Specific Issues That Impact Evaluation And Treatment

Several factors can have an impact on wound healing in the extremities and over joints. These include intrinsic patient characteristics and chronic diseases that may hinder the normal healing process, such as age, comorbidities, keloids, and suspected abuse or assault.

Extremes of age have clinical relevance to wound healing. Elderly patients tend to have thin skin and decreased subcutaneous fat, especially over the dorsum of the hand or the anterior shin, making wound edges more difficult to oppose. This also results in decreased tissue viability when under the tension of sutures. Elderly patients are more likely than others to have underlying systemic medical conditions that may contribute to delayed wound healing. In addition, they are less likely to be adequately immunized against tetanus. Only 28 percent of people over age 70 in the United States have detectable serum antibody to tetanus. 6

Extremely young patients are also at high risk for poor wound healing. They may have difficulty limiting movement of the injured extremity, and they are more likely to contaminate their wounds. The general rule to follow is "the smaller the child, the larger the dressing."

Many comorbid medical conditions may adversely affect wound healing in the extremities. Patients with diabetes mellitus are more prone to wound infection as a result of peripheral vascular disease and hyperglycemia. Other medical conditions that can hamper wound healing include chronic renal insufficiency, end-stage liver disease, anemia, chronic corticosteroid use, obesity, and connective tissue diseases such as Ehlers-Danlos and Marfan syndromes and osteogenesis imperfecta.

Keloid formation can be a problem for many patients. It is more common in patients of African and Asian descent but can occur in patients of any ethnic origin. The most common sites are the ears, lower abdomen, sternum, and upper extremity. Previous keloid formation in a given patient should alert the physician to the risk of subsequent keloids.

Injuries over the midshafts of long bones should alert the emergency physician to the possibility of assault. The patient should be questioned as to the mechanism of injury and examined thoroughly for ecchymoses and lacerations in various stages of healing. It is the physician's duty to report suspected abuse to the local law enforcement agency in accordance with individual state laws.

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