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Management of a Dehisced Hand Wound Using Hydrogen Peroxide, Electrical Stimulation, Silver-containing Dressings, and Compression: A Case Study

Case Report

Management of a Dehisced Hand Wound Using Hydrogen Peroxide, Electrical Stimulation, Silver-containing Dressings, and Compression: A Case Study

Index: Ostomy Wound Management 2015;61(7):32–37

Abstract

Wound dehiscence is the separation of a wound along surgical sutures. A 57-year-old, otherwise healthy mechanic presented with a large open wound of >1 month duration on his left hand. His wound had dehisced after treatment that involved cleansing, surgical sutures, and oral antibiotics. He presented with a 5.0 cm x 0.7 cm x 0.3 cm lesion through the palmar creases of the hand with edema around the fourth and fifth digits and a callous formation around the distal portion of the wound. The wound had scant serosanguinous drainage and some induration at the periwound area, as well as a moderate foul odor. Tendons were not affected, but function was limited, the hand was painful, and the patient had been unable to work. Treatment was initiated with twice-a-week immersion of the hand in hydrogen peroxide diluted with water subjected to high-voltage pulsed current electric stimulation (HVPC). The wound was dressed with silver-containing dressings secured with stretch gauze and a compression garment. The wound was completely closed after 9 visits (35 days). No functional limitations of the hand or fingers, no cosmetic defect, and no wound recurrence were noted 9 months after healing. Although uncommon, dehisced wounds, especially in certain anatomical locations such as the hand, can be difficult to heal and may cause long-term problems with functioning. The treatment combination facilitated expedient healing of this dehisced hand wound. Research is needed to help elucidate the observations from this case study. 

Introduction

Wound dehiscence is the separation of a wound along surgical sutures. When a sutured wound dehisces, normal wound healing progress is disrupted; the edges of the wound start to separate and the granulation and epithelialization process is compromised or stalled. Risk for wound dehiscence includes iatrogenic factors such as poor surgical technique, wound location (eg, mobile or high-stress/strain area such as the hand and back), excessive motion, high body mass index, smoking, diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, and prolonged operative time.1

A Canadian nursing committee reported the prevalence of wound dehiscence is 1% to 3% in clients with surgical site infections2; no data regarding wound dehiscence prevalence specific to hand wounds was available in the literature. Current medical treatments for wound dehiscence include antibiotic therapy, surgical debridement, and appropriate surgical technique and sutures, with possible secondary intention healing if primary intention healing is unsuccessful.2,3 Hand wounds can be particularly difficult to manage,4 in part because the hand contains more than a dozen highly dexterous muscles together with corresponding vascularization and nerve innervations. Based on a prospective, cohort study5 on improvement of quality of life after fasciectomy for Dupuytren contracture, hand function is of great importance in maintaining quality of life in human beings. Thus, although the specific impact on quality of life from hand wounds has not been studied, a dehisced hand wound will likely limit a patient’s functional activities, impair upper extremity function, limit the patient’s working abilities, and may lead to a decrease in patient quality of life.

In order to preserve hand function, clinicians need to be particularly cautious when managing hand wounds. A deep and/or large hand wound becomes difficult to treat when a wound environment fails to support a natural and timely healing process; adverse environments for wound healing may include an excessive amount of proteases owing to infection and inflammation.6 This is also true in dehisced hand wounds.

High-voltage, pulsed current electric stimulation therapy (HVPC). HVPC has been widely used in chronic wound care.7-12 Through randomized, controlled trials, researchers have reported HVPC can significantly decrease wound size and facilitate healing in patients with pressure and chronic leg ulcers.7-11 A meta-analysis12 published in 2014 summarized previous research on electric stimulation therapy for wound healing of a variety of wound types (including pressure ulcers, diabetic wounds, and venous and arterial ulcers) and found electric stimulation was an effective treatment in increasing wound healing rates and may be superior to standard care for ulcer treatment.

Hydrogen peroxide. The use of hydrogen peroxide in wound healing is controversial. In a review article, Schafer et al13 concluded excessive reactive oxygen species (ROS) with high concentrations of hydrogen peroxide could impair wound healing by causing oxidative damage. In an in vitro study, Thomas et al14 found hydrogen peroxide reduced cell migration and proliferation, but Drosou et al’s15 review of the available animal and human studies contradicts those findings. After reviewing the available evidence in the literature, Schreml et al16 concluded using a low concentration of hydrogen peroxide promotes healing because it functions as a signaling molecule; high concentrations delay healing through oxidative damage. Thus, it is reasonable to believe hydrogen peroxide diluted with water could facilitate wound healing.

Silver dressings. Silver-containing dressings are commonly used in the wound care field.17 Results of a meta-analysis18 of previous randomized, controlled trials indicate silver dressings are effective in wound healing and improving patients’ quality of life. Although a hand wound, especially a dehisced hand wound, may be especially difficult to treat, careful selection of management procedures enables complete and optimal wound healing.

