All topics are updated as new evidence becomes available and our peer review process is

complete.
Literature review current through: Apr 2017. | This topic last updated: Sep 19, 2016.

INTRODUCTION Competent fracture care requires a basic knowledge of bone biology

and healing, a systematic approach to fracture evaluation and description, and a practical
understanding of basic splinting and casting techniques. The general principles of bone
healing and proper fracture description will be reviewed here. Fractures that are
complicated, high risk, or unresponsive to appropriate conservative management should
be promptly referred to an orthopedic surgeon

For information on specific fractures, please see the relevant topic reviews. Stress
fractures and pediatric fractures are reviewed separately. (See "Overview of stress
fractures" and "General principles of fracture management: Fracture patterns and
description in children".)

BIOLOGY OF BONE HEALING Bone is a composite structure with mineral and organic
components. The mineral component contains calcium, phosphate, and hydroxyl ions
which are organized into a compound called hydroxyapatite (Ca5(PO4)3(OH)). This
mineral skeleton provides the strength, stiffness, and rigidity characteristic of bone. The
organic or protein component consists primarily of type I collagen, which lends tensile
strength and resiliency. The outer covering of bone, the periosteum, provides the vascular
supply that plays an essential role in fracture healing. The periosteum in children is
substantially thicker and more robust than in adults, accounting in part for the more rapid
healing of pediatric fractures [1,2]. (See "Normal skeletal development and regulation of
bone formation and resorption".)

Bone healing is usually divided into three slightly overlapping stages: inflammatory,
reparative, and remodeling [2-7]. It is difficult to provide an approximate time frame for
each phase because healing rates vary widely according to age and comorbidities. As an
example, a simple toe fracture in a healthy young child may heal completely in four weeks
while the same fracture in a 65 year old smoker may not heal completely for several years.

The initial inflammatory phase is dominated by vascular events. Following a fracture, a

hematoma forms which provides the building blocks for healing. Subsequently,
reabsorption occurs of the 1 to 2 mm of bone at the fracture edges that have lost their
blood supply. It is this bone reabsorption that makes fracture lines become
radiographically distinct 5 to 10 days after injury. Next, multipotent cells are transformed
into osteoprogenitor cells, which begin to form new bone.

In the reparative phase, new blood vessels develop from outside the bone that supplies
nutrients to the cartilage, which begins to form across the fracture site. Nearly complete
immobilization is desirable during both the inflammatory phase and the early reparative
phase to allow for the growth of these new vessels. However, once neovascularization is
complete, progressive loading and stress across the fracture site are desirable to augment
callus formation.

Callus typically forms as a collar of new, endochondral bone around the fractured area.
This callus is initially highly cartilaginous, but hardens as mineralization and endochondral
calcification occur during the remodeling phase. Late in the reparative phase, clinical union
of the fracture occurs. Clinical union occurs when the fractured bone does not shift on
clinical examination, the fracture site is nontender, and the patient can use the injured limb
without significant pain. Because the initial callus is cartilaginous, clinical union may occur
before evidence of radiographic union is appreciable on radiographs. Clinical union
classically marks the end of the reparative phase of fracture healing.

In the remodeling phase, the endochondral callus becomes completely ossified and the
bone undergoes structural remodeling. The process of remodeling occurs quickly in young
children, who remodel their entire skeleton every year. By late childhood, the rate of
skeletal remodeling is approximately 10 percent per year and continues near this level
throughout life [8].

In addition to patient age, other factors affecting the rate of bone remodeling include
thyroid and growth hormone levels, calcitonin, glucocorticoids, and nutritional status [3,9].
Common conditions that impair fracture healing include diabetes mellitus, arteriovascular
disease, anemia, hypothyroidism, malnutrition (eg, vitamin C or D deficiencies, inadequate
protein intake), excessive chronic alcohol use, and tobacco use. Specific medications may
also impair fracture healing, including nonsteroidal antiinflammatory drugs, glucocorticoids,
and certain antibiotics (eg, ciprofloxacin). (See "Bone disease with hyperthyroidism and
thyroid hormone therapy" and "Bone disease in diabetes mellitus" and "Vitamin
supplementation in disease prevention" and "Osteoporotic fracture risk
assessment" and "Pathogenesis, clinical features, and evaluation of glucocorticoid-
induced osteoporosis" and "Nonselective NSAIDs: Overview of adverse effects", section
on 'Possible effect on fracture healing'.)

FRACTURE DESCRIPTION

Overview The essential first step of fracture treatment is to precisely identify the type of
fracture present. At a minimum, a fracture should be identified using the following:

Name of the injured bone

Location of the injury (eg, dorsal or volar; metaphysis, diaphysis, or epiphysis)
Orientation of the fracture (eg, transverse, oblique, spiral)
Condition of the overlying tissues (eg, open or closed fracture).

Other important descriptors include fracture angulation, comminution, and displacement.

Each aspect of fracture description is discussed below and diagrams depicting common
fracture types are provided (figure 1 and figure 2).
Fractures are described based upon the radiographs obtained. A table describing the most
common radiographic views according to injury location is provided (table 1). See the topic
reviews dealing with specific fractures for additional information about the radiographs
needed for these injuries.

Location: bone and aspect Proper fracture description begins with precise
identification of the injured bone. Lay terminology such as "finger" or "wrist" should be
avoided; precise anatomic terms, such as "proximal phalanx" or "scaphoid" should be
used.

Once the fractured bone is identified, the aspect of the injury is described using precise
anatomic terms (figure 3). "Medial" and "lateral" are such common and precise descriptors.
With hand and forearm fractures, the descriptors "radial" and "ulnar" are used instead of
medial and lateral, and "dorsal" and "palmar" are used instead of anterior and posterior.

Long bone fractures should be described using the involved regions of the bone:
metaphysis, diaphysis, or epiphysis (figure 1). Diaphyseal fractures are further
characterized as involving the proximal, middle, or distal third of the bone, or the junction
between two of these regions.

Fractures that extend into a joint space are referred to as "intra-articular." Intraarticular
fractures are generally more serious injuries and commonly require surgery since optimal
healing requires precise anatomic reduction. Intraarticular fractures are characterized by
the percentage of the joint space they disrupt. As an example, a fracture of the distal
interphalangeal joint where one third of the affected bone is displaced is described as
involving 30 percent of the joint space.

Some fractures are associated with unique names that are more easily identifiable and
descriptive than the traditional anatomic approach. For instance, a "supracondylar
fracture" is more recognizable, descriptive, and concise than a "fracture of the distal
humerus at the metaphyseal-diaphyseal junction." A table listing several of these common
fractures is provided (table 2).

The Salter-Harris classification scheme is used to describe fractures involving the growth
plate (figure 4). The risk of complications involving the growth plate increases in parallel
with the Salter-Harris type (ie, type I fractures are at low risk and type V are at greatest).
(See "General principles of fracture management: Fracture patterns and description in
children".)

Orientation: Transverse, oblique, and spiral A fracture line may have one of three
possible orientations: transverse, oblique, or spiral (figure 2). Transverse fracture lines
travel perpendicular to the long axis of the bone. Typically caused by a direct force causing
the bone to bend, fractures with a transverse orientation are the most common fracture
type.
Oblique and spiral fractures run diagonally down the long axis of a bone. Oblique fracture
lines are typically shorter than those of spiral fractures, and result from twisting or rotary
forces. Long oblique fractures may easily be mistaken for spiral fractures. In a true spiral
fracture, a severe rotary force causes the bone to splinter, disrupting the bone in a
characteristic pattern that involves a fracture line that travels in two different oblique
directions (image 1 and image 2).

Displacement and angulation Angulated or displaced fractures result in the loss of

normal anatomic alignment. These fracture types commonly result in more severe soft
tissue injuries than nondisplaced fractures. By convention, any fracture malalignment is
described by referring to movement of the distal fragment relative to the proximal bone.

Displacement describes movement when two ends of a fracture move away from each
other in an anterior-posterior plane or a medial-lateral plane. It can be quantified by the
percentage of bone that is malaligned. For instance, a femur fracture where only 25
percent of the fracture surfaces remain in contact might be described as "75 percent
medially displaced." Displacement can also be quantified in millimeters of displacement.
Special cases of displacement occur when fracture ends are crushed together
("impacted") or pulled apart ("distracted").

Angulation refers to motion relative to the long axis of the bone. When describing
angulation, both the direction and the degree (ie, angle formed by the major bone
fragments) of malformation are important. The direction of angulation is best
communicated by identifying the orientation of the fracture apex. In other words, the
fracture fragments will form a V shape, and the apex is the point of the V. The direction of
the apex is used to describe the fracture. The amount of angulation is typically reported in
degrees.

Fractures with multiple parts

Comminution versus segmentation Fractures that create more than two fracture
fragments from the same bone are called comminuted (figure 2). Recognizing
comminution has important implications since many comminuted fractures require surgical
treatment. The degree of comminution is directly proportional to the force of injury;
comminuted fractures are associated with more severe soft tissue injuries.

Segmental fractures occur when two fracture lines divide the bone into three or more large
pieces. Segmental fractures are associated with poorer outcomes, the need for surgical
fixation, and significant accompanying soft tissue injury.

Compression and impaction Compression and impaction describe fractures when

bones or fragments are driven into one another. Compression fractures occur in vertebral
bodies and lead to a collapse of the endplates. Impacted fractures occur when forces
exerted down the length of a long bone drive one fracture fragment into the other,
"telescoping" them.
Open versus closed fractures Open fractures are those in contact with the outside
environment (ie, open to air), and represent orthopedic emergencies requiring immediate
irrigation and debridement in the operating room and treatment with intravenous
antibiotics. This decreases the risk of osteomyelitis and other infectious complications. In
addition to infection, open fractures are associated with higher rates of compartment
syndrome, neurovascular injury, and other soft tissue injuries compared with closed
fractures.

Sometimes open fractures are obvious, as the bone can be seen protruding through the
skin. More often, skin covers the involved bone, leaving a small skin laceration or puncture
wound as the only sign. A careful examination of the wound is necessary.

Of note, hand surgeons generally do not consider minor fractures of the distal phalanx with
small adjacent lacerations or nailbed injuries to be open fractures requiring emergent
treatment, even though they may technically meet the definition of an open fracture.

The severity of open fractures may be classified using the following system [10]:

Type 1 Puncture wound (1 cm) with minimal contamination and minimal muscle
injury.
Type 2 Laceration (>1 cm) with moderate soft tissue damage.
Type 3 Extensive soft tissue damage with severe crush injury of muscle and
massive contamination, including comminuted bone fragments (type 3A), periosteal
stripping (type 3B), or arterial injury requiring repair (type 3C).

PRECISE "RADIOGRAPHIC" DESCRIPTION Using the framework presented above,

the clinician can convey a complete verbal snapshot of a fracture using few words. For
providers with less experience managing orthopedic injuries, a simple Fracture Description
Tool can be helpful to practice describing fractures or to make sure terminology is accurate
before calling a consultant (figure 5). To use the tool, choose a word provided for each
italicized category. The sentences produced should completely and precisely describe the
fracture.

SUMMARY AND RECOMMENDATIONS

Bone is a composite structure with mineral and organic components. The mineral
skeleton provides strength, stiffness, and rigidity. The organic or protein component
consists primarily of type I collagen, which lends tensile strength and resiliency. The
outer covering of bone, the periosteum, provides the vascular supply that plays an
essential role in fracture healing. (See 'Biology of bone healing' above.)
Following fracture, bone healing occurs in three slightly overlapping stages:
inflammatory, reparative, and remodeling. Each phase is described in the text.
Healing rates vary widely according to patient age, comorbidities, and other factors
such as thyroid and growth hormone levels, calcitonin levels, and nutritional status.
 Common conditions that impair fracture healing include diabetes mellitus,
arteriovascular disease, anemia, hypothyroidism, malnutrition (eg, vitamin C or D
deficiencies, inadequate protein intake), excessive chronic alcohol use, and tobacco
use. Specific medications may also impair fracture healing, including nonsteroidal
antiinflammatory drugs, glucocorticoids, and certain antibiotics (eg, ciprofloxacin).
The essential first step of fracture treatment is to identify precisely the type of
fracture present. At a minimum, a fracture should be identified using the following:
Name of the injured bone
Location of the injury (eg, dorsal or volar; metaphysis, diaphysis, or epiphysis)
Orientation of the fracture (eg, transverse, oblique, spiral)
Condition of the overlying tissues (eg, open or closed fracture)

Other important descriptors include fracture angulation, comminution, and

displacement. Each aspect of fracture description is discussed in the text;
diagrams depicting common fracture types are provided (figure 1 and figure 2).
(See 'Fracture description' above.)
Open fractures are those in contact with the outside environment (ie, open to air),
and represent orthopedic emergencies requiring, in the large majority of cases,
immediate irrigation and debridement in the operating room and treatment with
intravenous antibiotics. (See 'Open versus closed fractures' above.)

ACKNOWLEDGMENT The editorial staff at UpToDate would like to acknowledge Mark

B Stephens, MD, who contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Eiff MP, Hatch RL. Fracutre Management for Primary Care, 3rd, Elsevier Saunders,
Philadelphia 2012. p.26.
2. Wilkins KE. Principles of fracture remodeling in children. Injury 2005; 36 Suppl 1:A3.
3. Jones ET. Skeletal growth and development as related to trauma. In: Skeletal Trauma in
Children, 3rd, Green NE, Swiontkowski MF. (Eds), Saunders, Philadelphia 2003. p.6.
4. McGowan HJ. Sports Medicine Reource Manual, 1st, Seidenberg P, Beutler AL. (Eds),
Saunders, Philadelphia 2007. p.147.
5. Macmahon P, Eustace SJ. General principles. Semin Musculoskelet Radiol 2006; 10:243.
6. Tsiridis E, Upadhyay N, Giannoudis P. Molecular aspects of fracture healing: which are the
important molecules? Injury 2007; 38 Suppl 1:S11.
7. Dimitriou R, Tsiridis E, Giannoudis PV. Current concepts of molecular aspects of bone
healing. Injury 2005; 36:1392.
8. Buckwalter JA, Glimcher MJ, Cooper RR, Recker R. Bone biology. I: Structure, blood
supply, cells, matrix, and mineralization. Instr Course Lect 1996; 45:371.
9. Gaston MS, Simpson AH. Inhibition of fracture healing. J Bone Joint Surg Br 2007;
89:1553.
10. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe)
open fractures: a new classification of type III open fractures. J Trauma 1984; 24:742.
Topic 220 Version 11.0

General principles of fracture management: Early and late complications

Author:
Allyson S Howe, MD, FAAFP, CAQ Sports Medicine
Section Editors:
Patrice Eiff, MD
Chad A Asplund, MD, FACSM, MPH
Deputy Editor:
Jonathan Grayzel, MD, FAAEM

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Apr 2017. | This topic last updated: Feb 23, 2017.

INTRODUCTION Fractures are associated with a range of potential complications.

Acute complications occur as a direct result of the trauma sustained and can include
damage to vascular structures, nerves, or soft tissue. Delayed complications may occur
after initial treatment or in response to treatment. Therefore, reevaluation at regular
intervals during healing is prudent in most cases.

Major acute and long-term complications of fractures are described here. The
management of specific fractures and some specific complications are discussed in detail
separately. (See "Acute compartment syndrome of the extremities" and "Treatment and
prevention of osteomyelitis following trauma in adults" and "Clinical presentation and
diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower
extremity".)

LIFE-THREATENING CONDITIONS Certain fractures can cause severe hemorrhage

or predispose to other life-threatening complications. Femur fractures that disrupt the
femoral artery or its branches are potentially fatal [1]. Pelvic fractures can damage pelvic
arteries or veins causing life-threatening hemorrhage; the more displaced the pelvic
fracture, the greater the potential blood loss [2]. Hip fractures, particularly in the elderly,
may prevent ambulation, resulting in potentially life-threatening complications, such as
pneumonia, thromboembolic disease, and possibly rhabdomyolysis, if there is a prolonged
period of immobility. Patients with multiple rib fractures are at substantial risk for
pulmonary contusion and related complications. (See "Midshaft femur fractures in
adults" and "Pelvic trauma: Initial evaluation and management" and "Hip fractures in
adults" and "Initial evaluation and management of rib fractures".)

ACUTE COMPLICATIONS
Arterial injury Proper fracture healing requires adequate blood supply to the injured
site. However, fractures can involve sharp bone fragments that injure adjacent arteries,
causing hemorrhage and possibly disruption of distal blood supply to a limb, and
potentially impairing bone healing. Certain fractures are associated with particular arterial
injuries (table 1) [3]. In all cases, the distal and proximal pulses of any fractured extremity
should be examined to determine the adequacy of arterial flow. Immediate reduction and
immobilization is required for any fracture associated with neurovascular compromise. A
detailed examination of the extremity should be documented at the initial presentation so
that changes in the neurovascular status can be recognized.

In cases of high-velocity trauma, angiography may be needed to define vascular injury, as

the presence of distal pulses does not always indicate intact proximal arteries. Signs of
disrupted arterial flow may include a cool extremity, mottled skin color, and loss of
sensation. (See "Overview of acute arterial occlusion of the extremities (acute limb
ischemia)", section on 'Clinical presentations'.)

