Journal of the American Association for Laboratory Animal Science
Copyright 2022
by the American Association for Laboratory Animal Science
Association of Primate Veterinarians Guidelines
for Wound Management of Nonhuman Primates
Purpose
The Association of Primate Veterinarians recognizes that
injuries occur periodically in nonhuman primates (NHP) in
social housing as well as in single housing settings. This docu-
ment describes the types of wounds typical to NHP, therapeutic
approaches, and considerations to reduce the occurrence of
wounds. These guidelines were developed to provide veteri-
narians and animal caregivers with NHP-specific information
on wound management in these species. These guidelines are
not meant to address general veterinary wound management
principles, but to emphasize issues unique to wound manage-
ment in NHP.
Background
Wounding risks inherent to social housing of NHP can be
reduced by appropriate behavioral assessment and cage en-
hancements rather than through elimination of social housing
as a management strategy. Social housing should be overseen by
trained individuals with knowledge of species-specific behav-
ior, as animals housed socially require ongoing monitoring to
ensure compatibility and to reduce the possibility of injury.4,6,40
It is important for veterinarians, researchers, animal care staff,
and institutional animal care and use committees to recognize
that wounding is a potential sequela of providing appropriate
social enrichment and housing to these animals.
Injuries may occur in established NHP groups when there
is social instability, during animal introduction attempts or as
a result of the animal's environment. Intraspecies aggression
between animals housed in social groups is most common dur-
ing the breeding season of seasonal NHP species, during the
formation of new social groups, or introduction of unfamiliar
animals into existing social groups. Injuries may also occur as a
result of ambient environmental conditions that may be difficult
to control in outdoor housed animals. NHP housed indoors may
present with wounding due to injury from partners, particularly
during initial pairing attempts.
Animals display varying types of injuries including lacera-
tions, punctures, abrasions, maceration of distal extremities, and
crushing injuries. In species with notable sexual dimorphism
and elongated canines in males, deep penetrating lacerations
caused by the cutting edges are likely to be readily recognizable.
Staff should be appropriately trained to identify more subtle
injuries such as deep punctures from tips of male canine teeth,
and abrasions or contusions as is typical with female-pattern
trauma, both of which can result in minor skin involvement,
but cause severe damage to underlying tissues.
Guidelines
Specific Wound Types
Crush Injury.
Crush trauma may result in potentially life-threatening rhab-
domyolysis that develops from repeated bites from animals with
short canine teeth (females and juveniles). While the outward
appearance is superficial skin trauma with potential bruising
or swelling, the underlying muscle damage can be extensive
and severe with systemic release of intracellular contents, such
Vol 61, No 4
July 2022
Pages 315–319
as myoglobin, lactic acid, and potassium. Dark urine (myo-
globinuria) or anuria may be noted in cases of severe injury
or delayed treatment. Potentially fatal complications of crush
trauma and subsequent rhabdomyolysis include hypovolemic
shock, acute kidney injury, and hyperkalemia. Diagnosis of
rhabdomyolysis can be made with evidence of wounding, pres-
ence of elevated serum CK and AST, and myoglobinuria in the
absence of hematuria. Severe myonecrosis may also be visual-
ized via ultrasonography. Early intensive volume expansion
therapy may correct hypovolemia and prevent acute kidney
injury. It is important to consider the use of colloidal as well as
crystalloid fluid therapy. Crystalloids may redistribute to the
interstitial space, exacerbating development of compartmental
syndrome. Other treatment methods should focus on prevention
or mitigation of the effects of myoglobin crystal formation, and
antibiotic and analgesic therapy with particular care to avoid
nephrotoxic agents. Indicators of acidosis (venous blood pH,
bicarbonate, base excess, and lactate levels) have been shown
to be indicative of survival in rhesus macaques presenting with
rhabdomyolysis. In particular, two or more indicators of acidosis
at clinical presentation suggest a guarded to poor prognosis;
elevated lactate levels remain a predictive factor of mortality
after fluid resuscitation therapy.26 Pregnant patients should have
fetal viability evaluated throughout the course of treatment, as
the prognosis for fetal survival is poor.
