What is the best way to manage a heel wound with staples?

Management of Heel Wounds with Staples

For heel wounds with staples, the most effective management approach is to remove the staples, perform sharp debridement as needed, and apply appropriate wound dressings based on wound characteristics, while ensuring proper pressure offloading.

Assessment and Initial Management

• Evaluate the wound for:

  • Signs of infection (erythema, warmth, purulence, odor)
  • Depth and extent of tissue involvement
  • Presence of necrotic tissue
  • Amount of exudate
  • Vascular status (palpate dorsalis pedis and posterior tibial pulses)

• Remove staples as they are not recommended for heel wound closure 1

  • Metal staples can cause additional tissue trauma in pressure-prone areas like the heel
  • Staples are associated with higher inflammation in contaminated wounds compared to some closure methods 2

Debridement Approach

• Implement sharp debridement as the primary method 3, 1

  • Remove all necrotic tissue, slough, and foreign material
  • Trim surrounding hyperkeratosis (callus)
  • Frequency should be determined by clinical need 3
  • May require local anesthesia if patient has intact sensation

• Avoid alternative debridement methods 3, 1:

  • Do not use enzymatic debridement unless sharp debridement is unavailable
  • Do not use ultrasonic debridement
  • Avoid autolytic, biosurgical, hydrosurgical, chemical, or laser debridement

Wound Dressing Selection

• Choose appropriate dressing based on wound characteristics 3, 1:

  • For dry or necrotic wounds: Continuously moistened saline gauze or hydrogels
  • For exudative wounds: Alginates or foams
  • For wounds needing autolysis: Hydrocolloids
  • For moistening dry wounds: Films (occlusive or semi-occlusive)

• Dressings to avoid 3, 1:

  • Do not use topical antiseptic or antimicrobial dressings
  • Avoid honey or bee-related products
  • Do not use collagen or alginate dressings specifically for healing purposes
  • Avoid topical phenytoin or herbal remedies

Pressure Offloading

• Implement appropriate pressure offloading strategies:
  • For plantar heel wounds: Total contact casting when possible 1
  • When non-removable devices are contraindicated: Use removable walkers 1
  • For non-plantar heel wounds: Consider shoe modifications, temporary footwear, or orthoses 1
  • Instruct patients to limit standing and walking 1

Infection Management

• For infected wounds:
  • Obtain deep tissue cultures before starting antibiotics 1
  • For superficial infections: Start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 3, 1
  • For deep infections: Initiate broad-spectrum parenteral antibiotics 3, 1
  • Adjust antibiotic regimen based on clinical response and culture results 1
  • For diabetic foot osteomyelitis: 6 weeks of antibiotic therapy if infected bone is not resected; no more than 1 week if all infected bone is resected 3

Adjunctive Therapies

Consider these only when standard care has failed:

• For non-infected, neuro-ischemic wounds: Sucrose-octasulfate impregnated dressing 3, 1
• For post-surgical wounds: Negative pressure wound therapy may be beneficial 1
• When resources exist and standard care has failed: Hyperbaric oxygen therapy or topical oxygen therapy 3, 1
• For specific cases: Autologous leucocyte, platelet, and fibrin patch or placental-derived products 3, 1

Follow-up and Monitoring

• Change dressings at least daily to:
  • Apply clean wound covering
  • Allow careful examination of the wound for infection 3
• Regular follow-up based on risk stratification:
  • High-risk patients: Every 1-3 months 1
  • Monitor for signs of healing or deterioration

Common Pitfalls to Avoid

1. Leaving staples in place, which can cause additional trauma and inflammation in heel wounds
2. Using inappropriate dressings that don't match wound characteristics
3. Inadequate pressure offloading, which is critical for heel wound healing
4. Failing to address underlying vascular insufficiency
5. Using topical antimicrobials without evidence of benefit
6. Applying total contact casting for infected wounds, which limits wound visualization 3