Arterial disruption can occur with fractures in the region of the elbow or knee. Fractures
around the elbow without distal pulses but with a warm hand demonstrating good capillary
refill warrant orthopedic consultation but can generally be observed. Conversely, fractures
around the knee without distal palpable pulses are considered a surgical emergency and
the surrounding vascular anatomy should be evaluated emergently with diagnostic
imaging.

Nerve injury Nerves are susceptible to damage from fracture fragments acutely but
can also be injured during treatment from complications of casting or by excessive callus
formation. (See "Overview of upper extremity peripheral nerve syndromes", section on
'Compression' and "Overview of upper extremity peripheral nerve syndromes", section on
'Transection' and "Overview of lower extremity peripheral nerve syndromes", section on
'Compression' and "Overview of lower extremity peripheral nerve syndromes", section on
'Transection'.)

Certain nerves are particularly susceptible to injury because of their proximity to common
fracture sites (table 1). As an example, the median nerve is often injured in association
with distal radius fractures. The reported incidence of this complication is up to 17 percent
[4]. The mechanism for median nerve injury can involve stretching of the nerve due to
fracture fragment displacement, or possibly swelling around the distal radius or excessive
wrist flexion of the cast, both of which increase pressure within the carpal tunnel [5].
Humeral shaft fractures are commonly associated with radial nerve injury, manifested by
loss of the ability to extend the wrist and fingers. This can be seen on presentation or after
splinting. Most often, no intervention other than observation is necessary and the injury
eventually resolves with time. (See "Distal radius fractures in adults" and "Midshaft
humeral fractures in adults", section on 'Radial nerve injury'.)
With any extremity fracture, sensory and motor function should be examined at the time of
presentation. Pain often limits the initial evaluation and adequate analgesia must be
provided. Immediate reduction and immobilization is required for any fracture associated
with neurovascular or skin compromise.

Complete or partial nerve transection, or excessive nerve stretch or compression, from

fracture fragments or the force of the initial trauma can lead to chronic nerve injury. Nerve
injury that is not present initially but presents after immobilization can be caused by
excessive pressure from the cast or splint, or from stretching of the nerve from abnormal
positioning during immobilization. Generally, such delayed injuries result in neurapraxia, in
that the nerve fibers are not permanently damaged, but physiologically the nerve signal is
interrupted. Transient neurapraxia generally resolves by two to three months with proper
treatment, which includes ensuring that the nerve is allowed to heal without stretching or
prolonged compression [6]. Reexamination following immobilization to characterize any
residual deficits is essential and should be documented.

Compartment syndrome The muscle groups of human limbs are divided into sections,
or compartments, formed by strong, potentially unyielding, fascial membranes. Acute
compartment syndrome (ACS) occurs when increased pressure within a compartment
compromises the circulation and function of tissues within that space. With fractures,
bleeding or swelling within a fascial compartment creates the increased pressure. ACS is
discussed in detail separately. (See "Acute compartment syndrome of the extremities".)

Long bone fractures are the injuries most commonly associated with ACS, particularly
fractures of the tibia, distal radius, supracondylar area of the humerus, and occasionally
the femur (table 2). In addition to excessive intracompartmental fluid, ACS can also be
caused by casts or bandaging that limits the space available for soft tissue swelling.

Early recognition of ACS and immediate fasciotomy may be limb sparing. Early symptoms
and signs can include pain out of proportion to the apparent injury, persistent deep ache or
burning pain, paresthesias, and pain with passive stretching of muscles in the affected
compartment. When ACS is recognized, any circumferential cast, splint, or bandage
should be loosened or cut to decrease the intracompartmental pressure, and orthopedic
surgery consultation obtained immediately.

Thromboembolic disease Major orthopedic trauma substantially increases the risk for
venous thrombosis and its sequelae (eg, pulmonary embolism) (table 2). Therefore,
patients hospitalized with major fractures receive prophylactic treatment to prevent the
development of deep vein thrombosis (DVT). Although minor fractures are associated with
an increased risk for DVT, thromboprophylaxis is typically not indicated. (See "Prevention
of venous thromboembolic disease in surgical patients", section on 'Surgical risk groups'.)

Given the increased risk for DVT associated with trauma, imaging studies are needed to
assess fracture patients with suggestive clinical findings. The diagnosis and management
of DVT is discussed separately. (See "Overview of the causes of venous thrombosis",
section on 'Trauma' and "Clinical presentation, evaluation, and diagnosis of the
nonpregnant adult with suspected acute pulmonary embolism" and "Clinical presentation
and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower
extremity".)

Fat embolism syndrome Fat embolism syndrome (FES) is a difficult diagnosis

associated with closed long bone fractures of the lower extremity, most commonly
involving the femoral shaft. FES typically manifests 24 to 72 hours after injury with
dyspnea, tachypnea, and hypoxemia. Neurologic abnormalities and a petechial rash may
be present. Severe respiratory distress and death can occur. FES is discussed in detail
separately. (See "Fat embolism syndrome".)

Open fractures Open fractures are those with direct communication between the
fracture and the environment due to traumatic disruption of the intervening soft tissue and
skin. Open fractures have a higher incidence of infection than closed fractures. Up to 10
percent of open fractures may still develop acute compartment syndrome as the open
wound may not decompress all affected compartments in the limb [7]. (See "Treatment
and prevention of osteomyelitis following trauma in adults" and "Acute compartment
syndrome of the extremities".)

Management of open fractures depends to some degree upon the extent of soft tissue
damage, the degree of wound contamination, and the underlying health of the patient. All
open fractures receive the following treatment [8]:

Immobilization
Antibiotics
Tetanus prophylaxis as indicated (see "Tetanus")
Analgesia as needed
Prompt irrigation and debridement

Irrigation of an open wound using a sterile isotonic saline solution and low pressure is a
sound approach. According to an international, blinded, randomized trial involving 2447
patients, no improvement in outcome was noted when either higher pressure irrigation or a
soap solution was used to clean open fractures [9]. (See "Surgical management of severe
extremity injury", section on 'Debridement and stabilization'.)

In addition, early wound closure reduces infection risk and is performed whenever possible
[8]. The pathogens and antibiotics used for prophylaxis against open fracture infection are
discussed separately. (See "Treatment and prevention of osteomyelitis following trauma in
adults".)

Classification systems have been developed to determine the risk of infection in open
fractures. Risk increases in correlation with the size of the wound, severity of soft tissue
and bone damage, degree of contamination, and whether wound coverage is adequate.
The most commonly used classification system is described in the attached table (table 3)
[8,10]:

In addition to fracture characteristics, the number and severity of patient comorbidities also
increases the risk of infection. Host factors associated with infection and compromised
wound healing include age 80 years, nicotine use, diabetes, active malignancy,
pulmonary insufficiency, and immunocompromised states. The following infection rates
have been reported [11]:

Class A (no comorbid factors): 4 percent

Class B (1 to 2 comorbid factors): 15 percent
Class C (3 or more comorbid factors): 31 percent

Fracture blisters Blisters can develop over the site of traumatic fractures, usually in
areas where the skin is significantly swollen or the soft tissue is injured. They typically
develop within the first one or two days after the acute trauma. Blisters are filled with either
clear fluid (partial thickness skin injury) or blood (full thickness, hemorrhagic injury) [12].
The most common locations for fracture blisters are over the tibia, ankle, and elbow [13-
15].

In a retrospective series of 53 fracture blisters associated with trauma, patients who had
surgery within four hours after their acute injury had the lowest incidence of blister
formation (2 percent), while the highest incidence was reported among those whose
surgery was delayed over 24 hours (8 percent) [15]. When fracture blisters were present
before surgery, wound complications (eg, post-operative wound infections) developed at a
higher rate. Fifteen of the blisters in this series were found to have sterile, transudative
fluid in subepidermal vesicles. When blisters ruptured, the wound was contaminated by
skin flora in all 11 cases.

Fracture blisters should not be disrupted if at all possible. Once disrupted, they can
become infected with skin flora. Disrupted blisters may do better if an ointment such
as silver sulfadiazine is applied to promote re-epithelialization and to prevent infection or
by leaving the blistered skin on as a biologic dressing after the blister has drained.

NON-ACUTE COMPLICATIONS

Osteomyelitis Osteomyelitis is infection localized to bone. Trauma, including fractures,

is one of several possible causes. Osteomyelitis is discussed in detail separately; aspects
of particular relevance to fractures are described here. (See "Overview of osteomyelitis in
adults".)

Post-traumatic osteomyelitis accounts for up to 47 percent of cases [16]. Open fractures

are at greater risk, with infection rates reported to range from 2 to 50 percent [8,10,17].
The extent of soft tissue injury at presentation appears to be the most significant risk
factor. With open fractures, copious irrigation and fracture stabilization are important for
reducing the risk of infection [8].

Acute osteomyelitis usually presents with gradual progression of dull localized pain over
several days. Local findings (tenderness, warmth, erythema, swelling) and systemic
symptoms (fever, rigors) may be present. Decreased range of motion, point tenderness,
and joint effusions may be seen but are also present with uninfected fractures, making
clinical diagnosis potentially difficult.

In some cases, osteomyelitis presents with few symptoms or signs. This is more common
with subacute or chronic infections, with infections of the hip, pelvis, or vertebrae, and in
young patients. Chronic osteomyelitis may present with pain, erythema, or swelling,
sometimes in association with a draining sinus tract. Fractures that are healing slower than
expected or that remain extremely painful despite adequate immobilization may be
complicated by osteomyelitis. Intravenous antibiotics and surgical debridement are the
mainstays of therapy.

Nonunion and malunion Incomplete healing of a fracture where the cortices of the
bone fragments do not reconnect is called a nonunion. When a fracture heals with a
deformity (eg, angulation, rotation, incongruent joint surface), this is called a malunion. A
subset of fractures is more susceptible to these complications (table 2).

Nonunions commonly present with persistent pain, swelling, or instability beyond the time
when healing should normally have occurred. In most cases, symptomatic nonunions are
treated with open reduction and fixation. Some nonunions are asymptomatic and treatment
is unnecessary. An example of such a nonunion is spondylolysis of the lumbar pars
interarticularis, where a fibrous union can provide sufficient stability and often forms
without causing persistent symptoms.

Common reasons for nonunion and malunion include a tenuous blood supply to the
fractured bone (eg, scaphoid, proximal fifth metatarsal, talar neck), behaviors that interfere
with bone healing (eg, smoking, chronic alcohol abuse), poor bone fixation (ie, excessive
movement at the fracture site), poor apposition of bone fragments (ie, fragment ends too
far from one another), and infection [18]. Fractures sustained during high energy trauma,
particularly open fractures and those associated with severe soft tissue injury, are at
increased risk for nonunion. Patients whose baseline risk for nonunion is elevated due to
chronic disease, such as those with diabetes, osteoporosis, obesity, malnutrition, or
neuropathy, must be reevaluated frequently (usually weekly or every other week) during
the course of fracture healing. Immunosuppression, malignancy, and local infection may
also impair fracture healing. (See 'Osteomyelitis' above.)

Some medications may inhibit bone healing and should be used cautiously after a fracture
occurs. However, many studies of the effect of medications upon bone healing use animal
models and should be interpreted conservatively when considering the effect on humans.
The following table lists some of the agents known to adversely affect bone healing after a
fracture (table 4). Drugs that affect bone metabolism generally are discussed in detail
separately. (See "Drugs that affect bone metabolism".)

Drugs that may impair fracture healing include the following:

Nonsteroidal anti-inflammatory drugs (NSAIDs): The effect of these drugs on bone

healing is discussed separately. (See "Nonselective NSAIDs: Overview of adverse
effects", section on 'Healing of musculoskeletal injury'.)
Glucocorticoids: Glucocorticoids are known to impair bone metabolism and reduce
bone density, but animal studies of their effect on fracture healing have shown
inconsistent results. Effects may be dose dependent [19]. (See "Pathogenesis, clinical
features, and evaluation of glucocorticoid-induced osteoporosis", section on
'Pathogenesis'.)
Select antibiotics: Multiple fluoroquinolones have been implicated in impaired
fracture healing [20]. The mechanism is thought to involve effects on cartilage growth
and production. Studies of gentamicin and tetracycline report mixed results in effects
on bone healing [21,22].
Bisphosphonates: In animal studies, bisphosphonates are found to aid in the
formation of dense, strong callus. However, some authors suggest that these drugs
may arrest bone remodeling and weaken bone [23,24]. Controlled studies of fracture
healing in patients who take bisphosphonates are lacking.
Chemotherapy agents: Some chemotherapeutic medications inhibit rapidly
reproducing cells, and these may impair normal bone healing following a fracture.
Anticoagulants: Often do not allow the production of a hematoma as a precursor to
the collagenous scaffolding needed for fracture repair.

A number of environmental factors increase the risk of nonunion, including cigarette

smoking and excessive alcohol use [25-30].

Certain fractures are more often associated with nonunion because of their tenuous blood
supply. These include fractures of the following bones:

Scaphoid Scaphoid fractures have a high propensity for nonunion despite optimal
care. (See "Scaphoid fractures".)
Fifth metatarsal Fractures of the proximal diaphysis of the fifth metatarsal (Jones
fracture) are at high risk for nonunion despite optimal care. (See "Proximal fifth
metatarsal fractures".)
Hamate Hook of the hamate fractures are commonly misdiagnosed as wrist
sprains and frequently result in nonunion. (See "Hamate fractures".)
Tibia Open tibia fractures with significant displacement are at high risk for
nonunion. (See "Overview of tibial fractures in adults".)
 Femoral neck and talar neck These fractures have a higher incidence of
nonunion and avascular necrosis due to their relatively tenuous blood supply.

Complex regional pain syndrome Complex Regional Pain Syndrome (CRPS), also
known as Reflex Sympathetic Dystrophy (RSD), is a complex disorder of the extremities
characterized by localized pain, swelling, limited range of motion, vasomotor instability,
skin changes, and bone demineralization. Fractures, with or without a nerve injury, are a
common inciting event. Early recognition and initiation of therapy is important for
successful treatment. CRPS is discussed in detail separately. (See "Complex regional pain
syndrome in adults: Pathogenesis, clinical manifestations, and diagnosis" and "Complex
regional pain syndrome in adults: Prevention and management".)

Post-traumatic arthritis Fractures with joint involvement can cause damage to

articular cartilage, ultimately resulting in premature osteoarthritis. (See "Risk factors for
and possible causes of osteoarthritis" and "Clinical manifestations and diagnosis of
osteoarthritis".)

SUMMARY AND RECOMMENDATIONS

Fractures are associated with a range of potential complications. Pelvis and femur
fractures can cause severe hemorrhage; hip and multiple rib fractures predispose to
other life-threatening complications, primarily deep vein thrombosis and pulmonary
contusion respectively. (See 'Life-threatening conditions' above.)
Acute complications occur as a direct result of the trauma sustained and can include
damage to vascular structures, nerves, or soft tissue. Long bone fractures (eg, tibia)
are most often associated with acute compartment syndrome, a limb-threatening
condition. (See 'Arterial injury' above and 'Nerve injury' above and 'Compartment
syndrome' above.)
Major orthopedic trauma substantially increases the risk for venous thrombosis, and
prophylactic treatment is indicated in most cases. (See 'Thromboembolic
disease' above.)
Delayed complications may occur after initial treatment or in response to treatment.
Examples include osteomyelitis, nonunion, and post-traumatic osteoarthritis. Open
fractures are at greater risk for osteomyelitis. The particular fracture types and
medications associated with fracture nonunion are described in the text. Frequent
reevaluation of high risk fractures is imperative to help prevent nonunion or malunion.
(See 'Osteomyelitis' above and 'Nonunion and malunion' above and 'Complex
regional pain syndrome' above and 'Post-traumatic arthritis' above.)

General principles of acute fracture management

Authors:
Richard Derby, MD
Anthony Beutler, MD
Section Editors:
Patrice Eiff, MD
Chad A Asplund, MD, FACSM, MPH
Deputy Editor:
Jonathan Grayzel, MD, FAAEM

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Apr 2017. | This topic last updated: Dec 07, 2016.

INTRODUCTION Patients with suspected fractures require urgent and sometimes

emergent evaluation to determine if serious complicating conditions exist. Such conditions,
including any neurovascular injury, often require immediate surgical consultation [1,2].
Nevertheless, many fractures are uncomplicated and can be managed effectively in a non-
surgical setting.

The acute management of uncomplicated fractures is reviewed below and involves the
following steps:

Initial clinical assessment

Radiographic assessment
Immobilization
Pain management
Patient education and follow-up care

Basic concepts of fracture healing, the proper way to describe fractures based upon
clinical findings and radiographic appearance, pediatric fracture management, and the
basic principles of long-term fracture management are discussed separately.
(See "General principles of fracture management: Bone healing and fracture
description" and "General principles of fracture management: Fracture patterns and
description in children" and "General principles of definitive fracture management".)

