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Complications of wound healing
/content/chapter/10.22233/9781905319558.chap12
Complications of wound healing
- Author: Ed Friend
- From: BSAVA Manual of Canine and Feline Wound Management and Reconstruction
- Item: Chapter 12, pp 254 - 270
- DOI: 10.22233/9781905319558.12
- Copyright: Copyright © 2017 British Small Animal Veterinary Association
- Publication Date: March 2009
Abstract
Wound healing complications are often difficult to deal with, as there are so many factors involved in the wound healing process and an almost infinite variety of wound types. Furthermore, the complication may be as a result of surgical intervention, and there may be as a result of surgical intervention, and there may be extra pressure from an owner for the problem to be resolved, as it may be perceived as being the fault of the veterinary surgeon. There is no generic formula or ‘recipe’ that can be applied to any one type of wound. This chapter finishes with a description of the causes and treatment of some wound complications, with specific guidance. It is important to remember that these general principles , discussed in the first section, can be applied to any type of wound. The following sections are covered: Why and how do complications occur?; Managing complications of conservative (non-surgical) wound management; and Managing complications of surgical wound management. Case examples: Management of a non-healing wound; Management of a wound dehiscence and Management of a persistent seroma.
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12.1
This 6-year-old neutered female Chihuahua had been attacked by another dog. (a) The wound was heavily contaminated and so initially conservative wound management was indicated. (b) After 6 days of open wound management, delayed primary closure using active suction drains was performed. The wound healed completely (the other dressings were for further wounds still being managed conservatively). © 2009 British Small Animal Veterinary Association
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12.1
This 6-year-old neutered female Chihuahua had been attacked by another dog. (a) The wound was heavily contaminated and so initially conservative wound management was indicated. (b) After 6 days of open wound management, delayed primary closure using active suction drains was performed. The wound healed completely (the other dressings were for further wounds still being managed conservatively).
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12.2
Decubital ulcer over the elbow of a 10-year-old male entire German Shepherd cross. This region is very difficult to treat as it is a pressure point when the animal lies down, as well as being a high-motion area. © 2009 British Small Animal Veterinary Association
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12.2
Decubital ulcer over the elbow of a 10-year-old male entire German Shepherd cross. This region is very difficult to treat as it is a pressure point when the animal lies down, as well as being a high-motion area.
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12.3
(a) A wound to the dorsal paw of the left pelvic limb in a 2-year-old Italian Greyhound. This area is difficult to treat as there is no redundant skin on the distal limb, and this is a high-motion area as there are underlying joints. A free skin graft was performed after the wound had been prepared for surgery. (b) Fourteen days after free skin graft surgery. The application of the skin graft has enabled healing to occur, despite skin tension in the area and motion from the underlying digits. © 2009 British Small Animal Veterinary Association
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12.3
(a) A wound to the dorsal paw of the left pelvic limb in a 2-year-old Italian Greyhound. This area is difficult to treat as there is no redundant skin on the distal limb, and this is a high-motion area as there are underlying joints. A free skin graft was performed after the wound had been prepared for surgery. (b) Fourteen days after free skin graft surgery. The application of the skin graft has enabled healing to occur, despite skin tension in the area and motion from the underlying digits.
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12.5
A small benign neoplasm had been removed from the skin overlying this elbow. The surgeon had used pieces of plastic tubing as a way of relieving tension in the skin but the tubing had itself caused pressure necrosis of the underlying skin. This would have complicated further surgery had the original wound not healed. © 2009 British Small Animal Veterinary Association
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12.5
A small benign neoplasm had been removed from the skin overlying this elbow. The surgeon had used pieces of plastic tubing as a way of relieving tension in the skin but the tubing had itself caused pressure necrosis of the underlying skin. This would have complicated further surgery had the original wound not healed.
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12.6
Contraction. (a) A 10-month-old male Shar Pei, 10 days after lateral wall resection. Two sides of the closure around the drainage board have dehisced due to excessive tension on the skin. If more of the area around the drainage board had dehisced, leaving the wound for second intention healing may have risked stenosis or closure of the external ear canal. (b) A middle-aged Collie cross with loss of ventral and lateral abdominal skin following bite wounds. The wound was left for second intention healing and eventually healed completely. The resulting epithelium was thin and sparsely haired, however, and so prone to damage. Contraction also led to lateral deviation of the prepuce. © 2009 British Small Animal Veterinary Association
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12.6
Contraction. (a) A 10-month-old male Shar Pei, 10 days after lateral wall resection. Two sides of the closure around the drainage board have dehisced due to excessive tension on the skin. If more of the area around the drainage board had dehisced, leaving the wound for second intention healing may have risked stenosis or closure of the external ear canal. (b) A middle-aged Collie cross with loss of ventral and lateral abdominal skin following bite wounds. The wound was left for second intention healing and eventually healed completely. The resulting epithelium was thin and sparsely haired, however, and so prone to damage. Contraction also led to lateral deviation of the prepuce.
