Complex Wounds

What makes a wound complex?

Wounds with exposed tendons, nerves, bones and orthopedic hardware are often described as ‘complex'. A series of other factors including associated diseases, large size, crushing injury, infection, chronicity and history of previous radiation all add to the complexity of a wound.

The presence of diabetes, collagen vascular disease, (i.e. lupus, rheumatoid arthritis) arteriosclerosis and venous incompetence all complicate wound healing. These factors require specialized attention and should be addressed to maximize healing potential.

Wounds that fail to heal or periodically reopen may be associated with an underlying chronic bone infection (osteomyelitis) or the presence of a foreign body (i.e. glass, metal fragments). Additionally, the use of radiation for treating tumors can produce permanent tissue damage and diminished healing potential.

Certainly the size and mechanism of injury add to the complexity of the wound. Industrial and farming injuries often produce large wounds with crushed tissues and extensive contamination. Rigorous, focused surgical intervention is frequently required to repair these serious injuries.

How are complex wounds treated?

Complex wounds can be categorized as acute (new onset) or chronic (long standing). In general, new wounds are treated with meticulous surgical cleansing (debridement) that may be repeated several times. When a clean wound is achieved then important exposed structures such as, tendon, nerve, bone and orthopedic hardware are covered with healthy tissue. Coverage may be achieved by rearranging local skin or muscle (local flap). Larger wounds may require microsurgical transplantation of expendable tissue from other regions of the patient's body (free flap). Grafted skin is often utilized to provide the final layer of coverage. Proper nutrition and physical therapy facilitate a good recovery.

Chronic, non-healing wounds require medical detective work. The root cause or causes of the compromised healing should be determined in order to create a successful treatment plan. Removing or reducing the sources of impairment is the key to success.

Careful examination, imaging (i.e. MRI, MRA, arteriogram) and lab tests are all utilized to investigate the reason for impaired healing. A multidisciplinary evaluation is frequently beneficial.

Not all complex wounds require sophisticated surgery to heal. Following surgical cleansing, dressing changes, hydrotherapy, topical growth factors and skin substitutes can be utilized to encourage wounds to heal spontaneously. New technologies including the wound vacuum can facilitate the closure of difficult wounds by reducing swelling and stimulating the formation of new blood vessels. Limited surgical interventions may also have a significant impact. Removal of bony prominences and Achilles tendon lengthening often benefit individuals with abnormal weight distribution during walking. Surgical cleansing and applications of skin grafts can be performed on an outpatient basis.

Treating chronic wounds in patients with inadequate circulation, underlying bone infection, damaged orthopedic hardware and multiple medical problems can provide a serious challenge. Sophisticated surgery involving a coordinated team of surgeons and physicians from multiple specialties is often required to solve these difficult problems.