INITIAL CLINICAL ASSESSMENT The clinician begins the assessment of any patient
who has sustained significant trauma by looking for life-threatening injuries using the basic
approach outlined in Advanced Trauma Life Support. Patients presenting to a clinic
following major trauma or who appear to have sustained significant injury are best
transferred to the emergency department for thorough evaluation.

History For patients without apparent life-threatening injuries who appear appropriate
for office management, assessment begins with a focused history. Analgesia is sometimes
needed before a history can be obtained.

The history should generally include:

 Mechanism of injury
Localization and characterization of symptoms and any dysfunction in the affected
area
Significant past injuries or surgeries in the affected area
Concomitant injuries ("Did you injure any other part of your body?")
Chronic medical conditions and medications
Allergies
Last meal (in case an injury requiring urgent surgery is identified)

Details of the mechanism of injury and an understanding of the injury patterns associated
with particular mechanisms are important. Injury patterns guide the examination and
choice of radiologic studies. Often they help the clinician to consider less obvious
associated injuries to bones, ligaments, or tendons.

As an example, falling onto an outstretched hand (FOOSH) is most often associated with a
distal radius fracture but may also cause an occult metacarpal or scaphoid fracture. Any
patient with radial-sided wrist pain after FOOSH requires careful examination of the entire
hand and wrist, including the scaphoid bone. Specific scaphoid radiographs are performed
on any patient with "snuffbox" tenderness (ie, tenderness over the scaphoid in the area
between the abductor pollicis longus and extensor pollicis longus). (See "Distal radius
fractures in adults" and "Scaphoid fractures".)

Although extremity fractures are associated with domestic violence less frequently than
some other injuries, a significant number of patients presenting to clinics with fractures
sustained their injuries from such violence [3-5]. Therefore, it is important to ask patients
whether this is the case and to provide appropriate referral as needed. (See "Intimate
partner violence: Diagnosis and screening".)

Examination While the patient's history and injury mechanism guide the examination, a
general assessment of the involved region should always be performed. This includes
evaluating neurovascular function and looking for signs of soft tissue damage and breaks
in the skin over the area of injury, which suggests the presence of an open fracture. The
neurovascular examination includes palpating distal pulses, measuring capillary refill, and
testing motor function, sensation, and two-point discrimination distal to the fracture site.

Palpate the entire area around the fracture site to exclude adjacent injuries. This includes
the entire bone in question, adjacent bones, and at least one joint above and below the
injury site. Avoid testing passive range of motion or manipulating the affected area or limb
until radiologic assessment is completed in order to prevent exacerbating fracture
displacement, soft tissue damage, or neurovascular compromise [1,2].

The general rule of fracture immobilization is "splint it where it lies." The major exception to
this rule occurs when distal neurovascular function is not intact. If pulses are undetectable,
motor function is absent, or other signs of significant distal neurovascular compromise
exist, the physician should promptly reduce any apparent dislocation or reposition the
injured extremity. If neurovascular function improves following repositioning, the injury
should be splinted in this new position, neurovascular status verified following splint
application, and emergent surgical consultation obtained so definitive care can be
provided. If neurovascular status does not improve despite repeated attempts at reduction
or repositioning, the injury is splinted in the position of maximum neurovascular function
and immediately transferred for definitive care.

In skeletally immature patients, the clinician must be alert to the possibility of physeal
injury. Proper identification and treatment of growth plate fractures is essential to minimize
the risk of growth arrest or asymmetric bone growth [1,6,7]. (See "General principles of
fracture management: Fracture patterns and description in children".)

INITIAL RADIOLOGIC ASSESSMENT

Plain radiographs A basic discussion of how to describe fractures and bone

radiographs is found separately. (See "General principles of fracture management: Bone
healing and fracture description".)

Three guidelines are helpful when obtaining radiographs of a potential fracture site:

Obtain multiple and orthogonal views "One view is no view" is a common

radiologic maxim. Two orthogonal views are the absolute minimum needed for
adequate assessment.
Ensure radiographs are of high quality (proper angle, technique, and exposure) and
include the entire bone or joint in question.
Obtain advanced imaging when clinical findings suggest fracture, but plain
radiographs are unrevealing.

Orthogonal views are radiographs taken at 90 degrees to each other; most often these
consist of an anterior-posterior (AP) and lateral view. However, in some situations, AP and
lateral views alone are insufficient to diagnose obscure fractures and radiographs using
particular perspectives are needed. As examples, a scaphoid view may reveal a scaphoid
fracture not seen on a standard AP radiograph of the wrist, while a fracture of the hook of
the hamate may be apparent only on a carpal tunnel view. (See "Scaphoid
fractures" and "Hamate fractures".)

Fractures can sometimes be difficult to see on the best of radiographs. Hence,

radiographs that are over- or underpenetrated, improperly angled (eg, not true laterals),
omit important anatomy, or contain overlying shadows can hinder diagnosis and should
not be accepted. Radiographs of a specific bone or joint should include the entire
structure.

Stress fractures, scaphoid fractures, physeal fractures, hip fractures in the elderly, and
many other bony injuries may not appear on initial plain radiographs. Computed
tomography (CT) and magnetic resonance imaging (MRI) reveal occult fractures in many
such cases [1,8]. An alternative approach is to assume the presence of a fracture, treat the
injury accordingly, and obtain follow-up radiographs a week or two later. Many occult
injuries become apparent on subsequent radiographs.

Musculoskeletal ultrasound Although musculoskeletal ultrasound is not the primary

imaging modality used to diagnosis fractures, it is being used more often in particular
settings as an alternative imaging method due to its portability, availability, and lack of
ionizing radiation. It is often used to make rapid assessments in the military setting,
emergency departments, sports medicine clinics, and ski resort medical stations.

According to a systematic review of eight studies involving varying methods and different
extremity fractures, the sensitivity of ultrasound to detect an extremity fracture ranges from
85 to 100 percent, while specificity ranges from 73 to 100 percent [9]. In addition,
sonography may be useful for identifying some non-extremity fractures [10]. A meta-
analysis of 16 studies of point of care ultrasound (POCUS) in the management of pediatric
distal forearm fractures reported 97 percent sensitivity and 95 percent sensitivity [11].
Individual studies of POCUS for metacarpal and phalanx fractures in both pediatric and
adult populations have reported lower sensitivities and specificities 92 percent and 87
percent (metacarpal); 79 percent and 90 percent (proximal/middle phalanx) [12,13].

Given the increasing availability of ultrasound and its other advantages, it is reasonable to
assess low-risk fractures with ultrasound. In cases where the clinical and sonographic
findings are consistent, the risk for displacement or other significant complication is low,
and the patient is unlikely to be harmed by immobilization, no further imaging beyond
ultrasound may be necessary. However, all high-risk fractures require more definitive
imaging.

OPEN FRACTURES Open fractures are at risk of developing osteomyelitis. Initial

treatment includes irrigation, possibly prophylactic antibiotics, and tetanus immunization as
indicated. The management of open fractures and related issues are reviewed separately.
(See "General principles of fracture management: Early and late complications", section
on 'Open fractures' and "Treatment and prevention of osteomyelitis following trauma in
adults".)

IMMOBILIZATION Fracture immobilization is of benefit in the great majority of cases. It

prevents fracture displacement or loss of reduction, protects the area from further injury,
and reduces pain. Several methods can be used to immobilize uncomplicated fractures,
including splinting, casting, bracing, buddy taping, and sling and swathe (picture
1 and picture 2 and picture 3 and figure 1).

In the acute setting, splinting is the preferred method for immobilizing fractures that are at
low risk for displacement primarily because of the soft tissue swelling that develops around
most fracture sites. A cast applied to the site of an acute injury cannot accommodate such
swelling, and can lead to tissue ischemia, pressure-related injury, and even iatrogenic
compartment syndrome [14]. Conversely, a cast applied to an already swollen extremity
may become loose as swelling subsides, providing inadequate support and immobilization.
Additional benefits of splinting include the relative ease of application, lower risk of skin
breakdown, and improved hygiene [15].

Certain unstable fractures may require acute casting or operative fixation to prevent
displacement. Such fractures may include those that required reduction, fracture
dislocations, segmental or spiral fractures, and simultaneous fractures of both the ulna and
radius [1].

A thorough discussion of fracture splinting, including equipment, techniques, and

complications, is found separately. (See "Basic techniques for splinting of musculoskeletal
injuries".)

PAIN MANAGEMENT Adequate analgesia is an important aspect of acute fracture

management. Fracture immobilization, ice, elevation of the affected limb, and analgesic
medications all reduce pain. Splinting prevents motion at the fracture site, which is a major
source of pain. The noncircumferential nature of splints allows ice to be placed in nearly
direct contact with the injured tissue. Additional reduction in swelling and pain may be
achieved by elevating the fracture site above the level of the heart.

Initially, analgesics are often required for effective pain control. For minor
fractures, acetaminophen or a nonsteroidal antiinflammatory drug (NSAID) is often
sufficient for adequate analgesia. The potential effects of NSAIDs on fracture healing are
discussed separately. (See "Nonselective NSAIDs: Overview of adverse effects", section
on 'Possible effect on fracture healing'.)

More severe pain associated with an acute fracture often requires treatment with opioids.
Care should be taken when dosing opioid medications in patients with impaired renal
clearance, particularly older patients. If the necessary resources are available, regional
nerve blocks provide an effective means of controlling pain for some fractures while
avoiding unwanted systemic side effects [16,17]. Pain management in older patients with
significant trauma, including major fractures, is discussed separately. (See "Geriatric
trauma: Initial evaluation and management", section on 'Analgesia'.)

Acute fracture pain lasts from a few days to a week. Pain that persists or increases after
this initial period may represent a complication and should be investigated. Such
complications may include acute compartment syndrome, pressure-related injuries of the
skin and soft tissue, and movement or displacement at the fracture site due to inadequate
immobilization [1]. (See "Acute compartment syndrome of the extremities" and "General
principles of fracture management: Early and late complications".)

Delayed complications related to a cast or splint may also manifest as worsening pain. Any
patient with a splint or cast who complains of new or worsening pain in that region should
be urgently assessed. Fracture care providers must ensure that patients have 24 hour
access to facilities where casts can be removed and fractures evaluated.

PATIENT EDUCATION AND FOLLOW-UP CARE Once a fracture and any associated
injuries have been stabilized, the clinician must provide clear instructions for injury care
and monitoring, including cast or splint care, and a follow-up plan must be in place. For
uncomplicated fractures, a return visit should take place within three to seven days. Earlier
follow up may be necessary if a cast was applied.

All patients should be given verbal and printed instructions explaining the signs and
symptoms indicating that immediate reevaluation is needed. Such signs include:

New or worsening pain

Diminished circulation in the affected extremity (cool or dusky digits, diminished
capillary refill)
Diminished motor function in the affected extremity (no longer able to move digits)
Bleeding or discharge from the cast or splint
Feelings of pressure, grinding, or numbness in the area of the fracture
Significant damage to the cast or splint

The printed instructions should also contain telephone numbers for follow up and
directions for splint and cast care.

INFORMATION FOR PATIENTS UpToDate offers two types of patient education

materials, The Basics and Beyond the Basics. The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on patient info and the keyword(s) of interest.)

Basics topic (see "Patient education: Cast and splint care (The Basics)")
Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

Begin the assessment of any patient who has sustained significant trauma by
looking for life-threatening injuries. Patients presenting to a clinic following major
trauma or who appear to have sustained significant injury are best transferred to the
emergency department.
The history of any patient with a potential fracture should generally include:
Mechanism of injury
Localization and characterization of symptoms and dysfunction in affected area
Significant past injuries or surgeries in the affected area
Concomitant injuries ("Did you injure any other part of your body?")
Chronic medical conditions and medications
Allergies
Last meal (in case an injury requiring urgent surgery is identified)
(see 'History' above)
The history and injury mechanism guide the physical examination of patients with a
possible fracture. A general assessment of the involved region should always be
performed, including evaluation of neurovascular function and investigation for signs
of soft tissue damage and breaks in the skin over the area of injury, which suggests
the presence of an open fracture. Palpate the entire area around the fracture site,
including the entire bone in question, adjacent bones, and at least one joint above
and below the injury site. (See 'Examination' above.)
Three basic principles are helpful when obtaining radiographs of a potential fracture:
Obtain multiple and orthogonal views "One view is no view" is a common
radiologic maxim. Two orthogonal views are the absolute minimum needed for
adequate assessment.
Ensure radiographs are of high quality (proper angle, technique, and exposure)
and include the entire bone or joint in question.
Obtain advanced imaging when clinical findings suggest fracture, but plain
radiographs are unrevealing (see 'Initial radiologic assessment' above). A basic
discussion of how to describe fractures and bone radiographs is found
separately. (See "General principles of fracture management: Bone healing and
fracture description".)
Fracture immobilization is of benefit in the great majority of cases. It prevents
fracture displacement or loss of reduction, protects the area from further injury, and
reduces pain. Several methods can be used, but in the acute setting splinting is
generally preferred. (See 'Immobilization' above and "Basic techniques for splinting of
musculoskeletal injuries".)
Adequate analgesia is an important aspect of acute fracture management. Fracture
immobilization, ice, elevation of the affected limb, and analgesic medications all
reduce pain. For minor fractures, acetaminophen or a nonsteroidal antiinflammatory
drug (NSAID) is often sufficient for adequate analgesia, but opioids may be required
and should be used if necessary. (See 'Pain management' above.)
After initial evaluation and treatment is completed, the clinician must provide clear
instructions for injury care and monitoring, including cast or splint care, and a follow-
 up plan must be in place. For uncomplicated fractures, a return visit should take place
within three to seven days. Earlier follow up may be necessary if a cast was applied.
(See 'Patient education and follow-up care' above.)

General principles of definitive fracture management

Authors:
Anthony Beutler, MD
Stephen Titus, MD
Section Editors:
Patrice Eiff, MD
Chad A Asplund, MD, FACSM, MPH
Deputy Editor:
Jonathan Grayzel, MD, FAAEM

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Apr 2017. | This topic last updated: Mar 30, 2017.

INTRODUCTION Immobilization provides the basis for fracture healing. For many
complex and unstable fractures, immobilization is achieved by means of internal fixation.
However, many stable fractures at low risk of displacement can be immobilized effectively
with casting, which can be performed by orthopedists or knowledgeable primary care
clinicians.

The basic principles and techniques of casting and the follow-up care needed for patients
treated in this manner are reviewed here. The assessment and initial management of
acute fractures is discussed separately. (See "General principles of fracture management:
Bone healing and fracture description" and "General principles of acute fracture
management".)

CASTING

Overview Casting is standard treatment for many closed, nondisplaced, or reduced

fractures [1]. Casts provide a stable, protected environment in which the external,
periosteal callus can form and normal bone healing can proceed [2].

The optimal time to place a cast is after post-traumatic swelling has resolved. This usually
takes five to seven days following an injury but varies depending upon the location and
type of fracture. Most often a splint is used in the interim. Nevertheless, several fracture
types are best managed with acute casting. In such cases, the casts are either maintained
in a single piece or converted into functional splints by creating valves in the cast (ie, two
incisions along the entire length, thereby dividing the cast into two pieces) that can
accommodate some soft tissue swelling.
Fractures likely to require casting acutely include those with the following characteristics
[1]:

Reduction was required

Two adjacent bone are involved (eg, fracture of radius and ulna)
Segmental fractures
Spiral fractures
Fracture dislocations
Fractures where muscles exert strong forces that may cause displacement

Some fractures, such as those of the proximal humerus, are not amenable to casting,
while others that should be casted, such as certain ankle fractures in children, are often
not [1]. Nevertheless, casting remains the treatment of choice for most nonoperative
fractures. Successful casting requires three things: proper materials, proper positioning,
and selection and application of the appropriate type of cast. These are discussed below.

Materials Myriad materials are available for casting, but, fiberglass and plaster of Paris
are the most widely used and least expensive. Fiberglass is lighter, stronger, more
breathable, and sets more quickly than plaster (picture 1) [3]. According to a laboratory
study using a prosthesis model of limb swelling, fiberglass applied with a stretch-relax
technique accommodates swelling better and causes less skin surface pressure than
plaster [4]. However, fiberglass is a skin irritant, and clinicians should wear gloves when
applying a fiberglass cast. (See 'Application of cast' below.)

Plaster molds more uniformly than fiberglass, which is an advantage in maintaining

fracture reduction. Plaster also sets more slowly, making it easier for less experienced
clinicians to apply it correctly. However, plaster tape is messier, heavier, and breaks down
more easily than fiberglass tape, and it can produce a significant exothermic reaction while
it sets. For these reasons, many clinicians prefer fiberglass for most casting applications.

Protection of the skin from the overlying fiberglass or plaster is essential to prevent
breakdown and related complications. Skin protection begins with the application of a
stockinette, the first layer of any cast, followed by adequate but not excessive amounts of
padding (picture 2 and picture 3). Both stockinette and cast padding have traditionally
been made of cotton, but synthetic materials are becoming available. Several forms of
synthetic stockinette and padding materials are designed to allow for the cast to become
wet.

