Chronic Wounds: Evaluation and Management

 

Chronic wounds are those that do not progress through a normal, orderly, and timely sequence of repair. They are common and are often incorrectly treated. The morbidity and associated costs of chronic wounds highlight the need to implement wound prevention and treatment guidelines. Common lower extremity wounds include arterial, diabetic, pressure, and venous ulcers. Physical examination alone can often guide the diagnosis. All patients with a nonhealing lower extremity ulcer should have a vascular assessment, including documentation of wound location, size, depth, drainage, and tissue type; palpation of pedal pulses; and measurement of the ankle-brachial index. Atypical nonhealing wounds should be biopsied. The mainstay of treatment is the TIME principle: tissue debridement, infection control, moisture balance, and edges of the wound. After these general measures have been addressed, treatment is specific to the ulcer type. Patients with arterial ulcers should be immediately referred to a vascular surgeon for appropriate intervention. Treatment of venous ulcers involves compression and elevation of the lower extremities, plus exercise if tolerated. Diabetic foot ulcers are managed by offloading the foot and, if necessary, treating the underlying peripheral arterial disease. Pressure ulcers are managed by offloading the affected area.

A chronic wound is one that fails to progress through a normal, orderly, and timely sequence of repair, or in which the repair process fails to restore anatomic and functional integrity after three months.1 In 2014, wound care for Medicare beneficiaries cost an estimated $28 billion to $96.8 billion.2 A 2012 German study found a 1% to 2% prevalence of chronic nonhealing wounds in the general population.3 Chronic wounds, typically diabetic ulcers, preceded 85% of amputations.4 Some chronic wounds can take decades to heal, thus contributing to secondary conditions such as depression, and can ultimately lead to isolation and family distress. The five-year mortality rate after developing a diabetic ulcer is approximately 40%5; therefore, proper diagnosis and treatment of wounds and management of comorbidities are imperative.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The ankle-brachial index may not be accurate in patients with diabetic foot ulcers; the toe-brachial index should be used instead to screen for peripheral arterial disease.14

C

Disease-oriented study

Compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care.29

B

Cochrane review of lower-quality RCTs

Offloading with a total contact cast is the optimal treatment for diabetic foot ulcers.32,33

A

Cochrane review of RCTs and a single RCT comparing treatment outcomes

A repositioning schedule should be established to treat and prevent pressure ulcers in hospitalized patients, and patients should not be positioned on bony prominences.36,37

C

Consensus guidelines


RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The ankle-brachial index may not be accurate in patients with diabetic foot ulcers; the toe-brachial index should be used instead to screen for peripheral arterial disease.14

C

Disease-oriented study

Compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care.29

B

Cochrane review of lower-quality RCTs

Offloading with a total contact cast is the optimal treatment for diabetic foot ulcers.32,33

A

Cochrane review of RCTs and a single RCT comparing treatment outcomes

A repositioning schedule should be established to treat and prevent pressure ulcers in hospitalized patients, and patients should not be positioned on bony prominences.36,37

C

Consensus guidelines


RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN WOUND CARE

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not culture or treat clinically uninfected lower extremity wounds with systemic antibiotics.

American Podiatric Medical Association

Do not use whirlpools for wound management.

American Physical Therapy Association


Source: For more information on the Choosing Wisely

The Authors

show all author info

STEVEN BOWERS, DO, CWSP, FACHM, FAPWCA, is the network medical director of wound care and hyperbaric medicine at St. Luke's University Health Network, Bethlehem, Pa....

EGINIA FRANCO, MD, is a wound care fellow at the University of Illinois Hospital and Health Sciences System, Chicago. At the time this article was written, she was a third-year family medicine resident at St. Luke's University Health Network.

Address correspondence to Steven Bowers, DO, CWSP, FACHM, FAPWCA, St. Luke's University Health Network, 801 Ostrum St., Bethlehem, PA 18015 (email: steven.bowers@sluhn.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

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