wound healing

Wound healing disorder: description

A wound is a transection of coherent tissue on the outer or inner surface of the body. If a wound does not heal or only badly, it is called a wound healing disorder. These include, but are not limited to, the development of bruising, accumulation of wound exudate under a wound (seroma), divergence of the wound margins, wound rupture, and especially infection.

In a chronic wound, the cohesion of the inner or outer skin barrier and underlying structures is by definition disrupted for at least eight weeks.

Occurrence

Between three and ten percent of wounds do not heal over a longer period of time. Around one percent of the total population has a chronic wound. In Germany, up to three million people should suffer from a wound healing disorder. This is one of the most common complications of surgery. In vascular surgery, wound healing disorders occur in up to 20 percent of all patients. People over the age of 60 have three times as many wound healing disorders as younger people. About 40 percent of long-term bedridden people suffer from a so-called decubitus ulcer – a badly healing ulcer due to bedsores.

The problem of a wound healing disorder is also the risk of recurrence. Since it usually arises on the basis of existing underlying conditions, it comes in more than 60 percent of cases repeatedly to a wound healing disorder.

wound healing

How the complex healing process of a wound runs, read in the article wound healing.

Wound healing disorder: symptoms

The main symptom of a wound healing disorder is the wound defect, which can show various forms. In addition, there are usually (severe) pains and also bleeding. In addition to the actual wound healing disorder further injuries such as bone, vascular or nerve damage can occur. Blood and lymph circulation disorders make the healing process more difficult and lead to other symptoms such as lymphoedema.

In a wound infection, the wound is red, overheated and foul smelling. The discharge of the wound increases significantly and there is (pressure) pain. Surrounding lymph nodes can swell as a sign of the immune reaction (painful). In addition to fever, this can be an indication of a dangerous blood poisoning (sepsis).

Wound healing disorder: causes and risk factors

Bad wound healing is triggered by a variety of factors. Often it is a chronic disease that a wound does not close. A distinction is made between local (ie in the area of ​​the wound) and systemic causes of a wound healing disorder.

Unfavorable wound conditions

The most important local risk factor for a wound healing disorder is unfavorable wound conditions. Especially wide, squeezed, dry or dirty wounds, which may also be infected, usually heal badly. The formation of pus and a bruise makes the healing process even more difficult. In addition, smooth cuts usually heal better than bites and small and superficial better than large and deep wounds.

Seams and bandages

The wound must be reached by sufficient oxygen. A wrong choice of dressing or a too tight seam can restrict the oxygen supply. The choice of wound dressing is therefore crucial for the healing process. Thus, the dressing should protect against dehydration, allow sufficient oxygen supply and do not stick with a newly formed skin layer.

When the wound has been sutured, it is important to find the right time for stringing (unless self-releasing suture material has been used). If the threads are pulled too early, the wound can rupture again. Too late stringing on the other hand favors the development of infections and hinders the final wound closure.

Age

In old age, wounds usually heal worse than in younger years. But this is also due to the more common comorbidities.

underlying diseases

The most common systemic causes of wound healing disorders are diabetes mellitus (especially diabetic foot syndrome) and vascular disease – especially chronic venous insufficiency (CVI, chronic venous insufficiency) and peripheral artery disease (PAOD).

Other diseases that can lead to a wound healing disorder are skin diseases, chronic pain disorders, tumors (and their treatment by radiation and chemotherapeutic agents), high bilirubin and urea levels, anemia and dehydration. In addition, disorders of the immune system and severe infections (such as tuberculosis, syphilis, HIV and other viral infections) favor a wound healing disorder.

Overall, imbalances in almost all systems of the human body lead to wound healing disorders, including hormonal (such as Cushing’s disease) and mental disorders (such as dementia, drug addiction). A wound does not heal if such imbalances are not counterbalanced.

Smoke

Smoking is an important risk factor for poorly healing wounds. One study found that 50 percent of smokers suffer from wound healing disorders compared to 21 percent of non smokers after surgery.

nutrition

Nutrition also plays an important role, because proteins, vitamins, minerals and trace elements are important for the healing process. Both low calorie intake and excessive obesity favor a wound healing disorder. Wounds heal badly when proteins and their constituents, the amino acids, are missing for tissue repair. A protein deficiency can also occur, for example, if the liver does not produce enough protein. Even with malignant tumors occur protein deficiency situations.

Postoperative wound care

Whether a wound heals well after surgery depends not only on the surgeon’s skill, but also on postoperative wound care and care. A wound does not heal after an operation, if the patient’s storage is neglected – if the patient is constantly on the wound, the sustained pressure load leads to a wound healing disorder.

If foreign objects such as prostheses are inserted during an operation, then a defense reaction of the body can additionally hinder the healing process. In general, particularly long operations and high blood loss in the context of the operation favor a wound healing disorder.

drugs

Caution is also required with drugs that can delay the healing process directly or indirectly. These include, for example, corticosteroids, anticancer drugs, psychotropic drugs and anticoagulants.