It is important to use the appropriate amount of padding, especially over bony

prominences, which are susceptible to pressure and skin breakdown from the cast. Extra
padding is often needed in such areas (eg, lateral epicondyle, ulnar styloid, medial and
lateral malleoli). However, care must be taken to avoid excess padding, especially around
the fracture site, as this can lead to a loose cast that provides inadequate immobilization
[1].
Type of cast When selecting the appropriate cast, the clinician must determine which
joints to include and how far the cast should extend. Maximal immobilization is achieved
with casts that include the joints proximal and distal to the fracture site. This is important in
treating any unstable fracture, such as a reduced distal radius fracture. Whenever
possible, the entire length of the fractured bone should be included in the cast [1]. The
accompanying table describes several common casts and the fractures for which they are
best suited (table 1).

Application of cast The key steps in the application of a fiberglass cast are outlined
below. For illustrative purposes, a short arm cast with a thumb spica is described, but the
basic steps apply to all fiberglass casts. Cast selection for specific injuries are found in the
UpToDate topics devoted to that injury. Descriptions of how some other types of casts are
applied are found separately: Long leg cast: (See "Tibial shaft fractures in adults", section
on 'Long leg casting'.) Standard short arm cast: (picture 4)

Select the appropriate padding and width for casting (fiberglass or plaster) tape.
Two-inch (5 cm) tape is generally good for the hand, 3 inch (7.5 cm) for the forearm,
and 4 inch (10 cm) for the lower extremity and upper arm (picture 3). The stockinette
width is also based on the size of the limb being casted (picture 2). Cutting the
stockinette slightly longer than the cast allows for the edges to be rolled back prior to
the application of the final layer of casting material, providing a smooth edge to the
cast.
First apply the stockinette (picture 5). Next, apply the padding (eg, Webril) by rolling
it onto the extremity in a distal to proximal direction; each layer should overlap the
preceding layer by approximately 50 percent (picture 6). Additional Webril or padding
should be placed over bony prominences. In general, about two layers of padding are
adequate for the upper extremity; three to four layers are used for the lower extremity.
Once the padding is in place and the limb properly positioned, moisten the casting
tape (picture 1). Cool water should be used for fiberglass tape. "Tepid" or room
temperature water works well for plaster. Warmer water will shorten the set time, but
may cause skin burns.
Roll the casting tape over the extremity moving distal to proximal (picture 7). When
applying fiberglass tape, stretch and then relax the tape during application to reduce
the skin surface pressure [4].
Special cuts can be used to help navigate smaller areas, such as around the thumb.
This helps to prevent bulking of the cast and can improve comfort.
After the first few layers of casting tape are applied, the cast should be molded if
necessary (picture 8). The goal of molding is to maintain alignment of an unstable
fracture. An oval or elliptical shaped cast is better suited for maintaining fracture
alignment than a perfectly cylindrical cast [2].

Improper molding or any sharp indentations in the cast can cause severe complications,
such as pressure sores and skin ulcers. Clinicians with little experience casting should limit
molding to gently compressing the cast into an elliptical shape at the area of the fracture.
The palms and heels of the hands should be used; avoid using fingers [2]. This approach
provides adequate molding while decreasing the risk for skin breakdown.

Practitioners with experience casting may use a three-point molding technique. The first
point of compression is directly over the apex of the fracture with the force directed
opposite the direction in which the fracture is most likely to displace. The two remaining
pressure points lie on the opposite side of the bone at either side of the apex. Force is
maintained at these three sites until the cast has set. As described above, the palms and
heels of the hand should be used to apply pressure and use of the fingers avoided.

Fold the ends of the stockinette over the set casting tape and apply the final layer of
tape (picture 9). In all, two layers of fiberglass tape are usually sufficient for short arm
casts, three layers for long arm casts and non-weightbearing short leg casts, and four
layers for weightbearing short leg casts (picture 10).
Inspect the cast to ensure that there are no rough or sharp edges protruding and
that sensation and blood flow distal to the cast end are intact. Written instructions
explaining proper cast care should be provided to the patient. (See 'Information for
patients' below.)

An alternative technique for applying a fiberglass cast may be useful for less experienced
clinicians [5]. This approach differs in that the casting tape is not moistened before it is
applied. Rather, the fiberglass tape is applied directly out of its packaging and a water
based gel, such as KY Jelly, is spread evenly over each roll after it is applied. This
technique allows for a longer set time and permits adjustments to be made to casting
position after each roll is placed.

The same steps described above are used when applying a short leg cast. A few special
considerations for the short leg cast include:

Cut the stockinette on the dorsal side just over and parallel to the ankle (ie,
tibiotalar) joint to prevent wrinkling, which can lead to skin irritation.
Four inch padding is needed for lower extremity casts; apply extra padding over
bony prominences (eg, malleoli, fibular head).
Maintain the ankle in 90 degrees of dorsiflexion (ie, neutral position) to create a
position of function (especially for weightbearing casts) and to prevent flexion
contractures.
Leave all five toes visible to allow for neurovascular assessment.

Positioning Casts should place the affected joints in their position of function whenever
possible (table 1). The wrist and hand are usually placed in a grasping position. The ankle
and elbow are usually casted at 90 degrees. Sometimes these general rules are adjusted
to obtain a better outcome. As an example, the wrist may be placed in a more neutral to
slightly flexed position to help maintain reduction when treating a distal radius fracture.
Changes in fracture position can occur during cast application despite an optimal reduction
and excellent casting technique with proper molding. Therefore, we suggest obtaining
radiographs immediately following cast application for any unstable fracture or any fracture
that required reduction prior to casting.

Complications Potential complications associated with fractures are reviewed

separately. Complications associated with casting are discussed below. (See "General
principles of fracture management: Early and late complications".)

While immobilization in a cast is important for maintaining reductions and provides the
basis for fracture healing, it can lead to joint stiffness, muscle atrophy, and disuse
syndromes, and increases the risk for thrombosis. Casts that are applied too tightly or that
become too tight due to soft tissue swelling can cause vascular compromise. Skin
breakdown, compression neuropathy, and acute compartment syndrome can also occur.
Any patient in a cast who complains of pain, burning, tingling, or numbness should be
evaluated immediately because of these potentially severe complications. (See "Acute
compartment syndrome of the extremities" and "Overview of lower extremity peripheral
nerve syndromes" and "Overview of upper extremity peripheral nerve
syndromes" and "Overview of acute arterial occlusion of the extremities (acute limb
ischemia)" and "Epidemiology, pathogenesis, and risk assessment of pressure
ulcers" and "Clinical presentation and diagnosis of the nonpregnant adult with suspected
deep vein thrombosis of the lower extremity".)

Depending upon the age and comorbidities of the patient, even routine casting may result
in prolonged losses of motion and muscular strength that require treatment with physical or
occupational therapy [1]. Other casting complications include skin burns, which are more
likely if plaster is used with hot water [6].

Cast removal Any clinician who places casts must ensure that the patient has
continuous access to cast removal by qualified personnel. Cast removal is not without risk.
Cast saw injuries, most often thermal or abrasive, occur in nearly one percent of removals.
To reduce the risk of injury during removal, we suggest using an up-and-down cutting
technique, in which the saw makes a series of cast punctures perpendicular to the skin,
rather than pulling the blade across the cast (and potentially the skin), along with ensuring
that blades are sharp. The risk of thermal injury may be reduced by using cooling
techniques for saw blades that are hot from prior use. According to a laboratory study of
six techniques for reducing saw blade temperature, cooling was most rapid with the
following techniques: oscillating the blade while using the vacuum; applying 70 percent
isopropyl alcohol to the blade with gauze or cast padding; or applying cool water to the
blade [7].

Keeping casts dry Particularly with children who must wear a cast during warm
weather, keeping a cast dry can be a challenge. According to an observational laboratory
study comparing six approaches, one effective and inexpensive method for maintaining a
dry cast is to enclose the cast in two plastic bags, one over the other, and then seal the
bags using duct tape [8]. Two strips of tape are applied circumferentially, one to each bag,
with half the tape overlapping the end of the bag and the other half on the skin, as shown
in the following photograph (picture 11). This approach was substantially more effective
than using a single plastic bag sealed with either a rubber band or duct tape, and equally
effective as commercial products. In some cases, commercial products may be more
convenient as they can be applied and removed quickly, and are reusable.

FOLLOW-UP VISITS

Overview After the initial cast is applied and fracture alignment is confirmed, the next
essential step is to ensure adequate and timely follow up. The interval between visits
depends on the nature of the fracture, the type of cast, and any concerns there may be
about patient compliance.

Even in the rare instance where no follow up is required (eg, healthy adult with a minor
fibular avulsion fracture treated in a pneumatic splint), the clinician should provide clear
instructions about whom to call for signs of skin breakdown, infection, neurovascular
compromise, or for worsening or persistent pain. Unstable fractures or post-reduction
fractures require more frequent reassessment, sometimes as often as twice a week initially
to ensure that correct fracture alignment is maintained [1].

As a general rule, lower extremity casting involves longer immobilization times to maximize
stability and strength. Upper extremity casting generally involves shorter periods of
immobilization in order to retain range of motion (ROM) [1].

Follow-up visits for stable fractures Initial follow up after casting of a stable fracture
is usually scheduled three to seven days later, with instructions to call or return earlier for
pain, swelling, or other acute symptoms. Subsequent follow-up visits vary according to the
patient and cast but are usually scheduled about every two to three weeks.

At each follow-up visit, the cast should be carefully checked for signs of wear and proper
fit. The cast should be replaced if it is too loose, too tight, or excessively worn. Most
weightbearing plaster casts maintain their integrity for two to three weeks, while non-
weightbearing plaster casts last about four weeks. Fiberglass casts typically remain intact
for two weeks longer than their plaster counterparts. These time frames are
approximations and depend on patient activity, weight, and age. The casts of children and
active adults should be checked more frequently to ensure proper immobilization [1].

Follow-up visits are ideal venues for teaching appropriate rehabilitative exercises and
ensuring compliance with activity restrictions.

Follow-up visits for unstable fractures Unstable fractures are prone to loss of
reduction or malalignment while being treated in a cast. The proper times to recheck
alignment depend on the fracture type and the age of the patient.
As an example, pediatric both-bone forearm fractures are among the most unstable
fractures. Since children heal at a relatively rapid rate and only limited degrees of
angulation are acceptable in the forearm, midshaft fractures of both the radius and ulna
require radiographic follow-up two times per week for the first two to three weeks after
injury.

Conversely, angulated distal radius fractures in adults need only be reassessed once
every 7 to 10 days post-injury. If excessive angulation is noted at that time, the bone can
be re-manipulated because fracture fragments remain relatively mobile in adults.

Radiographs to reassess fracture alignment in unstable fractures while they are healing
should be obtained in the cast. Radiographs taken in traditional plaster or fiberglass
generally provide sufficient clarity to judge the alignment of long bone fractures, although
evidence of healing may be obscured. Several types of casting tape offer superior
radiolucency (eg, 3M Scotchcast, M-PACT OCL Polylite), which may be helpful when
evaluating unstable fractures [9].

Orthopedic referral Between visits, patients can develop complications that warrant
orthopedic evaluation. As an example, unacceptable changes in fracture angulation may
appear on follow-up radiographs and orthopedic consultation should be obtained in such
cases to determine the best treatment. Any new deficit in neurovascular function requires
immediate evaluation by an orthopedic surgeon.

FRACTURE HEALING The goal of casting is to provide a sufficient period of

immobilization such that the fracture heals properly. However, prolonged immobilization
increases the risk of complications. An accurate assessment of fracture healing is
essential to striking a balance between these twin considerations. Unfortunately,
determining when clinical union has occurred can be problematic. Understanding the basic
biology of bone healing and then relying on a combination of clinical and radiographic
factors offers the best estimation of when a fracture is adequately healed [10].
(See 'Complications' above.)

Biology of fracture healing The biology of bone healing is discussed separately.

(See "General principles of fracture management: Bone healing and fracture description",
section on 'Biology of bone healing'.)

Clinical assessment of fracture healing Proper assessment of clinical union is

essential to optimize fracture healing and to prevent complications from excessive
immobilization. Biomechanical studies of fracture stiffness show that clinical union typically
occurs one to two weeks before evidence of radiographic union [11,12]. Additionally,
radiologic parameters of fracture healing have poor interobserver correlation [12], and tend
to underestimate healing progress when compared with clinical [11], biomechanical [11-
13], and histologic [13] measures.
Given the limitations of radiographic parameters, typical clinical practice is to schedule a
follow-up visit around the time of expected healing, usually around four to six weeks post-
injury. The cast is removed and clinical features of healing are assessed. These can
include the ability to bear weight [14], no tenderness to palpation at the fracture site [1],
and stability and absence of pain with manual stress testing [10]. If the fracture
demonstrates clinical healing and appropriate signs of healing are seen on radiographs,
then the fracture is deemed healed and the patient begins rehabilitation. If the fracture
does not demonstrate signs of clinical healing or appropriate healing is not seen on
radiographs, a cast is reapplied. Alternatively, a functional splint or brace, which allows for
some gentle range of motion (ROM) exercises to be done out of the device, can be used.
The fracture is then reassessed in two weeks.

Fracture healing depends on multiple biologic and biomechanical factors and some
patients may need to be recasted several times. If a fracture is not clinically healed four
weeks after the expected time of healing, additional confirmation of bony healing should be
sought through advanced imaging (magnetic resonance imaging [MRI] or computed
tomography [CT] scanning) and consultation with an orthopedic surgeon.

As a general rule, lower extremity casting involves longer immobilization times to maximize
stability and strength. Upper extremity casting generally involves shorter periods of
immobilization in order to retain ROM [1].

ADJUNCTIVE THERAPY FOR FRACTURE HEALING

Overview and basic measures A number of adjunctive therapies are used to aid
fracture healing. While a detailed discussion is beyond the scope of this review, a brief
description of some of the more commonly mentioned therapies is included here. Pain
management for patients with fractures and the effects of specific drugs on fracture
healing are discussed separately. (See "General principles of acute fracture
management", section on 'Pain management' and "General principles of fracture
management: Early and late complications", section on 'Nonunion and malunion'.)

For all patients with fractures, regardless of the site, it is important to ensure good
nutrition, including adequate intake of vitamin D and calcium, to maximize fracture healing.
Although evidence exists to support the role of vitamin D in fracture prevention, no direct
evidence supports the use of supplemental vitamin D for the treatment of acute fractures.
However, an observational study of 73 patients with tibia and femur fractures noted that
serum vitamin D concentrations drop during the early stages of fracture healing,
suggesting an increased need [15]. Encouraging increased exposure to natural sources of
vitamin D or prescribing supplemental vitamin D during the period of active fracture healing
seems a reasonable practice given the prevalence of vitamin D deficiency in the general
population and the low potential for toxicity. If supplemental vitamin D is prescribed, a daily
dose of 1000 international units during fracture healing seems reasonable. (See "Vitamin
supplementation in disease prevention", section on 'Vitamin D' and "Overview of vitamin
D".)

Cigarette smoking and excessive alcohol use impairs fracture healing. Patients should be
encouraged to stop smoking and limit alcohol consumption. (See "General principles of
fracture management: Early and late complications", section on 'Nonunion and malunion'.)

Pharmacologic adjuncts

Systemic therapies A wide range of pharmacologic treatments to accelerate fracture

healing are being studied. Such treatments include growth hormone (GH), bone
morphogenetic proteins (BMP), parathyroid hormone (PTH), platelet-derived growth factor,
and bisphosphonates. Most studies are preliminary and the appropriate role for these
therapies in the treatment of acute fractures remains speculative [16-19]. The use
of teriparatide for fracture healing (and other indications) is reviewed separately.
(See "Parathyroid hormone therapy for osteoporosis", section on 'Fracture healing'.)

Local therapies Locally injected or applied treatments to improve fracture healing,

such as platelet-rich therapies, are under investigation. However, studies are preliminary
and the appropriate role for such therapies in the treatment of acute fractures remains
speculative [20].

Prevention of complex regional pain syndrome Complex Regional Pain Syndrome

(CRPS), also known as Reflex Sympathetic Dystrophy, is a complex disorder of the
extremities characterized by localized pain, swelling, limited range of motion (ROM),
vasomotor instability, skin changes, and bone demineralization. Fractures, with or without
a nerve injury, are a common inciting event. Measures to prevent this debilitating
syndrome, including supplemental vitamin C, are discussed separately. (See "Complex
regional pain syndrome in adults: Prevention and management" and "Complex regional
pain syndrome in adults: Pathogenesis, clinical manifestations, and diagnosis".)

Nonpharmacologic adjuncts Several nonpharmacologic interventions have been

used to aid fracture healing. Among these are electromagnetic stimulation (bone
stimulators) and ultrasound. Electromagnetic stimulation is used most often to hasten
healing after internal fixation or bone grafting that has been performed for fractures that
failed to heal with standard treatment (ie, nonunions) [21]. Electromagnetic bone
stimulation is often used to augment a trial of conservative therapy in atypical or stress
fractures that would otherwise require surgery, and limited evidence suggests that these
interventions are effective [22-24].