Degloving.
Degloving soft-tissue injuries characterized by avulsions or
detachment of skin and subcutaneous tissue from underlying
muscle and fascia can occur to the head, flank, or extremities
of NHP resultant from a sudden shearing force from conspe-
cific aggression or complications from housing structures.1,49
Degloving wounds with concurrent deep soft-tissue injury
typically have higher rates of perioperative complications,
surgical intervention, and amputation. Delay of initial treatment
may increase the risk of infection or progression to necrotizing
fasciitis. Attempts at preservation of avulsed tissue is justified
to minimize future interventions, although partial loss of this
tissue is expected. Further surgical intervention such as skin
flap, graft, delayed primary closure, or secondary closure op-
tions may be required.21,58 Care should be taken throughout
management to preserve limb function with passive range of
motion and other physical therapy techniques.
Frostbite.
Frostbite in NHP may occur when skin is exposed to extreme
cold with distal extremities or other areas of reduced hair being
the most susceptible sites. Frostbite severity and tissue injury is
a result of not only extreme cold temperatures, but duration of
exposure. Because water is a more efficient thermal conductor
than air, exposure to standing water, slush, or snow can quickly
exacerbate cold injury.35 If frostbite occurs, the goals of treat-
ment are removal from the cold, rewarming frostbitten areas,
and prevention of complications. The affected part is rapidly re-
warmed by submersion in a water and antiseptic mixture (37 to
42 °C).22,23,37 Rewarming can be acutely painful and multi-modal
analgesia should be used.22,23,37 Rubbing or massaging affected
areas should be avoided to prevent further damage to tissue.23
Favorable prognostic indicators are the appearance of healthy
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Journal of the American Association for Laboratory Animal Science
July 2022

skin or clear blisters and a rapid response to tactile stimulation crushed tablets may be consumed by NHP when hidden in
of the affected area. Demarcation of non-viable tissues can take preferred foods and/or bitterness masking powders; however,
weeks to develop. The potential for damaged tissue to recover consumption must be confirmed to ensure analgesia is provided.
should be considered if debridement or amputation is required.
Antibiotic Prophylaxis.
In humans, if the affected area recovers, long term complications
Contamination of traumatic wounds through microorgan-
include chronic pain unresponsive to conventional analgesia,
isms in the environment influences wound care. Lacerations
cold sensitivity, and sensory loss.22 Management of frostbite
and punctures in outdoor housed animals are typically con-
cases may be prolonged and can take months to heal. Addi-
taminated with a variety of bacteria, and infection is common
tional potential complications for NHP with frostbite include
without antibiotic treatment. In contrast, wounds in indoor
wound infection, rhabdomyolysis, tetanus, and a greater risk of
housed animals are often addressed before infection occurs,
subsequent cold-related injury.37 Frostbite should be prevented
making the use of antibiotics unnecessary. Wound characteristics
by implementation of housing practices that avoid temperature
such as extensive lacerations to the extremities can be associated
extremes and provide protection from cold, wind, and moisture.
with a higher incidence of infectious complications. It is essential
Bandaging to determine when the benefits of antimicrobial prophylaxis
Standard three-layer bandage techniques utilized across outweigh the associated risks such as potential antimicrobial
veterinary medicine of a primary contact dressing, secondary resistance, diarrhea, drug specific toxicities, and potential drug
absorptive layer, and tertiary outer layer can be modified when interactions.7 Bacterial culture with antibiotic sensitivity testing
applied to NHP, with the main consideration being the ability to should be submitted prior to initiating antibiotic treatment or
manipulate and remove bandages with greater ease than most to refine empirical antibiotic choices.
other veterinary patients. Various methods can be utilized to
Tetanus Prophylaxis.
