This article is intended to provide readers with a simple overview to wound care and a general understanding of related terms. I am a licensed Physical Therapist Assistant who spent time training in wound care as it relates to that specific healthcare discipline. Physical therapy’s role continues to expand when it comes to wound observation, treatment, and patient education. Much of this information will be valuable to “preppers” due to the assumed lack of easy access to medical care. It will hopefully give readers confidence in recognizing and treating certain common wound types and provide a better idea of what types of first aid dressings to purchase. Wounds improperly treated can be detrimental to one’s overall health – affecting all other systems within the body in addition to the first observed damage to the integumentary system.
Note: For this piece, burns will be considered separate from other wound types for clarity
of explanation.
The first thing to consider when observing the wound is the phase of healing. This will determine the most important steps to take. There are three overlapping phases. Immediately after a wound occurs, our bodies initiate the inflammatory phase, lasting roughly from day 1 to day 10. This stage is characterized by the five cardinal signs of inflammation (tumor/swelling, rubor/redness, calor/warmth, dolar/pain, and functio/loss of function). As these cardinal signs begin to subside, the body will enter the proliferative phase (from 3 to 21 days). Here, formation of new tissue, called granulation tissue, begins. Capillaries, or blood vessel endings, start to bud and fill the wound bed. They create a positive environment for the development of epithelial cells that will become the new epidermis, or outermost layer of skin. Finally, we have the maturation phase. This phase can last anywhere from 7 days after the injury to 2 years post-injury. The differentiation of cell types is observable through the formation of a scar, originally immature, raised, and red. Later, the scar will be distinguishable by a pale, flattened, pliable surface. A mature scar typically possess 75-80% of the strength seen in the original tissue. Keloid or hypertrophic scarring may also occur, meaning the skin remains raised due to excessive collagen lysis (formation).
Occasionally, wounds are unable to follow this three-step process independently. A wound may require assistance to heal by “intention.” Primary intention is frequently seen if minimal tissue loss has occurred. The wound is properly cleaned, then smooth edges are either stitched, stapled, or adhered with wound glue to facilitate healing. This process is considered uncomplicated and typically results in a clean, quick progression.
Secondary intention refers to allowing a wound to close on its own through the body’s natural healing process, but this may require regular inspection, cleaning, wrapping, etc.
Lastly, tertiary intention. This is also considered delayed primary intention healing. A wound may be intentionally left open to delay progression in the instance of impaired vascular supply or infection.
Next, let’s consider the types of wounds we may encounter with a few short definitions.
Starting with acute wounds:
Abrasion – a scrape where the superficial skin has been rubbed or torn off. It is caused by a combination of friction and shear forces, typically over a rough surface.
Avulsion – This is also referred to as a “de-gloving.” It is a serious wound that causes the skin to be detached from underlying structures.
Incisional wound – Usually associated with surgeries, this is created via a sharp object (such as scissors or a scalpel).
Laceration – This can be considered either a wound or an irregular tear of tissues resulting from trauma. The characteristics of a laceration depend on the mechanism of injury; shear, tension, or high-force compression.
Penetrating – This wound enters the interior of an organ or cavity through various mechanisms.
Puncture – Occurs when a sharp, pointed object penetrates the skin and underlying tissues. Risks of contamination and resulting infection are possible, but there is typically little damage beyond the immediate area of the injury.
Skin tear – When fragile skin experiences trauma from bumping into an object, adhesive removal, shear, or friction forces, a skin tear may occur. This can range from a flap-like tear with either viable or non-viable tissue, or full-thickness tissue loss.
Next up, ulcers:
Arterial insufficiency – When blood flow is diminished or blocked, ischemia can result in distal areas of the body, primarily in the lower extremities. These ulcers are frequently found near the lateral malleolus (bony prominence on the outer side of the ankle). They may appear as a hole-punch shape, with minimal swelling and drainage. The surrounding area is shiny, light in color, and hairless. Recommendations include rest, limb protection, and avoiding unnecessary elevation of the leg. This will greatly increase pain and result in further loss of blood to the affected area. Use of heating pads or soaking the lower limb in hot water may be beneficial in managing symptoms. Continuing to move the leg is especially important to increase the blood moving all the way through the limb.
