Wound ulcer

Rahul AP. BPT,MPT;MIAP.CVTP

• An injury to the tissue can be simply called as a wound

• A pressure ulcer is a wound caused by unrelieved pressure on the dermis and underlying vascular structure, usually between bone and support surface

Normal wound healing

• 3 overlapping phase

Inflammatory phase

• Characterized by vasodilatation, release of histamine and stimulation of nociceptive receptors

• This can be correlated with redness, heat, swelling and pain

Proliferative phase

• Characterized by the formation of granulation tissue

• Wound contraction starts

• Fibroblast in the wound develops in to collagen matrix

Maturation /remodeling phase

• Remodeling of the new epithelium

• It is an ongoing processes even after wound closure takes months to years

• Pt intervention starts at this stage

• In case of pressure wounds, when pressure is not relieved damage happens which cannot be repair or recover on their own

• When deeper vessels occluded decreased blood flow leads to cell death next to necrosis and finally a visible wound

• Superficial dermis can tolerate ischemia for 2-8hrs

• Deeper muscle fat tissue etc for 2hrs and less

• It occurs frequently who are immobilized for a long period of time

• Can occur at any age depends on the period

• It increases the risk of death in elderly individuals

Clinical presentation

• First sign of pressure ulceration is blanchableerythema with increased skin temperature

• Progression to superficial abrasion, blister

• Full thickness skin loss -bleeding is minimal

• Main areas – sacrum, coccyx, greater trochanter, ischial tuberosity ,calcaneus and lateral malleolus

Blanchable Erythema

Superficial abrasion

Full thickness skin loss

Wound examinationHistory

• It is taken to determine the primary problems

• History should include queries like mechanism of injury, date of onset, progression

• How long has wound been present

• Treatment history to date

• What types of health-care providers have been involved in the management of the wound

• History of previous wounds

• Co-morbidities – Patient’s capacity to heal can be limited by specific disease effects on tissue like integrity and perfusion, mobility, compliance, nutrition and risk for infection.

A. Diabetes

• abnormal glucose levels are not compatible with wound healing

• decreased sensation in feet cause high risk for breakdown

B. Vascular

• 1. Coronary Artery Disease – decreased circulating oxygen

• 2. Congestive Heart Failure – edema in lower extremities

• 3. Peripheral Vascular Disease – inadequate vascular support

• 4. Peripheral Arterial Disease – inadequate arterial support

C. Cancer

• 1. Radiation – high risk or may cause skin breakdown

• 2. Antineoplastic medications impair wound healing

Subjective examination

• It is to gather information about the current symptoms

• He should be questioned about behavior and characteristics of symptoms (pain associated with wound or to any extremity, are there any certain positions which keep symptoms better or worse)

Objective examination

• Here observation is the important component of data gathering

• Typically includes-type of lesion (ischemic arterial ulcer, venous insufficiency ulcer, neuropathic, rheumatoid ulcer etc)

• Stage of wound (stage 1 to 4)

• Type of drainage- will check the amount, color, consistency, and odor,serous (clear, watery); serosanguinous (clear red or reddish brown); purulent (thick, yellow, cloudy)

• Presence of edema

ischemic arterial ulcer

venous insufficiency ulcer

Neuropathic ulcer

rheumatoid ulcer

Aims of treatment

• Teach the patient self-care of wound management and identification of signs of infections

• Provide a moist wound healing environment

• reduces the necrotic tissue at wound site

• Decrease pain associated with wound

• Decrease the risk of infection

• Improve physical functions (if decreased secondary to wound)

Intervention

• Physical therapy intervention for wound management includes verity of modalities and appropriate wound dressing to promote healing

• the intervention plan should have a holistic view eg: patient with signs and symptoms with venous disease may also present with poor ankle ROMs.

• Wound must be cleansed and dressed but the limb should get compression for optimum healing.

Ultrasound therapy

• US can increase tissue temperature and it includes-acceleration of metabolic rate, reduction or control of pain and muscle spasm, increase circulation and increase soft tissue extensibility.

• It heats smaller and deeper areas than most superficial area. US heats tissue with high US absorption coefficient- tissues with high collagen content like tendon ligament joint capsule but not for fat with water content.

• US is not ideal for muscle heating because of low absorption but very effective in heating scar in muscle area because of increased collagen content

• Application of ultrasound stimulates cell activity and it accelerate inflammatory process.