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12.8
A 2-year-old male Terrier cross that had a jaw wound sutured following a fight with another dog. (a) The wound dehisced 5 days postoperatively due to infection and excessive tension at the site. (b) After open wound management, the wound was closed with an advancement skin flap, eliminating tension as a possible cause for further dehiscence. © 2009 British Small Animal Veterinary Association
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12.8
A 2-year-old male Terrier cross that had a jaw wound sutured following a fight with another dog. (a) The wound dehisced 5 days postoperatively due to infection and excessive tension at the site. (b) After open wound management, the wound was closed with an advancement skin flap, eliminating tension as a possible cause for further dehiscence.
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© 2009 British Small Animal Veterinary Association
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12.9
A non-healing wound developed caudal to the pinna base 4 months after total ear canal ablation and lateral bulla osteotomy had been performed in a 10-year-old neutered female Cavalier King Charles Spaniel. It was surgically explored, and infected aural epithelium was found in the middle ear. The wound healed uneventfully following thorough debridement. © 2009 British Small Animal Veterinary Association
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12.9
A non-healing wound developed caudal to the pinna base 4 months after total ear canal ablation and lateral bulla osteotomy had been performed in a 10-year-old neutered female Cavalier King Charles Spaniel. It was surgically explored, and infected aural epithelium was found in the middle ear. The wound healed uneventfully following thorough debridement.
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12.10
Closure of skin defects in areas of tight skin can be challenging, especially in the distal limb. In this case, a lateral genicular axial pattern flap has been used to close a skin defect between the stifle and hock. Two active suction drains have been placed. © 2009 British Small Animal Veterinary Association
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12.10
Closure of skin defects in areas of tight skin can be challenging, especially in the distal limb. In this case, a lateral genicular axial pattern flap has been used to close a skin defect between the stifle and hock. Two active suction drains have been placed.
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12.11
Wound swelling 6 days after exploratory laparotomy in a 10-year-old neutered male DSH cat. This was initially diagnosed as a likely seroma, but on ultrasound examination an incisional hernia through the body wall was demonstrated. © 2009 British Small Animal Veterinary Association
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12.11
Wound swelling 6 days after exploratory laparotomy in a 10-year-old neutered male DSH cat. This was initially diagnosed as a likely seroma, but on ultrasound examination an incisional hernia through the body wall was demonstrated.
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12.12
Cytological preparation of neat seroma fluid (modified Wright’s stain; original magnification X100); inset: concentrated preparation (×1000) showing erythrophagocytic macrophages. (Courtesy of Oliver Coldrick, TDDS Laboratories) © 2009 British Small Animal Veterinary Association
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12.12
Cytological preparation of neat seroma fluid (modified Wright’s stain; original magnification X100); inset: concentrated preparation (×1000) showing erythrophagocytic macrophages. (Courtesy of Oliver Coldrick, TDDS Laboratories)
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12.13
(a) A traumatic ventral abdominal wound was sutured in a 5-year-old neutered male DSH cat. Seroma formation over 3–4 days postoperatively caused disruption of the suture line and dehiscence, followed by necrosis of adjacent skin. At this stage it was impossible to tell that the initial problem was a seroma. (b) The wound was managed with debridement and flushing with sterile isotonic solution, followed by placement of Penrose drains and careful apposition of tissues. The wound went on to heal uneventfully. © 2009 British Small Animal Veterinary Association
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12.13
(a) A traumatic ventral abdominal wound was sutured in a 5-year-old neutered male DSH cat. Seroma formation over 3–4 days postoperatively caused disruption of the suture line and dehiscence, followed by necrosis of adjacent skin. At this stage it was impossible to tell that the initial problem was a seroma. (b) The wound was managed with debridement and flushing with sterile isotonic solution, followed by placement of Penrose drains and careful apposition of tissues. The wound went on to heal uneventfully.
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The patient on presentation.
The patient on presentation. © 2009 British Small Animal Veterinary Association
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The patient on presentation.
The patient on presentation.
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Non-healing ventral abdominal wounds. Note the shiny, thin epithelium caudal to the wounds.
Non-healing ventral abdominal wounds. Note the shiny, thin epithelium caudal to the wounds. © 2009 British Small Animal Veterinary Association
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Non-healing ventral abdominal wounds. Note the shiny, thin epithelium caudal to the wounds.
Non-healing ventral abdominal wounds. Note the shiny, thin epithelium caudal to the wounds.
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The defect after resection of the granulation bed and unhealthy epithelium. ---- Incisions for two rotation flaps.
The defect after resection of the granulation bed and unhealthy epithelium. ---- Incisions for two rotation flaps. © 2009 British Small Animal Veterinary Association
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The defect after resection of the granulation bed and unhealthy epithelium. ---- Incisions for two rotation flaps.
The defect after resection of the granulation bed and unhealthy epithelium. ---- Incisions for two rotation flaps.
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Rotation flaps were carefully raised deep to the subdermal plexus, taking care not to traumatize the tissues. The flap base must be as wide as the widest part of the flap, or blood supply distal to this part may be compromised.