Although the US Food and Drug Administration (FDA) has approved low intensity pulsed
ultrasound (LIPUS) for the treatment of acute fractures and nonunions, debate continues
about the quality of the evidence supporting this intervention [25]. A systematic review and
meta-analysis of 12 studies (including eight randomized placebo-controlled trials) including
648 fractures, found the available studies to be highly heterogeneous and
methodologically limited (study methods and the risk of bias were often unclear), and
concluded that the evidence does not support routine use of ultrasound for fracture healing
[26]. A subsequent randomized trial involving just under 500 patients with tibial shaft
fractures reported no difference in radiographic healing or in functional measures between
patients treated with LIPUS compared with those treated with a sham device [27]. Another
systematic review of 26 randomized controlled trials involving patients with any kind of
fracture or osteotomy, concluded that LIPUS does not improve outcomes important to
patients (eg, time before return to work, need for subsequent operation) [28].

INFORMATION FOR PATIENTS UpToDate offers two types of patient education

materials, The Basics and Beyond the Basics. The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on patient info and the keyword(s) of interest.)

Basics topic (see "Patient education: Cast and splint care (The Basics)")
Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

Casts provide a stable, protected environment in which the external periosteal callus
can form and normal bone healing can proceed. The optimal time to place a cast is
after post-traumatic swelling has resolved, which usually takes five to seven days.
(See 'Overview' above.)
Fiberglass and plaster of Paris are the two most common types of fracture "tape"
used for casting. Fiberglass is lighter, stronger, more breathable, and sets more
quickly than plaster. Plaster molds more uniformly and may be easier for less
experienced clinicians to use. (See 'Materials' above.)
The steps involved in applying a cast are described in the text; common casts and
their application are summarized in the accompanying table (table 1). For proper cast
application, it is important that the clinician do the following:
Protect the skin with a stockinette, the first layer of any cast, and adequate but
not excessive amounts of padding.
Use extra padding over bony prominences.
 Ensure maximal immobilization for unstable fractures by including the joints
proximal and distal to the fracture site in the cast.
Casts should place the affected joints in their position of function (ie, neutral
position) whenever possible. (See 'Application of cast' above.)
Casting has a number of potential complications, including pressure sores,
neurovascular compromise, acute compartment syndrome, and disuse atrophy.
Therefore, any patient in a cast who complains of pain, burning, tingling, or numbness
should be evaluated immediately. (See 'Complications' above.)
The intervals between follow-up visits depend on the nature of the fracture, the type
of cast, and any concerns there may be about patient compliance. Children with
unstable fractures need to be reexamined frequently, in some cases as often as two
times each week; responsible adults with stable minor fractures may require only one
follow-up visit. (See 'Follow-up visits' above.)
A combination of clinical and radiographic factors offers the best estimation of
fracture healing. Assessment of healing is usually performed around the time when
union would normally be expected. (See 'Clinical assessment of fracture
healing' above.)
All patients with fractures require good nutrition to maximize fracture healing. A
number of adjunctive therapies for fracture healing are available but few rigorous
studies have been performed and the appropriate role of such treatments remains to
be determined. (See 'Adjunctive therapy for fracture healing' above.)

Basic principles of wound management

Authors:
David G Armstrong, DPM, MD, PhD
Andrew J Meyr, DPM
Section Editors:
Hilary Sanfey, MD
John F Eidt, MD
Joseph L Mills, Sr, MD
Eduardo Bruera, MD
Deputy Editor:
Kathryn A Collins, MD, PhD, FACS

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Apr 2017. | This topic last updated: Dec 04, 2016.

INTRODUCTION A wound is a disruption of the normal structure and function of the

skin and skin architecture [1]. An acute wound has normal wound physiology and healing
is anticipated to progress through the normal stages of wound healing, whereas a chronic
wound is defined as one that is physiologically impaired [2,3].

To ensure proper healing, the wound bed needs to be well vascularized, free of devitalized
tissue, clear of infection, and moist. Wound dressings should eliminate dead space, control
exudate, prevent bacterial overgrowth, ensure proper fluid balance, be cost-efficient, and
be manageable for the patient and/or nursing staff. Wounds that demonstrate progressive
healing as evidenced by granulation tissue and epithelialization can undergo closure or
coverage. All wounds are colonized with microbes; however, not all wounds are infected
[4,5].

Many topical agents and alternative therapies are available that are meant to improve the
wound healing environment and, although data are lacking to support any definitive
recommendations, some may be useful under specific circumstances [6,7].

The basic principles and available options for the management of various wounds will be
reviewed. The efficacy of wound management strategies for the treatment of specific
wounds is discussed in individual topic reviews:

(See "Management of diabetic foot ulcers".)

(See "Medical management of lower extremity chronic venous disease", section on
'Ulcer care'.)
(See "Clinical staging and management of pressure-induced skin and soft tissue
injury", section on 'Wound management'.)
(See "Treatment of chronic lower extremity critical limb ischemia".)
(See "Overview and management strategies for the combined burn trauma patient".)

MEDICAL CARE

Role of antibiotics All wounds are colonized with microbes; however, not all wounds
are infected [4,5]. Thus, antibiotic therapy is not indicated for all wounds, and should be
reserved for wounds that appear clinically infected [8]. There is no published evidence to
support antibiotic therapy as "prophylaxis" in noninfected chronic wounds, or to improve
the healing potential of wounds without clinical evidence of infection. Clinical signs of
infection that warrant antibiotic therapy include local (cellulitis, lymphangitic streaking,
purulence, malodor, wet gangrene, osteomyelitis, etc) and systemic (fever, chills, nausea,
hypotension, hyperglycemia, leukocytosis, confusion) symptoms [9,10]. (See "Evaluation
and management of suspected sepsis and septic shock in adults" and "Cellulitis and skin
abscess: Treatment".)

Control of blood sugar Although there is no overwhelming clinical evidence in support

of short-term glycemic control as directly affecting wound healing potential or preventing
infection [11,12], most clinicians make glycemic control a priority when treating wounds
and infection. (See "Susceptibility to infections in persons with diabetes mellitus".)
Patients at risk for the development of chronic wounds often have comorbid conditions
associated with immunocompromised states (eg diabetes), and may not have classic
systemic signs of infection such as fever and leukocytosis on initial presentation [13]. In
these patients, hyperglycemia may be a more sensitive measure of infection.

WOUND DEBRIDEMENT Wounds that have devitalized tissue, contamination, or

residual suture material require debridement prior to further wound management. Acute
traumatic wounds may have irregular devitalized edges or foreign material within the
wound, and surgical wounds that have dehisced may have an infected exudate, bowel
contamination, or necrotic muscle or fascia. These materials impede the body's attempt to
heal by stimulating the production of abnormal metalloproteases and consuming the local
resources necessary for healing.

Characteristics of chronic wounds that prevent an adequate cellular response to wound-

healing stimuli include accumulation of devitalized tissue, decreased angiogenesis,
hyperkeratotic tissue, exudate, and biofilm formation (ie, bacterial overgrowth on the
surface of the wound) [14]. These wounds need planned serial debridement to restore an
optimal wound healing environment.

Wound bed preparation facilitates ordered restoration and regeneration of damaged

tissue, and may enhance the function of specialized wound care products and advanced
biologic tissue substitutes [15,16].

Irrigation Irrigation is important for decreasing bacterial load and removing loose
material, and should be a part of routine wound management [1,17,18]. Warm, isotonic
(normal) saline is typically used; however, systematic reviews have found no significant
differences in rates of infection for tap water compared with saline for wound cleansing
[19,20]. The addition of dilute iodine or other antiseptic solutions
(eg, chlorhexidine and hydrogen peroxide) is generally unnecessary. These solutions have
minimal action against bacteria and could potentially impede wound healing through toxic
effects on normal tissue [21-23]. (See 'Antiseptics and antimicrobial agents' below.)

Low pressure irrigation (eg, <15 pounds per square inch [psi]) is usually adequate to
remove material from the surface of most wounds. Decreased bacterial load has been
documented clinically with the use of pulsed irrigation in lower extremity chronic wounds
[24]. Bacteria do not appear to accompany the irrigation fluid into adjacent tissues in
animal studies even at higher pressure levels [25]. In an experimental model, high-
pressure irrigation decreased bacterial levels more than bulb irrigation (average reduction,
70 versus 44 percent) with no increase in the rate of bacteremia [26]. For highly
contaminated wounds, the benefits of reducing bacterial load may outweigh the risk of
speculative adjacent tissue damage associated with the use of higher irrigating pressures.
Although higher pressure irrigators may lead to local tissue damage and increased tissue
edema, there are no specific data available to suggest a specific cutoff pressure above
which tissue damage or impaired, rather than improved, wound healing will occur.
Surgical Sharp excisional debridement uses a scalpel or other sharp instruments (eg,
scissors or curette) to remove devitalized tissue and accumulated debris (biofilm). Sharp
excisional debridement of chronic wounds decreases bacterial load and stimulates
contraction and wound epithelialization [27]. Surgical debridement is the most appropriate
choice for removing large areas of necrotic tissue and is indicated whenever there is any
evidence of infection (cellulitis, sepsis). Surgical debridement is also indicated in the
management of chronic nonhealing wounds to remove infection, handle undermined
wound edges, or obtain deep tissue for culture and pathology [28-30]. Serial surgical
debridement in a clinical setting, when appropriate, appears to be associated with an
increased likelihood of healing [29,31].

In patients with active infection, antibiotic therapy should be targeted and determined by
wound culture and sensitivity to decrease the development of bacterial resistance [32,33].
(See "Cellulitis and skin abscess: Treatment".)

In patients with chronic critical limb ischemia, surgical debridement must be coupled with
revascularization in order to be successful [34]. (See "Treatment of chronic lower extremity
critical limb ischemia".)

Enzymatic Enzymatic debridement involves applying exogenous enzymatic agents to

the wound. Many products are commercially available (table 1), but results of clinical
studies are mixed and their use remains controversial [35]. Ulcer healing rates are not
improved with the use of most topical agents, including debriding enzymes [36].
However, collagenase may promote endothelial cell and keratinocyte migration, thereby
stimulating angiogenesis and epithelialization as its mechanism of action, rather than
functioning as a strict debridement agent [37]. It also remains a good option in patients
who require debridement but are not surgical candidates.

Biologic An additional method of wound debridement uses the larvae of the Australian
sheep blow fly (Lucilia [Phaenicia] cuprina) or green bottle fly (Lucilia [Phaenicia] sericata,
Medical Maggots, Monarch Labs, Irvine, CA) [38,39]. Maggot therapy can be used as a
bridge between debridement procedures, or for debridement of chronic wounds when
surgical debridement is not available or cannot be performed [40]. Maggot therapy may
also reduce the duration of antibiotic therapy in some patients [41].

Maggot therapy has been used in the treatment of pressure ulcers [42,43], chronic venous
ulceration [44-47], diabetic ulcers [38,48], and other acute and chronic wounds [49]. The
larvae secrete proteolytic enzymes that liquefy necrotic tissue which is subsequently
ingested while leaving healthy tissue intact. Basic and clinical research suggests that
maggot therapy has additional benefits, including antimicrobial action and stimulation of
wound healing [39,44,50,51]. However, randomized trials have not found consistent
reductions in the time to wound healing compared with standard wound therapy (eg,
debridement, hydrogel, moist dressings) [52,53]. maggot therapy appears to be at least
equivalent to hydrogel in terms of cost [53,54].
Dressing changes include the application of a perimeter dressing and a cover dressing of
mesh (chiffon) that helps direct the larvae into the wound and limits their migration (movie
1). Larvae are generally changed every 48 to 72 hours. One study that evaluated maggot
therapy in chronic venous wounds found no advantage to continuing maggot therapy
beyond one week [45]. Patients were randomly assigned to maggot therapy (n = 58) or
conventional treatment (n = 61). The difference in the slough percentage was significantly
increased in the maggot therapy group compared with the control groups at day 8 (67
versus 55 percent), but not at 15 or 30 days.

The larvae can also be applied within a prefabricated "biobag" (picture 1), commercially
available outside the United States, that facilitates application and dressing change [55-
58]. Randomized trials comparing "free range" with "biobag" contained larvae in the
debridement of wounds have not been performed.

A main disadvantage of maggot therapy relates to negative perceptions about its use by
patients and staff. One concern among patients is the possibility that the larvae can
escape the dressing, although this rarely occurs. Although one study identified that
approximately 50 percent of patients indicated they would prefer conventional wound
therapy over maggot therapy, 89 percent of the patients randomly assigned to maggot
therapy said they would undergo larval treatment again [59]. Pain associated with maggot
therapy may limit its use in approximately 20 percent of patients [60].

TOPICAL THERAPY

Growth factors Growth factors important for wound healing include platelet derived
growth factor (PDGF), fibroblast growth factor (FGF) and granulocyte-macrophage colony
stimulating factor (GM-CSF). (See "Wound healing and risk factors for non-healing".)

Recombinant human growth factors have been developed and are being actively
investigated for the treatment of chronic ulcers, mostly those affecting the lower extremity.

Platelet-derived growth factor Becaplermin is a platelet-derived growth factor

(PDGF) gel preparation that promotes cellular proliferation and angiogenesis, and
thereby improves wound healing [61]. It is approved for use in the United States as an
adjuvant therapy for the treatment of diabetic foot ulcers and is the only
pharmacological agent approved for treatment of chronic wounds. The growth factor
is delivered in a topical aqueous-based sodium carboxymethylcellulose gel. It is
indicated for noninfected diabetic foot ulcers that extend into the subcutaneous tissue
and have an adequate vascular supply [62]. A black box warning mentions a concern
for malignancy; however, the overall malignancy risk is believed to be low.
Malignancy complications of this therapy may reflect usage of the agent in multiple
courses of treatment, and possible selective transformation of wounds already at risk
[63]. A post-marketing study found an increased rate of mortality secondary to
malignancy in patients treated with three or more tubes of becaplermin (3.9 versus
 0.9 per 1000 person years) compared with controls [64,65]. (See "Management of
diabetic foot ulcers", section on 'Growth factors'.)
Epidermal growth factor In a study of chronic venous ulcers, topical application of
human recombinant epidermal growth factor was associated with a greater reduction
in ulcer size (7 versus 3 percent reduction) and higher ulcer healing rate (35 versus
11 percent) compared with placebo, but these differences were not statistically
significant [66]. Epithelialization was not significantly affected.
Granulocyte-macrophage colony stimulating factor Intradermal injections of
granulocyte-macrophage colony stimulating factor (GM-CSF) promote healing of
chronic leg ulcers, including venous ulcers [67,68]. A trial that randomly assigned 60
patients with venous ulcers to four weekly injections with GM-CSF 200 mcg, 400 mcg,
or placebo found significantly higher rates of healing at 13 weeks in the GM-CSF
group (57, 61, and 19 percent, respectively) [68]. GM-CSF has been used in various
types of chronic wounds to promote healing [69]. (See "Medical management of lower
extremity chronic venous disease", section on 'Ulcer care'.)

Antiseptics and antimicrobial agents Most topically-applied antiseptic and

antimicrobial products are irritating, partially cytotoxic leading to delayed healing, and can
cause contact sensitization. However, two of these agents may be associated with
potential benefits in select populations:

Iodine-based Cadexomer iodine (eg, Iodosorb) is an antimicrobial that reduces

bacterial load within the wound and stimulates healing by providing a moist wound
environment [70]. Cadexomer iodine is bacteriocidal to all gram-positive and gram-
negative bacteria. For topical preparations, there is some evidence to suggest that
Cadexomer iodine generates higher healing rates than standard care.

Silver-based Although silver is toxic to bacteria, silver-containing dressings have not

demonstrated significant benefits [71-73]. A systematic review evaluating topical silver in
infected wounds identified three trials that treated 847 participants with various silver-
containing dressings [74]. One trial compared silver-containing foam (Contreet) with
hydrocellular foam (Allevyn) in patients with leg ulcers. The second compared a silver-
containing alginate (Silvercel) with an alginate alone (Algosteril). The third trial compared a
silver-containing foam dressing (Contreet) with best local practice in patients with chronic
wounds. Silver-containing foam dressings were not found to significantly improve ulcer
healing at four weeks compared with non-silver-containing dressings for best local
practices. Nevertheless, silver dressings are used by many clinicians to decrease the
heavy bacterial surface contamination [75].

Honey Honey has been used since ancient times for the management of wounds.
Honey has broad spectrum antimicrobial activity due to its high osmolarity, and high
concentration of hydrogen peroxide [76]. Medical grade honey products are now available
as a gel, paste, and impregnated into adhesive, alginate, and colloid dressings [77,78].
Based upon the results of systematic reviews evaluating honey to aid healing in a variety
of wounds, there are insufficient data to provide any recommendations for the routine use
of honey for all wound types; specific wound types, such as burns, may benefit, whereas
others, such as chronic venous ulcers, may not [79-85].

Beta blockers Keratinocytes have beta-adrenergic receptors, and beta blockers may
influence their activity and increase the rate of maturation and migration. The use of
systemic beta blockers has been studied in burn patients [86], and several case studies
have presented the use of topical timolol in chronic wounds [87-89].

Timolol is a topically applied beta blocker with some limited evidence that it promotes
keratinocyte migration and epithelialization of chronic wounds, which have been
unresponsive to standard wound interventions.

