot control exudate leve...

Allergy should be suspected when there is skin inflammation in the distribut...

Negative‐pressure wound therapy. Gauze covered by an occlusive film forms a ...

Topical oxygen therapy. A circular device is placed directly on the wound be...

Chapter 14

A simplified diagram showing the overlapping phases of wound healing. Inflam...

Perianal ulceration caused by nicorandil.

An ischaemic ulcer caused by systemic sclerosis and peripheral arterial dise...

A recalcitrant venous ulcer that has failed to heal despite compression ther...

Sickle cell ulcers. Vasodilator drugs may reduce pain and aid healing.

Pyoderma gangrenosum being treated with corticosteroids.

Cutaneous Crohn's disease causing ulceration and inflammation in the natal c...

Rheumatoid ulcer requiring treatment with immune‐modulating therapies such a...

Guide

Cover Page

Title Page

Copyright Page

List of Contributors

Foreword

Table of Contents

Begin Reading

Index

Wiley End User License Agreement

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Wound Healing

Second Edition

EDITED BY

Annie Price

Cardiff and Vale University Health BoardCardiff, UK

Joseph E. Grey

Cardiff and Vale University Health BoardCardiff, UK

Girish K. Patel

Cardiff and Vale University Health Board Cardiff, UK

Keith G. Harding CBE

Welsh Wound Innovation CentrePontyclun, UK

This edition first published 2022© 2022 John Wiley & Sons Ltd

Edition HistoryWiley‐Blackwell (1e, 2006)

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Annie Price, Joseph E. Grey, Girish K. Patel, and Keith G. Harding to be identified as the authors of the editorial material in this work has been asserted in accordance with law.

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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging‐in‐Publication Data

Names: Price, Annie (Of Welsh Wound Innovation (Organization)) editor. | Grey, Joseph E., editor. | Patel, Girish (Of Cardiff University) editor. | Harding, K. G. (Keith G.), editor.Title: ABC of wound healing / edited by Annie Price, Joseph E. Grey, Girish Patel, Keith G. Harding.Other titles: ABC series (Malden, Mass.)Description: Second edition. | Hoboken, NJ : Wiley, 2022. | Series: ABC seriesIdentifiers: LCCN 2021028004 (print) | LCCN 2021028005 (ebook) | ISBN 9780470658970 (paperback) | ISBN 9781118593844 (adobe pdf) | ISBN 9781118593837 (epub)Subjects: MESH: Wounds and Injuries–diagnosis | Wounds and Injuries–therapy | Ulcer–therapy | Wound Healing–physiology | HandbookClassification: LCC RD93 (print) | LCC RD93 (ebook) | NLM WO 39 | DDC 617.1–dc23LC record available at https://lccn.loc.gov/2021028004LC ebook record available at https://lccn.loc.gov/2021028005

Cover Design: WileyCover Image: Courtesy of Professor Keith G. Harding

List of Contributors

Jonathan J. CubittConsultant Burns and Plastic SurgeonWelsh Centre for Burns and Plastic SurgerySwansea Bay University Health BoardSwansea, UK(Chapter 4)

William A. Dickson MBERetired Consultant Burns and Plastic SurgeonWelsh Centre for Burns and Plastic SurgerySwansea Bay University Health BoardSwansea, UK(Chapter 4)

Michael E. EdmondsConsultant PhysicianDiabetic Foot ClinicKing’s College HospitalLondon, UK(Chapter 5)

Stuart EnochProfessor, Higher Surgical Education Directorate of Education and ResearchDoctors Academy Group (Intl)(Chapters 2, 13)

Amy FerrisConsultant GeriatricianCardiff and Vale University Health BoardCardiff, UK(Chapter 11)

Jacqui Fletcher OBESenior Clinical AdvisorStop the Pressure ProgrammeNHS England and NHS Improvement(Chapter 7)

Andrew FreedmanReader in Infectious DiseasesCardiff University School of MedicineCardiff, UKHonorary Consultant PhysicianCardiff and Vale University Health BoardCardiff, UK(Chapter 9)

Joseph E. GreyConsultant PhysicianDepartment of Gerontology,Cardiff and Vale University Health BoardCardiff, UK(Chapters 1, 6, 7, 11, 13)

Rhiannon L. HarriesConsultant Colorectal SurgeonSwansea Bay University Health BoardSwansea, UK(Chapter 3)

Brendan HealyConsultant in Microbiology and Infectious DiseasesPublic Health WalesCardiff, UK(Chapter 9)

Samantha HollowayReaderCardiff University School of MedicineCardiff, UK(Chapter 13)