• The skin repair and wound contraction will be accelerated.

• US stimulates the collagen secretion and have an affect on elastin properties which strengthen scar tissue.

• Procedure is done by covering the wound by a hydrogel and deliver US by a hand held applicator.

• Another option is apply US transmission gel over periwound area and treat from this region instead of the wound bed.

• The parameters that have been found to be effective for healing wound is 20% duty cycle, 0.8-1.0 W/cm² intensity, 3MHz frequency, for 5-10 minutes

• Treatment duration depends on the area of the wound

Electrical stimulation

• Electrical stimulation has effectiveness in facilitating healing in both acute and chronic wounds.

• It is used to eliminate bacterial load, promote granulation, reduce inflamation,edema,reduce wound related pain

• Electric stimulation has a galvanotoxic effect on the cells needed for healing

• By using high volt pulsed current (HVPC) directly in the wound can create these changes –attraction of neutrophils, macrophages, and epidermal cells which facilitate debridement and reepithelialization.

Method of application

Direct method of application-it includes an ES unit treatment and non treatment electrodes and a saline soaked gauze or hydrogel dressing over wound bed to enhance electrical conductivity.

Indirect method of application-here electrodes are placed around the periwound skin using gel.

Radiant heat

Infrared red radiation increases local wound and skin temperature facilitating metabolic rate and improving circulation to the wound site.

This technique is effective in treating chronic wounds even in the presence of vascular compromise.

Normothermia can be accomplished by warm up wound therapy system which includes, delivering moist heat through a non contact dressing.

Using a warming card which is placed in a sleeve on top of the sterile wound cover giving warmth up to 38degree C.

Negative pressure wound therapy(NPWT)

Npwt is a wound healing technique used to facilitate wound closure in acute surgical and challenging slow healing wounds.

VAC or vacuum assisted closure is the device used to provide negative pressure treatment.

An open cell foam dressing is placed in the wound and a suction tube is connected from the foam to the portable pump, an air tight seal is created over the foam and suction tube with a film.

A controlled amount of negative pressure (sub atmospheric) is applied through the foam to the wound bed.

For the first few days 48hrs pressure applied continuously via portable pump, after the withdrawal of significant amount of wound fluids it is done intermittently.

The foam is changed in every 12 hrs(infected wounds)

Short wave diathermy

• PSWD and CSWD have been used to treat chronic open wounds

• It provides radio waves to produce thermal and non thermal effect by facilitating one phase of healing to next.

• PSWD heats superficial tissues and CSWD heats deep muscle and joint tissue

• It increases fibroblast proliferation, collagen formation and tissue perfusion

• Treatment is delivered usually with out touching the skin, but with newer units pad can be placed over the wound dressing, compression garments etc..

Ultraviolet radiation

• It is a form of energy between x ray and visible light

• It is divided in to wavelength and bands

• Three bands useful for human skin are UVA,UVB and UVC

• It has bactericidal effects and it increases blood flow, enhance granulation tissue formation, stimulation of vitamin D

• Procedure is done on a clean wound with dressing removed using UVB or UVC lamp

• Treatment distance dosage frequency will vary on the status of the wound

Hyperbaric oxygen therapy

• HBO delivers 100% o2 to an individual who rest inside a sealed chamber at a pressure greater than atmosphere (full body chamber)

• It increases the amount of o2 available for cell metabolism, increase o2 in hypoxic tissue

• Topical hyperbaric o2 therapy THBO is used now a days Instead of full body chamber, localized limb chambers are used, so THBO delivered o2 directly to the surface of the wound through a portable unit.

• It is also used in combination therapy along with stimulation or with cold laser

Hyperbaric oxygen therapy

Hyperbaric oxygen therapy

Topical hyperbaric o2 therapy

Compression therapy

• The concept of compression therapy is based on a simple and efficient mechanical principle consisting of applying an elastic garment around an area of the body to control edema

• Edema not only inhibit wound healing by affecting perfusion of the tissue but also inactivates the ability of the skin to manage Bactria

• It should apply as soon as signs of swelling appears when leg wounds are present

Elevation

• It is not a compression technique but used to reduce some type of swelling (mild acute swelling) and is a precursor to compression

• Proper positioning and active ROM exercise should teach the patient in corporate with other means of swelling controlling technique like compression etc

Four layer bandage system

• Four-layer bandaging is a high-compression bandaging system (sub-bandage pressure 35-40mmHg at the ankle) that incorporates elastic layers to achieve a sustained level of compression over time. Since the development of the four-layer system over 15 years ago.