WOUND DRESSINGS When a suitable dressing is applied to a wound and changed

appropriately, the dressing can arguably have a significant impact on the speed of wound
healing, wound strength and function of the repaired skin, and cosmetic appearance of the
resulting scar. No single dressing is perfect for all wounds; rather, a clinician should
evaluate individual wounds and choose the best dressing on a case-by-case basis.
Examples of differing types of wounds and potential dressings are given in the tables
(table 2 and table 3). In addition, wounds must be continually monitored as their
characteristics and dressing requirements change over time [90].

There is little clinical evidence to aid in the choice between the different types of wound
dressings. Consensus opinion supports the following general principles for chronic wound
management [91], but similar principles may be used for acute wound management:

Hydrogels for the debridement stage

Low-adherent and moisture-retentive dressings for the granulation stage
Low-adherent dressings for the epithelialization stage

For acute and chronic wound dressing selection, the degree of drainage/moisture balance
should guide the clinician. For all intents and purposes, dressings are best suited to
manage the moisture level in and around the wound. Although some may have additional
benefits in terms of local antimicrobial effects, reduced pain on change, odor control, and
anti-inflammatory or mild debridement ability, these are secondary benefits [92].

Dressings are typically changed once a day or every other day to avoid disturbing the
wound healing environment. Because some dressings may impede some aspects of
wound healing, they should be used with caution. As examples, alginate dressings with
high calcium content may impede epithelialization by triggering premature terminal
differentiation of keratinocytes [91], and highly silver-containing dressings are potentially
cytotoxic and should not be used in the absence of significant infection. (See 'Antiseptics
and antimicrobial agents' above and 'Alginates' below.)
The advantages and disadvantages of the various dressing types are discussed below.
(See 'Common dressings' below.)

Importance of moisture For much of the history of medicine, it was believed that
wounds should not be occluded but left exposed to the air. However, an important study in
a pig model showed that moist wounds healed more rapidly compared with wounds that
dried out [93]. Similar results have been obtained in humans [94-96].

Occluded wounds heal up to 40 percent more rapidly than non-occluded wounds [94]. This
is thought to be due, in part, to easier migration of epidermal cells in the moist environment
created by the dressing [95]. Another mechanism for improved wound healing may be the
exposure of the wound to its own fluid [97]. Acute wound fluid is rich in platelet-derived
growth factor, basic fibroblast growth factor, and has a balance of metalloproteases
serving a matrix custodial function [98]. These interact with one another and with other
cytokines to stimulate healing [99]. On the other hand, the effect of chronic wound fluid on
healing may not be beneficial. Chronic wound fluid is very different from acute wound fluid
and contains persistently elevated levels of inflammatory cytokines which may inhibit
proliferation of fibroblasts [100-102]. Excessive periwound edema and induration
contributes to the development of chronic wound fluid and should be managed to minimize
this effect. (See "Wound healing and risk factors for non-healing".)

In addition to faster wound healing, wounds treated with occlusive dressings are
associated with less prominent scar formation [103]. One study of porcine skin found an
acceleration in the inflammatory and proliferative phases of healing when wounds were
covered with an occlusive dressing as opposed to dry gauze [104]. This "acceleration"
through the wound phases may prevent the development of a chronic wound state which
is typically arrested in the inflammatory phase of healing. Wounds that have a greater
amount of inflammation tend to result in more significant scars, and thus the decreased
inflammation and proliferation seen with wound occlusion may also decrease the
appearance of the scar.

An ideal dressing is one that has the following characteristics (table 2):

Absorbs excessive wound fluid while maintaining a moist environment

Protects the wound from further mechanical or caustic damage
Prevents bacterial invasion or proliferation
Conforms to the wound shape and eliminates dead space
Debrides necrotic tissue
Does not macerate the surrounding viable tissue
Achieves hemostasis and minimizes edema through compression
Does not shed fibers or compounds that could cause a foreign body or
hypersensitivity reaction
Eliminates pain during and between dressing changes
 Minimizes dressing changes
Is inexpensive, readily available, and has a long shelf life
Is transparent in order to monitor wound appearance without disrupting dressing

In most cases, a dressing with all of these characteristics is not available, and a clinician
must decide which of these is most important in the case of a particular wound. The
moisture content of a wound bed must be kept in balance for both acute and chronic
wounds. The area should be moist enough to promote healing, but excess exudate must
be absorbed away from the wound to prevent maceration of the healthy tissue.

Common dressings Although dressings can be categorized based upon many

characteristics (table 2), it is most useful to classify dressings by their water-retaining
abilities because the primary goal of a dressing is the maintenance of moisture in the
wound environment. As such, dressings are classified as open, semi-open or semi-
occlusive.

Open dressings include, primarily, gauze, which is typically moistened with saline before
placing it into the wound. Gauze bandages are available in multiple sizes, including 2 x 2
inch and 4 x 4 inch square dressings and in 3 or 4 inch rolls (eg, Kerlix). Thicker absorbent
pads (eg, ABD pads) are used to cover the gauze dressings. For managing large wounds,
self-adhesive straps (Montgomery straps) can be used to hold a bulky dressing in place.
As discussed above, dried gauze dressings are discouraged. Wet-to-moist gauze
dressings are useful for packing large soft-tissue defects until wound closure or coverage
can be performed. Gauze dressings are inexpensive but often require frequent dressing
changes.

Semi-open dressings typically consist of fine mesh gauze impregnated with petroleum,
paraffin wax, or other ointment, and have product names such as Xeroform, Adaptic,
Jelonet, and Sofra Tulle. This initial layer is covered by a secondary dressing of absorbent
gauze and padding, then finally a third layer of tape or other method of adhesive. Benefits
of semi-open dressings include their minimum expense and their ease of application. The
main disadvantage of this type of dressing is that it does not maintain a moisture-rich
environment or provide good exudate control. Fluid is permitted to seep through the first
layer and is collected in the second layer, allowing for both desiccation of the wound bed
and maceration of the surrounding tissue in contact with the secondary layer. Other
disadvantages include the bulk of the dressing, its awkwardness when applied to certain
areas, and the need for frequent changing.

Semi-occlusive dressings come in a wide variety of occlusive properties, absorptive

capacities, conformability, and bacteriostatic activity. Semi-occlusive dressings include
films, foams, alginates, hydrocolloids, and hydrogels, and are discussed below.

Films Polymer films are transparent sheets of synthetic self-adhesive dressing that are
permeable to gases such as water vapor and oxygen but impermeable to larger molecules
including proteins and bacteria. This property enables insensible water loss to evaporate,
traps wound fluid enzymes within the dressing, and prevents bacterial invasion. These
dressings are sometimes known as synthetic adhesive moisture-vapor-permeable
dressings, and include Tegaderm, Cutifilm, Blisterfilm, and Bioclusive. Transparent film
dressings were found to provide the fastest healing rates, lowest infection rates, and to be
the most cost-effective method for dressing split-thickness skin graft donor sites in a
review of 33 published studies [105].

Advantages of these dressings include their ability to maintain moisture, encourage rapid
re-epithelization, and their transparency and self-adhesive properties. Disadvantages of
film dressings include limited absorptive capacity, and they are not appropriate for
moderately to heavily exudative wounds. If they are allowed to remain in place over a
wound with heavy exudates, the surrounding skin is likely to become macerated. In
addition, if the wound dries out, film dressings may adhere to the wound and be painful
and damaging to remove.

Foams Foam dressings can be thought of as film dressings with the addition of
absorbency. They consist of two layers, a hydrophilic silicone or polyurethane-based foam
that lies against the wound surface, and a hydrophobic, gas permeable backing to prevent
leakage and bacterial contamination. Some foams require a secondary adhesive dressing.
Foams are marketed under names such as Allevyn, Adhesive, Lyofoam, and Spyrosorb.

Advantages of foams include their high absorptive capacity and the fact that they conform
to the shape of the wound and can be used to pack cavities. Disadvantages of foams
include the opacity of the dressings and the fact that they may need to be changed each
day. Foam dressings may not be appropriate on minimally exudative wounds, as they may
cause desiccation.

One small trial compared foams to films as dressings for skin tears in institutionalized
adults and found that more complete healing occurred in the group using foams [106].

Alginates Natural complex polysaccharides from various types of algae form the basis
of alginate dressings. Their activity as dressings is unique because they are insoluble in
water, but in the sodium-rich wound fluid environment these complexes exchange calcium
ions for sodium ions and form an amorphous gel that packs and covers the wound.
Alginates come in various forms including ribbons, beads, and pads. Their absorptive
capacity ranges depending upon the type of polysaccharide used. In general, these
dressings are more appropriate for moderately to heavily exudative wounds.

Advantages of alginates include augmentation of hemostasis [107,108], they can be used

for wound packing, most can be washed away with normal saline in order to minimize pain
during dressing changes, and they can stay in place for several days. Disadvantages of
alginates are that they require a secondary dressing that must be removed in order to
monitor the wound, they can be too drying on a minimally exudative wound, and they have
an unpleasant odor.

In a trial of 77 patients, patients with diabetic foot wounds were randomly assigned to
alginate or petroleum gauze dressings [109]. Patients treated with alginates were found to
have significantly superior granulation tissue coverage at four weeks of treatment,
significantly less pain, and fewer dressing changes than the petroleum gauze group.

Hydrocolloids Hydrocolloid dressings usually consist of a gel or foam on a carrier of

self-adhesive polyurethane film. The colloid composition of this dressing traps exudate and
creates a moist environment. Bacteria and debris are also trapped, and washed away with
dressing changes in a gentle, painless form of mechanical debridement. Another
advantage of hydrocolloids is the ability to use them for packing wounds. Disadvantages
include malodor and the potential need for daily dressing changes, and allergic contact
dermatitis has been reported [110]. Hydrocolloid products include DuoDERM, Tegasorb, J
and J Ulcer Dressing, and Comfeel.

Cadexomer iodine is a type of hydrocolloid in which iodine is dispersed and slowly

released after it comes in contact with wound fluid. The concentration of iodine released is
low and does not cause tissue damage [111]. A multi-center trial found that over a 12-
week period, Cadexomer iodine paste was more cost-effective than non-iodinated
hydrocolloid dressing or paraffin gauze dressing in patients with exudating venous ulcers
[112]. A systematic review found some evidence that topical application of Cadexomer
iodine enhanced venous ulcer healing rates compared with standard care (with and
without compression) [36]. The treatment regimen was complex and it is unclear if the
results are generalizable to most clinical settings. Iodine-induced hyperthyroidism has
been documented with use of Cadexomer iodine for leg ulcers [113]. (See 'Antiseptics and
antimicrobial agents' above.)

Hydrogels Hydrogels are a matrix of various types of synthetic polymers with >95
percent water formed into sheets, gels, or foams that are usually sandwiched between two
sheets of removable film. The inner layer is placed against the wound, and the outer layer
can be removed to make the dressing permeable to fluid. Sometimes a secondary
adhesive dressing is needed. These unique matrices can absorb or donate water
depending upon the hydration state of the tissue that surrounds them. Hydrogel products
include Intrasite Gel, Vigilon, Carrington Gel, and Elastogel.

Hydrogels are most useful for dry wounds. They initially lower the temperature of the
wound environment they cover, which provides cooling pain relief for some patients [114].
As a disadvantage, although there have been no reports of increased wound infection,
hydrogels have been found to selectively permit gram-negative bacteria to proliferate
[115].
Hydroactive Hydroactive, the most recently developed synthetic dressing, is a
polyurethane matrix that combines the properties of a gel and a foam. Hydroactive
selectively absorbs excess water while leaving growth factors and other proteins behind
[116].

A randomized trial compared hydroactive dressings with two different hydrocolloids and
found the hydroactive dressing to be equally effective at promoting ulcer healing and
alleviating ulcer-associated pain after 12 weeks of treatment [117]. Another study found
hydroactive dressings combined with enzymatic debridement to be more cost-efficient than
gauze alone in dressing pressure ulcers and venous stasis ulcers [118].

WOUND PACKING Wounds with large soft-tissue defects may have an area of dead
space between the surface of intact healthy skin and the wound base. These wounds are
described as tunneled or undermined. Undermining is defined as extension of the wound
under intact skin edges such that the wound measures larger at its base than is
appreciated at the skin surface.

When describing and documenting undermined wounds, it is important to accurately

measure the depth of undermining in centimeters and location of undermining using clock
formation as a guide (12:00, 6:00, etc.). The presence of necrotic tissue indicates the need
for surgical debridement to decrease bacterial burden and prevent sequelae of infection
[32].

Although there have been no specific trials comparing packed versus unpacked wounds,
wound packing is considered standard care [119]. Traditional gauze dressings are often
used to pack wounds associated with significant dead space or undermining to aid in
continuing debridement of devitalized tissue from the wound bed. The gauze is moistened
with normal saline or tap water and placed into the wound and covered with dry layers of
gauze. As the moistened gauze dries, it adheres to surface tissues, which are then
removed when the dressing is changed. Dressing changes should be frequent enough that
the gauze does not dry out completely, which can be two to three times daily. A
disadvantage of gauze dressings is that they can also remove developing granulation
tissue, resulting in reinjury. Thus, these dressings are discontinued when the necrotic
tissue has been removed and granulation is occurring. An alternative to gauze dressing for
managing wounds with significant dead space is negative pressure wound therapy.
(See 'Negative pressure wound therapy' below.)

Many of the materials that are used as topical dressings for wounds (foams, alginates,
hydrogels) can be molded into the shape of the wound and are useful for wound packing.
As with their use in dressing wounds, there is little consensus over what constitutes the
best material for wound packing. (See 'Wound dressings' above.)

Wound dressing changes associated with large defects can be managed without repeated
applications of tape to the skin by using Montgomery straps (picture 2).
WOUND CLOSURE Primary closure refers to the suture or staple closure of acute
surgical or traumatic wounds after appropriate wound preparation (figure 1 and figure 2).
(See "Minor wound preparation and irrigation" and "Closure of minor skin wounds with
sutures" and "Closure of minor skin wounds with staples".)

Delayed primary closure achieves skin edge apposition following an interval of wound
management. Delayed closure in abdominal wounds, chest wounds, and surgical wounds
without evidence of infection is widely accepted (figure 1) [120]. However, a chronic wound
should never be closed primarily. In contrast, delayed closure or coverage of chronic
wounds is accepted.

Negative pressure wound therapy Negative pressure wound therapy enhances

wound healing by reducing edema surrounding the wound, stimulating circulation, and
increasing the rate of granulation tissue formation [121-124]. The technique involves the
application of a controlled subatmospheric pressure to a wound covered with a foam
dressing. Negative pressure wound therapy is useful to manage large defects until closure
can be performed. It has also been used with modest success in the treatment of pressure
ulcers [125-127], and diabetic wounds [124,128]. (See "Negative pressure wound
therapy".)

WOUND COVERAGE

Skin grafts Split-thickness and full-thickness skin grafts are the most basic biologic
dressings and consist of skin taken from a donor site and grafted onto a wound on the
same patient. Skin grafts are used for wound closure, to prevent fluid and electrolyte loss,
and reduce bacterial burden and infection. Skin transplanted from one location to another
on the same individual is termed an autogenous graft or autograft.

Skin grafts are classified as either split-thickness or full-thickness, depending upon the
amount of dermis included in the graft. A partial or split-thickness skin graft contains a
variable thickness of dermis, while a full-thickness skin graft contains the entire dermis.
The characteristics of normal skin are maintained with a thicker dermal component.
However, thicker grafts require a more robust wound bed due to the greater amount of
tissue that needs to be revascularized. The choice between full- and split-thickness skin
grafting depends upon the condition of the wound, location, size, and need for cosmesis
[129,130].

Full-thickness skin grafts Full-thickness grafts contain the epidermis and dermis, and
thus retain more of the characteristics of normal skin, including color, texture, and
thickness, when compared with split-thickness grafts. Full-thickness skin grafts are limited
to relatively small, uncontaminated, well-vascularized wounds. The skin used for full-
thickness skin grafts is obtained from areas of redundant and pliable skin such as the
groin, lateral thigh, lower abdomen, or lateral chest. Donor sites are usually closed
primarily. The main disadvantages of full-thickness grafts include limited availability of
donor skin and the potential for fluid accumulation beneath the graft.

Split-thickness skin grafts Split-thickness skin grafts are commonly used tissue for
wound coverage. A split-thickness skin graft includes the epidermis and a variable amount
of dermis ranging between 0.008 to 0.012 inches (picture 3). Split-thickness skin grafts are
further categorized as thin (0.005 to 0.012 inches), intermediate (0.012 to 0.018 inches), or
thick (0.018 to 0.030 inches) based upon the thickness of graft harvested.

Compared with full-thickness skin grafts, split-thickness skin grafts tolerate a less-than-
ideal wound bed and have a broader range of applications. They can be used to resurface
large wounds, line cavities, resurface mucosal deficits, close donor sites of flaps, and
resurface muscle flaps. They also are used to achieve temporary closure of wounds
created by the removal of lesions that require pathologic examination prior to definitive
reconstruction. Split-thickness skin grafts have been used successfully in treating large
chronic wounds, including those on the leg and sole of the foot, provided the area can be
protected against chronic vertical and shear stresses.

