What is the best course of treatment for an elderly patient with an elbow abrasion (skinning of the elbow) due to a fall, who is unable to approximate skin edges?

Management of Elbow Skin Loss in Elderly Fall Patients

For an elderly patient with elbow skin loss from a fall where skin edges cannot be approximated, use moist wound healing with non-adherent dressings, ensure adequate nutrition and vitamin D supplementation, and arrange urgent wound care follow-up within 48-72 hours with consideration for dermal regeneration templates or skin grafting if the wound fails to granulate or involves exposed bone/joint structures.

Immediate Wound Management

Initial Assessment and Wound Care

• Perform a complete head-to-toe examination even for seemingly isolated injuries, as traumatic injuries may be occult in elderly patients 1
• Thoroughly irrigate and debride the wound to remove all devitalized tissue and debris 2
• Apply a non-adherent dressing with moisture-retentive properties (such as petroleum-impregnated gauze or hydrocolloid) to promote granulation tissue formation 1
• Avoid primary closure attempts when skin edges cannot be approximated without tension, as this increases risk of wound dehiscence and infection in elderly patients with fragile skin 2

Critical Pitfall to Avoid

Do not use antibiotics prophylactically in the absence of signs of infection or sepsis, as they are not recommended in blunt trauma per the 2023 WSES guidelines 1. However, maintain high suspicion for infection given the elderly patient's compromised immune response.

Comprehensive Fall Assessment (Mandatory)

Immediate Risk Factor Evaluation

Since this patient has already fallen, you must conduct a comprehensive fall evaluation to prevent recurrence and reduce mortality 3:

• Ask the critical question: "If this patient was a healthy 20-year-old, would they have fallen?" If no, proceed with comprehensive assessment 3
• Document fall circumstances: location, time spent on ground, loss of consciousness, near-syncope symptoms 3
• Perform orthostatic blood pressure measurements to assess for orthostatic hypotension 3, 4
• Conduct medication review focusing on psychotropic medications, vestibular suppressants, and polypharmacy (>3 medications daily) 3, 4
• Assess vision, gait using "Get Up and Go Test" (>12 seconds indicates high fall risk), balance, and lower extremity function 3, 4

High-Risk Injury Screening

• Evaluate specifically for hip fractures and cervical spine injuries, as elderly patients are more likely to sustain these from ground-level falls 1
• Screen for rib fractures which can exacerbate cardiopulmonary disease 1

Wound-Specific Treatment Algorithm

For Superficial Partial-Thickness Loss (No Bone/Joint Exposure)

1. Moist wound healing protocol with daily to twice-daily dressing changes 1
2. Ensure adequate protein intake (1.2-1.5 g/kg/day) and vitamin D 800 IU daily with calcium 1000-1200 mg daily 1
3. Arrange wound care follow-up within 48-72 hours 1
4. If no granulation tissue by 2 weeks, consider dermal regeneration template 5

For Deep Wounds or Exposed Structures

• Urgent plastic surgery consultation for consideration of dermal regeneration template followed by split-thickness skin grafting 2, 5
• This approach provides stable soft tissue coverage and maintains elbow range of motion better than allowing secondary intention healing 5
• Pedicled flaps from arm/forearm or fascio-cutaneous flaps may be required for extensive defects 2

Multifactorial Fall Prevention Interventions (Required)

Before Discharge

• Evaluate gait and perform "Get Up and Go Test" - do not discharge if patient cannot safely ambulate 3
• Consider admission if patient safety cannot be ensured at home 3
• Prescribe assistive device (walker/cane) if gait time >12 seconds, with proper fitting and training 4

Mandatory Referrals

• Physical therapy referral for gait training, balance exercises (3+ days/week), and strength training (2x/week) 3, 4
• Occupational therapy home safety assessment with direct intervention: remove loose rugs, ensure adequate lighting, install grab bars 4
• Arrange expedited outpatient follow-up within 1 week 3

Medication Optimization

• Review and discontinue high-risk medications including vestibular suppressants, psychotropic medications, tramadol, and unnecessary polypharmacy 3, 4
• Avoid sedating medications that increase fall risk 1

Monitoring and Follow-Up

Wound Care Monitoring

• Reassess wound every 48-72 hours initially for signs of infection, granulation tissue formation, and epithelialization 1
• If wound shows no improvement by 2 weeks or develops infection, escalate to advanced wound care or surgical consultation 2, 5

Fall Risk Monitoring

• Bone health evaluation with DEXA scan to assess fracture risk, as this patient is now at high risk for subsequent fractures 1, 4
• Continue multifactorial interventions with ongoing medication review and environmental modification 4
• Monitor for recurrent falls, as 6% of ground-level falls result in fractures and mortality can be as high as 7% in this age group 1