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October 2016 Veterinary Team Brief 27 Case Summary Rosie, a 6-month-old spayed female Chihuahua mix, presented for evaluation after being hit by a car several hours earlier. No systemic abnormalities were noted. Physical examination disclosed a large degloving injury over her right forelimb proximal to the carpal joint and extending distally to the tips of the phalanges. The wound involved approximately 50% of the distal limb circumference and consisted of full-thickness soft- tissue loss on the dorsal aspect of the metacarpus with exposure of the second, third, and fourth metacarpal bones. (See Figure 1.) The carpal and digital pads were intact. Palpation of the distal right forelimb elicited instability and crepitus in the wound Caleb Hudson, DVM, MS, DACVS (Small Animal) Gulf Coast Veterinary Specialists Houston, Texas Degloving Wound Management by Second-Intention Healing TEACHING TARGET IN-HOSPITAL TREATMENT AND AT-HOME CARE OF WOUND HEALING BY SECOND INTENTION ARE EQUALLY IMPORTANT COMPONENTS OF OPEN WOUND MANAGEMENT. CLIENT EDUCATION IS CRITICAL FOR A SUCCESSFUL OUTCOME. CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED region, and right forelimb radiographs showed fractures of the third, fourth, and fifth metacarpal bones and the first phalange of digit 3. Carpal palpation revealed no evidence of varus or valgus instability, indicating the carpal collateral ligaments were intact. Thoracic radiographs disclosed clear lung fields and a normal-sized cardiac silhouette with no evidence of pulmonary contusions. Surgical debridement was indicated, and Rosie was premedicated with hydromorphone and midazolam. Anesthesia was induced using propofol and maintained using isoflurane inhalant anesthesia. The degloving wound was flushed thoroughly with sterile saline and surgically debrided. A tissue sample d FIGURE 1 Degloving wound at initial presentation with exposure of the third metacarpal bone Photo courtesy of Dana Gale, DVM was collected from the wound site and submitted for bacterial culture and susceptibility testing.

OF WOUND HEALING BY SECOND INTENTION ARE … · degloving injury over her right forelimb proximal to the carpal joint and extending distally to the tips of the phalanges. The wound

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Page 1: OF WOUND HEALING BY SECOND INTENTION ARE … · degloving injury over her right forelimb proximal to the carpal joint and extending distally to the tips of the phalanges. The wound

October 2016 Veterinary Team Brief 27

Case Summary

Rosie, a 6-month-old spayed female Chihuahua mix, presented for evaluation after being hit by a car several hours earlier. No systemic abnormalities were noted. Physical examination disclosed a large degloving injury over her right forelimb proximal to the carpal joint and extending distally to the tips of the phalanges.

The wound involved approximately 50% of the distal limb circumference and consisted of full-thickness soft- tissue loss on the dorsal aspect of the metacarpus with exposure of the second, third, and fourth metacarpal bones. (See Figure 1.) The carpal and digital pads were intact. Palpation of the distal right forelimb elicited instability and crepitus in the wound

Caleb Hudson, DVM, MS, DACVS (Small Animal)Gulf Coast Veterinary SpecialistsHouston, Texas

Degloving Wound Management by Second-Intention Healing

TEACHING TARGETIN-HOSPITAL TREATMENT AND AT-HOME CARE

OF WOUND HEALING BY SECOND INTENTION ARE EQUALLY IMPORTANT COMPONENTS OF

OPEN WOUND MANAGEMENT. CLIENT EDUCATION IS CRITICAL FOR A SUCCESSFUL OUTCOME.

CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED

region, and right forelimb radiographs showed fractures of the third, fourth, and fifth metacarpal bones and the first phalange of digit 3. Carpal palpation revealed no evidence of varus or valgus instability, indicating the carpal collateral ligaments were intact. Thoracic radiographs disclosed clear lung fields and a normal-sized cardiac silhouette with no evidence of pulmonary contusions.