reduce or prevent bandage removal or tampering by the patient
Infection with Clostridium tetani after injury is a risk for
such as extending bandages across the torso to an opposing
unvaccinated animals housed in naturalistic or outdoor environ-
limb, bandaging joints in a flexed rather than extended position,
ments. Spores can persist in contaminated soil and on fomites
securing bandages under primate jackets, and/or anxiolytic
for years and are usually introduced through contamination of
medications. Plastic syringe caps with holes for air exchange
existing wounds or penetrating injuries.2 A recent study demon-
may be secured over tail tip injuries. When bandage tampering
strated that, while any wound exposed to C. tetani may result
does occur, exposed digits or tails should be carefully assessed
in clinical manifestations, NHP housed outdoors with multiple
for signs of constriction from underlying bandage layers. If NHP
wounds or wounds on the tail or digits are more susceptible
are not trained for conscious manipulations either by presenta-
to infection.53 Given that culture of the organism is difficult,
tion of the injured area or chaired restraint, the frequency of
diagnosis is based on clinical signs of disease and vaccination
bandage changes should be considered in regard to number of
history.20 Treatment should focus on neutralization of toxin
sedation events and stage of wound healing. Bandaging should
via administration of tetanus antitoxin or immunoglobulin
not be a criterion for single housing. In the authors’ experience,
therapy, targeted antibiotic therapy, and supportive care tailored
social housing does not necessarily increase the incidence of
to specific patient needs.1,31 However, prevention of disease
bandage tampering by the patient or its cage mates.
in high-risk populations through routine immunization with
Special Considerations tetanus toxoid should be encouraged over management of the
Analgesia. disease.1,20
Many NHP show little reaction to painful wounds, and signs Alternative Methods of Wound Healing
of pain may not be evident unless there is severe injury. Anal-
Skin Grafts.
gesics should be given immediately for wounds with emphasis
Skin graft techniques are often used to cover large skin deficit
on multimodal pain control. Pain-relieving drugs should not be
wounds with minimal tension and suitable cosmetic results
withheld or underdosed as a means to deter suture picking or
when mobilization of skin is challenging, such as for extremi-
bandage removal. Opioids or NSAIDs may be given alone or
ties.3,14,28,33,46,48 Xenograft and allograft skin transplantation
in combination. Commercially available sustained-release or
can provide a temporary protective wound covering for large
highly concentrated versions of meloxicam and buprenorphine
skin defects and has been previously described in NHP.27,35
are thought to provide more than 24 hours of analgesia, but
Autologous skin graft techniques allow for permanent recon-
may be associated with localized complications at the injection
struction when other primary closure or skin flap reconstruction
site if specific instructions for injection technique are not fol-
options have failed or are impractical. Descriptions of both
lowed.8,17,36,39 Local anesthetics provide additional pain relief
full-thickness (FTSG) and split-thickness skin grafts (STSG) in
when administered as splash blocks into open wounds, or as
veterinary species have indicated a high overall complication
local ring or nerve blocks.13 A total dose for local anesthetics
rate with anatomic location and bandage-induced sloughing as
should be calculated to avoid toxicity in small NHP. Mixing a lo-
contributing factors.19,44,47,57 Stabilization of graft tissue can be
cal anesthetic with buprenorphine or epinephrine may increase
achieved with peripheral application of skin adhesive for STSG
the duration of action of the local block.12,38,51 Bupivacaine has
and subcutaneous tacking and peripheral sutures for FTSG.3
been used in combination with lidocaine in attempts to achieve
Once stabilized, a sterile, nonadherent dressing material should
faster onset of local anesthesia.1 However, lidocaine onset times
be applied over graft sites to provide a moist, protective environ-
may actually be delayed by changes in drug concentration and
ment, as any disruption within the first five days will damage
pH when the drugs are mixed; bupivacaine alone was found to
formation of vascular anastomoses resulting in graft failure.