Split-thickness skin grafts can be meshed to provide coverage of a greater surface area at
the recipient site, with expansion ratios generally ranging from 1:1 to 6:1. Split-thickness
skin graft donor sites heal spontaneously with cells supplied by the remaining epidermal
appendages. Donor sites can be re-harvested once healing is complete.

Split-thickness grafts have disadvantages that need to be considered. Split-thickness

grafts are more fragile, especially when placed over areas with little underlying soft tissue
bulk for support. They contract more during healing, do not grow with the individual, and
tend to be smoother and shinier than normal skin because of the absence of skin
appendages in the graft. They also tend to be abnormally pigmented, either pale or white,
or alternatively, hyperpigmented, particularly in darker-skinned individuals. For these
reasons, split-thickness skin grafts are more widely used for control of infection and
prevention of fluid/electrolyte loss rather than cosmesis [129,131].

Biologic (cell-based dressings) Biologic cell-based dressings are composed of a live-

cell construct that contains at least one layer of live allogenic cells.

Cell-based dressings can be used when traditional dressings have failed or are deemed
inappropriate [132]. One study suggested that advanced biologics should be used when
chronic wounds fail to heal at an appropriate rate of closure, (ie, 55 percent reduction in
wound area within four weeks of treatment) [133]. Cell-based dressings are ideal for the
treatment of chronic ulcers because additional cells and growth factors are added to a
deficient wound-healing environment. Accelerated wound healing reduces the risk of
wound infection.

Cell-based therapies may use epidermal and dermal elements. Other therapies focus on
dermal elements such as collagen and fibroblasts, which prevent wound contraction and
provide greater stability [134]. Apligraf combined with compression therapy has been
found to improve healing of venous stasis ulcers compared with compression therapy
[135]. Clinical rejection has not been reported. Cell-based therapies have also been
studied in patients with diabetes [136-139]. In one study of 208 patients with noninfected
neuropathic ulcers, weekly application of Graftskin for four weeks improved the rate of
complete wound healing compared with usual care (56 versus 38 percent) [136]. Other
studies have shown Dermagraft to be superior to standard care in the healing of diabetic
foot ulcers [140,141].

Acellular matrices serve as a scaffold, which may assist in forming some of the structure,
components, and signaling mechanism to assist in healing and regeneration. Some of
these include AlloDerm, which is made of decellularized allogenic dermal component, and
Integra, which is a bovine collagen-based dermal matrix. These been used successfully for
treating burn wounds [142-145].

ADJUNCTIVE THERAPIES

Hyperbaric oxygen therapy Hyperbaric oxygen therapy (HBOT) has been shown, in
vitro, to have effects on wound healing [146]. Endothelial progenitor cells play an important
role in wound healing because they participate in the formation of new blood vessels in
areas of hypoxia [147]. Although hyperoxia induced by HBOT effectively improves
endothelial progenitor cells' mobilization, therapy is not targeted to the wound site. Serious
adverse events can be associated with HBOT including seizures and pneumothorax.
(See "Hyperbaric oxygen therapy", section on 'Mechanisms of action'.)

When indicated, HBOT is accomplished in a specialized chamber that allows for patient
monitoring. Chamber pressure is typically maintained between 2.5 and 3.0 atmospheres of
pressured oxygen or air. Therapy for nonhealing wounds generally consists of daily
sessions of 1.5 to 2 hours for 20 to 40 days [146]. The mechanisms and technique of
HBOT are discussed in detail elsewhere. (See "Hyperbaric oxygen
therapy" and "Hyperbaric oxygen therapy", section on 'Technique'.)

HBOT has been used as an adjunct to wound care in the therapy of acute and chronic
wounds [148-153]. Most studies are observational and the few available trials are limited
by small sample size and low quality [154-156]. Systematic reviews have concluded that,
although hyperbaric oxygen may benefit some types of wounds (eg, diabetic ulcers), there
is insufficient evidence to support routine use [157,158]. Furthermore, although a number
of series and randomized trials of various sizes and quality have suggested its utility, later
works have suggested that HBOT may not have significant benefit in treatment of diabetic
foot ulcer healing and limb salvage [159]. (See "Overview of treatment of chronic wounds",
section on 'Hyperbaric oxygen therapy'.)

HBOT may be of value in patients with extensive soft tissue injury. A systematic review
identified three trials evaluating the use of HBOT in acute surgical and traumatic wounds
[160]. Due to the small numbers of included patients and heterogeneity of patients treated,
a metaanalysis could not be performed. The authors also noted a potential risk for bias. In
one of the trials, 36 patients with crush injuries were randomly assigned to a 90 minute
twice daily HBOT or sham treatments for a total of six days postoperatively [161]. The
group treated with hyperbaric oxygen had significantly more complete healing (17 versus
10 patients) and required fewer skin flaps, grafts, vascular surgery, or amputation (1
versus 6 patients). (See "Surgical management of severe extremity injury", section on 'Soft
tissue debridement/coverage'.)

Animal models of reperfusion following release of acute extremity compartment syndromes

suggest that the HBOT may be beneficial. (See "Patient management following extremity
fasciotomy", section on 'Hyperbaric oxygen'.)

A systematic review of HBOT in burn wounds found only two high quality trials and
concluded that there was insufficient evidence to support the use of HBO following thermal
injury [162]. The treatment of burn wounds is discussed in detail elsewhere. (See "Local
treatment of burns: Topical antimicrobial agents and dressings".)

HBOT may improve the survival of skin grafts and reconstructive flaps that have
compromised blood flow, thereby preventing tissue breakdown and the development of
wounds. Patients who require skin grafting or reconstructive flaps in areas with local
vascular compromise, previous radiation therapy, or in sites of previous graft failure may
benefit from prophylactic therapy. (See "Principles of grafts and flaps for reconstructive
surgery", section on 'Vascular compromise' and "Hyperbaric oxygen therapy", section on
'Radiation injury'.)

Other therapies A variety of other therapies, such as low frequency ultrasound

[163,164], electrical stimulation [165-168], electromagnetic therapy [169], and
phototherapy [170], have been investigated primarily for the treatment of pressure ulcers
or chronic venous wounds [171-175]. The treatment of pressure ulcers and chronic venous
wounds are discussed in detail elsewhere. (See "Clinical staging and management of
pressure-induced skin and soft tissue injury" and "Medical management of lower extremity
chronic venous disease", section on 'Ulcer care'.)

MANAGEMENT OF SPECIFIC WOUNDS

Acute wounds

Simple laceration Simple traumatic lacerations may be cleaned and closed

primarily with either staples or sutures. (See "Minor wound preparation and
irrigation" and "Closure of minor skin wounds with sutures" and "Closure of minor skin
wounds with staples".)
Complicated laceration Following cleansing of the wound and debridement, an
attempt is often made to close more complicated lacerations. It is not uncommon for
 the irregular skin edges or skin at sites where lacerations meet to break down. Plastic
surgery techniques may be needed to provide an acceptable cosmetic and functional
result. (See "Z-plasty".)
Large tissue defect Large tissue defects can result from traumatic wounds or the
need to remove devitalized tissue due to infection (eg, Fournier's gangrene). Once
the debridement is completed, the wound can be packed open with wet to moist
saline gauze dressings or using negative pressure wound therapy until the wound
bed allows for skin graft or flap closure [124].
Burns Burn wound care depends on many factors including the depth of the burn
and anatomic locations. (See "Emergency care of moderate and severe thermal
burns in adults", section on 'Wound management' and "Principles of burn
reconstruction: Overview of surgical procedures".)
Postoperative surgical incision Postoperative surgical incisions (clean, clean-
contaminated) are typically covered with a dry dressing that is held in place with an
adhesive (eg, tape, Tegaderm). The initial postoperative dressing can be removed
within 48 hours, provided the wound has remained dry. The timing with which the
patient can resume bathing/showering is not well defined [176]. A trial randomly
assigned 444 patients undergoing procedures classified as clean or clean-
contaminated (thyroid surgery, thoracoscopic surgery, open hernia repair, excision of
a skin tumor) to showering 48 hours after surgery or no showering [177]. The wound
was left uncovered for those who were allowed to shower, but covered with daily
dressing changes for those not allowed to shower. No significant difference was
found for the rate of surgical site infection between the groups (1.8 versus 2.7
percent).

Chronic wounds The management of chronic wounds (eg, pressure ulcers, diabetic
foot ulcers, ischemic ulcerations and gangrene, atypical and malignancy associated
wounds are reviewed separately.

SUMMARY AND RECOMMENDATIONS

For optimal wound healing, the wound bed needs to be well vascularized, free of
devitalized tissue, clear of infection, and moist. (See 'Introduction' above.)
Wound dressings should be chosen based upon their ability to manage dead space,
control exudate, reduce pain during dressing changes (as applicable), prevent
bacterial overgrowth, ensure proper fluid balance, be cost-efficient, and be
manageable for the patient or nursing staff. (See 'Wound packing' above and 'Wound
dressings' above.)
We suggest sharp surgical debridement over nonsurgical methods for the initial
debridement of devitalized tissue associated with acute and chronic wounds or ulcers
when possible (Grade 2C). (See 'Wound debridement' above.)
Topical agents such as antiseptics and antimicrobial agents can be used to control
locally heavy contamination. Significant improvements in rates of wound healing have
 not been found and tissue toxicity may be a significant disadvantage.
(See 'Antiseptics and antimicrobial agents' above.)
For deep wounds, negative pressure wound therapy may protect the wound and
reduce the complexity and depth of the defect. Negative pressure wound therapy is
frequently used to manage complex wounds prior to definitive closure. (See 'Negative
pressure wound therapy' above.)
Following wound bed preparation, acute wounds can often be closed primarily.
Chronic wounds that demonstrate progressive healing as evidenced by granulation
tissue and epithelialization along the wound edges can undergo delayed closure or
coverage with skin grafts or bioengineered tissues. (See 'Wound closure' above
and 'Wound coverage' above.)
Many other therapies have been used with the aim of enhancing wound healing and
include hyperbaric oxygen therapy, and wound stimulation using ultrasound,
electrical, and electromagnetic energy. Some of these therapies have shown a
marginal benefit in randomized studies, and may be useful as adjuncts for wound
healing. (See 'Adjunctive therapies' above.)

ACKNOWLEDGMENT We are saddened by the death of J Andrew Billings, MD, who

passed away in September 2015. UpToDate wishes to acknowledge Dr. Billings' many
contributions to palliative care, in particular, his work as our Editor-in-Chief and Section
Editor for Non Pain Symptoms: Assessment and Management.

Fundamentos basados en evidencias:

Las heridas cutneas son importantes en el consultorio de Medicina Familiar. Las

suturas, los adhesivos titulares, las suturas adhesivas, las grapas y las curas
oclusivas son opciones que se aplican en los pacientes ambulatorios.

Los mdicos deben estar familiarizados con diversas tcnicas de sutura,

incluyendo la sutura simple, la continua y la sutura de esquina (de colchonero
horizontal parcialmente enterrada). Aunque la sutura es el mtodo preferido para
la reparacin de heridas, los adhesivos titulares tienen la misma aceptacin por
parte del paciente, como as similares tasas de infeccin y riesgo de cicatrizacin
en reas de piel de baja tensin y pueden tener una relacin costo eficacia mayor.

La tcnica de aposicin de pelo con adhesivo tisular tambin es efectiva para

reparar las heridas del cuero cabelludo. El dolor del pinchazo del anestsico local
puede ser atenuado mediante el uso de agujas de pequeo calibre, administrando
la inyeccin lentamente y utilizando una solucin entibiada y neutralizada. Los
estudios han demostrado que luego del procedimiento, el agua corriente es segura
para la irrigacin, que el ungento de vaselina blanco es tan efectivo como el
ungento antibitico y que si la herida se humedece al cabo de 12 horas de la
sutura no aumenta el riesgo de infeccin. La educacin del paciente y un
procedimiento apropiado son muy importantes luego de la reparacin.

Recomendaciones prcticas

El suero fisiolgico o el agua corriente pueden usarse para irrigar la herida y

se evitar el uso de ioduro de povidona, detergentes o agua oxigenada.

Se puede disminuir la molestia de la inyeccin del anestsico local

administrando lentamente una solucin neutralizada.

La tcnica preferida para la reparacin de las heridas de piel es la sutura.

El resultado esttico de los adhesivos titulares son comparables a los de las

suturas, como as las tasas de dehiscencia y el riesgo de infeccin.

La aplicacin de vaselina a una herida estril facilita la cicatrizacin y es tan

efectiva como el ungento antibitico.

Heridas que requieren la consulta con el cirujano

Heridas profundas de la mano o del pie

Heridas profundas del espesor del prpado, labio u

orejas

Heridas con compromiso de nervios, arterias, huesos o

articulaciones

Heridas penetrantes de profundidad desconocida

Heridas contusas graves

Herida contaminadas que requieren drenaje

Heridas con mal pronstico esttico

Estas heridas merecen la consulta con el cirujano pero, finalmente, depende del
nivel de experiencia del mdico, su experiencia y su disposicin para el manejo de
las heridas.

El lapso ptimo desde que ocurri la herida hasta su reparacin no est

claramente definido. La decisin depende de la localizacin de la herida, la salud
del paciente, el mecanismo productor y los factores contaminantes.

Las heridas no contaminadas pueden repararse hasta 12 horas despus. Las

heridas limpias de tejido bien vascularizado (cara, cuero cabelludo) pueden
suturarse aun ms tarde en los individuos sanos, aunque debe minimizarse el
riesgo de infeccin. Independientemente de la localizacin. Para estas ltimas
heridas, los puntos simples interrumpidos flojos son suficientes. Si no hay
infeccin, la herida puede mantenerse cubierta de 3 a 5 das. Si hay infeccin, se
puede permitir que la herida cierre por segunda intencin.

Luego de irrigar copiosamente la herida, preferentemente con solucin salina o

agua corriente, entibiada, se procede a quitar los cuerpos extraos con una pinza
y los tejidos desvitalizados mediante desbridamiento romo, para reducir el riesgo
de infeccin. No conviene afeitar el pelo local para evitar la contaminacin. Se
debe evitar la aproximacin de los bordes de la herida de las cejas por el riesgo de
un crecimiento indeseable por una reaproximacin inapropiada, sin haber tenido
en cuenta la indemnidad de los bulbos pilosos.

Los anestsicos locales ms utilizados para las heridas pequeas son la lidocaina
al 1% o la bupivacaina al 0.25%. Para las heridas grandes de los miembros se
puede necesitar el bloqueo regional con el fin de evitar las dosis txicas del
anestsico local (lidocana 3-5 mg/kg sin epinefrina y hasta 7 mg/kg con
epinefrina; bupivacana, 1-2 mgkg sin epinefrina y hasta 3 mg/kg con epinefrina).
En los alrgicos a estos anestsicos se puede agregar una inyeccin intradrmica
de difenhidramina al 1%. En nios y pacientes que no toleran las inyecciones se
puede usar crema de lidocana/prilocana.

Tecnicas de reparacin

Suturas

Absorbibles: poliglactina 910, cido poligliclico, poliglecaprina 25. Se reabsorben

en 4-8 semanas.

No absorbibles: nylon y otras suturas monofilamento como el polipropileno. Deben

ser removidas.

Falta evaluar el papel de las suturas absorbibles continuas en heridas de piel de

baja tensin. La tasa de dehiscencia, el riesgo de infeccin y los resultados
estticos son comparables a los de las suturas no absorbibles; la relacin costo
efectividad es mayor debido a que no se requiere la extraccin de los puntos. No
se usa hilo de seda para la piel porque soporta poca tensin y provoca reaccin
tisular. Las suturas absorbibles se utilizan para las heridas en las mucosas.

Adhesivos titulares

El 2-octilcianoacrilato es un adhesivo con el que se obtienen resultados estticos

comparables a la suturas, como tambin son comparables las tasas de
dehiscencia y el riesgo de infeccin. Su tiempo de aplicacin es muy inferior, no
requiere anestesia y elimina la necesidad de un seguimiento debido a que
desaparece espontneamente a los 5-10 das.
Los adhesivos tisulares forman una barrera que favorece el cierre de la herida y
pueden tener efectos antimicrobianos. Son ms costosos que las suturas pero
tiene mejor relacin costo efectividad. Sin embargo, no son apropiados para zonas
de alta tensin, como las de las articulaciones, a menos que stas sean
inmovilizadas. Son ideales para heridas simples que quedan debajo de un yeso o
frula. Estn contraindicados en pacientes con riesgo de mala cicatrizacin
(diabticos, inmunosuprimidos) o heridas contaminadas, complejas o
anfractuosas. No se usan en las mucosas o zonas hmedas (ingle, axila).

Otras tcnicas

Para las heridas de las extremidades, tronco y cuero cabelludo, aunque no de la

cara, cuello, manos y pies, se puede usar una engrapadora automtica. Si se
planea hacer una tomografa computarizada o una resonancia magntica no estn
indicadas las grapas de acero inoxidable. Son una buena eleccin para
politraumatismos.

