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 2016 Team patient to the practice for frequent instructions to record the discussion progress examinations and bandage took place and be given a handout Management changes. They must also be willing detailing at-home bandage care to to monitor the patient’s bandage help reinforce the information. at home and restrict the patient’s activity, including keeping the Clients should understand at-home Karen Theresa Ellis, LVT, VTS (Surgery) patient indoors. care is as important as in-clinic Gulf Coast Veterinary Specialists management and be given specific Houston, Texas In Rosie’s case, the veterinary team examples of why certain rules must prepared the clients for an initial be followed. For example, if the A wound may be allowed to heal via hospitalization period for wound patient is restricted to leash-walking, second-intention healing vs primary management and a transition to the client must understand that he closure because of extensive tissue outpatient bandage care at gradually or she should walk the patient on a loss resulting in defects too large for increasing intervals. 4-foot leash, remaining in control to primary closure and/or presence of prevent further injury. Otherwise, infection.¹ Second-intention healing Discharge Instructions clients may allow a patient restricted requires a significant time and When the patient is ready to monetary investment from clients, transition to at-home care, a detailed and ensuring they understand the discharge summary with specific Clients should in-hospital treatment and at-home instructions should be printed and care required for a successful out- reviewed with the client before the understand come is crucial to patient recovery. patient is brought to the discharge at-home care room, to allow the client to focus on is as important In Rosie’s case, the veterinary team the information and ask questions clearly explained the treatment plan without distractions. The client as in-hospital details to her owners, including should sign the practice’s copy of the management. potential risks, complications, preventive measures, and at-home bandage monitoring and care.

Before treatment, a team member, usually a veterinary nurse, should review a written estimate of all proposed treatment costs with the client, including the potential for additional expenses associated with any healing complications.

At-home care is an important component of the treatment plan and is critical to the successful management of wound care. Clients d FIGURE 7 Using patterned or customized bandages on patients helps pet owners feel excited must be willing and able to bring the about bandage visits.

October 2016 Veterinary Team Brief 31 CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED

Allowing to leash-walking to walk freely in understand the plan may be changed their fenced yard, believing it is a because of the patient’s progress— clients to safe, confined space and not realizing not because of any setback—and view the the patient could chase a squirrel and helps them feel more involved in the wound during reinjure the healing wound. patient’s care. Allowing clients to view the wound during bandage bandage Rosie’s owners were instructed to changes and see the healing process, changes and examine her bandage site twice a day, or sharing photographs at each visit, see the check for toe swelling and bandage also helps keep clients engaged in the slippage, restrict her activity to cage patient’s recovery. healing rest with strict leash-walking, and to progress make her wear an E-collar at all times Patients needing long-term bandages helps keep to prevent her licking or chewing the can be given patterned bandages bandage. The collar’s importance was or customized decorations to help them engaged emphasized because some owners clients feel excited about the bandage in the remove them when the patient seems visits. (See Figure 7, page 31.) When uncomfortable. the patient finally “graduates” from patient’s needing bandages, providing clients recovery. Rosie’s owners were also instructed to with a picture book of the bandages place a plastic bag over her bandage created especially for their pet can before taking her outdoors to keep it also strengthen the bond with the clean and dry and to remove the bag veterinary team. once indoors to prevent moisture forming inside the bag. When the Clients should be encouraged outer layer of the bandage becomes to contact a veterinary team wet, exogenous bacteria can migrate member by phone or email with into the wound.² any questions about a patient’s bandage and know when the Client Communication patient requires immediate atten- Second-intention wound healing is tion. Ask clients to email photo- a long process, and many adapta- graphs of areas of concern before a tions (eg, bandage type, frequency patient’s appointment. Advise them of change, medications needed) that that attempts to alter a bandage at differ from the original treatment home (eg, adding tape, elastic plan and expected healing duration bandages, or duct tape to keep it can occur. The veterinary team in place) could be detrimental to prepared Rosie’s owners for possible wound healing or cause serious changes in healing time and complications. Explaining in explained that progress observed at advance how these measures can each examination appointment increase healing time and incur could affect the treatment plan. additional expense may improve Open communication helps clients client compliance.

