Wound Healing Concepts

• Skin is the largest external organ.
• Skin covers greater than 20 ft², weighs 6-8 lbs.
• Skin thickness varies from 0.5-6 mm.
• Skin receives half of the body's circulating blood volume.
• Normal skin pH ranges from 4 to 6.5, creating an acid mantle-protective barrier against bacterial and fungal infections.

Skin Functions

• Skin protects against fluid and electrolyte loss by providing thermoregulation.
• Skin protects against mechanical injury by promoting sweat excretion.
• Skin protects against UV injury by providing sensation.
• Skin protects against pathogens and provides Vitamin D synthesis.

Epidermis Description

• The epidermis is the outermost avascular layer providing sun and H2O loss protection.
• The epidermis regenerates approximately every 28 days and synthesizes vitamin D.
• Epidermal thickness ranges from 0.06-1.5mm, thickest on plantar surfaces of foot and palms.
• The epidermis has 5 layers and maintains contact with the dermis.
• The epidermis is mainly made up of keratinocyte cells for division & mobilization.
• The epidermis is involved in pigmentation and allergen recognition.

5 Layers of Epidermis

• Stratum Corneum consists of dead keratinocyte cells, flakes, and sheds.
• Stratum Lucidum is found on palms and soles of feet.
• Stratum Granulosum is a granular layer.
• Stratum Spinosum is a spiny layer.
• Stratum Basale is attached to the dermis by a thin basement membrane and is responsible for the mitotic activity of keratinocyte cells.

Basement Membrane Zone

• Located between the epidermis and dermis.
• Rete ridges interlock to keep the layers in place.
• Aging causes flattening of rete ridges, leading to tears in older adults.

Dermis Description

• The thickest layer of skin provides support to the epidermis.
• Major proteins are collagen and elastin for mechanical strength.
• Contains nerve endings, blood and lymphatic vessels, capillaries, sweat and sebaceous glands, and hair follicles supplying nutrition.
• It has 2 layers resisting shearing forces.

Dermis Layers

Papillary

• Unique pattern allows fingerprint identification and has capillaries and pain/touch receptors.
• Involved in moisture retention.

Reticular

• Dense collagen for shape and firmness anchors skin to subcutaneous tissue.
• Contains sweat glands, hair follicles, and blood vessels.
• Lubricates skin via sebaceous glands.
• Involved in inflammatory response.

Hypodermis

• Known as subcutaneous tissue.
• The hypodermis is primarily composed of adipose and connective tissue and is the largest layer.
• It contains major blood vessels, nerves, and lymphatic vessels.
• The hypodermis attaches the dermis to underlying structures.
• It promotes ongoing blood supply to the dermis for regeneration and provides thermal insulation.
• The hypodermis stores calories/energy.
• It controls body shape, acts as a mechanical shock absorber, and provides a cushion between skin layers, muscles, and bones.
• The hypodermis promotes skin mobility.

Hypodermis Effects of Aging

• There is a 20% loss of dermal thickness resulting in paper-thin appearance.
• Proportional reduction in collagen fibers, blood vessels, and nerve endings leads to altered sensation, thermoregulation, moisture retention, and sagging skin.

5 Elements of a Basic Skin Assessment

Temperature

• Normally warm when performed bilaterally, using the back of the hand.
• Warmer indicates inflammation or infection.
• Cooler indicates poor vascularization.

Color

• Assesses skin tone using the Fitzpatrick Skin Type.

Moisture

• Dryness indicates xerosis.
• Moisture-associated skin damage (MASD) indicates incontinence, perspiration, periwound maceration, or edema.

Turgor

• Assesses hydration.
• Normal skin returns to its original state quickly.
• Slow return indicates aging or dehydration.

Integrity

• Assesses for breaks or damage to skin.
• No open areas suggests intactness.

Color Meaning

• Paleness may indicate poor circulation.
• Erythema varies with natural skin color.
• Hyper- or hypo-pigmentation may reflect variations in melanin deposits or blood flow.
• Blue/Gray (cyanosis) indicates low oxygen saturation.
• Pallor indicates anemia or arterial insufficiency.
• Yellow indicates jaundice (biliary tract disease or liver problems).
• Liver spots indicate aging or exposure to UV radiation.