Cooperation of the patient

Last but not least, patient cooperation also plays a crucial role. Only a consistent adherence to the ordered therapy can prevent a wound healing disorder or bring their treatment to success.

Wound healing disorder: examinations and diagnosis

Specialists in wound healing disorders are superficial wounds, especially dermatologists and internal wounds surgeons. If the wound hits after an operation, you should first contact the surgeon. First, the doctor will ask the following questions:

• Since when does this wound exist?
• How did the wound come about?
• Do you suffer from pain or fever?
• Was the wound healed better in the meantime?
• Have you already experienced wound healing disorders?
• Are you aware of previous illnesses?
• Did you react to a wound treatment (also allergic)?

With the help of the temporal delimitation of the duration of the wound, the wound can be classified as acute or chronic. The question of fever and the measurement of body temperature are important in order to detect possible blood poisoning (sepsis) as early as possible.

After talking, the doctor will examine the wound and examine it. It checks for circulation, motor function and sensitivity around the affected area. With closer inspection of the wound healing disorder, it is important to assess how deeply the wound expands and which structures are affected. For example, if the wound has reached the bone, bone infection can be imminent. These so-called osteitis or osteomyelitis can have serious consequences.

Assessing the state of the wound is also important. Among other things, the doctor must pay attention to pus, redness and dead tissue. So he can estimate whether the wound is aseptic (germ-free), contaminated or septic (infected). Finally, it will roughly determine the phase of wound healing for therapeutic and prognostic purposes.

For larger and more severe wound healing disorders further investigations are necessary.

blood test

A blood test can indicate an infection and allows the evaluation of red and white blood cells as well as platelets.

imaging

For deeper and inner wounds as well as the suspicion of foreign bodies or broken bones, an imaging should be carried out as part of the wound healing disorder diagnostics: First, an ultrasound examination can already help. If it is not a superficial wound, the extent must be estimated using computed tomography (CT), magnetic resonance imaging (MRI) or X-ray.

Wound smear marrow aspirate / biopsy

If there is a suspicion of wound infection, it is essential to take a wound smear. This serves to determine the exact type of agent and to clarify whether it is resistant to certain antibiotics. Only after removal of a wound swab should a possible antibiotic treatment be started, otherwise the result will be falsified.

If it is suspected that the wound may be a tumorous process, wound material should be taken for a (histo) pathological examination (biopsy).

differential diagnosis

An important alternative diagnosis for a wound healing disorder is the pyoderma gangrenosum, which often occurs in connection with rheumatoid arthritis, chronic intestinal diseases, diseases of the blood-forming system and also in (drug) suppression of the immune system. Mostly it is located on the lower extremity. A pyoderma gangrenosum may be similar to a wound healing disorder, but it is a profound inflammation that also affects adipose tissue and blood vessels. Because there are no clear diagnostic markers, Pyoderma gangrenosum is an exclusion diagnosis (only if all other diseases with similar symptoms have been ruled out, can pyoderma gangrenosum be assumed).

Wound healing disorder: treatment

A wound healing disorder requires specific treatment to avoid serious consequences. The treatment of complicated wound healing disorders should be done in a special wound center.

Fighting the cause

A number of causes of wound healing disorders can be tackled, at least in part. In this sense, it is important to identify the underlying cause of the delay in the healing process. For example, the treatment of diabetes mellitus should be better stopped. A wound does not heal or only with difficulty if the basic problem persists.

If there is malnutrition or malnutrition, nutritional therapy must be initiated in addition to the local wound care to compensate for deficits. In the case of a wound healing disorder, so-called supplement nutrition is also suitable for this purpose.

wound hygiene

The main goal of local therapy is to facilitate a problem-free healing process and to prevent damaging influences. Wound hygiene plays a very important role, not only in the wound itself, but also in the wound margins and the immediate environment. On the one hand, wounds should be kept clean, but on the other hand they should not be cleaned or disinfected too intensively. Often rinses with sterile (salt) water or wound baths (body warm tap water) are recommended. In order to prevent local reactions, no aggressive rinsing solutions should be used. Special funds should only be used in consultation with the doctor. Only products that are approved for direct wound application are suitable. Iodine can cause cell death and must therefore be used with caution, especially in the initial treatment.

debridement

Very important part of the wound care is the so-called debridement, in order to create an optimal wound base for wound healing. Debridement refers to wound cleansing and related (surgical) removal of dead tissue (necroses), debris and foreign bodies from the wound.

This is particularly indicated for severe signs of inflammation, systemic infections and large deposits as well as much dead tissue. Everything is then removed until healthy tissue is on the surface. Among other things, this leads to a better oxygenation of the wound.

After this intensive wound cleansing the non-healing wound must be cleaned again and again in the course, but not in the same intensity. Often the wound is simply rinsed with sterile (salt) water for this purpose.

Surgical interventions for wound healing disorders also involve the removal of cavities with wound exudate or major bruising, and in severe cases, the (partial) amputation of body parts, such as a toe. In case of a wound infection, the (re) opening of a wound may be necessary.