Steven L.A. JefferyConsultant Burns and Plastic SurgeonRoyal Centre for Defence MedicineBirmingham, UKProfessor of Wound Study Birmingham City UniversityBirmingham, UKHonorary Visiting ProfessorCardiff UniversityCardiff, UK(Chapter 2)

David LeaperEmeritus Professor of SurgeryUniversity of Newcastle upon TyneNewcastle upon Tyne, UK(Chapter 3)

Paul MartinProfessor of Cell BiologySchools of Biochemistry and Physiology, Pharmacology & NeuroscienceUniversity of BristolBristol, UK(Chapter 12)

Duncan A. McGroutherSenior ConsultantDepartment of Hand and Reconstructive MicrosurgerySingHealth Duke‐NUS Academic Medical CentreSingapore(Chapter 12)

Christine Moffatt CBEInternational Professor of Clinical NursingSchool of Social SciencesNottingham Trent UniversityNottingham, UK(Chapter 10)

Girish K. PatelConsultant DermatologistWelsh Institute of DermatologyCardiff and Vale University Health BoardCardiff, UKHonorary ProfessorCardiff University School of BiosciencesCardiff, UK(Chapters 1, 6, 8, 11, 14)

Vincent PiguetProfessor and Department Division DirectorDermatology, Department of MedicineUniversity of TorontoToronto, CanadaDivision HeadDermatologyWomen’s College HospitalToronto, Canada(Chapter 8)

Annie PriceSpecialist Registrar in Rehabilitation MedicineCardiff and Vale University Health BoardCardiff, UK(Chapter 5)

Gregory SchultzEmeritus ProfessorUniversity of FloridaGainesville, FL, USA(Chapter 14)

Melanie Thomas MBENational Clinical Lead for Lymphoedema in WalesLymphoedema Network WalesNHS Wales Health Collaborative, UK(Chapter 10)

Jared TorkingtonConsultant Colorectal SurgeonCardiff and Vale University Health BoardCardiff, UK(Chapter 3)

Foreword

The goal of treating wounds is to achieve healing and prevent secondary wound breakdown. Dressings have been used for thousands of years and several notable medical advances have contributed to better wound care. In the 1800s, Lister demonstrated the benefits of antiseptic surgery in reducing infection risk and throughout the 18th and 19th centuries, debridement techniques were developed and advanced by military surgeons. In the late 1800s, sterilised gauze was mass‐produced as ready‐to‐use surgical dressings. George Winter’s observations in 1962, that wounds kept moist healed faster than those kept dry, led to the development of many new materials and advanced wound dressings. Over the past 60 years, there has been an explosion of treatments and current practice involves the use of dressings, devices, drugs, surgical interventions and biologically based treatments to enhance wound healing.

Although a wide range of materials exists, the major benefits of dressings are in managing exudate, minimising leakage and controlling odour and pain. More recently, there has been a rapid increase in the use of devices, from beds and mattresses that aim to prevent and treat pressure injuries, to therapeutic footwear used in diabetic foot disease and negative‐pressure devices for a range of wound types. Drugs are often needed to assist in wound healing. The most obvious example is the use of antibiotics for treating wound infection. However, at a time when antimicrobial resistance is seen as a global health challenge, greater understanding and appropriate selection of agents to treat wound infection are urgently needed. Surgery is an essential component for some wound healing problems. This can range from simple draining of an abscess or debridement of unhealthy tissue on the wound surface, through to specialist vascular, orthopaedic or reconstructive procedures. Advances in the understanding of wound healing biology have led to an interest in biological therapies, from platelet concentrate to stem cells.

While treatment advances are rapidly expanding the options for wound care, recent studies have revealed that there are ongoing problems with wound assessment and diagnosis. Without understanding the cause of the wound and appreciating factors that contribute to delayed or non‐healing, successful treatment is less likely. An emphasis on clinical assessment coupled with developments in wound diagnostics may help, but there is also a need for greater engagement of medical specialties and their integration with other members of a multidisciplinary team.

Complete healing of a wound is an obvious measure that should be the goal of care when relevant. However, reduction in wound size, pain, leakage and infection, or improvement in quality of life could also be seen as measures of success in patients who do not have the potential to heal their wounds. Similarly, prevention of recurrence, avoidance of complications and provision of care in dedicated settings should be seen as alternative measures of success. There is a need to capture these factors when evaluating both treatments and services.

Though scientific advances and enhancing the evidence base for existing treatments are important, innovations in service provision and education of healthcare professionals in the management of wounds should not be underestimated. The future for individuals with wound problems requires the ability to access a relevant and capable multidisciplinary team that is appropriate for their needs. Comprehensive, appropriate and patient‐centred wound care utilising evidence‐based treatments has the potential to benefit many. It is only in recent years that the complexity of the wound healing process and the wide range of factors that can influence healing have been recognised. Greater funding and focus on this subject are essential if the current situation is to be improved.

