Chronic Wounds

A chronic wound is defined as a wound that fails to proceed through an orderly and timely process to produce intact skin, or a healthy protective scar.

Normal tissue repair occurs in three phases:

1. Inflammatory phase: Vasoconstriction occurs first, platelets collect and deposit substances to form a clot. Then, healing continues with vasodilatation, where your immune system activates, to destroy germs and bring in fresh nutrients. This phase lasts from the initial injury to about 4 days.

2. Proliferative phase: This phase is where most of what we think of as” healing” occurs. Your body is busy bringing in growth factors to lay down new blood vessels and form new connective tissues. This phase lasts from day 4 to about day 21.

3.  Maturation phase: Now your wound is “closed”, but your body continues to make and remodel the scar tissue. This phase can last from day 21 to two or more years. A chronic wound develops when your body “gets stuck” in any of these phases, taking longer to resolve the injury.

Here are some common chronic leg wounds and their causes:

Venous Stasis Ulcers:

Venous stasis ulcers occur as a result of valve incompetence in the veins of your lower leg. This means that old blood cannot return to your heart in an efficient manner. Because blood and other fluids are allowed to pool in your lower leg, your skin can become very fragile. Therefore even a minor trauma to your leg can make a big wound, and sometimes it will not heal as fast as it should. Sometimes ulcers can occur “for no reason”, or they seemingly “just appear”. You may have a history of blood clots in your legs, obesity, previous history of healed ulcers, dermatitis, and/or lymph-edema.

Symptoms of a Venous Stasis Ulcer:

- Location: Usually found on the inside of your lower leg and/or your ankle, very seldom on the upper leg or foot.
- Shape: Usually irregular in shape, vary in size.
- Wound base: The wound itself can be shallow, or of partial thickness.  Sometimes the wound may have granular yellow slough on the surface.
- Characteristics: Surrounding tissue is sometimes itchy, weepy, and brown with swelling; usually with large amounts of drainage.  Most people have little pain but this can vary from person to person. 

If you think you have a venous stasis ulcer see your primary care provider, who may refer you to a wound care specialist for the following treatment options:

- Debride (cleanse) necrotic tissue to facilitate an environment conducive to healing
- Treat the wound using advanced wound care techniques and products
- Protect and treat the surrounding tissue using graduated compression wraps or stockings, if tolerated.
- Help you learn about the process of wound prevention, to reinforce a good healthy lifestyle
- Institute exercises to promote blood flow and venous return

Arterial Ulcers:

Arterial ulcers can occur as a result of insufficient blood supply to your lower legs. Arterial blood is rich in vital oxygen and nutrients that are necessary to keep tissues healthy. “Hardening of the arteries” can prevent this good blood from reaching your lower legs. Therefore, you may be prone to delayed healing if you were to bump your leg, or receive a cut or scrape.  
Patients may have a history of smoking and/or diabetes.

Symptoms of an Arterial Ulcer:

- Location: Between the toes, on the tips of toes, on the “knuckles” of your toes, around the outside of your ankle, on the shin, and sites subjected to trauma or rubbing of footwear
- Shape: Even wound margins, oval-to-round “punched-out” appearance.  Vary in size. May or may not have swelling in the legs.  At risk for infection.
- Wound Base: Can be deep or shallow.   Usually pale in color, may have tough, yellow, sloughing tissue,
- Characteristics: Usually patients have severe pain often relieved by elevating the leg and made worse when your leg is down.  Usually you will have decreased skin temperature, absent or diminished pulses, bluish colored skin, thickened toenails and you may notice hair loss on your leg and toes.

If you think you have an arterial ulcer see your primary care provider, who may refer you to a wound care specialist for the following treatment options:

- Check pulses, skin temperature, and perform an “ABI” ( a non-invasive special test to check blood flow)
- Treat the wound using advanced wound care techniques and products
- Cleanse the area to facilitate an environment conducive to healing – very cautiously if the wound is painful covered by necrotic tissue
- Protect and treat the surrounding tissue
- Help you learn about the process –for  wound prevention and to reinforce a good healthy lifestyle
- Institute exercises to promote blood flow
- Refer you to a vein specialist if necessary to surgically reestablish blood supply.

Diabetic Ulcers:

Diabetic ulcers are usually caused by neuropathy, or loss of sensation, or movement, of a body part. Usually the feet are the most effected body part. These wounds can be slow to heal due to the systemic effects of diabetes.

Symptoms of a Diabetic Ulcer:

- Shape: Highly variable, depending on cause and effected body part.
- Location: Usually found on the feet of persons with diabetes, or on the legs.
- Wound Base: Can be deep, red or pale in color, yellow, stringy slough is very common.
- Characteristics: These wounds are usually painless, due to absent sensation in the foot. They may have low to moderate drainage, usually pulses are present. Prone to infection and osteomyelitis an infection of the bone. Diabetic neuropathy is a common problem, leading to loss of sensation, the ability to move the foot, or the foot’s ability to produce sweat and oils.  

If you think you have a diabetic ulcer see your primary care provider, who may refer you to a wound care specialist for the following treatment options:

- Evaluate the wound in order to determine the appropriate cleansing method.
- Moisture control to protect surrounding skin
- Advise  you regarding ways to reduce pressure on the wound, and how to prevent wounds from occurring
- Refer you to your PCP for blood sugar control
- Discuss proper nutrition, or refer you to a dietary specialist.

Patient Care Specialists would like to say thank you to Jan Cobb at the Wound Care Clinic of Traverse City for providing this information about Chronic Wounds.