COMPLICATIONS OF WOUND HEALING

COMPLICATIONS IN SOFT TISSUE WOUND HEALING

◼ Delayed wound healing: It can be by the local factors to the wound itself, including infection or
abnormal bacterial presence, maceration, necrosis, pressure, trauma, and edema.

◼ Infection(178): Infection of wound due to entry of bacteria delays the healing. Pathogenic
organisms causing surgical wound infections vary according to the anatomical site of surgery.
Antibiotic resistant organisms, such as methicillin resistant Staphylococcus aureus (MRSA), are
more commonly encountered, reflecting the hospital flora. The challenge clinically and
microbiologically is to identify those wounds in which healing is impaired as a result of infection
or heavy bacterial burden and in which systemic or topical antimicrobial treatment will be of
benefit. Staphylococci and streptococci are the most commonly encountered pathogenic
organisms in community acquired superficial wounds. Infected wounds are managed by wound
toilet and surgical debridement along with antibiotic course.
◼ Stitch abscess: Infection of suture track . It can lead to superficial cellulitis and even deeper
seated infection. It can also affect the aesthetic outcome of the surgery.

◼ Implantation (epidermal) cyst : It may occur due to persistence of epithelial cells in the wound
after healing. Asymptomatic epidermoid cysts do not need treatment. Inflammation can be
resolved by intralesional injection with triamcinolone. Usual surgical approach is simple excision.
Incision and drainage may be performed in an infected cyst.

◼ Deficient scar formation:it is due to inadequate formation of granulation tissue, which results in
wound dehiscence. Granulation tissue may persist under several circumstances resulting from
underlying conditions and/or errors in the stages of wound healing (errors in the proliferative
phase and remodeling phase). This occurs during healing of wound by secondary
intention.inadequate granulation tissue formation can be due to diabetes mellitus,rheumatoid
arthritis,vascular or arterial insufficiency,zinc deficiency,low human growth hormone levels,older
age,obesity,trauma,excess moisture,tissue hypoxia,medications (steroids, nsaids,
chemotherapy),alcoholism,tobacco abuse.
◼ Wound dehiscence(168): Dehiscence is a mechanical failure of wound healing in which local
factors play a very important role. For example, infection predisposes a wound to disruption in
the early postoperative period. The persistent presence of micro-organisms leads to an increased
number of phagocytes that release proteolytic enzymes, free radicals and inflammatory mediators.
The effect of these substances is additional tissue injury and wound deterioration. Chronic tissue
hypoxia also leads to collagen with inadequate tensile strength which contributes to wound
dehiscence. The management of wound dehiscence ranges from simple dressing to further
surgery for wherein the wound is laid open, is washed daily and dressing done along with
intravenous antibiotics according to culture and sensitivity (169).

◼ Exuberant granulation / proud flesh: Another deviation in wound healing is the formation
of excessive amounts of granulation tissue, which protrudes above the level of the surrounding
skin and in fact blocks re-epithelialization

◼ Hypertrophied scars and keloid formation: At times scar formed is excessively ugly and
painful. Excessive formation of collagen in healing may result in keloid (claw like) formation.
Hypertrophic scars and keloids are the result of an exaggerated response of the skin following
injury. These proliferative scars are more common in darker skin types and are characterized by
increased collagen, elastin, fibronectin and glycosaminoglycan contents, as well as low
collagenase activity(170-174) .Hypertrophic scars are raised and stay within the boundaries of the
original wound, usually regressing spontaneously. Keloids also are raised but spread beyond the
original wound boundaries, invading the surrounding skin; they also may continue to grow over
time and often recur following excision. Hypertrophic scars usually are more responsive to
different treatment modalities than keloids(175,176) . These can be managed by using corticosteroids
(softens and flattens scars), topical silicone gel, pressure (in the early phase of hypertrophic scar
formation and as prophylaxis in keloid prone patients or keloid prone regions) and surgery which
ranges from simple excision and primary closure, Z- or W-plasty to hide the scar within the skin
creases (relaxed skin tension lines) and skin graft for wound closure with minimal tension (177)
.
◼ Excessive contraction : The development of contractures is by definition the pathologic
(179)

shortening of scar tissue, resulting in deformities as opposed to wound contraction, which occurs
in an open wound with the positive outcome of reducing the wound surface area. These disorders
represent aberrations in the fundamental processes of wound healing, which include cell
migration and proliferation, inflammation, increased synthesis and secretion of cytokines and
extracellular matrix (ECM) proteins, and remodelling of the newly synthesized matrix. Scar
contracture can be managed through massaging the area locally.
◼ Pigmentation of healed wounds may at times may have rust like colour due to staining with
haemosiderin. Some colored particulate material left in the wound may persist and impart color to
the healed wound. Management includes photo avoidance and photo protection, use of
photodynamic therapy and lasers, use of topical agents like hydroquinone 4 %, retinoic acid
cream 0.1 % or chemical peel with 20–30 %salicylic acid (180).

