Deconstructing the Stalled Wound
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Index: WOUNDS. 2012;24(3):58–66.
Abstract: The stalled wound refers to a wound that has entered a nonhealing or intransigent phase. This can occur as a progression of an acute wound to one of chronicity dictated by events within the wound milieu or following alterations in host immunity. The occurrence may be related by a number of variable factors that collectively or individually can halt the process of orderly healing. A number of biologic events occurring at the wound bed interface, outside the wound (exudate), and related to systemic chronic disease profiles have been identified. This assists clinicians and researchers in developing a systematic approach to managing and reversing this undesired event. First, host factors related to any background chronic disease are checked and controlled. Second, the focus turns to local wound factors adopting accepted principles of wound care to control the wound environment, adding systemic therapies where necessary. If this fails to change the healing milieu, more sophisticated, specialized local wound interventions are introduced. This systematic approach to the stalled wound in individual steps, or collectively, would be expected to re-advance the wound to a normal healing pattern.
The stalled wound is one that has entered a nonhealing or intransigent phase. This can occur as a progression of an acute wound to one of chronicity dictated by events within the wound milieu or following alterations in host factors. A stalled wound may occur spontaneously and unexpectedly in the midst of a supposedly successful healing plan. Information relating to intracellular signaling and recognition of basic biologic processes occurring at a molecular level has increased significantly in the last decade. Much of this information can be extrapolated and analyzed to give direction and impetus to changing the direction of the stalled wound to one akin to acute healing. Occasionally, simply changing dressing routine or introducing new elements to the wound milieu may be enough to kick-start a new wound healing process. There appears to be a certain tolerance that can occur to a dressing regime where the status quo is not enough to take healing to its natural endpoint. New biologic information that is available will aid in developing a scientific based approach to the stalled wound.
The “Stalled Wound” Concept
In many cases, the definition of a stalled wound overlaps with that of a chronic wound. A wound that does not decrease in size by 30% in 3 weeks or by 50% in 4–5 weeks is considered chronic. These figures are based on studies, such as Sheehan et al’s,1 which demonstrated that if the size of the wound does not decrease by 50% in 4 weeks, the wound has a 91% chance of not healing in 12 weeks.1 However, the stalled wound may not necessarily always be a chronic wound, but may occur in the process of the normal healing of an acute wound that suddenly appears to halt in its tracks, often with no apparent reason.
In searching for a reason, obvious causes need to be excluded—those related to wound management and host factors. Thus, physical factors, as opposed to physiologic factors, should be examined first. These include ruling out infection and vascular complications, ensuring proper offloading, performing adequate debridement, and facilitating a moist healing environment.