FitzPatrick Skin Type

Type I

• Pale white skin, blue/green eyes, blonde hair.
• The skin always burns and does not tan.

Type II

• Fair skin and blue eyes.
• The skin burns easily and tans poorly.

Type III

• Darker white skin.
• The skin tans after the initial burn.

Type IV

• Light brown skin.
• The skin burns minimally and tans easily.

Type V

• Brown skin.
• The skin rarely burns and tans darkly easily.

Type VI

• Dark brown or black skin.
• The skin never burns and always tans darkly.

Comprehensive Skin Assessment

Inspection

• Skin is normally smooth, slightly moist, and has a uniform tone throughout.
• Assess for pigmentations, pallor, cyanosis (nail beds), jaundice, hyperpigmentation, hypopigmentation, scars, and bruises noting the location, color, length, and width.

Palpation

• Assesses moisture, edema, tenderness, elasticity, and texture.

Olfaction

• Assess for smell.

Observation of hair and nailbeds

• Assesses for clubbing, texture, color, and shape.

Skin Alterations

• Assesses for previous scars, graft sites, and healed ulcer sites.

Skin Alterations

Dermatitis

• Inflammatory skin response to an agent.
• Skin appears red, scaly, and itchy.
• The condition may blister, ooze, develop a crust or flake off.
• Examples are atopic dermatitis (eczema), dandruff, and rash caused by contact with poison ivy or certain metals.

Vasculitis

• Inflammation and necrosis of the blood vessels.
• Associated with many conditions: malignancies, connective tissue, inflammatory diseases, medications, chemicals, infections.
• Usually bilateral and below the knees.
• Variable manifestations include erythema to widespread purpura, necrosis, and ulceration.
• Treatment involves elevation, compression, antihistamines, NSAIDs, and steroids.

Basal Cell Carcinoma

• Most common form of skin cancer.
• Has a Limited capacity to metastasize.
• Arises in the basal cells of the epidermis.
• Appears as an open sore, red patch, pink growth, or shiny bump.
• Caused by UV exposure.

Squamous Cell Carcinoma

• Second most common skin malignancy.
• Uncontrolled growth of abnormal cells arising in the squamous cells of the epidermis.
• Scaly red patches or open sores.
• Presents as elevated growths with a central depression.
• Can metastasize, mostly on areas exposed to the sun.
• Major cause is UV exposure.

Malignant Melanoma

• Begins Melanocytes

Types of Infections

Viral

• Herpes 1&2
• Herpes Zoster (shingles)
• Warts

Fungal

• Ringworm
• Athlete's foot
• Yeast infection

Bacterial

• Abscess
• Cellulitis
• Impetigo

Immune Disorders

• Lupus
• Psoriasis
• Scleroderma

Cellulitis

• Bacterial skin infection marked by swollen, red, hot and tender skin, and fever.
• Commonly affects lower legs.
• Can affect skin surface or underlying tissues and can spread to lymph nodes and bloodstream.
• Can lead to antibiotic-resistant infections such as MRSA (life-threatening).
• Management includes antibiotics, elevation, and cooling.
• Needs differential diagnosis from DVT.

Scleroderma

• Chronic connective tissue disease classified as an autoimmune rheumatic disease.
• It is caused by excessive collagen production.
• Skin appears hard and shiny, with loss of mobility, and often has a history of Raynaud's.
• Symptoms range from mild to life-threatening.
• Localized form is more common in children, manifested as waxy patches which may thicken skin and affect joint motion.
• Systemic form is more common in adults and may affect connective tissue in the skin, esophagus, GI tract, lungs, kidneys, heart, blood vessels, muscles, and joints.
• Occurs more frequently in females compared to males (4:1), with a common onset between 25-55 years old.
• There is no cure, treatment focuses on symptom management.

Shingles/Herpes Zoster

• Viral disease caused by the reactivation of the varicella virus, which is the same virus responsible for chickenpox.
• Contagious if the individual has not had chickenpox.
• Affects the cutaneous nerves usually in a single dermatome.
• Pain, itching, and burning precede lesions by 3-5 days.
• Pain may be severe.
• Managed with antiviral agents.
• Ocular complications may arise.

