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Chapter XI

WOUND HEALING

CLASSIFICATION OF ULCERS

PHASES OF WOUND HEALING

DIABETIC FOOT ULCER ASSESSMENT

o ANATOMICAL CONSIDERATION

o MEASUREMENTS AND HEALING

In this section we will deal with various aspects on how to deal with wounds, once we have failed to prevent them. The section will consist of classification of wounds and of processes of wound healing, the assessment of wounds at the time of presentation and as they are treated, the causes for delayed wound healing, the functions of dressings and a note on applications of various kinds and the practical recommendations on them.

Diabetic Foot Ulcers are best treated after classifying the ulcer. This helps in planning the treatment as well as in prognosis. Patient can be counseled properly when the ulcer is classified scientifically. There are number of systems of classifications which are in practice. The main three are Wagner's classification, Texas University Classification and the recent one developed by Mike Edmonds and Ali Foster. The last one is more practical. However the use of classification depends on the person treating the foot ulcer. It is necessary to adopt one method of classification in our day to day practices so that we can over a period follow and compare our results.

The details of three classifications are as follows:

Wagner's Classification For Foot Ulcers

Grade 0 - Pre-ulcerative lesion, healed ulcers, presence of bony deformity

Grade I - Superficial ulcer without subcutaneous tissue involvement

Grade 2 - Penetration through the subcutaneous tissue (may expose bone, tendon, ligament or joint capsule)

Grade 3 - Osteitis, abscess, or osteomyelitis

Grade 4 - Gangrene of the forefoot

Grade 5 - Gangrene of the entire foot

Edmonds & Fosters Classification:

Stage 1 Normal Foot Stage 2 High Risk Foot Stage 3 Ulcerated Foot

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Stage 4 Cellulitic Stage 5 Necrotic Stage 6 Major Amputation

The University of Texas Health Science Center San Antonio Diabetic Wound Classification System

TABLES

Wound Healing:

Wound healing consists of well orchestrated and predictable chain of events that re-establish the integrity of the damaged tissue. Healing process starts off as a series of programmed, separate yet interdependent responses to the injury. Many wounds pose no challenge to the body's innate ability to heal; some wounds, however, may not heal easily either because of the severity of the wounds themselves or because of the various factors which may not help or impede the well orchestrated and orderly chain of events called wound healing.

Wound healing is generally divided into three phases.

In acute phase the physiological factors, which come into play limit the damage. In this phase the wounds are vulnerable to infection. In the second phase, the proliferative phase, the formation of fibro vascular granulation tissue is followed by epithelialization. The third phase of healing process is completed by remodelling and scar maturation.

1st phase of wound healing:

Inflammatory Stage:

This stage occurs during the first few days following an injury. The wounded area attempts to restore its normal state (homeostasis) by constricting blood vessels to control bleeding. Platelets and fibrinogen make a clot. Inflammation (redness, heat, and swelling) also occurs and is a visible indicator of the immune response. White blood cells clean the wound of debris and bacteria.

If there is repeated insult, this stage will persist and progression to the next important step is either delayed or stopped in severe cases. Peripheral neuropathy predisposes diabetic patients to repeated injuries to the feet. This causes failure of healing of the wounds. Peripheral neuropathy can also impose inappropriate stresses on the bones, resulting in micro fractures. Delayed and abnormal healing of the bones cause bony prominences and swelling that contribute to ulceration.

This stage needs protection to prevent further spread of infection.

2nd phase of wound healing:

The proliferative stage lasts about 3 weeks (or longer, depending on the severity of the wound.) Granulation occurs, which means that special cells called fibroblasts make collagen to fill in the wound. New blood vessels form. New cells migrate to the wound. Epithelial cells form new skin. The wound gradually contracts and is

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covered by a layer of skin. This stage is also called the stage of repair. Though we distinguish the stage of inflammation and repair as distinct stages, both start off together with one being dominant initially, followed by the other. Proliferative phase characterized by the formation of fibrovascular granulation tissue is followed by epithelialisation. Wounds requires proper moist environment for healing.

3rd phase of wound healing:

Maturation and Remodeling Stage

This stage may last up to 2 years. The delicate epithelium and the collagen formed is vulnerable to destruction by the same factors which caused the ulcer in the first place. Protection of the delicate epithelium is the primary aim of management at this stage of wound healing. Offloading and prescription of appropriate footwear to achieve this is the mainstay of this stage of wound healing in diabetic foot. Characterized by scar maturation. In this phase prevention of repeat injury is important.

