What are considered optimal wound edges in an elderly patient with a complex medical history, such as a pressure ulcer or diabetic foot ulcer?

Optimal Wound Edges in Elderly Patients with Complex Wounds

Definition of Optimal Wound Edges

Optimal wound edges are characterized by attached, non-undermined borders with healthy granulation tissue that demonstrates active epithelialization and migration toward the wound center, without surrounding callus, necrotic tissue, or rolled/fibrotic edges that impede healing. 1, 2

Key Characteristics of Healing vs. Non-Healing Edges

Favorable Edge Characteristics

• Attached edges that are flush with the wound bed, not undermined or detached from underlying tissue 1
• Pink to red coloration indicating viable tissue and adequate perfusion 2
• Active epithelialization with visible migration of new epithelial cells from the wound periphery 2
• Absence of callus formation around the wound perimeter, particularly critical in diabetic foot ulcers 1
• No surrounding induration beyond expected inflammatory response 1

Problematic Edge Characteristics Requiring Intervention

• Undermined edges where tissue has separated from the wound base, creating pockets that harbor infection 1
• Rolled or hyperkeratotic edges that prevent epithelial migration and indicate stalled healing 2
• Callused perimeter that must be sharply debrided at every visit for diabetic ulcers 1
• Fibrotic edges that are firm and non-pliable, impeding wound contraction 2
• Friable or discolored granulation tissue at wound margins, which may indicate infection even without purulent drainage 1

Clinical Assessment Algorithm

Step 1: Evaluate for Infection at Wound Edges

• Examine for at least two signs of inflammation: erythema, warmth, induration, pain/tenderness, or purulent secretions 1
• Note that neuropathy may blunt pain and ischemia may reduce erythema, so absence of classic signs does not exclude infection 1
• Undermining of wound edges is a secondary finding that correlates with infection, even when purulence is absent 1

Step 2: Assess Perfusion Status

• Palpate dorsalis pedis and posterior tibial pulses; if both are absent, suspect peripheral arterial disease 1
• Measure ankle-brachial index (ABI); ABI <0.6 indicates significant ischemia that impairs wound healing 1
• For wounds not healing despite adequate ABI, measure toe pressure (healing unlikely if <30 mmHg) or TcPO2 (healing unlikely if <30 mmHg) 1

Step 3: Remove Barriers to Edge Migration

• Sharp debridement of all callus and necrotic tissue is mandatory at every visit, as this is the single most important intervention for wound edge optimization 1
• Debride using scalpel, scissors, or tissue nippers to create clean, viable wound margins 1
• Remove any eschar covering wound edges unless it is stable, dry, and non-infected (particularly on heels) 3

Management Based on Edge Pathology

For Callused or Hyperkeratotic Edges (Diabetic Ulcers)

• Aggressive sharp debridement at every clinical encounter to remove all callus surrounding the wound 1
• Apply hydrogels to maintain moisture and facilitate autolysis of remaining non-viable tissue 1, 4
• Implement total contact casting or non-removable offloading device to prevent continued mechanical trauma 1

For Undermined Edges (Suspected Infection)

• Obtain specimens for aerobic and anaerobic culture before starting antibiotics 1
• Initiate empiric antibiotics targeting S. aureus and streptococci for mild infections 1
• For moderate to severe infections with undermining, consider urgent surgical consultation for deep abscess drainage 1

For Rolled or Fibrotic Edges (Stalled Healing)

• Sharp debridement to convert chronic wound edges to acute edges 1
• Reassess vascular status; if toe pressure <30 mmHg or TcPO2 <25 mmHg, pursue revascularization 1
• If no improvement after 6 weeks of optimal management, consider revascularization regardless of initial perfusion measurements 1

Wound Bed Score Correlation

Research demonstrates that wounds with optimal edges (scored 2 points for "healing edges") have significantly higher rates of complete closure compared to those with rolled or non-advancing edges (scored 0 points) 2. Each one-unit increase in total wound bed score, which includes edge assessment, results in a 22.8% increase in odds of healing 2.

Critical Pitfalls to Avoid

• Failing to debride callus at every visit in diabetic foot ulcers, which creates a mechanical barrier preventing edge migration 1
• Overlooking undermined edges as a sign of deep infection requiring more aggressive intervention than superficial wound care 1
• Continuing conservative management when edges show no advancement after 6 weeks, rather than reassessing perfusion and considering revascularization 1
• Applying occlusive dressings to ischemic wound edges without first ensuring adequate perfusion (ABI >0.5, ankle pressure >50 mmHg) 1

Monitoring and Reassessment

• Measure wound dimensions weekly using planimetry to objectively document edge migration 5
• Wounds should demonstrate measurable reduction in size within 4-6 weeks of optimal management 1
• If edges remain static or wound enlarges despite appropriate care, escalate to vascular imaging and multidisciplinary consultation 1