Surgical debridement was indicated, and Rosie was premedicated with hydromorphone and midazolam. Anesthesia was induced using propofol and maintained using isoflurane inhalant anesthesia. The degloving wound was flushed thoroughly with sterile saline and surgically debrided. A tissue sample

d FIGURE 1 Degloving wound at initial presentation with exposure of the third metacarpal bone

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was collected from the wound site and submitted for bacterial culture and susceptibility testing.

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28 veterinaryteambrief.com October 2016

CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED

Treatment Plan

Three treatment options were considered: surgical reconstruction with a skin flap or free skin graft, limb amputation, and open wound care and promotion of second- intention healing.

! Surgical reconstruction was not pursued because of the wound location and the underlying orthopedic injuries.

! Amputation, which is a viable option for a severe degloving wound, was also not pursued because limb preservation is preferable when possible.

! Open wound management with bandaging and promotion of a wound environment conducive to second-intention healing was selected as Rosie’s best treatment option.

Second-intention wound healing is the healing process by initial granula-tion tissue formation followed by myofibroblast-mediated wound contraction and epithelialization (ie, growth of epithelial tissue over the wound surface).1-5 (See Table 1.) Second-intention healing can be used to treat many wound types; however, morbidity associated with wound contraction may result when second-intention healing is used to treat wounds in high motion areas such as joints.

Second-Intention Wound Healing1-6

TABLE

1Process Underlying Events Approximate Timing

Granulation tissue formation

• New capillaries develop in the wound site

• Fibroblast migration into wound • Fibroblast-mediated collagen

production

Days 5 to 25

Wound contraction • Wound fibroblasts differentiate into myofibroblasts

• Myofibroblasts contain smooth muscle actin

• Myofibroblast contraction decreases wound surface area

Days 8 to 180

Epithelialization • Epithelial cell proliferation • Epithelial cells migrate across

wound surface • Contact inhibition limits

epithelial proliferation

Days 18 to 180

Type of Dressing

Stage of Wound Healing

Indication for Use

Product

Adherent Inflammatory Necrotic tissue in wound

Cotton gauze

Hydrophilic Inflammatory and repair

Highly exudative wound

Calcium alginate dressingMaltodextrin dressing

Hydrogel Inflammatory and repair

Minimally exudative wound

Hydrogel dressingHydrocolloid dressing

Nonadherent Maturation Wound with intact skin surface

Petrolatum impregnated gauzeTeflon padRayon pad

Examples of Primary Dressing Options for Wound Management

TABLE

2

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October 2016 Veterinary Team Brief 29

A calcium alginate dressing was applied as the contact layer on the surface of Rosie’s wound. Other types of wound dressings are avail-able (see Table 2), but calcium alginate absorbs exudate and creates a hydrophilic gel over a wound surface, making it a good choice for highly exudative wounds.6 Also:

! The contact layer of Rosie’s bandage was covered with a secondary layer consisting of cotton cast padding to absorb exudate and protect the wound.

! The tertiary bandage layer consist-ed of woven cotton followed by elastic bandaging tape to provide compression and protect the outer surface of the bandage.

! A palmar fiberglass splint was incor-porated into the tertiary bandage layer and empirical treatment with oral cefpodoxime q24h was initiated pending culture and susceptibility results.

A bacterial culture obtained during the initial wound debridement showed no growth, but cefpodoxime was continued for 2 weeks prophylac-tically. Pain management consisted of oxymorphone IV boluses q6h for the first 2 days and oral tramadol every q8-12h thereafter.

Two days after surgical debridement, Rosie’s bandage was removed, the wound was flushed, and the calcium alginate dressing and bandage were replaced. Four days after initial wound debridement, Rosie’s bandage

d FIGURE 2 Degloving wound 4 days after initial debridement. Note the presence of early granulation tissue starting to form diffusely over the wound surface and necrotic tissue around the phalanges at the distal edges of the wound.

d FIGURE 3 Degloving wound 11 days after initial debridement. A mature bed of granulation tissue covers 95% of the wound surface and some contraction of the wound edges has occurred.

was removed under general anesthe-sia. The second and third phalanges and associated digital pad on the second digit were excised because they were necrotic. The remainder of the wound site appeared healthy with some early granulation tissue formation. (See Figure 2.) Wound management with calcium alginate dressings was continued.