32 veterinaryteambrief.com October 2016 STATEMENT OF OWNERSHIP, MANAGEMENT, AND CIRCULATION Publication title: Veterinary Team Brief Publication number: 2324-917X Filing date: 10/1/16 Issue frequency: 10 times per year Number of issues published annually: 10 Annual subscription price: $50.00 Complete mailing address of known office of publication: 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104 Contact person: Lynn Bush- ell Telephone: 813-381-3585 Complete mailing address of headquarters or general business office of publisher:2021 S. Lewis Ave, Suite 760, Tulsa OK 74104 Full names and complete mailing addresses of publisher, editor, and managing editor: Eliza- Conclusion beth Green, 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104; Amy Mohl, 2021 S. Lewis Ave, Any long-term treatment can be challenging for Suite 760, Tulsa OK 74104; Paulette Senior, 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104 Owner: Educational Concepts LLC, 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104— clients because of the time commitment and Owners: Siegfried Ventures, 1924 S. Utica Ave, Tulsa OK 74104; Elizabeth Green, 2021 financial investment required, but frequent S. Lewis Ave, Suite 760, Tulsa OK 74104; John O’Brien, 12118 Nieman Rd, Overland communication can help guide them through Park KS 66213; Antoinette Passaretti, 3936 Sawmill Rd, Doylestown PA 18902 Known bondholders, mortgages, and other security holders owning or holding 1 percent the patient’s recovery process. In Rosie’s case, or more of total amount of bonds, mortgages or other securities: None Issue date the combined commitment to care and for circulation data below: September 2016 communication by the clients and all veterinary EXTENT AND NATURE OF CIRCULATION team members helped ensure successful Average No. No. Copies of treatment of her degloving injury. n Copies Each Single Issue Issue During Published Preceding 12 Nearest to References 1. Slatter D. Textbook of Small Animal Surgery. 3rd ed. Months Filing Date Philadelphia, PA: Saunders; 2003:265. Total number of copies 53,624 51,901 2. Swaim SF, Renberg WC, Shike KM. Small Animal Bandaging, Casting, and Splinting Techniques. Ames, IA: Wiley-Blackwell; 2011:10. Paid and/or requested circulation (1) Outside-County Paid/Requested Mail 42,095 40,765 Subscriptions Stated on PS Form 3541 TEAM (2) In-County Paid/Requested Mail 0 0 TAKEAWAYS Subscriptions Stated on PS Form 3541

(3) Sales through dealers and carriers, 7 9 Veterinarian: Degloving injuries street vendors, counter sales, and other frequently require multiple bandage non-USPS paid distribution changes over many weeks. Empower (4) Other classes mailed through USPS 0 0 the team to educate clients about home care for these challenging cases, Total paid and/or requested circulation 42,102 40,774 including the time commitment and financial investment, and they will Nonrequested distribution by mail frequently develop lasting bonds with (1) Outside-county as stated on PS form 3541 9,850 10,896 patients and clients. (2) In-county as stated on PS Form 3541 0 0 Nursing Team: Veterinary nurses play an important role in all aspects of (3) Other classes mailed through USPS 0 0 care of wounds left to heal by second intention, from the initial anesthetic (4) Nonrequested copies distributed 1,391 0 event to frequent bandage changes outside the mail to ongoing client communication, Total nonrequested distribution 11,241 10,896 especially about the likelihood the treatment plan may change because 53,343 51,670 every patient progresses differently. Total distribution Client Care Team: Patients with wounds Copies not distributed 281 231 that require long-term care and frequent Total 53,624 51,901 bandaging will be regular visitors to the practice. Help clients stay on track by Percent paid and/or requested circulation 78.9% 78.9% scheduling appropriate progress examinations, reminding clients of their Publication of statement of ownership: Printed in the October 2016 issue of this upcoming appointments, and facilitat- publication. Signature and title of editor, publisher, business manager, or owner: Elizabeth ing adding any photos or communica- Green, Publisher tion logs to the medical record. I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions (including fines or imprisonment) and/or civil sanctions (including civil penalties). October 2016 Veterinary Team Brief 33