How to manage a wound with exposed bone or tendon due to lack of soft tissue coverage?

From the Guidelines

Wounds with exposed bone or tendon due to lack of soft tissue coverage require immediate surgical intervention, such as skin grafting or flap procedures, to provide coverage and prevent infection, as recommended by the most recent guidelines 1. The goal of treatment is to create an environment that prevents infection while promoting granulation tissue formation, which serves as the foundation for eventual epithelialization or surgical closure.

• Cleaning the wound with sterile saline or mild antiseptic solution like 0.9% sodium chloride or diluted povidone-iodine is essential to prevent infection.
• Applying a non-adherent dressing such as petroleum-impregnated gauze (Xeroform) or silicone-based dressings can help maintain a moist wound environment without sticking to exposed tissues.
• Topical antimicrobials like silver sulfadiazine or bacitracin may be applied to prevent infection.
• Debridement, as described in the 2012 guidelines 1, is also crucial in removing necrotic or nonviable tissue, slough, or foreign material from the wound, which can aid in granulation tissue formation and reepithelialization.
• Negative pressure wound therapy (NPWT) may be considered for wound care after complete removal of necrosis in necrotizing infections, as suggested by the 2018 consensus conference 1. However, surgical intervention is the most critical step in managing wounds with exposed bone or tendon, and it should be prioritized to prevent infection and promote healing 1.

From the Research

Wound Management with Exposed Bone or Tendon

To manage a wound with exposed bone or tendon due to lack of soft tissue coverage, several techniques can be employed:

• Debridement: removal of dead tissue and foreign material from the wound to promote healing 2, 3, 4
• Negative Pressure Wound Therapy (NPWT): application of negative pressure to the wound to increase blood flow, reduce exudate, and promote granulation tissue formation 2, 5, 4
• Antibiotic therapy: use of antibiotics to prevent or treat infection 2, 4
• Soft tissue reconstruction: use of flaps or skin grafts to cover the wound and promote healing 5, 3, 4

Wound Coverage Techniques

Various wound coverage techniques can be used, including:

• Split-thickness skin grafting: a layer of skin is taken from a donor site and applied to the wound 3
• Flap creation: a flap of tissue is created and used to cover the wound 5, 3
• Complete primary wound closure: the wound is closed immediately after debridement 3
• Secondary intention: the wound is allowed to heal on its own without immediate closure 3

Considerations for Wound Management

When managing a wound with exposed bone or tendon, it is essential to consider the following:

• The use of custom-made NPWT dressings can promote wound healing and prevent infection 2
• Immediate postoperative application of NPWT can be effective in promoting wound healing and preventing complications 5
• The choice of wound coverage technique depends on the size and location of the wound, as well as the patient's overall health 3
• Antibiotic beads can be used to prevent infection in wounds awaiting soft tissue coverage 4