Rotation flaps were carefully raised deep to the subdermal plexus, taking care not to traumatize the tissues. The flap base must be as wide as the widest part of the flap, or blood supply distal to this part may be compromised. © 2009 British Small Animal Veterinary Association
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Rotation flaps were carefully raised deep to the subdermal plexus, taking care not to traumatize the tissues. The flap base must be as wide as the widest part of the flap, or blood supply distal to this part may be compromised.
Rotation flaps were carefully raised deep to the subdermal plexus, taking care not to traumatize the tissues. The flap base must be as wide as the widest part of the flap, or blood supply distal to this part may be compromised.
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An active suction drain has been placed under the flaps; it does not exit through the base of a flap (which would compromise blood flow). Simple interrupted subcuticular sutures of synthetic absorbable suture material have been placed, followed by surgical skin staples.
An active suction drain has been placed under the flaps; it does not exit through the base of a flap (which would compromise blood flow). Simple interrupted subcuticular sutures of synthetic absorbable suture material have been placed, followed by surgical skin staples. © 2009 British Small Animal Veterinary Association
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An active suction drain has been placed under the flaps; it does not exit through the base of a flap (which would compromise blood flow). Simple interrupted subcuticular sutures of synthetic absorbable suture material have been placed, followed by surgical skin staples.
An active suction drain has been placed under the flaps; it does not exit through the base of a flap (which would compromise blood flow). Simple interrupted subcuticular sutures of synthetic absorbable suture material have been placed, followed by surgical skin staples.
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The wounds have healed well by the time of staple removal 9 days postoperatively.
The wounds have healed well by the time of staple removal 9 days postoperatively. © 2009 British Small Animal Veterinary Association
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The wounds have healed well by the time of staple removal 9 days postoperatively.
The wounds have healed well by the time of staple removal 9 days postoperatively.
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The patient on presentation.
The patient on presentation. © 2009 British Small Animal Veterinary Association
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The patient on presentation.
The patient on presentation.
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The wound in the precrural/inguinal region contains a large amount of purulent material and the previous suture line has dehisced.
The wound in the precrural/inguinal region contains a large amount of purulent material and the previous suture line has dehisced. © 2009 British Small Animal Veterinary Association
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The wound in the precrural/inguinal region contains a large amount of purulent material and the previous suture line has dehisced.
The wound in the precrural/inguinal region contains a large amount of purulent material and the previous suture line has dehisced.
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Application of a wet-to-dry dressing. Bandaging a male dog in this area can be difficult, as the penis must be exposed for urination. An indwelling catheter should be avoided because of the risk of ascending infection.
Application of a wet-to-dry dressing. Bandaging a male dog in this area can be difficult, as the penis must be exposed for urination. An indwelling catheter should be avoided because of the risk of ascending infection. © 2009 British Small Animal Veterinary Association
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Application of a wet-to-dry dressing. Bandaging a male dog in this area can be difficult, as the penis must be exposed for urination. An indwelling catheter should be avoided because of the risk of ascending infection.
Application of a wet-to-dry dressing. Bandaging a male dog in this area can be difficult, as the penis must be exposed for urination. An indwelling catheter should be avoided because of the risk of ascending infection.
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After 2 days of twice-daily debriding dressings granulation tissue is already starting to form in the wound.
After 2 days of twice-daily debriding dressings granulation tissue is already starting to form in the wound. © 2009 British Small Animal Veterinary Association
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After 2 days of twice-daily debriding dressings granulation tissue is already starting to form in the wound.
After 2 days of twice-daily debriding dressings granulation tissue is already starting to form in the wound.
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The wound 9 days after conservative management had begun.
The wound 9 days after conservative management had begun. © 2009 British Small Animal Veterinary Association
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The wound 9 days after conservative management had begun.
The wound 9 days after conservative management had begun.
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Seroma on the dorsal thorax 10 days after Penrose drain removal.
Seroma on the dorsal thorax 10 days after Penrose drain removal. © 2009 British Small Animal Veterinary Association
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Seroma on the dorsal thorax 10 days after Penrose drain removal.
Seroma on the dorsal thorax 10 days after Penrose drain removal.
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Two active suction drains have been placed, with the bulbs secured to the animal’s collar. Hair growth has occurred since surgery.
Two active suction drains have been placed, with the bulbs secured to the animal’s collar. Hair growth has occurred since surgery. © 2009 British Small Animal Veterinary Association
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Two active suction drains have been placed, with the bulbs secured to the animal’s collar. Hair growth has occurred since surgery.
Two active suction drains have been placed, with the bulbs secured to the animal’s collar. Hair growth has occurred since surgery.
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Appearance of the wound 2 weeks after active suction drains were removed. There has been no recurrence of the seroma.
Appearance of the wound 2 weeks after active suction drains were removed. There has been no recurrence of the seroma. © 2009 British Small Animal Veterinary Association
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Appearance of the wound 2 weeks after active suction drains were removed. There has been no recurrence of the seroma.
Appearance of the wound 2 weeks after active suction drains were removed. There has been no recurrence of the seroma.