Description of Intervention
Hand therapist routinely manage various kinds of wounds, depending on their clinic’s focus and population. Therapists working on burn specialty services as well as those that see complex trauma will have skill sets that allow them to manage larger and more complex wounds. Some hand therapists have special experience or certification in wound management that allows them to manage involved wounds.
Hand Therapists often remove sutures, provide limited levels of debridement and instruct patients in wound management. Therapists must have the ability to assess a wound and to determine when they can manage it independently, when they require specialist consultation, when the wound requires physician intervention or when they should refer a patient with a wound to a wound care specialist. An understanding of current science for wound management as well as of the constantly changing types of wound dressings are essential to provide the highest level of care.
Indications for Intervention
Therapists may manage any healing wound. Some damaged skin may be intact upon first evaluation. However, because of the specific injury and edema, an open wound may develop after an initial closed presentation. This may occur in conjunction with compartment syndrome, infection or boney instability that compromises skin integrity from the inside out.
Necrotic tissue requires debridement for several reasons. Necrotic tissue can be a source of bacteria and cause infection. Necrotic tissue can also prevent the formation of granulation tissue or re-epithelialization. Dried exudate forms scabs that block re-epithelialization.
Patients require information about maintaining wound hygiene. The initial treating clinician may delegate the patient wound management education to the therapist. Verbal and written instructions facilitate best compliance.
Evaluation to Determine Need for Intervention
Wound bed evaluation makes up the most essential component of wound assessment. The therapist must determine whether the survey of the wound bed indicates either healing or non-healing traits. Therapists must interpret wound assessment data to determine the best treatment options for wound coverage and to enable progress toward closure. The three key characteristics are:
Wound assessment data interpretation includes the following factors:
Drainage type—Bloody? Yellow? Pus?
Wound color: Red? Yellow? Black? Combination?
Odor
Chronicity of wound: the longer a wound remains open increases infection rate
Wound edges: Macerated? Jagged? Dry?
Periwound presentation
Importantly, one must r/o contact dermatitis. As Barrett1 explains, the hallmarks of this disorder consist of redness, soreness or inflammation after direct contact with a substance. It may present as a red, itchy or uncomfortable rash. Contact dermatitis will respond to treatment of rash and removal of irritant. Contact dermatitis also does not have a history of trauma.
Primary Wound Bed Assessment
| | Healing | Non-Healing |
|---|
Size | Decreasing | Unchanged or increasing |
Drainage/Exudate | Less | Same or more |
Granulation Tissue/Re-epithelialization | Present | Lacking |
Infection Sign | (-) | (+) |
From Nora Barrett Nora Barrett, MS, OTR/L, CHT, WCC Moving your wound care practice forward ASHT Annual Meeting 10-21
Therapists document wound size in length, width and depth in centimeters on a weekly basis.
The assessment of drainage/exudate follows this terminology (Barrett1):
None—tissue dry
Scant—tissue moist, no measurable drainage
Minimal/Small—tissues wet, <25% dressing saturation
Moderate—tissues wet, 25-75% dressing saturation
Copious/large-tissue fluid filled, >75% dressing saturation
Differentiating local infection from systemic infection also serves to manage wounds.
Local signs of infection include:
The acronym “NERDS” also helps to determine if an infection is local:
Non-healing
Exudative
Red, bleeding surface
Debris
Smell—unpleasant
Systemic signs of infection that urgently require involvement of MD include (Barrett1)
When evaluating for systemic infection, using the acronym STONES helps guide decision making:
Size larger
Temperature
ExpOsed bone
New areas of breakdown
Exudate/Erythema/Edema
Smell-foul
Wounds that demonstrate hyper granulation tissue—tissue that extend higher than the border of the skin— will require special care.
Intervention Options
The ultimate goal of wound care is wound closure. In addition, sound wound care minimizes the need for antibiotic management. Therapists must determine whether or not a wound is progressing toward closure. The history of the injury, coupled with the treatment goal changes how to view wound status. If the wound has the characteristics of healing, then the current wound care plan continues. If it has non-healing qualities, the therapist must consider how to change the plan—the type of dressing— to facilitate closure.
In their 2013 article, Broussard et all2 describe a wound care algorithm. While this has been updated to include contact layer dressings, the more recent algorithms also make the choices more complex. Barrett1 recommends this 2013 format as one of the best set of rules for dressing decision making.
Description of Intervention
Hand therapist routinely manage various kinds of wounds, depending on their clinic’s focus and population. Therapists working on burn specialty services as well as those that see complex trauma will have skill sets that allow them to manage larger and more complex wounds. Some hand therapists have special experience or certification in wound management that allows them to manage involved wounds.