Las tiras de cierre para piel pueden ser efectivas para heridas pequeas, simples,
en zonas de baja tensin, con bordes bien aproximados, pero pueden resultar en
la dehiscencia de la herida. La tintura de benzocana utilizada como adjunto puede
causar reaccin inflamatoria.

Tiempo de espera para retirar los puntos de sutura o

grapas
Sitio de la herida Das
Cara Tres a 5
Cuero cabelludo Siete a 10
Brazos Siete a 10
Tronco 10-14
Piernas 10-14
Manos o pies 10-14
Palmas o plantas 14-21

Gua para la profilaxis del ttanos en adultos (19-64 aos) sometidos al

manejo rutinario de una herida

Todas las otras

Herida pequea, limpia
heridas*
Vacuna Vacuna
con con
Antecedente
toxoide Ig toxoide Ig
de toxoide
diftrico antitetnica diftrico antitetnica
tetnico
y y
tetnico tetnico
 y vacuna y vacuna
pertusis pertusis
acelular acelular
o Difteria o Difteria
y toxoide y toxoide
tetnico tetnico
reducido reducido
Desconoce
o menos de Si No Si Si
3 dosis
Ms de 3
No No No No
dosis

Traduccin y resumen objetivo: Dra. Marta Papponetti. Especialista en Medicina Interna.

Overview
Introduction

Wound irrigation is the steady flow of a solution across an open wound

surface to achieve wound hydration, to remove deeper debris, and to
assist with the visual examination. The irrigation solution is meant to
remove cellular debris and surface pathogens contained in wound
exudates or residue from topically applied wound care products.
Compared to swabbing or bathing, wound irrigation is considered to be
the most consistently effective method of wound cleansing. [1]
Normal wound healing is characterized by 3 interrelated phases:
inflammatory, proliferative or fibroplastic, and remodeling. In normal
wound healing, infectious microorganisms, foreign debris, and necrotic
tissue are removed from the wound during the inflammatory phase due to
vascular and cellular responses to trauma. However, weaknesses in the
bodys inflammatory response can cause deficits in its ability to
overpower surface microorganisms. This can lead to delayed
angiogenesis and granulation tissue formation, as well as infection.
Contaminating microorganisms can upset collagen synthesis and modify
matrix metalloproteinases, leading to anoxia and impeding neutrophil and
macrophage function.
Combined with debridement, irrigation is a critical step in facilitating
progression from the inflammatory to proliferative phase of wound healing
by removing debris that can impede the healing process. When
performed properly, wound irrigation can aid in wound healing from the
inside tissue layers outward to the skin surface. It may also help prevent
premature surface healing over an abscess pocket or infected tract. [2] The
goal of irrigation is to clean the wound while avoiding trauma to wound
bed and minimizing risk of driving bacteria further into the wound bed.
Key considerations - Selecting an irrigation solution

Choosing an appropriate solution is a critical step in wound irrigation.

Solutions intended for topical use include topical cleansers, antibiotics,
antifungals, antiseptics and anesthetics. Ideally, an irrigant should be
isotonic, nonhemolytic, nontoxic, transparent, easy to sterilize, and
inexpensive. Unfortunately, such a solution does not yet exist. Current
literature generally favors use of normal saline. Many antiseptics and
antibiotics have been employed, but the ideal additive is the subject of
debate. Cytotoxicity of the solution should certainly be considered. In
particular, antiseptic solutions, such as povidone-iodine, chlorhexidine,
and hydrogen peroxide, may be toxic to tissues and may negatively
influence acute wound healing. Some conventional topical irrigants are
discussed below.
Normal saline
Normal saline is isotonic and the most commonly used wound irrigation
solution due to safety(lowest toxicity) and physiologic factors. A
disadvantage is that it does not cleanse dirty, necrotic wounds as
effectively as other solutions. Similar wound infection rates have been
reported with potable tap water versus saline in adult and pediatric
populations. [3, 4] It is important to note the date of opening a saline
container, as bacterial growth in saline may be present within 24 hours of
opening the container.
Sterile water
Prepared by distillation, sterile water is nonpyrogenic and contains no
antimicrobial or bacteriostatic agents or added buffers. It is often used in
irrigation, particularly in developing countries, as a less expensive
alternative to isotonic saline. Sterile water is hypotonic and may cause
hemolysis and will be readily absorbed by the tissues during surgical
procedures; therefore, its use under such conditions is not recommended.
Water toxicity may result when excess volumes are used.
Potable water
Potable water is recommended in the event that normal saline or sterile
water are not available. Its use is particularly attractive in austere
environments. In fact, a few studies have shown potable water to be as
effective at reducing bacterial counts as normal saline.
Commercial wound cleansers
Commercial wound cleansers are increasingly used in irrigation.
Detergent irrigation is meant to remove, rather than kill, bacteria and has
seen promising results in animal models of the complex contaminated
musculoskeletal wound. [5]Due to the surfactant content in cleansers, less
force is required to remove bacteria and cellular debris. Thus, cleansers
may be best suited for wounds with adherent cellular debris or in dirty,
necrotic wounds. Trigger sprays can help direct the cleanser more
effectively and safely. Cleansers typically contain preservatives to slow
growth of bacteria, molds, and fungi, and extend product shelf life.
Povidone iodine
Povidone iodine is a broad spectrum antimicrobial solution effective
against a variety of pathogens including Staphylococcus aureus.
However, similar wound infection rates have been reported in adult and
pediatric populations with saline irrigation versus 1% povidone-
iodine. [3, 4] A disadvantage is its cytotoxicity to healthy cells and
granulating tissues. The solution dries and tends to discolor skin. It may
also cause local irritation to the periwound skin.
Hydrogen peroxide
A 3% solution of hydrogen peroxide is a commonly used wound
antiseptic. However, few studies report on its efficacy in wound healing
and as an antiseptic, and its use remains controversial. While some
studies have shown hydrogen peroxide to be cytotoxic to healthy cells
and granulating tissues, other animal and human studies have shown no
negative effect on wound healing. [6, 7] Several studies have also shown
hydrogen peroxide to be ineffective in reducing bacterial count. [7] The
American Medical Association summarized that the effervescing
cleansing action of hydrogen peroxide may act as a chemical debriding
agent to help lift debris and necrotic tissue from the wound surface when
used at full strength [8] If used, irrigation with normal saline after full-
strength hydrogen peroxide use is recommended. Use of hydrogen
peroxide is not recommended in wounds with sinus tracts.
Sodium hypochlorite
Sodium hypochlorite (ie, Dakins solution) has been classically used in
pressure ulcers with necrotic tissue to help control infection. Sodium
hypochlorite is known to have a bactericidal effect against most
organisms commonly found in open wounds. It is occasionally used over
cancerous growths to control bacteria and minimize odor. However, the
solution is known to be cytotoxic to healthy cells and granulating tissues,
and its use is not recommended for periods longer than 7-10 days.
Key considerations - Selecting method of solution delivery to the wound

The ideal irrigation technique and pressure required for optimal outcome
are still undetermined in the literature. [9] Equipment used for irrigation
includes bulb syringes, piston syringes, pressure canisters, whirlpool
agitator, whirlpool hose sprayer, irrigation fluid in plastic containers with a
pour cap or nozzle, and pulsed lavage (eg, jet lavage, mechanical lavage,
pulsatile lavage, mechanical irrigation, high-pressure irrigation).
Continuous irrigation is the uninterrupted stream of irrigant to the wounds
surface. Pulsed irrigation is the intermittent or interrupted pressurized
delivery of an irrigant, typically measured by the number of pulses per
second. Power-pulsed lavage is a wound irrigation system that uses an
electrically powered pump system to deliver a high volume of irrigation
solution under pressure. Outcomes of pulsed versus continuous pressure
appear to be similar.
Advantages of pressurized canisters compared to traditional methods of
irrigation include speed, simplicity and cost-effectiveness. Semirigid
ampoules and pressurized canisters also allow practitioners to irrigate
wounds without the risk of needle-stick injuries. Disadvantages include
the reliability of canisters and difficulties in warming contents to consistent
ambient temperature.
Key considerations - Choosing a sufficient pressure

The amount of pressure used in wound irrigation appears to be a

determining factor in successful wound cleansing, yet a paucity of well-
supported literature exists regarding optimal irrigant pressure. High
pressure is often used to describe acute wound irrigation; however,
pressure parameters have varied within this definition. For the purposes
of this discussion, high-pressure lavage, usually performed using syringes
and needles, is 35-70 pounds per square inch (psi), and low-pressure
irrigation is 1-15 psi, as defined by the American College of Surgeons.[10]
Seminal studies of high-pressure pulsating jet lavage (70 psi) indicated it
is more effective in reducing bacterial populations and removing necrotic
tissue and foreign particles versus bulb syringe and other low-pressure
systems. [11, 12] However, especially in chronic wounds, high pressure
irrigation systems have been shown to damage granulation and epithelial
tissue or cause discomfort to the patient. In all wounds, high pressure
may also drive bacteria into deeper compartments, causing increased risk
of infection, particularly in highly vascularized areas such as the scalp
and face.
Complications of high-pressure irrigation in acute bone and joint surgery
include visibly damaged bone, intramedullary seeding of bacteria, and
delayed healing of the fracture by lavage of the fracture zone. [13] With
high-pressure lavage, a possibility exists of pushing surface contaminants
into the mucosal epithelium.
Original Agency for Health Care Policy and Research (AHCPR)
guidelines describe safe and effective irrigation pressures as being 4-15
psi, based on a series of different studies. [12, 14, 15] Pressures greater than
15 psi may cause wound trauma and drive bacteria further into wounds.
These authors recommend using a 35-mL piston syringe with an 18-
gauge or 19-gauge tip for irrigation. A syringe with an attached 19-gauge
needle typically delivers an output pressure range of 11-31 psi; however,
the end pressure that reaches the wound could be as low as 8 psi. [16, 17]
Studies suggest that pressures of 8-12 psi are strong enough to
overcome adhesive forces of bacteria; [3, 17] however, maintaining
consistent pressure across the tissue beds has long been challenging to
control. Owens et al concluded from a controlled animal study that use of
a low-pressure device and saline solution to irrigate wounds is the best
choice in maintaining bacteria clearance longer than 48 hours. [18] Earlier
versus later (3 hours versus 12 hours) irrigation in a contaminated wound
model has also been reported to result in superior bacterial removal. [19]
Although current evidence appears to support greater advantages with
low-pressure wound irrigation, pressures lower than 4 psi have been
found to be insufficient in removing surface pathogens and debris. Needle
and syringe-generated pressures of 13 psi have been found to be more
effective in reducing inflammation and infection when compared to a bulb
syringe. [17] Manually squeezing punctured containers of irrigation fluid is
inadequate for pressure irrigation. In general, wound soaking without
suction is not effective in cleaning contaminated wounds and may
increase wound bacterial counts.
In summary, the benefits of higher pressures in reducing bacterial count,
dirt, and tissue debris in heavily contaminated wounds may outweigh the
risk of tissue injury. In relatively clean wounds, the potential damage of
tissue resulting from high-pressure irrigation may outweigh the benefits. [9]
Key considerations - Using sufficient volume

Increased volume improves wound cleansing to a point, but optimal

volume in wound irrigation remains largely understudied. Volumes of 50-
100 mL per centimeter of laceration length or per square centimeter of a
wound are commonly reported in the literature. [3, 20]
Importantly, irrigation volume should be determined according to wound
characteristics and degree of contamination. In the case of more
contaminated wounds, the wounds should be irrigated until all visible
debris is removed. Copious amounts of potable tap water or saline should
be used for irrigation and decontamination of chemical burns. [21]
Key considerations - Precautions and protection against splashback

Irrigation, particularly high pressure, can splash and spread bacteria to

surrounding areas and people. The use of a plastic shield at the end of
the irrigating syringe reduces this hazard. Where needed, a face shield,
mask, and protection over scrubs is advised. IV sites and other open
areas should be protected from splashing.
Indications

Most wounds should be irrigated initially and at each dressing change. All
wound surfaces should be irrigated, which may require opening wound
edges and flaps for exposure. Wounds should be irrigated again upon re-
examination.
Precautions and contraindications

Pulsed lavage should not be performed over exposed blood vessels,

nerves, tendons, or bone.
Pulsed lavage should not be performed in the presence of active, profuse
bleeding (precautionary measures for patients on anticoagulation
medication).
Improper technique may harm the wound bed.
Patients with sensory impairment are unable to provide accurate
feedback needed to guide the clinician if improper technique is used.
Hydrodebridement

Hydrodebridement is the synchronous application of an irrigant in tandem

with debridement. Particularly in the presence of thick exudate, slough, or
necrotic tissue, hydrodebridement may aid in cleansing and mechanical
debridement. Both low-pressure and high-pressure methods of
hydrodebridement have been used to optimize the effects of debridement,
reduce bioburden, and manage exudateall integral parts of wound bed
preparation.
An emerging application of low-pressure hydrodebridement is in tandem
with negative-pressure wound therapy (NPWT). Some NPWT systems
are equipped with technology that allows automatic instillation of topical
solutions to be delivered and removed from the wound site during NPWT.
This technology is indicated for patients who would benefit from vacuum-
assisted drainage and controlled delivery of topical wound treatment
solutions and suspensions over the wound bed. NPWT can be used with
a range of solutions intended for topical use, including cleansers,
antibiotics, antifungals, antiseptics, and anesthetics. Regular instillation of
topical solutions during NPWT can assist with wound cleansing, irrigation,
pain, and removal of infectious material. [21] See the image below.

Wound receiving
negative-pressure wound therapy (NPWT) and solution instillation.

Instilling solutions with NPWT increases the viscosity of the wound fluid
and allows more efficient removal through the reticulated open-cell foam
dressing and into the canister. Solutions are delivered continuously or at
timed intervals, and are gravity fed, or intermittently pumped into the
wound, depending upon the NPWT system. Wounds with significant
debris and bacterial contamination can be irrigated when needed at
increased pressures (fluid delivered at 8-12 psi such as with a 35 mL
syringe and a 19-gauge angiocatheter) during NPWT dressing changes.
NPWT with solution instillation has been advocated in cases of diffuse or
extensively treated osteomyelitis, large areas of postdebrided exposed
bone or joint, and in cases of critical bacterial colonization levels as an
alternative to antibiotic-impregnated beads when
appropriate. [22] Anecdotal evidence suggests topical solution instillation
may enhance the efficacy of NPWT in cases of high levels of exudate and
slough content, as well as acute traumatic wounds or wounds acutely
debrided due to infected hardware or soft tissue. [23, 24] However, large
controlled studies are needed to substantiate the effects of solution
instillation with NPWT.
Although topical antibiotics are commonly used in wound infection
prophylaxis and treatment, well-controlled research supporting optimal
topical antibiotic treatment regimens is lacking. In addition, risk of
antibiotic resistance is an ongoing concern in the practice of topical
antibiotic use. The overall effectiveness of topical antibiotics is a subject
of hot debate that is beyond the scope of this article. The authors support
short-term use of appropriate topical antibiotic solutions, such as
vancomycin, bacitracin, and silver-based solutions (silver nitrate) with
NPWT in wounds that require antimicrobial therapy for management.
Continuous hydrocleansing has been reported to impede formation of
biofilms that allows bacteria to adhere to wound surfaces. [25] Evidence
suggests these biofilms gain resistance to antimicrobial treatments over
time and that selected topical antibiotics may be most effective within 24
hours of sharp debridement. [26]
Solutions that contain hydrogen peroxide or alcohol should not be used
with NPWT reticulated open-cell foam. Also, according to manufacturers
guidelines, instillation of fluids into thoracic or abdominal cavities is not
recommended due to the potential risk of altered core body temperature
and fluid retention within the cavity. In addition, topical wound solutions
should not be infused into wounds with unexplored tunnels or
undermining because the solutions may enter into unintended cavities.
High-pressure hydrodebridement, or hydrosurgery, combines lavage and
sharp debridement instrumentation. This technology is used to soften and
mechanically debride devitalized tissue, often prior to reconstruction.
Modern hydrosurgical devices project a high-velocity, razor-thin saline jet
stream, capable of cutting tissue, across an operating window into an
evacuation canister, creating a localized vacuum. The saline beam is
aimed parallel to the wound so that the cutting mechanism is a highly
selective form of tangential excision. Suction allows the surgeon to hold
and cut targeted tissue while aspirating debris from the site. In this way,
selective debridement of necrotic and damaged tissues is facilitated, and
viable and peripheral tissue is spared.
Advantages of hydrosurgical tools are ease of use, precision, speed and
safety in wound cleansing. Excision of contoured areas, web spaces, and
facial structures may be improved with the technology. Hydrosurgery is
most beneficial when the tissue to be removed is softer than the tissue
that should remain intact. For example, debriding desiccated eschar in
pressure sores covered with dry eschar is not effective. [27] Results of one
study showed a significant increase in bacterial air contamination
following debridement with a hydrosurgery tool; appropriate precautions
should be taken. [28] Further controlled studies are required to investigate
the cost-effectiveness of high pressure hydrodebridement in wound
management.