This new edition of the ABC of Wound Healing aims to take the reader through these issues and provide a ready guide to the recognition, investigation and management of a variety of wound types. It is aimed at ensuring that individuals with wounds receive the standard of care appropriate for modern‐day clinical practice.

Professor Keith G. Harding CBE

CHAPTER 1 Wound Assessment

Joseph E. Grey1 and Girish K. Patel2,3

1 Department of Clinical Gerontology, Cardiff and Vale University Health Board, Cardiff, UK

2 Welsh Institute of Dermatology, Cardiff and Vale University Health Board, Cardiff, UK

3 Cardiff University School of Biosciences, Cardiff, UK

OVERVIEW

Most wounds heal without difficulty, but all wounds have the potential to become chronic.

The key to successful wound management is diagnosis and treatment of the underlying cause, which requires a detailed history and assessment.

Certain wound characteristics point to a specific diagnosis and indicate the status of the wound, e.g. infected or clean, healing or non‐healing.

Many local and systemic factors may impede healing; these should be identified and corrected where possible.

Despite best practice, a small minority of wounds will never heal; improving quality of life and preventing complications are the treatment goals in these cases.

The majority of wounds, of whatever aetiology, heal without difficulties (see Chapters 2–4). Some wounds, however, are subject to factors that impede but do not prevent healing if managed appropriately. In contrast, most common chronic wounds do not heal until the underlying disease is adequately treated (see Chapters 5–8). A minority of wounds do not heal despite best practice, where control of symptoms and prevention of complications, rather than healing, become the goals of treatment.

Complications of chronic wounds

Sinus formation

Fistula

Unrecognised malignancy

Malignant transformation in the ulcer bed (Marjolin ulcer)

Osteomyelitis

Contractures and deformity in surrounding joints

Systemic amyloidosis

Heterotopic calcification

Colonisation by multiple drug‐resistant pathogens leading to antibiotic resistance

Anaemia

Septicaemia

Approach to patients with wounds

In patients with wounds, it is important that the normal processes of developing a diagnostic hypothesis are followed before attempting to treat the wound. A detailed clinical history should be taken, along with an examination of the wound, surrounding skin and (where relevant) the limb, and any appropriate investigations should be performed. Seek to define the cause of the wound and factors that might impede healing. In order to aid management, regular wound assessments are used to monitor progress.

A systematic approach to wound assessment is helpful. The following factors should be considered as part of every wound assessment.

Site of the wound

The site of the wound may aid diagnosis; diabetic foot ulcers often arise in areas of abnormal pressure distribution caused by disordered foot architecture. Venous ulcers mostly occur in the gaiter area of the leg. Non‐healing ulcers, sometimes in unusual sites, should prompt consideration of malignancy.

Size of the wound

This should be assessed at first presentation and regularly thereafter to monitor response to treatment and provide an indication of healing. The simplest method is using a ruler to measure wound dimensions (longest length and perpendicular width). Wound surface area can be measured using an acetate tracing; the outline of the wound margin is traced onto transparent acetate sheets marked with 1 cm squares and the longest diameter in one plane is multiplied by the longest diameter in the perpendicular plane (for approximately circular wounds) or the number of squares contained within the wound outline are added together (for irregularly shaped wounds). These methods are relatively subjective and can be unreliable; accuracy is also affected by patient positioning, body curvature or tapering of the limbs. More sophisticated methods include using digitised area measurement software or laser techniques, but these require training and specialist equipment. Clinical photography should be carried out whenever possible.

Common types of chronic wounds. (a) Venous leg ulcer. (b) Pressure injury. (c) Post‐operative wound dehiscence. (d) Diabetic foot ulcer.

Causes of ulceration.

Vascular (venous, arterial, lymphatic, vasculitis)

Neuropathic (e.g. diabetes, spina bifida, leprosy)

Metabolic (e.g. diabetes, gout)

Connective tissue disease (e.g. rheumatoid arthritis, scleroderma, systemic lupus erythematosus)

Pyoderma gangrenosum (often a reflection of systemic disorder)

Haematological disease (red blood cell disorders, e.g. sickle cell disease; white blood cell disorders, e.g. leukaemia; platelet disorders, e.g. thrombocytosis)

Dysproteinaemias (e.g. cryoglobulinaemia, amyloidosis)

Immunodeficiency (e.g. HIV, immunosuppressive therapy)

Neoplastic (e.g. basal cell carcinoma, squamous cell carcinoma, metastatic disease)

Infectious (bacterial, fungal, viral)

Panniculitis (e.g. necrobiosis lipoidica)