Candidiasis/Yeast Infection

• Fungal overgrowth caused by candida-albicans or other candida species affects the skin, genitals, throat, mouth, or blood.
• Presents are red pinpoint papules frequently with satellite lesions.
• Overgrowth of normally present flora may be due to antibiotics, diabetes, topical steroids, skin maceration, or immune deficiencies.

4 Phases of Wound Healing

Hemostasis Phase

• This stage lasts 0-24 hours.
• Epinephrine is released to minimize bleeding into the soft tissue.
• Platelet cells are responsible for the clot formation and release of cytokines.
• Tissue injury causes hemorrhage into the wound, which leads to platelet aggravation.
• This aggregation results in fibrin clot formation and hemostasis, followed by fibrinolysis to break down the fibrin clot.

Inflammatory Phase

• This stage lasts 1-10 days.
• The body mounts an acute inflammatory response.
• Neutrophils clear invading microbes/bacteria and cellular debris in the wound area via phagocytosis.
• Macrophages, similar to neutrophils, are a rich source of biological regulators: cytokines, growth factors, bioactive lipid products, and proteolytic enzymes.
• Clinical observations include erythema, warmth, edema, and pain.
• Goals are to contain exudate in the wound, reduce edema in tissues, remove necrotic tissues, promote granulation, and prevent maceration of the surrounding skin.

Proliferation Phase

• This stage lasts 3-21 days.
• Migration across the matrix within the wound occurs.
• In the dermis, fibroblasts and endothelial cells support capillary growth, collagen formation, and granulation tissue formation at the injury site.
• Fibroblasts produce collagen, glycosaminoglycans, and proteoglycans within the wound bed.
• Clinical observations include beefy red granulation and epithelialization.
• Goals are to stimulate angiogenesis, promote epithelialization, prevent epiboly, protect the wound, and maintain a moist wound environment.

Remodeling/Maturation Phase

• This stage lasts 7 days - 2 years.
• The wound is now closed, lasting up to 1 year for healthy adults and 2 years for children, elderly, or immunocompromised patients.
• There is a regression of newly formed capillaries.
• Fibroblast activity is high with extracellular matrix remodeling for shrinking, thinning, and paling scars.
• Scar tissue is only 80% as strong as original tissue.
• Goals include educating pressure relief techniques, skin inspection, soft tissue mobilization, and gradual stress on tissue.

Wound Closure

Superficial Wound Healing

• Type is often included under primary intention.

Primary Intention

• Edges are closed by approximating wound margins immediately.
• It is the best choice for recent, clean wounds, well-vascularized areas, minimal tissue loss (surgical incision, laceration, puncture, superficial and partial-thickness wounds.
• Typically has minimal scarring and heals quickly.
• Surgical techniques include sutures, staples, and adhesives.
• Surgical complication of wound rupturing along the suture line.
• Risk factors are age, diabetes, obesity, poor knotting of sutures, increased abdominal pressure (lifting).

Secondary Intention

• Wound closes on its own without superficial closure.
• This is used for wounds with significant tissue loss or necrosis, or for irregular or non-viable wound margins that cannot be re-approximated.
• Contamination from infection or debris.
• Granulation tissue gradually fills the wound bed to the levels of surrounding skin.
• Wound contraction and scar formation occurs.
• Larger scars are typical, and often require skin grafts or reconstructive surgery to minimize cosmetic and functional issues.

Tertiary Intention

• Delayed Primary Intention.
• Wound left left open and then sutured closed 4-7 days after diminished signs of infection.
• Usually for traumatic wounds.
• This closure happens when a wound with a Heavy contamination needs time for infection to clear before closure.

Skin Graft

• Type of medical grafting involving the transplantation of skin.
• The procedure will need to treat extensive wounds and burns.

Chronic Wounds

• Fails to progress in a timely manner through the normal phases of healing.
• Exceeds a time frame of >30 days duration for complete healing.
• Gets stuck in inflammatory phase.
• Presence of infection and biofilm common.
• Biofilm: Complex microbial community embedded in an EPS which attaches it to a living surface whilst also stopping recognition from the immune system
• Failure to respond to interventions.
• Risk factors include comorbid conditions, poor circulation, nutritional deficiencies, adverse pressure, and advanced age.

