What is the appropriate acute management of a forearm wound with exposed tendon and insufficient skin for primary suture closure?

Acute Management of Forearm Wound with Exposed Tendon and Insufficient Skin

Do not attempt primary closure—leave the wound open and manage with copious irrigation, cautious debridement, and moist wound dressing, followed by delayed primary closure or advanced coverage techniques once the wound bed is optimized.

Initial Wound Management

The most critical principle from the IDSA guidelines is clear: infected wounds should not be closed, and primary closure of contaminated wounds is controversial 1, 2. For wounds with insufficient skin for primary closure and exposed tendons, attempting to force closure will lead to infection, tissue necrosis, and worse functional outcomes.

Immediate Steps (First 24 Hours)

Wound Cleansing:

• Irrigate copiously with sterile normal saline only—no iodine, no antiseptics, no soap 1. The AAOS guidelines provide strong evidence (2023) that simple saline without additives is optimal for traumatic wounds 3
• Remove only superficial debris initially
• Avoid aggressive debridement that enlarges the wound or removes potentially viable tissue 1

Tetanus Prophylaxis:

• Administer tetanus toxoid (0.5 mL IM) if last dose >5 years ago for dirty wounds, or >10 years for clean wounds 2
• Tdap is preferred over Td if not previously given 2

Antibiotic Coverage: Given exposed tendon (a deep structure), initiate empiric antibiotics to prevent tendonitis and deep space infection 1:

• Oral outpatient: Amoxicillin-clavulanate (first-line) 1
• IV if hospitalized: Ampicillin-sulbactam, piperacillin-tazobactam, or second-generation cephalosporin 1
• Avoid first-generation cephalosporins alone—inadequate coverage 1

Elevation: Elevate the forearm continuously for the first few days to reduce edema and accelerate healing 1

Wound Coverage Strategy

Option 1: Delayed Primary Closure (Preferred for Most Cases)

Approximate wound edges with Steri-Strips rather than sutures, then plan for delayed primary or secondary closure 1, 2. This approach:

• Allows wound bed preparation without forcing closure
• Reduces infection risk
• Permits assessment of tissue viability over 3-5 days

Option 2: Negative Pressure Wound Therapy (NPWT/VAC)

For wounds with exposed tendons where skin grafting isn't immediately possible, NPWT is highly effective 4, 5:

• Stimulates granulation tissue over exposed tendons 4
• Reduces tissue edema and facilitates delayed closure 5
• Can achieve closure in 4-23 days (average 8 days) when combined with progressive suture tightening techniques 5
• Reduces bacterial contamination 5

Application technique:

• Apply NPWT directly over exposed tendon (with protective interface layer)
• Change every 48-72 hours
• Monitor for granulation tissue formation
• Once adequate granulation covers tendon, proceed to skin grafting or delayed closure

Option 3: Dermal Matrix Substitutes

For wounds where NPWT alone is insufficient, esterified hyaluronic acid matrix (eHAM) or similar dermal substitutes can be applied after debridement 6:

• Provides scaffold for revascularization
• Enables granulation tissue formation over exposed structures
• High success rates for complete reepithelialization 6
• Can be followed by split-thickness skin graft once vascularized

Option 4: Autologous Homologous Skin Construct (AHSC)

For complex wounds with exposed tendons, AHSC represents a newer option that achieved complete closure in 9 weeks with functional, pliable skin in combat injuries 7:

• Requires small full-thickness skin harvest
• Processed and returned in 48 hours
• Prevents contractures and maintains tendon gliding
• Superior functional outcomes compared to STSG alone

Critical Pitfalls to Avoid

Never force primary closure when skin edges cannot be approximated without tension—this guarantees infection and potential tendon necrosis 1, 2.

Never debride exposed tendons to facilitate skin grafting—this destroys function 8. The goal is to cover viable tendons, not remove them.

Never use caustic solutions (iodine, hydrogen peroxide, antiseptics) in the wound—these damage tissue and impair healing 9.

Watch for compartment syndrome in forearm injuries—pain disproportionate to injury suggests this complication 1.

Monitor for deep infections: Tendonitis, osteomyelitis, and septic arthritis require 3-6 weeks of antibiotics 1.

Follow-Up Protocol

• 24-hour follow-up (phone or in-person) to assess for infection progression 1
• If infection worsens despite antibiotics, hospitalize immediately 1
• Plan definitive closure at 5-14 days once wound bed is clean and granulating
• Early active range of motion exercises (starting day 3 post-procedure) to prevent tendon adhesions 8

Definitive Coverage Timeline

• Days 3-5: Reassess wound bed; if clean with healthy granulation, proceed to coverage
• Skin grafting: Only after complete granulation coverage of tendon
• Flap reconstruction: Reserved for failures of conservative management or when immediate coverage of critical structures is needed
• Moist wound environment throughout healing process optimizes outcomes 9

The key principle is patience over urgency—allowing proper wound bed preparation prevents the catastrophic complications of forced closure, including infection, tendon necrosis, and loss of limb function.