8. ABNORMAL WOUND HEALING
Failure to progress through normal orderly
stages of wound healing.
Chronicity typically defined by failure to progress
normally over a 30 day period.
Most common “hangup” appears to be in the
inflammatory phase.
Visually; inadequate granulation, persistent or
excessive exudate, deficient wound contraction
and/or absence of neo-epithelialization.
8
13. A GOOD H & P
Past Medical History
Past Surgical History
Past Wounding History; location, timing,
treatment
Medications
Family History
Review of Systems
Thorough Exam
14. GENERAL APPEARANCE
Cushingoid (puffy) appearance
Rheumatoid joints
Cachexia
Scleroderma face
Abnormal affect and behavior
Focal neurologic deficit
Tobacco
15. DIABETES MELLITUS
20.8 mil (7% of pop.) 6.2 mil undiagnosed!
800,000 new cases per year (120,000 DFU’s)
Lifetime risk of ulceration 15%
Complex multifactorial effect of DM on micro and
macro-vascular complications
Reduced flexibility and resistance of tissues to
tensile compression and shear forces
Strong evidence through DCCS and UKPDS that
tight control delays onset of both primary and
secondary complications
15
16. NEUROPATHY
MOTOR
Anterior tibial weakness
Pedal muscle atrophy
Fat pad atrophy
Digital instability and
deformities
Increased peak pressures
due to deformities
Ulcerations over
deformities
16
17. NEUROPATHY
SENSORY
Diabetic sensory
polyneuropathy
Peri-nerve edema
Increased wounding risk
due to loss of protective
sensation (L.O.P.S.)
Unable to feel pressure or
pain over prominences or
with trauma
17
18. NEUROPATHY
AUTONOMIC
Faulty sweat gland
activity
Dry, fissured skin leads to
infection and ulceration
Uncontrolled
vasodilatation due to
decreased arteriolar tone
18
19. RHEUMATOID DISEASE
Systemic autoimmune disorder of unknown etiol.
Leg ulcerations in 8 – 9% of patients
Ulcer is smooth, irregularly shaped and painful
Felty’s Syndrome; Combination of RA,
splenomegaly, granulocytopenia and leg ulcers
Systemic Treatment: High dose steroids,
cyclophosphamide, Dapsone, disease modifying
agents
Wound treatment: Standard wound care,
bioengineered skin
21. SYSTEMIC LUPUS (SLE)
Systemic autoimmune disease of unknown etiology
Incidence of leg ulcers 2 – 8%
Ulcers typically over pre-tibial areas and extremely
painful
Characterized by well defined wound margins, purulent
bed and varying amount of granulation
Surrounding skin may be normal or erythematous with
evidence of atrophie blanche
Treatment is challenging; topical retinoic acid,
intralesional steroids
23. SCLERODERMA
Autoimmune disorder
of unknown etiology
Ulcers usually over
digits and bony prom.
Epithelialization
usually difficult
C.R.E.S.T. Syndrome
Occlusive dressings
23
24. RAYNAUDS
Intermittent, severe
ischemia of fingers/toes
May be precipitated by
cold or localized trauma
Sympathetic mediation
Soft tissue atrophy and
non-healing ulcerations
Vasodilators, platelet
agents, Pentoxyfilene,
24 PD-5’s, nitrates
25. VASCULITIS
Inflammation of blood
vessel of ? Etiology
Male = Female
Prevalent in elderly
Flat, red nodules
macules or purpura
Lesions frequently
ulcerate and are
difficult to heal
25
26. FACTOR V LEYDEN
Protein C resistance
Increased risk of
thrombosis, venous >
arterial
Progressive
thrombotic occlusion
leads to poor blood
supply and wounding
Difficult to heal
26
27. RENAL FAILURE
Foot ulceration 5x higher
in stage 4 & 5 CKD
2x higher prevalence of
amputation, PAD,
neuropathy
Dialysis is independent
risk factor for ulceration
Multifactorial proposed
etiologies
27
28. PROTEIN ENERGY MALNUTRITION
Rapid and insidious onset
Populations at risk – elderly and poor
Albumin, fibrinogen and globulin all important
Indices: albumin, transferrin, TLC, pre-albumin
Hyperglycemia delays wound healing
Variety of supplements available
B & C vits: immunity, inflammation and collagen
D,E,A,K vits: clotting, healing and anti-oxidants
Fe, Zn, Cu: small amounts but critical
28
31. CHEMOTHERAPY
49 pts with stage II – III breast cancer received 3
drug chemo with vinorelbine, cisplatin and 5-FU
for up to 6 cycles and up to 30 minutes pre-op.
No wound infections or delays in healing noted
Colleoni, et al, 2003
100 pts treated with multi-agent platinum based
chemo following surgery for ovarian ca had no
increase (11%) in wound complications
compared to those receiving no chemo
Kolb, et al, 1992
31
32. CHEMOTHERAPY
Bevacizumab (Avastin) - Monoclonal antibody
against VEGF inhibits angiogenesis in tumor and
healthy tissue alike
Cetuximab (Erbitux) - Monoclonal antibody
against EGFR. Led to slightly prolonged
hospital stays and drain removals
Harari, et al, 2003
32
33. RADIATION THERAPY
Impairs vascularity
and depletes cell lines Hypoxic
Impacts all phases of
wound healing
Progressive over time
Good response to
HBOT Hypovascular Hypocellular
Radiation Proctitis
Clark, Cone et al, 2008
33
35. PYODERMA GANGRENOSUM
Non-infectious
neutrophilic dermatosis
Painful ulcers of varying
depth and size
Violaceous borders
Most commonly
associated with
underlying disease
Pathergy !
35
36. FACTITIOUS DISORDER
Accompanies various
psychiatric disorders
Lesions in various
stages of healing
Usually sharp borders
Tend to be in
accessible areas,
usually sparing mid-
back
36
38. SMOKING
Impairs wound healing via
local hypoxia, endothelial
and vasomotor dysfunction,
atherosclerosis, platelet
activation and inhibition of
collagen synthesis
Increased risk of post-op
infection and wound rupture
compared to non-smokers
38