◼ Neoplasia: Rarely, scar may be the site for development of carcinoma later eg: squamous cell
carcinoma in Marjolin’s ulcer i.e a scar formed following burns on skin .

◼ Periwound dermatitis: This is more common in chronic wounds due to exudate composition

which differs from fluids produced in acute wounds or burns. Chronic wound exudate
contains proteolytic enzymes and other components that degrade skin integrity and predispose it
to inflammation. Moisture associated skin damage can also be caused by bodily fluids or other
contaminants that enter the periwound areas. Periwound issues affect the integrity and healthy
functionality of the skin surrounding the wound and may include maceration, excoriation, dry
(scaly) skin, eczema, callus (hyperkeratosis), infection, inflammation.

◼ Edema and periwound edema: Another complication that impairs wound healing is periwound
edema. Edema can slow healing, bring it to a standstill. It can cause stiffness and pain, leads to
issues with mobility, increase the risk of infection, decrease blood flow, lead to decreased
elasticity of blood vessels, cause ulcerations in the affected skin and lead to breakdown of fragile
periwound skin, and add tension on wound edges that prevents wound closure. In a situation
where pressure is the primary issue, edema can cause compression of small vessels, thus further
decreasing blood flow and potentiating the development of a pressure ulcer or injury. Also,
increased moisture associated with edema can lead to maceration, which causes the epidermal
layers of the skin to break down, further affecting healing.Most of the time mild edema will
dissipate on its own. Raising the affected area above the level of the heart can aid in edema
reduction. Increased ambulation and physical activity, compression therapy, and therapeutic
massage may also help with edema reduction. In situations where edema is more severe, higher
levels of compression and even medications may be necessary to aid in reducing fluid buildup,
especially if underlying medical conditions are contributing factors to edema development.

◼ Hematomas: Hematomas are not usually seen in chronic non-healing wounds, but the
development of a hematoma or a seroma at a surgical site is a common phenomenon that can lead
to infection and incisional dehiscence. The risk can be reduced with meticulous hemostasis, and if
 small seromas or hematomas develop they may be evacuated by gentle manipulation or aspiration
without the need for reoperation. This process may need to be repeated once or twice, but they
usually resolve without difficulty. In the case of larger hematomas, surgical evacuation and
drainage may be required.

COMPLICATIONS IN HARD TISSUE HEALING

◼ Delayed union: Delayed union is defined as the absence of radiographic progression of healing
or the instability of a fracture upon clinical examination between 4 and 6 months after
injury.Delayed union may be caused by inadequate blood supply, infection, faulty
immobilization or reduction, by poor fixation, by lack of appropriate nutrients for bone healing
and by high energy injuries. Delayed union of a fracture may be influenced by the patient’s
age ,the fracture type or impaired blood supply. Infection is an indirect cause of delayed union.
In some cases of infection, frequent disturbance of the wound for irrigation and dressing
interrupts strict immobilization, leading to delayed union or even non union. 

◼ Malunion: Malunion refers to the healing of a fracture with incorrect anatomical alignment.

◼ Non union: Non union is defined as a fracture that does not unite within 9–12 months or the
extension of the healing process beyond the expected rate. There is a gap between the fracture
fragments with sclerosis at the ends either hypertrophic callus or atrophic callus. The fracture
repair process may be halted due to instability, poor blood supply, infection, nutrition
deficiency, or weakening of the bone structure by pathological processes. A torn provisional
callus may prevent the continuation of the fracture repair process, or fracture fragments may
not have covered enough space to provide a bridge for the callus. It is generally agreed that the
most important aetiologic factors of non-union are instability and impaired vascularity. In
Hypertrophic non-union Callus is formed, but the bone fractures have not joined. This can be
due to inadequate fixation of the fracture, and treated with rigid immobilisation. In Atrophic
non-union no callus is formed. This is often due to impaired blood supply to the bone
fragments or metabolic causes (e.g. diabetes or smoking. Failure of initial union, when bone
fragments are separated by soft tissue Atrophic non-union can be treated by improving fixation,
removing the end layer of bone to provide raw ends for healing.