In diabetes, hyperglycemia, vascular inadequacy and repeated trauma like walking will cause delay in wound healing often allowing the infection to become chronic or spread up in the leg.

Diabetic Foot Ulcer Assessment:

(This section is adopted from Wagner FW Jr; A classification and treatment program for diabetic neuroapthic and dysvascular foot problems in American Academy of Orthopedic Surgeons; Instructional course lecture vol. 28 St. Louis Mosby Year Book 1979.)

It needs understanding of multiple aspects. Following is an exhaustive guide to help a clinician assess and treat ulcers effectively.

I. General wound parameters:

Periwound erythema:

It could be either congestive or exudative redness surrounding the wound caused by engorgement of the capillaries in the lower layers of the skin.

None: Blanches on digital pressure.

Mild: Redness that does not blanch with digital pressure: may or may not be warm to the touch.

Marked: Prominent redness or bluish coloration: usually warm to the touch.

Periwound edema:

It is an excessive accumulation of tissue fluid, in the tissue surrounding the wound.

Graded none, mild, or marked.

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Wound purulence:

A viscous, yellowish white or green fluid formed in the infected tissue.

Graded none, mild, or marked.

Wound fibrin:

It is seen as a yellowish white meshwork, not removable with a sterile swab or gauze. It adheres to the wound but can be removed with a scalpel blade by gentle scraping.

Graded none, mild, or marked.

Limb pitting edema:

Localized excessive accumulation of interstitial fluid.

None: Absent

Mild: Digital pressure leaves a small but rebounding (within a few seconds) depression at the site.

Marked: Digital pressure for 30 seconds leaves a persistent depression site.

Limb brawny edema:

This gives a solid, wood like appearance, to the lower limbs.

None: Absent.

Mild: Appears in a limited area.

Marked: Whole log involvement.

Wound granulation:

It is the formation of small granular masses, in the base of the wound that have a

beefy-red appearance.

None: Absent.

Mild: Beginning to fill in and may not be epithelialized.

Marked: Epithelialized and filling in.

II. Anatomic considerations:

Dorsalis Pedis pulse: This artery is usually palpable in the groove between the first tendons on the medial side of the dorsum of the fool.

0- 1 +: Not palpable or barely present.

2+: Present, but diminished.

3-4+: Normal.

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III. Wound measurements:

Size (cm2): A standard metric circle template (Berol RapiDesign. is used to approximate the area of the ulcer.) An X-ray film from which the coating of the images is removed by washing could also gauge it.

Depth (mm): Measure the wound at its deepest part at a 90-degree angle to the skin. Use a sterile swab as an aid. Graded < 5, 5 - 10, 10 - 20 mm.

Undermining (mm): Measure the deepest part of any tunnelling or shearing. Use a sterile swab as an aid. Graded 0< 2, 2 - 5 >5 mm.

Duration: Calculate the approximate duration from the wound's onset (break in the skin to the date of assessment.

(Adopted from Wagner FW Jr; as above)

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REMINDER! REMINDER!!

TEN COMMANDMENTS OF DIABETIC FOOT CARE

1. DO NOT walk barefoot.

2. INSPECT the feet daily for blisters, wounds, bleeding, smell, increased temperature

at pressure points of feet and edema.

3. DO NOT apply hot fomentation / cold compresses / electric heating pads / strong

counter irritant ointments to legs and feet.

4. USE correct footwear. Choose your footwear after consulting your doctor. Always

wear footwear with socks with loose elastic.

5. DO NOT walk bearing weight on an affected / ulcerated foot or after surgery.

6. DO NOT sit cross-legged for long time.

7. DO NOT remove foot wear during travel and place your feet on any hot surface.

This can cause burns.

8. CUT the nails regularly, trimmed square.

9. DO NOT cut corns / calluses with a blade or a knife. Home surgery is dangerous.

10. CLEAN the feet twice a day with soap and water. Wipe the web spaces dry and

apply softening agent to feet. Do not use the Pumis Stone.

11. The eleventh commandment (if you can help it ) DO NOT AMPUTATE.