Rosie remained hospitalized and her bandages were changed every 2 to 4 days for the first 2 weeks of treatment. During bandage changes, the wound surface was lavaged with sterile saline.

The volume and character of wound exudate, as well as the appearance of the tissue on the wound surface, were evaluated for evidence of infection.

By hospital day 11, a healthy bed of mature granulation tissue covered most of the wound and the edges had started to contract, resulting in a smaller wound surface area. (See Figure 3.) By hospital day 14, the amount of wound exudate had decreased significantly and the calcium alginate dressing was changed to a petroleum-impregnated nonadherent dressing.

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30 veterinaryteambrief.com October 2016

CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED

Outcome

Rosie was discharged on hospital day 14, and the wound was managed on an outpatient basis. By 6 weeks post- injury, the wound had contracted and epithelialized to approximately one-third of its size at initial presen-tation, and by 7 weeks post-injury,

was continuing to contract to form a narrow scar. (See Figure 6.) n

References1. Pavletic MM. Atlas of Small Animal Wound

Management and Reconstructive Surgery. 3rd ed. Ames, IA: Wiley-Blackwell; 2010:17-29.

2. Hosgood G. Stages of wound healing and their clinical relevance. Vet Clin North Am Small Anim Pract. 2006;36(4):667-685.

3. Hosgood B. Open wounds. In: Tobias KM, Johnson SA, eds. Veterinary Surgery: Small Animal. St Louis, MO: Elsevier Saunders; 2012:1210-1220.

4. Cornell K. Wound healing. In: Tobias KM, Johnson SA, eds. Veterinary Surgery: Small Animal. St Louis, MO: Elsevier Saunders; 2012:125-134.

5. Prpich CY, Santamaria AC, Simcock JO, Wong HK, Nimmo JS, Kuntz CA. Second intention healing after wide local excision of soft tissue sarcomas in the distal aspects of the limbs in dogs: 31 cases (2005-2012). J Am Vet Med Assoc. 2014;244(2):187-194.

6. Fahie MA, Shettko D. Evidence-based wound management: a systematic review of therapeutic agents to enhance granulation and epithelializa-tion. Vet Clin North Am Small Anim Pract. 2007; 37(3):559-577.

the wound was less than 1 cm in diameter. (See Figures 4 & 5.) By 8 weeks post-injury, the wound was completely epithelialized and the bandage was removed.

When Rosie presented for a final medical progress examination 8 months after her injury, she walked on her right forelimb with only subtle lameness and the wound site

d FIGURE 4 Degloving wound 6 weeks post-injury. Significant wound contraction and epithelialization has occurred. The open portion of the wound is covered by a mature bed of healthy granulation tissue.

d FIGURE 5 Degloving wound 7 weeks post-injury. Wound epithelialization is approximately 95% complete.

d FIGURE 6 Mature scar at the site of the previous degloving wound 8 months post-injury

Resources

! Atlas of Small Animal Wound Management and Reconstructive Surgery, 3rd ed. Pavletic MM. Wiley-Blackwell; 2010.

! Veterinary Surgery: Small Animal. Tobias KM, Spencer JA, eds. Elsevier Saunders; 2012.

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October 2016 Veterinary Team Brief 31

Clients should understand at-home care is as important as in-hospital management.

Team Management

Karen Theresa Ellis, LVT, VTS (Surgery)Gulf Coast Veterinary SpecialistsHouston, Texas

A wound may be allowed to heal via second-intention healing vs primary closure because of extensive tissue loss resulting in defects too large for primary closure and/or presence of infection.¹ Second-intention healing requires a significant time and monetary investment from clients, and ensuring they understand the in-hospital treatment and at-home care required for a successful out-come is crucial to patient recovery.