Causes of Delayed Healing

Local Factors (Wound)

• Oxygenation
• Infection
• Foreign body
• Desiccation (extremely dry)
• Maceration (wet)
• Mechanical stresses

Systemic Factors (Individual)

• Age
• Stress
• Comorbidities
• Obesity
• Smoking
• Medications
• Nutrition

Local Wound Conditions and Wound Complications

Obesity

• Decreased vascularity in adipose tissue.
• Skin folds harbor microorganisms.
• Friction from skin-on-skin contact.
• Increased wound tension.
• Increased tissue pressure.
• Venous hypertension.
• Decreased ability to reposition self.

Resulting Wound complications

• Infections
• Dehiscence
• Hematoma and seroma formation
• Pressure and venous ulcers

Other Healing Factors

Oxygenation

• Early wound becomes hypoxic due to vascular disruption and high oxygen consumption by metabolically active cells.
• Hypoxia stimulates wound healing via releasing growth factors and Angiogenesis.
• Oxygen is needed to sustain the process.

Age

Associated with decreased:

• Dermal thickness (thinning skin)
• Amount and flexibility of collagen and elastin, leading to skin wrinkling
• Size of rete ridges, increasing the risk of skin tears
• Sensation and metabolism.
• Sweating due to atrophy of sweat glands, which can lead to dryness
• Subcutaneous tissue, less padding over bony prominences

Associated with increased:

• Time for epidermal regeneration, leads to a slower healing processes.
• Damage to skin from sun.

Smoking

• Post-operatively, smokers show delayed wound healing and an increase in infections, wound rupture, wound and flap necrosis, and a decrease in the tensile strength of the wound.

Nutrition

• Malnutrition or specific nutrient deficiencies impact wound healing.
• Patients require supplementation for chronic or non-healing wounds.
• Carbohydrate, protein, fat, vitamin, and mineral metabolism affect the process.
• Carbohydrates are a primary energy source being used for wound healing.
• Fatty acids are nutritional support to meet energy demands and provide essential building blocks.

Medications

• Commonly used medications can significantly impact healing:
  • Glucocorticoid steroids (anti-inflammatory agents)
  • Non-steroidal anti-inflammatory drugs (NSAIDs) during long term use
  • Chemotherapeutic Drugs

Verified Burn Care Centers Requirements

• Comprehensive care within 24 hrs of admission.
• At least one full-time equivalent Burn PT and one OT, depending on center volume, with qualified therapists available 7 days/week.
• Inpatients should receive a minimum of daily therapy services.
• Competency-based burn therapy orientation program for all therapists assigned to the burn center requires recertification at least once every two years.

Hospitalization for Burns

• Full thickness burns or partial thickness greater than 10% total body surface area

Circumferential burns

• Suspected or confirmed inhalation injury Children aged under 14, with weight less than 30kg or under 1 year old
• Additional trauma/comorbidity Burns to face, hands, feet, genitalia, perineum, joint surfaces, eyes or ears
• Chemical burns require pain management

Burn Types

Thermal

• External heat sources raise the temperature of the tissues causing cell death or charring, this includes fire, contact, scald/grease.
• i.e. hot metal, liquids, steam, & flames

Chemical

• Contact to skin or eyes by strong acids, alkalines, detergents, solvents.
• i.e. house cleaners, bleach, battery acids, & ammonia chlorine

Radiation

• Excessive exposure to UV rays or radiation exposure from either X-Rays, MRI, or medical imaging

Electrical

Burn caused by faulty wiring or lightning strike creating an electrical current

Others

Frostbite, inhalation

Burn Degrees

• 1°

• Superficial thickness +Painful without blisters or scarring

• 2°

• Superficial partial +Epidermis-thickness burns do not need surgery but may scar

• 2°

• Deep partial +Epidermis and partial dermis and needs surgery that form more scars

• 3°

• Full Thickness +Epidermis and Dermis are dry resulting in needing large amounts of skin grafting

• 4°

• Epidermis, Dermis, adipose tissue, muscle. Results in loss of the burned part

Severity of Burns

• Major burn size is determined by size and depth, +Usually if that is a third degree the burn is major if that is not the case it has to exceed 2-3cm or be a second
• Minor burns typically encompass less than 10% total body surface area, are predominantly superficial and are rarely hospitalized

Burn Therapy Interventions

Interventions include Pain management, bandages and therapy For burn >10-20% TBSA, interventions include Airway breathing circulation, fluid retention and therapy

