What is the best management approach for a patient with a dehisced wound, potentially with underlying conditions such as diabetes or poor circulation?

Management of Dehisced Wounds

Immediate sharp debridement to remove all necrotic tissue and slough is the critical first step, followed by moisture-retentive dressings, strict pressure offloading if on the lower extremity, and urgent vascular assessment in patients with diabetes or poor circulation. 1, 2, 3

Immediate Assessment and Debridement

Perform sharp debridement immediately using scalpel, scissors, or tissue nippers to remove all necrotic tissue, slough, and surrounding callus from the wound base. 2, 4, 3 This is the single most important intervention—debridement converts a chronic wound into an acute wound that can progress through normal healing stages. 5

• Use conservative, tissue-preserving technique rather than aggressive excision, as overly aggressive debridement can expose bone or tendon and lead to chronic osteomyelitis or amputation. 3
• Debride before obtaining wound cultures if infection is suspected. 4
• Plan for frequent repeat debridement (typically weekly or more often) based on clinical need if significant necrotic tissue reaccumulates. 4

Critical Vascular Assessment (Especially for Diabetes/Poor Circulation)

Obtain urgent vascular evaluation immediately in all patients with diabetes or suspected poor circulation, as approximately 50% of diabetic foot ulcers have peripheral artery disease. 1, 4

• Measure ankle-brachial index (ABI), toe pressures, and transcutaneous oxygen pressure (TcPO₂). 4, 3
• If severe ischemia is present (ABI <0.5, ankle pressure <50 mmHg, or toe pressure <30 mmHg), revascularization must occur before aggressive wound therapy—otherwise treatment will fail. 1, 4, 3
• Note that palpable foot pulses do not reliably rule out peripheral artery disease, and ABI may be falsely elevated due to medial artery calcification in diabetic patients. 1

Infection Recognition and Management

Assess for clinical signs of infection at every dressing change: increased exudate, odor, pain, surrounding erythema, warmth, or purulent drainage. 1, 4, 3

• If infection is present, obtain tissue specimens from the debrided wound base via curettage or biopsy—never use superficial wound swabs as they yield contaminated results with skin flora and lead to inappropriate antibiotic selection. 1, 3
• Initiate prompt broad-spectrum antibiotics covering aerobic gram-positive cocci, gram-negatives, and anaerobes for infected wounds. 3
• Surgical drainage is mandatory if pus is present—"don't let the sun set on pus." 1 Surgical debridement is required for abscess, gas, or necrotizing fasciitis. 1
• Continue antibiotics until clinical signs of infection resolve (typically 2-4 weeks for severe soft tissue infections), not until the wound heals—antibiotics treat infection, not wounds. 1, 3
• Do not use antibiotics for uninfected wounds—they do not promote healing and contribute to resistance. 4

Wound Care Protocol

Stop all topical antibiotic ointments immediately—topical antimicrobials do not improve healing outcomes and are strongly discouraged. 4

• Cleanse wounds with sterile normal saline only—iodine or antibiotic-containing solutions are unnecessary. 3
• Select simple moisture-retentive dressings based on exudate control, comfort, and cost rather than antimicrobial properties. 1, 2, 4
• For heavy exudate, use absorbent dressings (foam or alginates); for dry wounds, add moisture. 1, 2
• Change dressings at least daily to allow careful wound examination. 1
• Maintain a moist wound-healing environment while avoiding tissue maceration. 1, 2

Pressure Offloading (Lower Extremity Wounds)

Implement strict offloading immediately for plantar wounds—this is non-negotiable for healing. 4, 3

• Use total contact casting or irremovable walkers for plantar wounds that are not infected. 4
• Protect the wound from all pressure and trauma during daily activities. 4
• Avoid total contact casts for infected wounds as they prevent wound visualization. 1

Medical Optimization

Address underlying host factors that impair healing:

• Optimize glycemic control immediately in diabetic patients—hyperglycemia impairs wound healing and immune function. 1, 4
• Mandate smoking cessation. 1
• Control edema through compression therapy when it doesn't compromise offloading. 1, 3
• Ensure adequate nutrition. 1
• Manage cardiovascular risk factors aggressively. 1, 4

Advanced Therapies for Non-Healing Wounds

Re-evaluate at 2 weeks after implementing optimal standard care (debridement, offloading, basic wound care). 4, 3

If wound shows insufficient improvement (<50% reduction in area) after 2 weeks, consider adjunctive therapies:

• Negative pressure wound therapy (NPWT) after revascularization and minor amputation when primary closure is not feasible, or for complex wounds with undermining after complete necrosis removal. 1, 2, 3
• Hyperbaric oxygen therapy may be considered for non-healing diabetic foot ulcers after revascularization. 1, 4
• Biologics (topical cytokine ointments, skin substitutes, cell-based therapies) when standard care fails. 1

Follow-Up Protocol

• Monitor hospitalized patients daily and outpatients every 2-5 days initially. 3
• Re-evaluate in 3-5 days (or sooner if worsening) for outpatient wounds. 3
• Hospitalize patients with: severe infection, systemic toxicity, metabolic instability, rapidly progressive infection, substantial necrosis, critical ischemia, or inability for self-care. 3

Critical Pitfalls to Avoid

• Never rely on superficial wound swabs—they yield contaminated results and lead to treatment failure. 1
• Never perform overly aggressive debridement—this exposes bone/tendon and causes chronic osteomyelitis. 3
• Never apply advanced therapies to actively infected wounds—infection must be controlled first. 3
• Never assume adequate perfusion based on palpable pulses alone in diabetic patients. 1