In Rosie’s case, the veterinary team clearly explained the treatment plan details to her owners, including potential risks, complications, preventive measures, and at-home bandage monitoring and care.

Before treatment, a team member, usually a veterinary nurse, should review a written estimate of all proposed treatment costs with the client, including the potential for additional expenses associated with any healing complications.

At-home care is an important component of the treatment plan and is critical to the successful management of wound care. Clients must be willing and able to bring the

patient to the practice for frequent progress examinations and bandage changes. They must also be willing to monitor the patient’s bandage at home and restrict the patient’s activity, including keeping the patient indoors.

In Rosie’s case, the veterinary team prepared the clients for an initial hospitalization period for wound management and a transition to outpatient bandage care at gradually increasing intervals.

Discharge InstructionsWhen the patient is ready to transition to at-home care, a detailed discharge summary with specific instructions should be printed and reviewed with the client before the patient is brought to the discharge room, to allow the client to focus on the information and ask questions without distractions. The client should sign the practice’s copy of the

instructions to record the discussion took place and be given a handout detailing at-home bandage care to help reinforce the information.

Clients should understand at-home care is as important as in-clinic management and be given specific examples of why certain rules must be followed. For example, if the patient is restricted to leash-walking, the client must understand that he or she should walk the patient on a 4-foot leash, remaining in control to prevent further injury. Otherwise, clients may allow a patient restricted

d FIGURE 7 Using patterned or customized bandages on patients helps pet owners feel excited about bandage visits.

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32 veterinaryteambrief.com October 2016

CLINICAL CASE: WOUND MANAGEMENT / PEER REVIEWED

to leash-walking to walk freely in their fenced yard, believing it is a safe, confined space and not realizing the patient could chase a squirrel and reinjure the healing wound.

Rosie’s owners were instructed to examine her bandage site twice a day, check for toe swelling and bandage slippage, restrict her activity to cage rest with strict leash-walking, and to make her wear an E-collar at all times to prevent her licking or chewing the bandage. The collar’s importance was emphasized because some owners remove them when the patient seems uncomfortable.

Rosie’s owners were also instructed to place a plastic bag over her bandage before taking her outdoors to keep it clean and dry and to remove the bag once indoors to prevent moisture forming inside the bag. When the outer layer of the bandage becomes wet, exogenous bacteria can migrate into the wound.²

Client CommunicationSecond-intention wound healing is a long process, and many adapta-tions (eg, bandage type, frequency of change, medications needed) that differ from the original treatment plan and expected healing duration can occur. The veterinary team prepared Rosie’s owners for possible changes in healing time and explained that progress observed at each examination appointment could affect the treatment plan. Open communication helps clients

understand the plan may be changed because of the patient’s progress—not because of any setback—and helps them feel more involved in the patient’s care. Allowing clients to view the wound during bandage changes and see the healing process, or sharing photographs at each visit, also helps keep clients engaged in the patient’s recovery.

Patients needing long-term bandages can be given patterned bandages or customized decorations to help clients feel excited about the bandage visits. (See Figure 7, page 31.) When the patient finally “graduates” from needing bandages, providing clients with a picture book of the bandages created especially for their pet can also strengthen the bond with the veterinary team.

Clients should be encouraged to contact a veterinary team member by phone or email with any questions about a patient’s bandage and know when the patient requires immediate atten-tion. Ask clients to email photo-graphs of areas of concern before a patient’s appointment. Advise them that attempts to alter a bandage at home (eg, adding tape, elastic bandages, or duct tape to keep it in place) could be detrimental to wound healing or cause serious complications. Explaining in advance how these measures can increase healing time and incur additional expense may improve client compliance.

Allowing clients to view the wound during bandage changes and see the healing progress helps keep them engaged in the patient’s recovery.