Hand Therapists often remove sutures, provide limited levels of debridement and instruct patients in wound management. Therapists must have the ability to assess a wound and to determine when they can manage it independently, when they require specialist consultation, when the wound requires physician intervention or when they should refer a patient with a wound to a wound care specialist. An understanding of current science for wound management as well as of the constantly changing types of wound dressings are essential to provide the highest level of care.
Indications for Intervention
Therapists may manage any healing wound. Some damaged skin may be intact upon first evaluation. However, because of the specific injury and edema, an open wound may develop after an initial closed presentation. This may occur in conjunction with compartment syndrome, infection or boney instability that compromises skin integrity from the inside out.
Necrotic tissue requires debridement for several reasons. Necrotic tissue can be
a source of bacteria and cause infection. Necrotic tissue can also prevent the formation of granulation tissue or re-epithelialization. Dried exudate forms scabs that block re-epithelialization.
Patients require information about maintaining wound hygiene. The initial treating clinician may delegate the patient wound management education to the therapist. Verbal and written instructions facilitate best compliance.
Evaluation to Determine Need for Intervention
Wound bed evaluation makes up the most essential component of wound assessment. The therapist must determine whether the survey of the wound bed indicates either healing or non-healing traits. Therapists must interpret wound assessment data to determine the best treatment options for wound coverage and to enable progress toward closure. The three key characteristics are:
Wound assessment data interpretation includes the following factors:
Drainage type—Bloody? Yellow? Pus?
Wound color: Red? Yellow? Black? Combination?
Odor
Chronicity of wound: the longer a wound remains open increases infection rate
Wound edges: Macerated? Jagged? Dry?
Periwound presentation
Importantly, one must r/o contact dermatitis. As Barrett1 explains, the hallmarks of this disorder consist of redness, soreness or inflammation after direct contact with a substance. It may present as a red, itchy or uncomfortable rash. Contact dermatitis will respond to treatment of rash and removal of irritant. Contact dermatitis also does not
have a history of trauma.
Primary Wound Bed Assessment
| | Healing | Non-Healing |
|---|
Size | Decreasing | Unchanged or increasing |
Drainage/Exudate | Less | Same or more |
Granulation Tissue/Re-epithelialization | Present | Lacking |
Infection Sign | (-) | (+) |
From Nora Barrett Nora Barrett, MS, OTR/L, CHT, WCC Moving your wound care practice forward ASHT Annual Meeting 10-21
Therapists document wound size in length, width and depth in centimeters on a weekly basis.
The assessment of drainage/exudate follows this terminology (Barrett1):
None—tissue dry
Scant—tissue moist, no measurable drainage
Minimal/Small—tissues wet, <25% dressing saturation
Moderate—tissues wet, 25-75% dressing saturation
Copious/large-tissue fluid filled, >75% dressing saturation
Differentiating local infection from systemic infection also serves to manage wounds.
Local signs of infection include:
The acronym “NERDS” also helps to determine if an infection is local:
Non-healing
Exudative
Red, bleeding surface
Debris
Smell—unpleasant
Systemic signs of infection that urgently require involvement of MD include (Barrett1)
When evaluating for systemic infection, using the acronym STONES helps guide decision making:
Size larger
Temperature
ExpOsed bone
New areas of breakdown
Exudate/Erythema/Edema
Smell-foul
Wounds that demonstrate hyper granulation tissue—tissue that extend higher than the border of the skin— will require special care.
Intervention Options
The ultimate goal of wound care is wound closure. In addition, sound wound care minimizes the need for antibiotic management. Therapists must determine whether or not a wound is progressing toward closure. The history of the injury, coupled with the treatment goal changes how to view wound status. If the wound has the characteristics of healing, then the current wound care plan continues. If it has non-healing qualities, the therapist must consider how to change the plan—the type of dressing— to facilitate closure.
In their 2013 article, Broussard et all2 describe a wound care algorithm. While this has been updated to include contact layer dressings, the more recent algorithms also make the choices more complex. Barrett1 recommends this 2013 format as one of the best set of rules for dressing decision making.
For images of the various types of dressings described below, we refer the reader to key word search engine images. The reader may also search for website images from medical product companies such as pharmacies that offer the dressings both via the internet and in “brick and mortar” outlets. Finally, the reader may wish to visit a business that sells wound care products.
Necrotic Wounds
Necrotic tissue requires either external or autolytic removal. Autolytic is the body’s natural way of removing debris—endogenous enzymes remove necrotic tissue from the wound bed. While safer, it takes longer than mechanical debridement. It requires a moist wound with good perfusion and nutrition. Younger patients have a better prognosis for success with autolytic tissue removal and elder patients actually may not be candidates.