have a similar onset of action to that of combinations of lidocaine
While STSG is more consistently successful compared to FTSG,
and bupivacaine.32,34,43,59 Tramadol has been used in combina-
it also carries the higher potential of long-term complications
tion with NSAID medications, but efficacy may be questionable.
such as contraction of graft/recipient beds, graft fragility, and
Tramadol has been shown to have low effectiveness for pain
poor cosmetic appearance due to lack of hair regrowth.3,48,50
management in humans and dogs.11,56 Oral formulations or
316

In the authors' experience, skin graft techniques in NHP can
be technically challenging due to friability of graft tissue and
complications of bandaging.
Laser Therapy.
The use of low-level laser therapy (LLLT) in wound healing
has been described in animals and humans. Reported positive
effects include stimulation of angiogenesis, augmentation of col-
lagen synthesis, increased tensile strength, diminution of wound
size, and reduced healing time.61 However, the few randomized,
controlled trials on treatment of chronic wounds collectively
provide variable and inconclusive evidence of its efficacy.9,30,52
LLLT therapy remains controversial as a therapy due to poorly
understood biochemical mechanisms and a wide variety of
recommended operation parameters.15 Use of LLLT in NHP
can be used to promote tissue healing, reduce inflammation,
and alleviate pain from wounding.20 Given that effectiveness of
treatment may require repetitive treatments over a prolonged
time, use of positive reinforcement training can facilitate the
treatment of NHP with therapeutic laser while in their home
enclosures to optimize wound care and minimize anesthesia.
Preventative Management
Entrapment.
The risk of animal or limb entrapment increases with the
desire to provide appropriately complex housing environments
to meet requirements of environmental enhancement plans for
NHP, particularly in facilities with animal movement doors
utilizing mechanical controls such as hydraulic or pneumatic
mechanisms. Prior to implementation, all housing structures
and enrichment devices should be thoroughly evaluated to
ensure that items are free of sharp edges and openings that
could lead to entrapment. Enrichment should be distributed in
a manner so as to preclude animals from reaching through an
opening to procure the desired item. When opening or closing
animal access doors, staff should ensure that animals are not
physically present in the door space and should be prepared to
stop door closure if an animal unexpectedly approaches during
operation. Similarly, extra care should be taken when reducing
the available cage space, placing cage dividers, and removing
animals with particularly long tails from caging (for example,
Macaca fascicularis, Cercocebus spp., Saimiri spp.) during restraint
procedures. Should entrapment of an animal or appendage oc-
cur, a full examination is recommended to evaluate potential
sequelae. Potential complications of entrapment may include
laceration or crushing traumatic injuries, orthopedic injury,
and nerve damage.
Blunting of Male Canines.
In accordance with previous policy statements by the USDA
Animal and Plant Health Inspection Service and the American
Veterinary Medical Association, APV does not endorse reduc-
tion or extraction of canine teeth in NHP unless required for
medical treatment or approved scientific research.5,58 Coronal
reduction or "blunting" of canine teeth is sometimes performed
with the misguided goal of reducing injury and wound severity
to other primates or handlers, but it is important to note that
wounding can still be caused by reduced or blunted teeth.29
In large group settings, blunting has been associated with
reduction in deep muscle or tendon injury, but not a reduction
in skin lacerations.24 Tooth compromise requiring extraction
is a common consequence of canine blunting in NHP due to
complications of thermal damage to the pulp or exposure of den-
tin.29 Adult male rhesus are seven times more likely to require
canine tooth extraction within 18 months post-blunting than
APV guidelines for wound management in NHPs
with unmanipulated teeth.45 Normal occlusion of the canines
sharpens the teeth post-blunting in some animals29 as will active
tooth honing. To minimize injury, recommended alternatives to
dental surgery include behavioral assessment and modification,
environmental enrichment, changes in group composition, and
improved animal housing and handling techniques.5,58
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