Knowledge and skills to be able to perform basic wound care is important for all soft tissue injuries, not only soft tissue injuries with a broken bone.

Choosing your type of wound care

Adequate use of wound dressings and topical agents is important for keeping the wound bed moist and clean, which allows wound healing. When vital structures such as bone, tendons, blood vessels and/or nerves are exposed and the wound cannot be closed primarily after debridement, wound care is indicated to bridge time to definitive soft tissue coverage with a flap.

In wounds without vital structures exposed, primary closure should also be performed as soon as possible. Skin grafting is recommended as soon as there is a healthy wound bed, this is often possible immediately after debridement. In infected and/or contaminated wounds, an extra debridement might be needed. In specific situations granulation tissue may help to achieve a graftable wound bed, but be aware that an open fracture is unlikely to heal without good soft tissue coverage and that waiting for granulation tissue to cover an open fracture is seldomly successful.

For information on the initial management of the wound in the emergency room, including how to stop lethal hemorrhage, initial cleaning and coverage in the emergency room, see Pre-hospital care for open fractures and Initial evaluation and management in open fractures in the ER.

Negative pressure therapy

Negative Pressure Therapy (NPT) or Vacuum Assisted Wound Care (VAC) involves applying sub-atmospheric pressure to the wound. It is applied to improve the quality of the wound bed by stimulating blood flow to the wound bed, removing exudate and reducing edema.

Indications for the use of NPT¹:

• Temporary wound treatment - awaiting definitive soft tissue reconstruction.
• Difficult wounds - Management of slow healing or deep open wounds
• Exposed vital structures – If vital structures like bone or tendons are exposed, but neither primary closure nor flap surgery are possible, then NPT can be used.
• Skin graft support - When applied on top of skin grafts, NPT can support graft survival.

Apply the NPT system according to the instructions and leave in place for several days, usually between 3 and 5 days. When the NPT system is removed, evaluate the condition of the wound and decide whether to continue with the NPT.

Other wound dressings

Standard dressings

Choice of dressing² depends on multiple factors, such as the type of wound, the stage of wound healing and the amount of exudate produced by the wound.If soft tissue coverage is not immediately performed after wound excision, use a temporary dressing² that avoids wound desiccation and infection and minimizes the number of dressing changes.

How to dress a wound:

1 Prepare the patient with adequate pain management 30 minutes before the dressing change.

2 Ensure that all materials are ready before starting to dress the wound.

3 Work in the cleanest manner possible, using clean gloves that must be changed in between patients. Sterile gloves can be used but are not necessary.

4 For each patient, use a new basic dressing pack.

5 Before dressing the wound, clean the wound using mild soap, water or saline solution.

6 Cover all parts of the wound completely to prevent the edges of the wound from drying out.

7 If possible, select a dressing technique that enables the patient to exercise when that is allowed.

The frequency of dressing changes depends on the type of wound and type of topical agent used. Redress contaminated wounds daily. When removing dressings, do it gently, otherwise newly formed tissue will be damaged. If the dressing is adherent to the wound, soak it with water and wash the wound gently after removing the dressing.

Always consider cleaning the wound, since no dressing beats a decent clean.

Every dressing change is an opportunity for surgical debridement with or without the need for anesthesia.

Be aware that dressing changes (even without debridement) can be very painful and adequate pain management is required.

Modern hydrocolloid dressings

Occlusive wound therapy provides a moist wound environment. When the inner layer of the dressing comes into contact with exudate, a gel forms. This facilitates autolytic debridement of the wound.
Example: Duoderm®

Use
Use for low to moderate exudating wounds.

Foam dressings

Foam dressings¹ are made out of semipermeable polyurethane and consist of cells that can hold fluids. Foam dressings have a cushioning effect and have the potential to absorb large amounts of exudate depending on the thickness of the dressing².

Use
Use for wounds that produce exudate.

Silver dressings

Silver dressings are thought to reduce the risk of invasive infection. If used for prolonged time, silver dressings could cause local and systemic toxicity. Reserve these dressings for critically colonized or infected wounds.

Hydrogel dressings

These are high water content gel dressings that facilitate autolytic debridement of the wound and assist with maintaining a moist wound environment.

Use
Use for wounds that produce exudate.

Fiber dressings

These calcium alginate dressings are absorbent, biodegradable and derived from seaweed. They maintain a moist wound environment that stimulates healing, while limiting wound secretions and minimizing bacterial contamination.

Use
These dressings are suitable for moderate to high levels of wound exudate. They are useful for large abdominal or upper torso scald burns, or to cover a donor site.

Topical agents

The basic principle of all agents is to provide a moist environment, which promotes wound healing. For open fractures moist gauzes are sufficient in the ER and vacuum assisted wound care (VAC) is first choice after debridement in the operating theatre.

For wound management of smaller wounds and wounds cannot be closed with flap, many different topical agents are used for wound care around the world. Here we introduce some of the most frequently recommended agents, based on expert opinion.

Please adhere to local wound care protocols, if available.

Silver sulfadiazine cream (SSD)

This agent has a broad antibacterial spectrum, acting against both Staphylococcus aureus and Pseudomonas aeruginosa. It's widely used as burn cream for burn wounds.

Example
Flammazine ®

Honey mixture

This agent is composed of 1/3 honey and 2/3 ghee/vegetable oil/glycerin/water. It has antibacterial properties, acting against Staphylococcus aureus and many other bacteria.

Example
Bee honey

Honey mixture

This agent acts effectively against Pseudomonas. Acetic acid may be useful in resource deprived settings, since it is relatively inexpensive and widely available.

Example
Diluted vinegar

Povidone-iodine

Povidone-iodine acts against Staphylococcus aureus. Using 5% or 10% betadine solution is recommended.

Example
Betadine ®

Silver nitrate solution

This agent acts against Pseudomonas and can be used to treat hypergranulation.

Example
0.5% AgNO₃

Fusidic acid

Fusidic acid acts against Staphylococcus aureus. However, the bacteria develop resistance after approximately 1 week of use. Therefore, another topical antibiotic should be used after 1-2 weeks.

Example
Mupirocin (Bactroban®) or tetracycline ointment.

Sodium hypochlorite solution in paraffin

This agent is used to remove slough from a ‘dirty’ or highly contaminated wound bed, and to induce granulation tissue formation.

Example
Eusol

Polyhexanide and propyl betaine-based gel

Fusidic acid acts against Staphylococcus aureus. However, the bacteria develop resistance after approximately 1-2 week of use. Therefore, another topical antibiotic should be used after 1-2 weeks.

Example
Prontosan ®