Burn Management

For partial thickness burns, therapy is usually provided. However, for full thickness burns surgical intervention alongside therapy

• For full thickness burns, healing includes skin grafting which results in Scarring or Contracture which may be able to graft

• 3rd degree burn: the need for healing includes skin contracture near to certain with often involves the skin/muscles/bones

Zones

• Zone of coagulation: Zone with most damage
• Zone of Stasis: Decreased profusion, potentially salvageable
• Zone of Hyperaemia/Inflammation: Displaying increased inflammatory vasodilation

Role of PT, Phases of Wound Healing in Relation to Burn Trauma

• In the zone of stasis, a superficial burn can turn into major wound there is infection, poor edema control, loss of proper solutions within the body and hypotension.

• Phases of wound healing: inflammation( increased blood flow and is a natural response of the body), proliferation, maturation

• PT Implications: Cardiovascular; increase in heart rate and possibly hypotension, Pulmonary; inflammation in lungs often results in respiratory distress, Immune System; barrier is influenced often leading to inflammatory responses and metabolic System; an Icnrease in tube feeding as it affects the need for more nutritious needs

• Burn shocks: loss a great amount of fluids that results to not pump too much blood through the body and systemic vasodilation decreases amount of blood flow to the brain/organ that causes damage.

Inhalation Injury

• The goal is to assess Mobility, positioning, posture, breathing techniques, airway clearance.
• Erythema is typically a sign that can determine anatomical part of the injury:
• Grade 1: Minor and patching will involved proximal or distal bronchi
• Grade 2: Moderate will involve in bronchorrhea
• Grade 3: Severe will have bronchial obstruction
• Grade 4: In massive which necrosis is taking place you have an endoluminal obliteration which can result to Exposed Tendons

Dorsal Hand

• Highrisk: is associated with significant extensor
• Action: is to Avoid flexion that will isolate MP flexion with IP extensor

Achilles Tendon

• Highrisk: is associated with significant with tendon damage that may required a Splint
• Action: long load stretching

Carbon Monoxide Poisoning

• Causes +Arrhythmia +Neuropsychiatric syndrome, confusion and in severe cases Coma/Seizue

Hetero topic Ossification

• Formation of bone in soft tissue in or around the joints +Treatment requires to wait years to complete

Amputation

• is done to developed in the Electrical, Frost bite and deep burns which can develop a significant infection +Traditional treatment includes; wrapping for pre prothesis

Compartment syndrome

• is found in a full thichkness and the main goal to treat is to avoid elevate limbs

Surgical Terms

• Is used when a Escharotomy or and infection arises.
• Implications: there is always PT is hold UNTIL AFTER surgery and will have restrictions

Skin Grafts

• Is typically considered deep partially to full thickness wounds.
• Grafts can be harvested from multiple areas and can be consider skin done by the body

Meshed

Small holes are put over the grafts

• Poor cosmesis can see that there are patters for the procedure to take place

Assessment

• Wound Size and Shape; usually measured by cm
• Edema in order to measure
• Circulatory and Sensations are also used to see how much blood/nerve flow and sensations

Causes of Delayed Healing

Infection Systemic Factor: age, stress, comorbidities, obesity, smoking and etc. Moist Wound Environment Prevents tissue dehydration and improve cellular health Increases the chance of wound re-epithelialization Decreases/eliminates pain

Best Practices

Identifies and knows the causes for healing Helps address their concerns for patients

Debridement

Removal of damage, tissue to help recover Enhance the treatment to determine is tissue is currently viable

Contraindications

Arterial Insufficiency

Tissue Types:

• Slough will needs to to removed by soft, wet or dry
• When to remove the Necrotic Tissue

Mechanical

• Wetting used on those
• Contraindications: if there is a clean or granulated use

Surgical

• Remove necrotic tissue with Adequate Profusion
• Malgiant for a bad wound requires to be prepared for bleeding with silver

Bacterial Balance

Normal level will contain WBCs, Lysosomal and growth factor Wetskin will cause rashes that may need skin breakdown

Wound edge

• Non-migrating cells may need the treatment of Re-Assess

Dressings

• They helps absorb or retain adequate moisture
• Contraindications will be water vs saline vs cleansers