Small wounds or wounds that cannot be closed primarily may be left open to heal by themselves, healing by secondary intention¹. The spontaneous wound healing process can be supported with conservative wound management. This strategy is often chosen for small wounds with a healthy wound bed, not for wounds with a fracture exposed.

It is important to keep the wound clean and moist, by covering it with the right dressings, including dressings with antimicrobial properties in case of contamination or infection.

Dry wounds - Wounds are occasionally left exposed to air for hours before being covered again, but this practice is unnecessary. During that time, the body simply recreates a moist environment by forming a scab: an ideal breeding ground for microorganisms. Even if a wound presents dry, it should be rehydrated, reassessed and covered, rather than left exposed.

Hypergranulation tissue

Hypergranulation tissue² can occur due to excessive inflammation in the proliferative phase of wound healing³, when tissue over grows beyond the wound surface. Hypergranulation tissue bleeds easily, and at a certain point, it inhibits epithelialization of the wound, thus stalling wound healing⁴.

Hypergranulation tissue can appear³

• Red,
• Uneven,
• Granular,
• Discolored,
• Raised,
• Swollen,
• Spongy.

Hypergranulation can arise due to multiple factors⁴ causing excessive inflammation, such as infection, friction on the wound area or the presence of foreign bodies, use of SSD for longer than one week, nutritional deficit or stress.

The cause of hypergranulation should be treated if hypergranulation is undesired. 

As a ‘healing by secondary intention’ strategy, allowing hypergranulation to take place can be helpful in covering small areas of exposed vital structures that are too small for flap coverage or in settings where the skills to perform flap surgery are not available.

Treatment of hypergranulation tissue

Treat small areas of hypergranulation tissue with topical agents that reduce moisture. For example²:

• Zinc oxide ointment
• Silver nitrate stick (apply Vaseline to the healthy skin surrounding the burn to protect it)
• Oxytetracycline hydrochloride and hydrocortisone acetate (Terra-Cotril®)
• Papaya
• Topical Steroid, Class III or V

Larger areas of undesired hypergranulation tissue may require surgical excision², because an excess of granulation tissue may contribute to extensive fibrosis in the long term. Excision of these larger areas of hypergranulation should be followed by skin grafting to cover the wound. Successful grafting will also decrease the chance of recurrence of hypergranulation.

Cortical bone fenestration – how to perform

In traumatic open fracture wounds, bone is often exposed. These wounds should usually be closed with local or free flaps. In certain cases, when these techniques are not available, healing by secondary intention may be chosen as a strategy.

If the periosteum has been stripped of the bone or if it was not kept moist, the cortical bone⁶ will be poorly vascularized and may not generate granulation tissue. In this case, healing by secondary intention is inhibited. Bone stripped of periosteum is also at risk of necrosis.

To promote wound healing and prevent bone necrosis, cortical bone fenestration⁶ can be performed. Cortical bone fenestration accesses the bone marrow by fenestrating the outer cortex of the bone. This activates marrow fibroblasts to promote the formation of granulation tissue. 

In this treatment, it is extremely important to prevent drying out. If the wound dries out, the negative aspects of bone fenestration are much bigger than the positive ones