Medi honey is an agent for autolytic debridement. A special type of honey indigenous to New Zealand, called Active Leptospermum (or Manuka) honey. it has demonstrated properties which assist in promoting an optimal healing environment. Possessing a low pH, Medi honey benefits chronic wounds because it promotes a lower overall wound ph. Its highly osmotic property assists in debridement and keeping the wound bed clean. Available in various dressing forms, it decreases inflammation. According to Barrett1, it is contra-indicated for deep wounds or wounds with tunneling.
Aquaphor® can debride a wound. Differing from many over-the-counter body lotions or creams, this ointment is water-free yet still adds significant moisture to a wound. It creates a protective barrier that allows for the flow of oxygen to create an ideal healing environment. Application of the product for a few minutes to “soak’ the tissue facilitates scab removal. The therapists then instructs the patient to repeat the Aquaphor® application. Barrett1 suggests instructing the patient to use a soap and water cleanse between applications to prevent trapping bacteria.
A wound with exposed tendon or bone needs protection. A hydrogel will fill any wound step off and can also include an antimicrobial agent. Hydrogel is the “gold standard” for maintaining moisture. Covering the hydrogel with a foam product allows the dressing to remain in place for several days. Foam may also include an anti-microbial agent. In addition, foam maintains the most moisture of all of the wound dressing coverings. Foam remains non-adhesive to open areas but adheres to closed skin. This helps prevent the moisture from going back into skin and so blocks maceration. The presence of infection disqualifies the use of a hydrocolloid because of its completely occlusive properties.
Previous rules about optimum wound maintenance include the goal of “clean and dry.” However, Parrish and Barrett1,3 state that newer research reveals that keeping a wound moist—not wet—constitutes the updated goal.
Therapists may treat typical hyper-granulation tissue with silver nitrate with a protective dressing such as foam, for approximately 48 hours. Silver nitrate is contraindicated in the presence of exposed tendon or bone. Foam dressings in conjunction with a compressive wrap such as Coban® or an Ace wrap serve as an alternative to silver nitrate.
Wound Infection Management
With local/superficial infection, the therapist may apply a topical antibiotic ointment. Bacteria tend to develop resistance to neomycin, so products with this ingredient, including Xeroform, should have no more than a 2-week period of use. Antimicrobial dressings such as those containing silver or Sorbact provide yet another option. Sorbact does not irritate as much as silver. Silver contact layer dressings are the newest option for skin protection and superficial infection treatment. This clear, perforated dressing can remain in place for 4-7 days. The patient can also remove it to shower and then replace it on the wound. The clarity of the contact layer allows the clinician to visualize the wound through the dressing. The perforations allow exudate to move through it.
For a deep infection, physician involvement becomes critical for debridement and antibiotics. However, patients with deep infections who have a less healthy circulatory system may also benefit from antimicrobial dressings. In addition, significant necrotic tissue has the ability to block a prescribed oral antibiotic from reaching the infected area so local anti-microbial application can provide additional benefit.
Moisture Content
After screening for or treating necrotic tissue and infection, the therapist then addresses wound moisture content. The depth of the wound in connection with its dryness or wetness will affect the choice of dressing. A superficial dry wound can benefit from a petrolatum or transparent film with a covering. A deeper, dry wound responds to hydrogel, again, with a covering. A superficial wet wound needs a dressing to absorb moisture. Alginate or hydrofiber serve extremely wet wounds. This is rare in hand care settings; however an environment of lymphedema might create such a wound. Deep, wet wounds require alginate or hydrofiber dressings to absorb the high amount of moisture. Moderately wet wounds can benefit from a foam dressing. As the dressing fills with moisture, the volume of moisture becomes apparent and signals the patient or caregiver to change to a new one.
Skin Substitutes
Therapists may work in clinics that use skin substitutes or they may evaluate a patient with one of these products in place. Surgeons use these as an alternative to skin flaps and in burn centers where a patient may not have enough donor skin to allow wound coverage. Skin substitutes require 2 surgeries, one to put it on and one to remove it—typically with 2-3 weeks in between the two. Once the dermis revascularizes, the silicone layer is removed.
Many skin substitute products now exist and they each have their advantages and disadvantages. Because each type has critical clinical nuances, therapists must learn what product the physician has applied. The internet can provide the important information regarding management. The skin substitutes have specific instructions for compatibility with dressings, moisture, compression and ability to mobilize joints. A 2022 article by Palackic et al4 describes the current skin substitutes with their idiosyncrasies in terms of management. The therapist must research the product to learn its risks. processes and methods.
