What should be included in a note for a patient with an elbow wound and edema to determine if they need further evaluation?

Documentation for Elbow Wound with Edema Requiring Referral

Your documentation should clearly justify the need for further evaluation by documenting specific wound characteristics, vascular status, infection indicators, and functional concerns that suggest complications requiring specialist intervention.

Critical Wound Characteristics to Document

• Wound duration and healing trajectory: Note if the wound has been present for >4 weeks without healing progression, as nonhealing wounds lasting this duration warrant heightened concern 1
• Wound dimensions and depth: Measure and record exact size, depth using sterile probe to assess for bone involvement (probe-to-bone has characteristic stony feel), and any undermining or tunneling 1
• Wound appearance: Document if the wound shows rapid growth, heaped-up appearance resembling exuberant granulation tissue, punched-out ulcer with raised/rolled edges, or hyperkeratosis with surrounding raised skin 1
• Wound bed characteristics: Record presence of necrotic tissue, slough, exudate quality (color, odor, quantity), and any exposed underlying structures such as tendons, nerves, or vessels 1

Edema Assessment and Documentation

• Edema characteristics: Document extent, laterality (unilateral vs bilateral), pitting vs non-pitting, and progression over time 2
• Timing relative to injury: Note that edema persisting beyond the inflammatory phase (typically 3-5 days) delays healing and contributes to complications including pain and stiffness 3
• Associated findings: Record any warmth, erythema spreading beyond wound margins, or signs of compartment syndrome 4
• Vascular assessment: Document presence or absence of dorsalis pedis and posterior tibial pulses; if pulses are not palpable, this indicates inadequate arterial supply requiring vascular evaluation 1

Infection Indicators Requiring Documentation

• Secondary signs of infection: Document wound dehiscence, bridging to other structures, undermining, pocketing, and any new areas of breakdown 1
• NERDS criteria for superficial infection: Nonhealing wound, Exudate increase, Red friable tissue, Debris/discoloration, Smell 1
• STONES criteria for deep infection: Size increasing, Temperature elevation, Os (probes to bone), New breakdown, Erythema/Edema, Exudate, Smell 1
• Systemic signs: Fever, leukocytosis, or metabolic instability warrant immediate evaluation for deep tissue infection or osteomyelitis 1

Vascular Compromise Documentation

• Clinical indicators: Document any signs suggesting arterial insufficiency including cool extremity, delayed capillary refill, pallor, or pain out of proportion to examination 1
• Ankle-brachial index (ABI): If available, document ABI <0.90 which is diagnostic for lower extremity arterial disease; ABI >1.40 suggests arterial calcification requiring alternative testing 1
• Need for urgent vascular imaging: Document if there is concern for vascular injury, particularly with large hematoma, proximity to major vessels, or isolated neurological deficit—these require CT angiography with 96.2% sensitivity for detecting vascular injuries 4

Functional and Anatomical Concerns

• Range of motion limitations: Document specific degrees of flexion-extension arc and any functional impairment 1
• Neurovascular status: Record any altered sensation (tingling, increased pain relative to typical wounds), motor deficits, or signs of nerve involvement 1
• Anatomical complexity: Note if wound overlies difficult anatomical sites such as joint spaces, tendons, or neurovascular structures that may require imaging to assess extent 1

Imaging Justification Documentation

• Initial imaging completed: Document that plain radiographs were obtained as first-line study to exclude fracture, particularly if any trauma occurred 1, 5
• Need for advanced imaging: Justify CT without contrast if fracture suspected but radiographs normal, or MRI without contrast for superior soft tissue detail to evaluate muscle tears, hematomas, or bone marrow edema 1, 4
• Red flags requiring urgent imaging: Document fever, spreading erythema, systemic symptoms, rapid progression with warmth/redness suggesting infectious process, or lump increasing in size requiring urgent referral 5

Common Pitfalls to Avoid

• Do not rely solely on classic infection signs: Inflammatory responses vary significantly based on bacterial burden, biofilm presence, and host immune status; use secondary signs and assessment tools 1
• Do not delay evaluation for vascular compromise: Signs of compartment syndrome or vascular injury require immediate imaging and specialist consultation 4
• Do not assume all edema is benign: Persistent edema beyond inflammatory phase indicates need for compression therapy, elevation, and investigation of underlying causes including venous insufficiency or lymphatic dysfunction 3, 2