• The four-layer bandage system is primarily used in the treatment of venous ulceration and achieves healing in patients with both deep, superficial and combined venous incompetence. Four-layer bandaging can also be used to prevent recurrence in patients who are unable to wear elastic stockings.

• The short-stretch, elastic effect noted in four-layer bandaging has made this a useful treatment.

Indications

Primary uses

• Treatment of venous ulceration

• Prevention of ulcer recurrence if hosiery is not tolerated

• Symptomatic relief of superficial thrombophlebitis

Other uses

• Traumatic wounds with local oedema, for example pretibial lacerations

• Venous/lymphatic disorders

• Ulceration of mixed aetiology with an oedematouscomponent

Contraindications

• Patients with heart failure should not receive high-compression therapy. In this instance high compression will redistribute blood towards the centre of the body, thereby increasing the pre-load of the heart and possibly causing further overload and death

• patients with severe obliterative arteriosclerosis should not receive compression therapy.

Application

Layer 1: orthopaedic wool: Orthopaedic wool provides a layer of padding that protects areas at risk of high pressure

Layer 2: crepe bandage: This is the least effective layer as it simply adds extra absorbency and smoothsdown the orthopaedic layer prior to the application of the two outer compression bandages.

Layer 3: elastic extensible bandage: It is a highly extensible bandage that provides a sub-bandage pressure of approximately 17mmHg when applied at 50% overlap using a figure-of-eight technique.

Layer 4: elastic cohesive bandage: A frequent misconception is that the outer cohesive layer within the four-layer system is there simply to maintain the bandage position. In fact, this layer provides the higher level of compression (sub-bandage pressure approximately 23mmHg)

Long and short stretch bandages

• This both bandages are used to control edema and provide compression to support the lymphatic system

• Long stretch bandages provide a high resting pressure means they constrict when the wearer is resting.

• They do not provide significant working pressure. they are readily available and easy to wear.

• Short stretch bandages provide low resting pressure but provide high working pressure

• They are less stretchy, provide rigid appearance after application and this make more appropriate for edema treatment

• Working pressure increases the work of muscle like pumping activity and lower resting pressure make bandage more tolerable

• It need special training to apply like no: of layers, age condition and tension of the bandage etc…

Lymphedema bandage

• This is highly specialized bandage with multiple layers of padding materials and short stretch bandage which provide support to the lymph edematous body part.

• It provides support to the tissues with elasticity loss and facilitates a mild tissue pressure to empty the lymph vessels.

• It is applied to head and neck, chest, abdomen, genital area and back.

Compression garments

• It is widely used by clients all over the world, it is designed to venous blood flow in Les.

• Now it is designed to manage burns surgical scars to provide support to venous circulation ant to prevent reaccumulation of fluids It is not used as a treatment to remove excess fluids

• Another one is quilted garment which provide compression which is used by person who cannot apply support garment and whose skin is fragile.

• Venous return and lymphatic drainage is attained by altering the stitching channels

Guidlines for compression bandaging

• Arterial wound- no compression or very light long stretch bandage in 12-25mmhg is used

• Venous wounds-compression is essential,shortstretch bandage with high working preassure40mmhg

• Neuropathic wounds-if no arterial involvement compression with short stretch wrap

• Lymphedema-short stretch compression wrap untlelimb reduction then modarate to high compression 20-30mmhg 30 -40 mmhg

• Edema-same as lymphedema short stretch compression 23hours/day.

Wound dressing

• A dressing is an adjunct used by a person for application to a wound to promote healing or to prevent further harm. A dressing is designed to be in direct contact with the wound, which makes it different from a bandage.

• Choosing appropriate dressing should be on the basis of wound and periwound tissue. A product that preserves wound hydration limit fluid loss is ideal

• In moist wound dressing the following wound characteristics must be considered.

• Infection-present /absent

• Necrosis-remove/not

• Drainage-dry, adequate or excessive

• Granulation-present/not

• Epithelielization-present/not

• Periwound area-intact/at risk

• Odor-minimal/need reduction

Primary dressing- that applied directly to the wound

Secondary dressing-that applied over primary one