*Note: if the individual is experiencing congestive heart failure, use of heat and exercise may be contraindicated due to the excessive strain they place upon the heart.
Venous insufficiency – Our veins contain tiny valves within them that help push blood back to the heart, against the force of gravity. When these valves malfunction, venous insufficiency, leading to venous ulcers, may occur. These wounds are most often located near the medial malleolus (bony prominence on the inside of the ankles). The wound appears irregular in shape and usually has excessive drainage. The surrounding skin frequently turns a brownish tint. Limb protection is also very important with these ulcers. Compression to control swelling, elevation to promote blood return, and regular exercise/walking are all beneficial.
*Note: compression is contraindicated if venous swelling has occurred secondary to congestive heart failure.
Neuropathic – These appear primarily on weight-bearing areas of the body, specifically the bottoms of the feet. When individuals with decreased sensation (often from diabetes and / or peripheral neuropathy) fail to detect and respond to prolonged stimuli to that region, a neuropathic ulcer may result. People at-risk for these should be sure to wear correctly fitting shoes and seamless socks. Limb protection and inspection is needed.
Pressure (also called decubitus ulcers) – These result from sustained pressure on tissues that exceeds the pressure within capillaries. Bony prominences are especially at risk for localized ischemia and necrosis. Frequently, these begin to appear as a deep purple bruise or blister underneath intact skin. The outer layer of skin then opens to reveal deeper levels of damage. Prevention is key through re-positioning at a minimum of every two hours, management of excess moisture near the wound, and limiting of friction forces over fragile skin.
Pressure wounds are classified differently than most other wounds. They are considered one of the following:
Stage 1- Non-blanchable erythema (redness) of intact skin.
Stage 2 – Partial-thickness skin loss with exposed dermis (second layer of skin).
Stage 3 – Full thickness skin loss, often with epibole (rolled edges), slough, and tunneling. Muscle, tendon, ligament, and bone may be exposed.
Stage 4 – Full-thickness skin and tissue loss with exposed and directly palpable muscle, ligaments, tendons, bone, etc.
Unstagable – Wound is obscured by slough or eschar (non-viable “dead” tissue).
Deep tissue pressure injury – Persistent non-blanchable deep red or purple discoloration.
Other common wounds are also classified by the depth of tissue they affect:
Superficial – Trauma caused to the skin with the epidermis remaining intact. This could be considered a non-blistering sunburn and it typically heals quickly during the inflammatory phase.
Partial-thickness – These extend past the epidermis and into, but not through the dermis. Blisters, abrasions, and skin tears are examples. Re-epithelialization will usually be the common mode of healing, however deeper wounds may require additional care.
Full-thickness – A full-thickness wound extends past the dermis and into the subcutaneous fat, the deepest layer of our skin. These are often deeper than 4 millimters, but this may vary by anatomical location. Secondary intention is the most common method of healing.
Subcutaneous – Very deep structures such as subcutaneous fat, muscle, tendon, or bone will be impacted. Secondary intention remains the most common method of healing.
Next, let us consider some common characteristics of wounds – as this also determines how to best approach them. Exudate (drainage) is seen in numerous wound types, but the appearance and its meaning greatly vary. Serous exudate is very common and considered a normal part of a healthy, properly healing wound in the inflammatory or proliferative phase. It is either clear or very light in color with a watery consistency. Sanguineous is similar, but presents with a tinge of red. This is either due to blood vessel growth or the disruption of otherwise viable blood vessels in or around the wound.
Next, serosanguineous has a light red or pink coloring. It is also considered healthy in healing wounds if found during the inflammatory or proliferative phases. A few types of exudate are considered problematic, however. One such type is seropurulent. This tends to be cloudy or opaque, with yellow or tan coloring. Consistency remains thin, watery. This is an early warning sign of potential infection. Lastly, we have purulent exudate. This is thick and viscous and frequently has a yellow or green color. Always abnormal to see, it is a prime indicator of an infected wound site.
(To be concluded tomorrow, in Part 2.)