Wound healing and risk factors for non-healing
- David G Armstrong, DPM, MD, PhD
David G Armstrong, DPM, MD, PhD
- Professor of Surgery
- Director, Southern Arizona Limb Salvage Alliance (SALSA)
- University of Arizona College of Medicine
- Andrew J Meyr, DPM
Andrew J Meyr, DPM
- Associate Professor
- Temple University School of Podiatric Medicine
- Section Editors
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles
- Professor of Surgery
- SIU School of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
A wound is a disruption of the normal structure and function of the skin and underlying soft tissue . Acute wounds in normal, healthy individuals heal through an orderly sequence of physiological events that include hemostasis, inflammation, epithelialization, fibroplasia, and maturation . When this process is altered or stalled, a chronic wound may develop and this is more likely to occur in patients with underlying disorders such as peripheral artery disease, diabetes, venous insufficiency, nutritional deficiencies, and other disease states. Chronic ulceration commonly affects the lower extremities with a prevalence that ranges between 0.18 and 1.3 percent in the adult population [2-5].
Wounding mechanisms, the normal phases of wound healing and alterations in wound healing due to disease are reviewed here. The clinical evaluation and topical management of open wounds is discussed separately. (See "Clinical assessment of wounds".)
Wounds are generally classified as acute or chronic. Although there is no specific time frame determining the difference between an acute or chronic wound, chronic wounds are generally associated with physiological impairments that slow or prevent wound healing. Wounds may be caused by a variety of mechanisms including acute injury to the skin (abrasion, puncture, crush), surgery and other etiologies that cause initially intact skin to break down (eg, ischemia, pressure).
Acute wounds have an easily identifiable mechanism of injury with skin integrity disrupted typically due to some form of trauma. Traumatic skin disruption can result from blunt or penetrating mechanisms (gunshot, animal bite) and an array of wound sizes, depths, and locations can result. Simple or complicated lacerations, abrasions, burns and significant tissue defects can occur, each requiring individualized management and care.
Patients with impairment in pain sensation are vulnerable to acute and chronic repetitive injuries. In some patients with sensory neuropathy, the injury may go unnoticed if the injured area is not routinely inspected. Patients with diabetes, particularly those with arterial obstruction, are at high risk. (See 'Diabetes' below.)
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- WOUND MECHANISMS
- PHASES OF WOUND HEALING
- IMPAIRED WOUND HEALING
- RISK FACTORS FOR NON-HEALING
- Peripheral artery disease
- Chronic venous insufficiency
- Immunosuppressive therapy
- Sickle cell disease
- Cancer therapy
- - Chemotherapy
- - Radiation therapy
- Spinal cord disease and immobilization
- Smoking and nicotine replacement therapy
- SUMMARY AND RECOMMENDATIONS