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October 2016 Veterinary Team Brief 33

TEAM TAKEAWAYS

Veterinarian: Degloving injuries frequently require multiple bandage changes over many weeks. Empower the team to educate clients about home care for these challenging cases, including the time commitment and financial investment, and they will frequently develop lasting bonds with patients and clients.

Nursing Team: Veterinary nurses play an important role in all aspects of care of wounds left to heal by second intention, from the initial anesthetic event to frequent bandage changes to ongoing client communication, especially about the likelihood the treatment plan may change because every patient progresses differently.

Client Care Team: Patients with wounds that require long-term care and frequent bandaging will be regular visitors to the practice. Help clients stay on track by scheduling appropriate progress examinations, reminding clients of their upcoming appointments, and facilitat-ing adding any photos or communica-tion logs to the medical record.

ConclusionAny long-term treatment can be challenging for clients because of the time commitment and financial investment required, but frequent communication can help guide them through the patient’s recovery process. In Rosie’s case, the combined commitment to care and communication by the clients and all veterinary team members helped ensure successful treatment of her degloving injury. n

References1. Slatter D. Textbook of Small Animal Surgery. 3rd ed.

Philadelphia, PA: Saunders; 2003:265.2. Swaim SF, Renberg WC, Shike KM. Small Animal Bandaging,

Casting, and Splinting Techniques. Ames, IA: Wiley-Blackwell; 2011:10.

STATEMENT OF OWNERSHIP, MANAGEMENT, AND CIRCULATIONPublication title: Veterinary Team Brief Publication number: 2324-917X Filing date: 10/1/16 Issue frequency: 10 times per year Number of issues published annually: 10 Annual subscription price: $50.00 Complete mailing address of known office of publication: 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104 Contact person: Lynn Bush-ell Telephone: 813-381-3585 Complete mailing address of headquarters or general business office of publisher: 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104 Full names and complete mailing addresses of publisher, editor, and managing editor: Eliza-beth Green, 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104; Amy Mohl, 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104; Paulette Senior, 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104 Owner: Educational Concepts LLC, 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104—Owners: Siegfried Ventures, 1924 S. Utica Ave, Tulsa OK 74104; Elizabeth Green, 2021 S. Lewis Ave, Suite 760, Tulsa OK 74104; John O’Brien, 12118 Nieman Rd, Overland Park KS 66213; Antoinette Passaretti, 3936 Sawmill Rd, Doylestown PA 18902 Known bondholders, mortgages, and other security holders owning or holding 1 percent or more of total amount of bonds, mortgages or other securities: None Issue date for circulation data below: September 2016

Publication of statement of ownership: Printed in the October 2016 issue of this publication. Signature and title of editor, publisher, business manager, or owner: Elizabeth Green, PublisherI certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions (including fines or imprisonment) and/or civil sanctions (including civil penalties).

EXTENT AND NATURE OF CIRCULATIONAverage No. Copies Each Issue During Preceding 12 Months

No. Copies of Single Issue Published Nearest to Filing Date

Total number of copies 53,624 51,901

Paid and/or requested circulation

(1) Outside-County Paid/Requested Mail Subscriptions Stated on PS Form 3541

42,095 40,765

(2) In-County Paid/Requested Mail Subscriptions Stated on PS Form 3541

0 0

(3) Sales through dealers and carriers, street vendors, counter sales, and other non-USPS paid distribution

7 9

(4) Other classes mailed through USPS 0 0

Total paid and/or requested circulation 42,102 40,774

Nonrequested distribution by mail

(1) Outside-county as stated on PS form 3541 9,850 10,896

(2) In-county as stated on PS Form 3541 0 0

(3) Other classes mailed through USPS 0 0

(4) Nonrequested copies distributed outside the mail

1,391 0

Total nonrequested distribution 11,241 10,896

Total distribution 53,343 51,670

Copies not distributed 281 231

Total 53,624 51,901

Percent paid and/or requested circulation 78.9% 78.9%