Artificial enzymes (for example in the form of collagenase ointments) can also dissolve wound coverings.

wound dressing

The choice of wound dressing should be made individually by an experienced wound expert and is not easy due to the large supply. Criteria are, among others, the healing phase, the infection status and the presence of dead tissue mass. Wound dressings in a wound healing disorder should in any case provide protection against dehydration, ensure a moist wound base and do not release fibers into the wound. At the same time, the oxygen supply should be ensured. Many dressings contain antimicrobial ingredients such as iodine, polihexanide or octenidine.

There are roughly three types of wound dressings. Passive associations offer only protection. Associations with interactive properties affect the wound directly (such as hydrocolloid dressing, vacuum therapy). Cultivated epidermal cells or autologous transplantation are so-called active wound dressings.

Conventional dressings such as gauze dressing and nonwoven are usually characterized by a special absorbency, tear resistance and air permeability. However, they carry the risk of sticking to the newly formed skin layer – an ointment dressing, on the other hand, can help. Conventional wound dressings serve primarily as an initial wound dressing.

Modern interactive dressing materials (such as hydrogels, alginae, foam dressings) provide a favorable, moist microclimate, allowing connective tissue and skin cells to multiply. At the same time, the bonding of the new skin cells with the dressing is usually prevented. In wet dressings, the balance must be maintained by a moist wound environment and the absorption of wound fluid by the wound dressing. Silver active compresses are not only absorbent and work against microorganisms, but also reduce the odor. In severe cases, a wound healing disorder can be additionally treated with wound drainage or vacuum sealing.

antibiotics

If there is a major wound infection, antibiotic treatment (antibiotics) can be carried out. Beforehand, a swab should be taken to determine the exact pathogen and possible resistance. The chosen antibiotic should cover the common causative agents of wound infection such as staphylococci, streptococci, Pseudomonas and Escherichia coli. If resistant pathogens (such as MRSA) are detected in the wound, they should at least be treated with regular flushing.

The antibiotics are mostly used systemically, for example as a tablet. Local antibiotic treatment in wound healing disorders is controversial, as locally given antibiotics can only unreliably reach the wound tissue, there is often a contact sensitization and the selection of multidrug-resistant germs is promoted.

Wound infections are potentially life-threatening and should therefore be treated consistently.

pain treatment

A wound healing disorder can be associated with significant pain, which in severe cases may also require treatment with opiates (very strong painkillers). In the area of ​​the wound surface anesthesia (superficial local anesthesia) can be performed.

Other methods

In addition to the wound healing disorder treatment methods described above, there are a variety of more or less controversial treatment offerings such as stimulation current, shockwave, infrared or magnetic therapy. In addition, specially prepared maggots in a dense, but not airtight bandage can contribute to the healing process. Their saliva contains enzymes that help with the removal of plaque and diseased tissue.

amputation

In spite of intensive and multidisciplinary treatment, in some cases amputation is the last therapeutic remedy for chronic wound healing disorders. For this reason, around 30,000 smaller and larger amputations per year are carried out in Germany.

Accelerate wound healing

The healing process of a wound can be supported. You can find out how to do this in the article Accelerating Wound Healing.

Wound healing disorder: disease course and prognosis

When an optimal wound milieu is achieved and the cause can be eliminated, the prognosis of a wound healing disorder is good. Often, however, the cause can not be completely eliminated, which worsens the prognosis.

A wound healing disorder after surgery leads to a longer hospital stay (with the associated risks) and can also result in surgical wound care.

In the long term, for cosmetic reasons after healing has taken place, a scar and wound correction can be carried out by a plastic surgeon or dermatologist.

complications

Particularly feared is an infection in the context of a wound healing disorder, which in turn can lead to an abscess and septicemia (sepsis). The latter is potentially fatal and requires more intensive treatments.

Wound healing disorders can also lead to vascular, nerve, tendon, muscle and bone damage.

The dreaded compartment syndrome is an emergency. In addition to an acute onset after a trauma, it can also arise chronically in the context of a serious wound healing disorder. The cause of the compartment syndrome is the compression of vessels and thus a suppression of blood flow by increased tissue pressure in a delimited area, especially in the area of ​​the lower leg. Typically, sufferers complain of a severe (new) pain. There are also sensory and motor disturbances. Among other things, the diagnosis can be made by an ultrasound examination. Most compartment syndrome requires acute surgical care.

Prevention of (re) wound healing disorder

To prevent a wound healing disorder, a wound should always be properly treated. First, it should be gently cleaned as well as the environment. A disinfection of the wound should be carried out with appropriate antiseptics and only in the case of heavy soiling, since otherwise more damage in the wound can occur. Then the wound can be covered with a wound dressing. In more severe cases you should go to the doctor, who may sew the wound. For each wound, especially dirty wounds, it should also be checked if there is adequate tetanus protection by vaccination.

Since many people affected by a wound healing disorder get similar wound problems again, preventive measures must be taken. This includes optimally treating existing underlying conditions, stopping the patient from smoking if necessary, and explaining what he thinks about wound healing recognizes early.