Mr. T, a 57-year-old, otherwise healthy mechanic, presented to the clinic (Daemen College Physical Therapy Wound Care Clinic) with a large open wound on his left hand of >1 month duration. He reported being injured coming out of a tree stand on November 2, 2013; he fell, catching his left hand on a cleat in the tree. He sustained a large laceration through the palmar surface. At that time, he went to a local general hospital for treatment. After basic examination, Mr. T was transferred without treatment to the largest trauma center in Buffalo, the Erie County Medical Center, where he was treated at the Emergency Department. The wound was cleansed and surgically sutured, and he was provided cephalexin and hydrocodone/acetaminophen and followed-up as an outpatient. He reported no other exams or interventions were given. According to surgery notes, the wound did not afflict tendons of the hand, and Mr. T stated he followed post-op instructions. However, he observed minimal to no progress with wound healing.
On November 14, 2013 (12 days post injury), Mr. T reported to his physician the wound had opened over the past week and had a foul smell, along with moist periwound skin and some serosanguinous drainage. Mr. T was diagnosed with wound dehiscence, treated with the same medications as described previously, and instructed to soak his hand in lukewarm water 3 times a day and then leave it open to air. Per Mr. T’s medical record, no other exam or treatment was provided at that time. Because healing progress was minimal, Mr. T was referred to the present wound clinic for evaluation and treatment on November 27, 2013.
At the initial evaluation on December 5, 2013, the lesion measured 5.0 cm x 0.7 cm x 0.3 cm through the palmar creases, with edema noted around the fourth and fifth digits and a callous formation around the distal portion of the wound (see Figure 1). The wound had scant serosanguinous drainage with some induration at the periwound area, as well as a moderate foul odor. Mr. T had no systemic symptoms, he rated his pain from the wound as 2 out of 10 on a visual analogue scale,21 and he was unable to make a full fist because of the wound and hand edema. Additionally, Mr. T reported he had not been working since sustaining the wound.
Following inspection, range of motion examination, and sensory testing, it was determined the wound did not afflict the tendons of the hand (ie, no significant change in sensation), and the fingers of the hand had full range of motion to the limit allowed by the diffuse hand swelling, especially around the fourth and fifth fingers. The wound was irrigated and cleansed with normal saline and then treated with HVPC electric stimulation therapy (RichMar Winner EVO ST4, Chattanooga, TN) using a basin with 1 gallon of water and 16 oz of hydrogen peroxide (473 mL, Hydrox, Hydrox Laboratories, Elgin, IL) for 45 minutes (see Figure 2). The wound then was covered with silver-containing dressings Acticoat™ and Allevyn™ Gentle Border gauze (both Smith & Nephew Medical, Hull, UK) and dressed with conforming stretch gauze for stabilization and a modified compression garment (Medigrip™, Medline, Mundelein, IL).
This care protocol and dressing change procedure was repeated 2 times a week. Patient visit notes and treatment procedures were documented in the electronic medical record system at each visit, and wound measurements and photos were obtained weekly.
On December 12, 2013 (1 week after presentation at the authors’ clinic), the wound was making excellent progress. It had decreased in size, odor, and drainage, and only a small open area measuring 1.2 cm x 0.3 cm x 0.1 cm remained at the base of the fourth and fifth digits (see Figure 3). The same treatment was continued. On December 19, 2013, the wound measured 0.8 cm x 0.3 cm x 0.1 cm (see Figure 4); at that time, Arglaes™ powder (Medline, Mundelein, IL) was added to the surface of the wound to absorb drainage and facilitate wound healing. On January 9, 2014, after 9 visits over a 35-day period, the wound was completely closed (see Figure 5) and Mr. T returned to work.
In order to facilitate tissue maturation and prevent wound reoccurrence, Mr. T was seen at the clinic for 2 additional visits (once a week) with the same protocol of electric stimulation, after which the closed wound was dressed only with the border gauze, conforming stretch gauze, and the modified compression garment. On January 21, 2014, Mr. T was discharged from the clinic with his wound completely closed, full range of motion of fingers and hand, and a small cosmetic defect (a tiny area of skin overlap over the palmar crease on the medial side) (see Figure 6). Clinicians reached out to Mr. T later that year (October) via phone, and Mr. T reported he had no pain or limitations in motion and function of the hand and fingers. Additionally, Mr. T reported the tiny area of skin overlap upon discharge blended into the palmar crease without cosmetic defect.