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Degloving Wound Management by Second-Intention Healing

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Degloving Wound Management by Second-Intention Healing CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED TEACHING TARGET IN-HOSPITAL TREATMENT AND AT-HOME CARE OF WOUND HEALING BY SECOND INTENTION ARE EQUALLY IMPORTANT COMPONENTS OF OPEN WOUND MANAGEMENT. CLIENT EDUCATION IS CRITICAL FOR A SUCCESSFUL OUTCOME. Degloving Wound Management by Second-Intention Healing Caleb Hudson, DVM, MS, DACVS (Small Animal) Gulf Coast Veterinary Specialists Houston, Texas Case Summary Rosie, a 6-month-old spayed female region, and right forelimb radiographs Chihuahua mix, presented for showed fractures of the third, fourth, evaluation after being hit by a car and fifth metacarpal bones and the several hours earlier. No systemic first phalange of digit 3. Carpal abnormalities were noted. Physical palpation revealed no evidence of examination disclosed a large varus or valgus instability, indicating degloving injury over her right the carpal collateral ligaments were forelimb proximal to the carpal intact. Thoracic radiographs disclosed joint and extending distally to the clear lung fields and a normal-sized tips of the phalanges. cardiac silhouette with no evidence of pulmonary contusions. The wound involved approximately 50% of the distal limb circumference Surgical debridement was indicated, and consisted of full-thickness soft- and Rosie was premedicated with Photo courtesy of Dana Gale, DVM tissue loss on the dorsal aspect of the d FIGURE 1 Degloving wound at initial hydromorphone and midazolam. presentation with exposure of the third metacarpus with exposure of the Anesthesia was induced using metacarpal bone second, third, and fourth metacarpal propofol and maintained using bones. (See Figure 1.) The carpal and isoflurane inhalant anesthesia. digital pads were intact. Palpation of The degloving wound was flushed was collected from the wound site the distal right forelimb elicited thoroughly with sterile saline and and submitted for bacterial culture instability and crepitus in the wound surgically debrided. A tissue sample and susceptibility testing. October 2016 Veterinary Team Brief 27 CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED TABLE Treatment Second-Intention 1-6 Plan 1 Wound Healing Process Underlying Events Approximate Timing Granulation tissue • New capillaries develop in the Days 5 to 25 Three treatment options were formation wound site considered: surgical reconstruction • Fibroblast migration into wound with a skin flap or free skin graft, • Fibroblast-mediated collagen limb amputation, and open wound production care and promotion of second- Wound contraction • Wound fibroblasts differentiate Days 8 to 180 intention healing. into myofibroblasts • Myofibroblasts contain smooth ! Surgical reconstruction was not muscle actin pursued because of the wound • Myofibroblast contraction decreases wound surface area location and the underlying orthopedic injuries. Epithelialization • Epithelial cell proliferation Days 18 to 180 ! Amputation, which is a viable • Epithelial cells migrate across option for a severe degloving wound surface • Contact inhibition limits wound, was also not pursued epithelial proliferation because limb preservation is preferable when possible. ! Open wound management with TABLE bandaging and promotion of a Examples of Primary Dressing wound environment conducive 2 Options for Wound Management to second-intention healing was selected as Rosie’s best treatment Type of Stage of Indication Product option. Dressing Wound Healing for Use Adherent Inflammatory Necrotic tissue Cotton gauze Second-intention wound healing is in wound the healing process by initial granula- tion tissue formation followed by Hydrophilic Inflammatory Highly exudative Calcium alginate dressing myofibroblast-mediated wound and repair wound Maltodextrin dressing contraction and epithelialization Hydrogel Inflammatory Minimally exudative Hydrogel dressing (ie, growth of epithelial tissue over 1-5 and repair wound Hydrocolloid dressing the wound surface). (See Table 1.) Second-intention healing can be Nonadherent Maturation Wound with intact Petrolatum impregnated used to treat many wound types; skin surface gauze however, morbidity associated with Teflon pad Rayon pad wound contraction may result when second-intention healing is used to treat wounds in high motion areas such as joints. 