One of the important qualities of each skin substitute is its infection rate. Because Integra® came into use first, it has the most outcome data related to it. Infection rate for Integra is 16-17%. Synthetic skin substitutes such as Suprathel or Polynovo have demonstrated lower infection rates.
Additional Wound Issues and Management Approaches
Wet-to-dry dressings have been a mainstay of wound debridement for many years. Data from Ovington in 20025 and again in 20106 describes the significant disadvantages of this approach to wound management. These include reduction of tissue temperature, healing impediment and increases susceptibility to infection. Wet-to-dry dressings have a higher infection rate compared to transparent films. An infection cancels any “cost savings” that a clinician may claim. Studies have shown that bacteria can penetrate 64 layers of gauze. Removal of the dried dressing disperses the bacteria into the surrounding air. Lastly, the pain it causes creates patient distress.
Soaks for fingertip infections such as paronychia (nail infection) and felon (pulp infection)—especially with high concentrations of antibacterial soaps and scrubs—are no longer indicated. The goal of the soak was to soften the infectious materials and helps it exit the pocket where it evolved. However, the data no longer supports this. In 2022, Macneal and Milroy7 published on the management of these nail infections and found that antimicrobial spray with an appropriate dressing had much better outcomes.
Therapists have noted an ever-increasing incidence of suture issues. These include the creation of open wounds with a high potential for infection. Patients may react to suture material or fail to absorb the “absorbable” type. To treat the skin irritation and infections that result, therapist will want to use a non-occlusive dressing. Soap and water cleansing and the use of an anti-microbial treatment will facilitate wound resolution.
Therapists may work in conjunction with a wound care specialist and a referring surgeon who may not work on premises. Live video or photo sharing with a wound care specialist will allow the primary therapist to provide high level wound care at a distance.
Associated Diagnoses Where This Intervention May be Relevant
Any diagnosis involving an open wound including a well co-apted suture line will require skilled wound care. images of the various types of dressings described below, we refer the reader to key word search engine images. The reader may also search for website images from medical product companies such as pharmacies that offer the dressings both via the internet and in “brick and mortar” outlets. Finally, the reader may wish to visit a business that sells wound care products.
Necrotic Wounds
Necrotic tissue requires either external or autolytic removal. Autolytic is the body’s natural way of removing debris—endogenous enzymes remove necrotic tissue from the wound bed. While safer, it takes longer than mechanical debridement. It requires a moist wound with good perfusion and nutrition. Younger patients have a better prognosis for success with autolytic tissue removal and elder patients actually may not be candidates.
Medi honey is an agent for autolytic debridement. A special type of honey indigenous to New Zealand, called Active Leptospermum (or Manuka) honey. it has demonstrated properties which assist in promoting an optimal healing environment. Possessing a low pH, Medi honey benefits chronic wounds because it promotes a lower overall wound ph. Its highly osmotic property assists in debridement and keeping the wound bed clean. Available in various dressing forms, it decreases inflammation. According to Barrett1, it is contra-indicated for deep wounds or wounds with tunneling.
Aquaphor® can debride a wound. Differing from many over-the-counter body lotions or creams, this ointment is water-free yet still adds significant moisture to a wound. It creates a protective barrier that allows for the flow of oxygen to create an ideal healing environment. Application of the product for a few minutes to “soak’ the tissue facilitates scab removal. The therapists then instructs the patient to repeat the Aquaphor® application. Barrett1 suggests instructing the patient to use a soap and water cleanse between applications to prevent trapping bacteria.
A wound with exposed tendon or bone needs protection. A hydrogel will fill any wound step off and can also include an antimicrobial agent. Hydrogel is the “gold standard” for maintaining moisture. Covering the hydrogel with a foam product allows the dressing to remain in place for several days. Foam may also include an anti-microbial agent. In addition, foam maintains the most moisture of all of the wound dressing coverings. Foam remains non-adhesive to open areas but adheres to closed skin. This helps prevent the moisture from going back into skin and so blocks maceration. The presence of infection disqualifies the use of a hydrocolloid because of its completely occlusive properties.
Previous rules about optimum wound maintenance include the goal of “clean and dry.” However, Parrish and Barrett1,3 state that newer research reveals that keeping a wound moist—not wet—constitutes the updated goal.
Therapists may treat typical hyper-granulation tissue with silver nitrate with a protective dressing such as foam, for approximately 48 hours. Silver nitrate is contraindicated in the presence of exposed tendon or bone. Foam dressings in conjunction with a compressive wrap such as Coban® or an Ace wrap serve as an alternative to silver nitrate.
