complications of wound healing

The complex wound healing process may be ‘derailed’ at many steps. The principle pathological problems may be summarised as;

• inadequate scar formation – leading to wound dehiscence; or
• excessive scar formation – either hypertrophic or ‘keloid’ scarring
• contracture formation – an exaggeration of normal wound edge contraction forming deformities (particularly after burn injuries)

Hypertrophic scars occur when the remodelling stage exists for a longer period of time and they are more cellular and more vascular than mature scars. They are red, raised, itchy and tender. They will eventually mature and become pale and flat. Such scars usually exist in areas where wound healing has been delayed, for example, due to infection, or in children or where skin tension is high (such as at the tip of the shoulder). They remain within the confines of the wound area itself.

Keloid scars, on the other hand are regions of extreme overgrowth beyond the confines of the original wound area. They are more frequently associated with certain racial groups, such as Afro-Carribeans. They often occur in the central chest region, back and shoulders (Russell et al 2000 p. 39).

pressure sores/ 'bed sores'

Sustained pressure over bony prominences can result in the formation of pressure sores (otherwise known as 'bed sores'), which can range in severity from erythema to deep necrotic ulcers complicated by osteomyelitis.

Tsokos et al (2000) note that pressure sores can be prevented, to a large extent, by the early use of risk assessment scores, modification of intrinsic and extrinsic patient-related risk factors (i.e. those factors relating to frequent changes of body position, nutrition etc), monitoring and prophylaxis (including the use of appropriate mattresses etc).

Deaths in nursing homes and hospitals, where issues of the appropriateness and standard of nursing care have been raised, require an assessment of the presence of, and extent of pressure sores.

In a German study, Tsokos et al (2000) examined 10,222 bodies prior to cremation for pressure sores, and found that there was a positive correlation between their prevalence and increasing age (particularly in women over 80 years). They were also more commonly found in those who had senile dementia, neurological diseases and poor nutrition (particularly marasmus). Residents of nursing homes/ senior citizen's homes were most likely to have pressure sores than those living at home.

Advanced grade sores (with deeper tissues being involved) were found in 87%, with 69% being found over the sacrum. In those with multiple sores, they were located in the following combinations;

• greater trochanter and sacrum (4%)
• hip and sacrum (3.2%)
• thoracic spinal column and sacrum (2.4%)

The following questions were thought to be of medico-legal relevance when faced with an evaluation of pressure sores in deaths where allegations of negligence/ malpractice had been made:

• Where, when and under what circumstances did the pressure sore develop?
• Was a pressure sore risk calculator used on admission of the patient?
• What intrinsic and extrinsic patient risk factors were identified?
• Was the prevention management adequately adjusted to the identified risk factors?
• Was the patient consistently monitored and were skin changes in skin areas at risk registered?
• If the formation of a pressure sore was noted, was treatment subsequently undertaken?
• Was the institutional documentation sufficient and are there enough data for a conclusive decision to be made?

references

• Russell R.C.G., Williams N.S., Bulstrade C.J.K. (2000) (Ed), ‘Bailey and Love’s Short Practice of Surgery’, 23^rd Edition, Arnold Publishing
• Tsokos M, Heinemann A, Puschel K (2000), 'Pressure sores: epidemiology, medico-legal implications and forensic argumentation concerning causality', Int J Legal Med 113:283-287