28 veterinaryteambrief.com October 2016 A calcium alginate dressing was applied as the contact layer on the surface of Rosie’s wound. Other types of wound dressings are avail- able (see Table 2), but calcium alginate absorbs exudate and creates a hydrophilic gel over a wound surface, making it a good choice for highly exudative wounds.6 Also: ! The contact layer of Rosie’s bandage was covered with a secondary layer consisting of cotton cast padding to absorb exudate and protect the wound. ! The tertiary bandage layer consist- ed of woven cotton followed by Photo courtesy of Dana Gale, DVM Photo courtesy of Dana Gale, DVM elastic bandaging tape to provide d FIGURE 2 Degloving wound 4 days after d FIGURE 3 Degloving wound 11 days after initial debridement. Note the presence of initial debridement. A mature bed of compression and protect the outer early granulation tissue starting to form granulation tissue covers 95% of the surface of the bandage. diffusely over the wound surface and wound surface and some contraction of ! A palmar fiberglass splint was incor- necrotic tissue around the phalanges at the wound edges has occurred. the distal edges of the wound. porated into the tertiary bandage layer and empirical treatment with oral cefpodoxime q24h was initiated pending culture and susceptibility results. was removed under general anesthe- The volume and character of wound A bacterial culture obtained during sia. The second and third phalanges exudate, as well as the appearance of the initial wound debridement and associated digital pad on the the tissue on the wound surface, were showed no growth, but cefpodoxime second digit were excised because evaluated for evidence of infection. was continued for 2 weeks prophylac- they were necrotic. The remainder tically. Pain management consisted of of the wound site appeared healthy By hospital day 11, a healthy bed oxymorphone IV boluses q6h for the with some early granulation tissue of mature granulation tissue covered first 2 days and oral tramadol every formation. (See Figure 2.) Wound most of the wound and the edges q8-12h thereafter. management with calcium alginate had started to contract, resulting dressings was continued. in a smaller wound surface area. Two days after surgical debridement, (See Figure 3.) By hospital day Rosie’s bandage was removed, the Rosie remained hospitalized and her 14, the amount of wound exudate wound was flushed, and the calcium bandages were changed every 2 to 4 had decreased significantly and alginate dressing and bandage were days for the first 2 weeks of treatment. the calcium alginate dressing was replaced. Four days after initial During bandage changes, the wound changed to a petroleum-impregnated wound debridement, Rosie’s bandage surface was lavaged with sterile saline. nonadherent dressing. October 2016 Veterinary Team Brief 29 CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED Photo courtesy of Dana Gale, DVM Photo courtesy of Dana Gale, DVM Photo courtesy of Dana Gale, DVM d FIGURE 4 Degloving wound 6 weeks d FIGURE 5 Degloving wound 7 weeks d FIGURE 6 Mature scar at the site of the post-injury. Significant wound contraction post-injury. Wound epithelialization is previous degloving wound 8 months and epithelialization has occurred. The approximately 95% complete. post-injury open portion of the wound is covered by a mature bed of healthy granulation tissue. Outcome the wound was less than 1 cm in was continuing to contract to form a diameter. (See Figures 4 & 5.) By narrow scar. (See Figure 6.) n 8 weeks post-injury, the wound was completely epithelialized and the References 1. Pavletic MM. Atlas of Small Animal Wound Rosie was discharged on hospital day bandage was removed. Management and Reconstructive Surgery. 3rd ed. 14, and the wound was managed on Ames, IA: Wiley-Blackwell; 2010:17-29. 2. Hosgood G. Stages of wound healing and their an outpatient basis. By 6 weeks post- When Rosie presented for a final clinical relevance. Vet Clin North Am Small Anim injury, the wound had contracted medical progress examination 8 Pract. 2006;36(4):667-685. 3. Hosgood B. Open wounds. In: Tobias KM, and epithelialized to approximately months after her injury, she walked Johnson SA, eds. Veterinary Surgery: Small one-third of its size at initial presen- on her right forelimb with only Animal. St Louis, MO: Elsevier Saunders; 2012:1210-1220. tation, and by 7 weeks post-injury, subtle lameness and the wound site 4. Cornell K. Wound healing. In: Tobias KM, Johnson SA, eds. Veterinary Surgery: Small Animal. St Louis, MO: Elsevier Saunders; 2012:125-134. 5. Prpich CY, Santamaria AC, Simcock JO, Wong HK, Nimmo JS, Kuntz CA. Second intention Resources healing after wide local excision of soft tissue sarcomas in the distal aspects of the limbs in dogs: 31 cases (2005-2012). J Am Vet Med Assoc. ! Atlas of Small Animal Wound Management and Reconstructive Surgery, 2014;244(2):187-194. 3rd ed. Pavletic MM. Wiley-Blackwell; 2010. 6. Fahie MA, Shettko D. Evidence-based wound management: a systematic review of therapeutic ! Veterinary Surgery: Small Animal. Tobias KM, Spencer JA, eds. Elsevier agents to enhance granulation and epithelializa- Saunders; 2012. tion. Vet Clin North Am Small Anim Pract. 2007; 37(3):559-577. 30 veterinaryteambrief.com October
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