Wound Infection Management
With local/superficial infection, the therapist may apply a topical antibiotic ointment. Bacteria tend to develop resistance to neomycin, so products with this ingredient, including Xeroform, should have no more than a 2-week period of use. Antimicrobial dressings such as those containing silver or Sorbact provide yet another option. Sorbact does not irritate as much as silver. Silver contact layer dressings are the newest option for skin protection and superficial infection treatment. This clear, perforated dressing can remain in place for 4-7 days. The patient can also remove it to shower and then replace it on the wound. The clarity of the contact layer allows the clinician to visualize the wound through the dressing. The perforations allow exudate to move through it.
For a deep infection, physician involvement becomes critical for debridement and antibiotics. However, patients with deep infections who have a less healthy circulatory system may also benefit from antimicrobial dressings. In addition, significant necrotic tissue has the ability to block a prescribed oral antibiotic from reaching the infected area so local anti-microbial application can provide additional benefit.
Moisture Content
After screening for or treating necrotic tissue and infection, the therapist then addresses wound moisture content. The depth of the wound in connection with its dryness or wetness will affect the choice of dressing. A superficial dry wound can benefit from a petrolatum or transparent film with a covering. A deeper, dry wound responds to hydrogel, again, with a covering.
A superficial wet wound needs a dressing to absorb moisture. Alginate or hydrofiber serve extremely wet wounds. This is rare in hand care settings; however an environment of lymphedema might create such a wound. Deep, wet wounds require alginate or hydrofiber dressings to absorb the high amount of moisture. Moderately wet wounds can benefit from a foam dressing. As the dressing fills with moisture, the volume of moisture becomes apparent and signals the patient or caregiver to change to a new one.
Skin Substitutes
Therapists may work in clinics that use skin substitutes or they may evaluate a patient with one of these products in place. Surgeons use these as an alternative to skin flaps and in burn centers where a patient may not have enough donor skin to allow wound coverage. Skin substitutes require 2 surgeries, one to put it on and one to remove it—typically with 2-3 weeks in between the two. Once the dermis revascularizes, the silicone layer is removed.
Many skin substitute products now exist and they each have their advantages and disadvantages. Because each type has critical clinical nuances, therapists must learn what product the physician has applied. The internet can provide the important information regarding management. The skin substitutes have specific instructions for compatibility with dressings, moisture, compression and ability to mobilize joints. A 2022 article by Palackic et al4 describes the current skin substitutes with their idiosyncrasies in terms of management. The therapist must research the product to learn its risks. processes and methods.
One of the important qualities of each skin substitute is its infection rate. Because Integra® came into use first, it has the most outcome data related to it. Infection rate for Integra is 16-17%. Synthetic skin substitutes such as Suprathel or Polynovo have demonstrated lower infection rates.
Additional Wound Issues and Management Approaches
Wet-to-dry dressings have been a mainstay of wound debridement for many years. Data from Ovington in 20025 and again in 20106 describes the significant disadvantages of this approach to wound management. These include reduction of tissue temperature, healing impediment and increases susceptibility to infection. Wet-to-dry dressings have a higher infection rate compared to transparent films. An infection cancels any “cost savings” that a clinician may claim. Studies have shown that bacteria can penetrate 64 layers of gauze. Removal of the dried dressing disperses the bacteria into the surrounding air. Lastly, the pain it causes creates patient distress.
Soaks for fingertip infections such as paronychia (nail infection) and felon (pulp infection)—especially with high concentrations of antibacterial soaps and scrubs—are no longer indicated. The goal of the soak was to soften the infectious materials and helps it exit the pocket where it evolved. However, the data no longer supports this. In 2022, Macneal and Milroy7 published on the management of these nail infections and found that antimicrobial spray with an appropriate dressing had much better outcomes.
Therapists have noted an ever-increasing incidence of suture issues. These include the creation of open wounds with a high potential for infection. Patients may react to suture material or fail to absorb the “absorbable” type. To treat the skin irritation and infections that result, therapist will want to use a non-occlusive dressing. Soap and water cleansing and the use of an anti-microbial treatment will facilitate wound resolution.
Therapists may work in conjunction with a wound care specialist and a referring surgeon who may not work on premises. Live video or photo sharing with a wound care specialist will allow the primary therapist to provide high level wound care at a distance.
Associated Diagnoses Where This Intervention May be Relevant
Any diagnosis involving an open wound including a well co-apted suture line will require skilled wound care.
