HPI: The patient is a 40 yo man who sustained traumatic abrasions of his leg and arm from a motorcycle accident on May 31, 2011. He has a history of chronic vesicular dermatitis of hands and feet complicated by recurrent staphyloccal cellulitis of legs. The wound on his right knee became infected and he was hospitalized over the summer on two occasions for parenteral antibiotics and debridement. As a result of this wound he has lot his job and his family is living marginally.
O/E: September 14, 2011. There is a nine cm relatively clean ulcer over the right knee. It has shown no tendancy to heal over the past month.
Clinical Photograph:
Diagnosis: Ulcer right knee.
Questions: How would you approach this lesion so that the patient can heal and get back to work? At present, he is getting dressing changes a few times a week and there are no plans for further surgical interventions. It looks like this will take months to heal by secondary intention.
Follow-Up: 10/19/2011 I have seen the patient on two occasions since this posting. The ulcer is ~ 75% better with just daily dressing changes with Vaseline impregnated gauze. He has not needed any further antibiotics. I expect it will be completely re-epitheliazed in two to three weeks.
The ulcer appears to have healthy granulation tissue and the lower half of the ulcer margin shows a bluish white colour which indicates healing process. But in the upper margin i would prefer to do a minimal debridement (OP dressing room).I have treated a similar ulcer in a 74 yr old man who did not want grafting with twice a week comfeel dressings..it was a 3 month old ulcer measuring 7cm which healed in 5 to 6 weeks..
ReplyDeletei prefer cleansing the ulcer with normal saline and cleansing the surrounding skin with povidone iodine since povidone iodine may retard the pace of healing if applied directly to the wound surface..if any yellowish slough is noted during any dressing session prompt removal of it with scalpel/ h2o2 must be considered...and only if there is recurrent slough formation, would consider culture & sensitivity ..other important things physiotherapy for the joint and foot end elevation, high protein diet.
Good luck
I tried to post a comment to this one but it wouldn't allow me to select my posting profile easily at work. Anyway, I would probably harvest some pinch grafts (with a No. 15 blade) from either the upper inner arm or other convenient, easier to heal site, and float them in the center of the wound. I've had good luck stimulating more rapid wound healing this way and they don't need to be sutured into place. I just float them into the center of the wound (spread about 1cm apart in all directions from the wound edge and the other pinch grafts), apply Vaseline carefully to them and cover the whole area with Telfa and a Coban wrap. I have them come back in one week and usually they all take. Then I still follow them every few weeks to assess their healing.
ReplyDeleteAlternatively, a STSG could do the job, but may not take as easily and would create a larger second wound.
I hope that helps,
Christine Weinberger
I don't know who sent this, but the comments are helpful!
ReplyDelete"The ulcer appears to have healthy granulation tissue and the lower half of the ulcer margin shows a bluish white colour which indicates healing process. But in the upper margin i would prefer to do a minimal debridement (OP dressing room).I have treated a similar ulcer in a 74 yr old man who did not want grafting with twice a week comfeel dressings..it was a 3 month old ulcer measuring 7cm which healed in 5 to 6 weeks..
i prefer cleansing the ulcer with normal saline and cleansing the surrounding skin with povidone iodine since povidone iodine may retard the pace of healing if applied directly to the wound surface..if any yellowish slough is noted during any dressing session prompt removal of it with scalpel/ h2o2 must be considered...and only if there is recurrent slough formation, would consider culture & sensitivity ..other important things physiotherapy for the joint and foot end elevation, high protein diet.
Good luck"
From Marigdalia Fort: PGY 1 U. of Pittsburgh:
ReplyDeleteI have never actually managed one of these cases myself, but have witnessed numerous wound reconstructions s/p MVC.
The patient has two comorbidities which might impair a plan for reconstruction: Hx of vasculitis and ?chronic cellulitis (infx). First, the patient needs to optimize his nutritional status (pre-albumin). Secondly he needs to clear infection from the wound bed; he may do this with serial pulse lavage with debridgments, IV abx and a silver wound vac placement. If the patient smokes, he should quit. If the patient is diabetic, he needs to maintain glucose levels <140. If he is able to optimize the wound bed and develop sufficient granulation tissue, he may consider a local vs regional flap reconstruction.
Interesting challenge.I would do a biopsy or curettage for tissue culture including atypical organisms.X ray to exclude patellar osteo. Providing the wound is not infected, I think he needs a skin graft . This would take a very long time to heal by secondary intention.
ReplyDeleteTania Phillips