Proper initial management of the wound promotes healing, reduces infection, and prevents complications. Critical considerations include identification of factors that potentiate infection, such as the elapsed time from injury, the degree of contamination, the depth of injury, and the presence of devitalized tissue or foreign material in the wound. Injuries by animal or human bite also need accurate and prompt identification. The patient’s ability to respond to potential infection is also important. Significant medical problems that affect wound healing include diabetes, cardiovascular disease, immunocompromised states, and medications that suppress the immune system. Tetanus status and nutritional status are also critical. Important features on examination of the wound include neurovascular compromise, function distal to the injury, the depth of wound and any involved structures (e.g., compound fracture, tendon injury), and the presence of devitalized tissue or foreign material.

There are three options for wound closure: primary (immediate suture closure), secondary (healing by secondary intention), or tertiary closure (delayed primary closure). When deciding, significant factors include the potential for wound infection, the condition of the soft tissues and the tension required to approximate them, and the need for hemostasis. Most wounds that are less than 6 hours old are in “the golden period” and contain less than 10⁵ colonies of organisms per gram of tissue and can be closed primarily (1). Acute wounds can also be classified into four categories: clean, clean-contaminated, contaminated, and dirty and infected (2). Do not close puncture wounds, human bites, wounds with inadequate hemostasis, and wounds under excessive tension. Devitalized tissues and foreign bodies must be removed before primary closure. Diabetics and immunocompromised patients will have a higher risk of infection and subsequent dehiscence.

The risk of tetanus is increased if the wound is more than 6 hours old, is deeper than 1 cm, or is contaminated. Crush or missile injuries and bite wounds also require a tetanus shot (3). Assess the patient’s tetanus immune status and give appropriate tetanus toxoid with or without immunoglobulin as indicated.

Prophylactic antibiotics are indicated for contaminated wounds in patients who are immunocompromised, are diabetic, or have indwelling prosthetic devices such as heart valves or joint prostheses. Bite wounds, necrotic wounds, and wounds contaminated with gastrointestinal or urologic organisms also should receive prophylactic antibiotics (4).

The four phases that acute and chronic wounds must pass through are hemostasis, inflammation, proliferation, and remodeling (Table 2.1).

The platelet is the most important component of the hemostasis phase. Not only does it help to form the wound clot (or temporary matrix) but also its alpha granules release growth factors, which play a critical role in accelerating wound healing.

Neutrophils, monocytes, and macrophages direct the inflammatory phase by removing devitalized tissue and destroying bacteria. They phagocytose bacteria and release proteases (matrix metalloproteinases [MMPs]).

The fibroblast and myofibroblast produce collagen during the proliferative phase and initiate wound contraction. By 6 weeks, collagen synthesis has peaked and the wound has achieved approximately 75% of its eventual tensile strength (5). Keratinocytes re-epithelialize the wound.

Fibroblasts then regulate remodeling as immature collagen (type 3) is broken down and mature collagen (type 1) is synthesized and re-aligned to increase the tensile strength of the wound.

Frequent debridement of the chronic wound bed has been shown to accelerate wound healing (11). Debridement is intended to remove necrotic debris, the cellular burden (senescent cells), and the biofilm of contaminated or infected matrix from the wound bed (12). In doing so the stimulus for white cell migration and the inflammatory process within the wound is removed (13). Debridement can be performed by surgical debridement, mechanical debridement (whirlpool, pulsed lavage), enzymatic means (papain-urea or collagenase), or autolytic means.

Quantitative tissue cultures reveal whether the wound is contaminated or infected (more than 10⁵ colonies per g of tissue) (14). Specific organisms can be addressed with topical agents such as ionic silver or cadexomer iodine. Agents such as povidone iodine (Betadine), 3% hydrogen peroxide, and 0.5% sodium hypochlorite (Dakin solution) kill fibroblasts and keratinocytes (15) and should be avoided. Systemic antibiotics may be required if extensive soft tissue, bone, or systemic infection is present.