After a quick triage assessment, you determine that even though Mike wore knee and elbow protectors and the abrasion wounds are superficial, the nature of his fall to knee and elbow could entail a potential deeper injury (consider sending to the emergency room (ER) for x-rays to rule out fractures).
You are also aware that the forearm and shin wounds present potential complications. Why? The location (close to the joint) and thickness of the skin over these parts of the body make these superficial abrasions full-thickness wounds.
How will you perform first aid to Mike to send him to the ER for x-rays? Using universal precautions and clean or aseptic technique, gently cleanse the wounds with saline pat with gauze (Kent et al., 2018; Pickering & Marsden, 2015). Apply a wound hydrogel, or petrolatum impregnated gauze, cover with sterile gauze, secure in place with tubular gauze, cotton stockinette, or self-adherent wrap. This will be simple for ER providers to remove to inspect wounds and not interfere with x-rays. You note that you do not have any at camp. Still, if you had had a silicone interface self-adherent border dressing, this would have worked nicely too and would have been easily removed and reapplied (this could potentially be left in place for 3 days if only scant wound drainage).
Mike comes back to your station the next day for a dressing change. His x-rays of the knee and elbow were all within normal limits. The ER staff told him to rest and elevate the elbow and knee and ice them (10 min on and 30 min off) for 24 hours and continue daily wound care with you. They also told him to take 600mg of ibuprofen as needed every 6 to 8 hours.
Today, his right elbow/forearm self-reported pain level is 6-8, and his right knee/shin is 4-5. Using universal precautions and clean technique, you change the dressing, continuing to use a hydrogel wound gel or petrolatum impregnated gauze over the entire wound, secured in place by a secondary dressing and tubular netting. You also protected the wound edges using a skin protectant wipe applied to the skin immediately around the open wound. This approach maintains a moist wound bed, prevents the dressing from sticking to the wound, allows for continued extremity motion, and protects the surrounding skin.
You change this dressing daily for the next 5 days. You note the shin wound is healing as expected, and the knee joint edema is resolved, with some bruising now evident. However, the elbow area and forearm wound remain edematous, painful to touch, and movement. There is still a moderate amount of serosanguineous to yellow exudate (no unusual odor) as well as dark red erythema extending 0.7 cm from the proximal wound edges. This wound is not following the expected pathway to healing.
What are some possible reasons?
- He reinjured it yesterday (re-injury would certainly put the wound back to square one as far as an inflammatory state).
- He is still taking 600 mg of ibuprofen every 6 to 8 hours (non-steroidal anti-inflammatory medications can impair wound healing, but please note his shin is healing).
- He is constantly removing and reapplying the same dressing himself because it is uncomfortable (this certainly could impair wound healing if he is not using clean technique and introducing contamination, as well as disrupting the wound bed often, however, why is the wound so uncomfortable? (We need to ask Mike to describe this discomfort in more detail).
- He is not getting adequate nutrition (yes, this certainly could impair wound healing, but his shin wound is healing, so let us look to more local factors).
While any of these may interfere with wound healing, we should also consider other potential complications. The two biggest ones to consider in Mike's case are:
- A missed foreign body (especially a wood splinter from the edge of the ramp).
- An infection.
A missed wood splinter or organic foreign body may not have been detected by x-ray. Close examination of the wound and gentle probing with the wood end of a sterile cotton-tipped applicator reveals a hard embedded splinter that you can remove with forceps. It is a thin 0.7 cm long wood splinter at the proximal end of the forearm wound pointing deep into the wound towards the elbow. You note that it did not measure long enough to potentially invade the joint space, even fully embedded.
After it was removed, Mike states he felt some immediate pain relief. You decide to use an antimicrobial wound dressing for this wound while continuing the same petrolatum impregnated gauze dressing for the shin wound (though now you can change it 3 x per week along with the new dressing orders for his forearm). You also just happen to have a sample tube of Cadexomer Iodine gel you brought with you in your first aid kit.
Mike's new forearm wound dressing includes:
- Applying skin protectant wipe to the wound edges every dressing change.
- Applying Cadexomer iodine gel to the wound bed.
- Covering with gauze.
- Securing dressing with tubular gauze or self-adherent wrap.
- Changing dressing 3 times per week.
You follow Mike's wounds for wound care 3 x a week for the next 2 weeks, and the wounds close within 3 weeks.