Compression dressings. Compression dressings are commonly used in clinical practice for the healing of venous leg ulcers. In a comparative systematic review and meta-analysis, Mauck et al19 reported moderate-quality evidence supports compression over no compression in promoting venous ulcer healing. Research evidence supporting the use of compression in other types of wounds is scarce. In a self-controlled (compression in 1 calf versus no compression in the other calf) case series study with 70 adult patients, Iwama et al20 found deep temperature in the compressed calf was higher than in the noncompressed calf and increased significantly after compression, whereas the noncompressed calf showed no temperature change. The authors concluded intermittent pneumatic compression can improve peripheral circulation.

A case involving a patient with a dehisced hand wound managed with hydrogen peroxide diluted with water, electric stimulation, and appropriate dressings is presented.

Case Report

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.

Discussion

Wound dehiscence is relatively uncommon, but extra caution and close monitoring are needed to follow any such event. Research studies regarding the management of postsurgical wound dehiscence are relatively scarce; in addition to antibiotics, debridement, and surgery, negative pressure wound therapy (NPWT) has been reported in a case report to treat dehiscence of an abdominal wound.22 After summarizing clinical experiences on 160 patients (NPWT: 46 cases, no NPWT: 114 cases) receiving long-segment thoracolumbar spinal fusion, Adogwa et al23 found NPWT reduced the incidence of postoperative wound infection and dehiscence as compared to no NPWT. However, the uneven surface and contour of the hand precluded the use of NPWT with this patient.

Care and closing of a dehisced hand wound require special techniques to minimize the risk of adverse consequences and optimize outcomes.4 In the present case, the dehisced hand wound was treated with HVPC in hydrogen peroxide water solution and dressed with silver-containing dressings, gauze dressings to secure the silver dressings, and compression. This combined intervention may provide an alternative option for the treatment of dehisced hand wounds when other treatments fail to close the wound in a timely fashion.

The use of HVPC in the present study is consistent with results from previous clinical trials regarding HVPC in facilitating wound healing.7-12 According to in vivo studies on rats, the wound healing effects of electric stimulation are likely due to the increased secretion of vascular endothelial growth factor (VEGF) and fibroblastic growth factor (FGF).24,25 In 2 review articles,26,27 researchers summarized the functions of these 2 molecules and stated VEGF and FGF are signal proteins that participate in critical rate-limiting steps of physiological vasculogenesis and angiogenesis. Angiogenesis lays the foundation for granulation tissue development and the epithelialization process. When a dehisced hand wound does not follow a normal healing path, HVPC may be useful to facilitate granulation tissue formation and re-epithelialization as may have happened in this case.

Persistent edema has been found in an in vivo animal study28 to disrupt myofibroblast formation and function, resulting in the lack of wound contraction. Mr. T had edema around the wound and in his 2 fingers, indicating the lack of endothelial migration and basement membrane restoration. Consequently, appropriate treatments for decreasing periwound edema were warranted. The modified compression garment not only decreased the swelling, but it also might have decreased the possibilities of hypergranulation and scar formation in this patient. Compression therapy in this patient may have contributed to the recovery of the dehisced hand wound in terms of cosmetic defect or compromise in hand function.

Tissue injury is associated with ROS, including hydrogen peroxide. In vitro study15 and a review of literature16 have shown hydrogen peroxide causes irreversible oxidation of biological molecules of proteins, lipids, and DNA, as well as the ability to defend against infection and regulate the inflammatory processes via redox signaling mechanisms.16 The present case may support the understanding that a low concentration of hydrogen peroxide does not impede wound healing.16 Additional supporting rationales behind its use in the present case may include antimicrobial properties and the ability to enhancing the conductivity of the water for HVPC.15,16 Thus, the results of this case study support that a low level of hydrogen peroxide will likely facilitate wound healing in situations with a high possibility of bacterial colonization.16 It is worth noting hydrogen peroxide solution with HVPC also may provide the wound extra topical oxygen as the hydrogen peroxide decomposes to produce water and oxygen. In a review article, Howard et al29 discussed the role of oxygen in wound healing and found oxygen therapy can help correct hypoxic wound conditions to optimize wound healing.

Successful use of silver-containing dressings is consistent with results of a meta-analysis showing various silver dressings facilitate wound healing.18 Additionally, silver dressings also were found to reduce odor and pain-related symptoms.18 Both the dressings used in Mr. T’s treatment contain silver. Evidence supporting the antimicrobial efficacy of silver-containing dressings is still lacking in research due to limited large, well-designed, randomized controlled trials.17 Nonetheless, the successful closure of the dehisced hand wound in the present case may shed light on the antimicrobial efficacy of silver-containing dressings. Open wounds are always susceptible to infection because skin lesions compromise the body’s primary defense system. Upon initial evaluation, Mr. T’s wound had a moderate foul smell, indicating a possible local infection, even when taking antibiotics. However, no cultures were obtained to confirm this clinical diagnosis.

Limitations

Case studies limit the ability to draw conclusions about the safety and effectiveness of any treatment modality. Testing this combined intervention on dehisced hand wounds in a large sample size study may be difficult because these wounds are uncommon. However, use of the combined intervention with HVPC, low concentrations of hydrogen peroxide, silver-containing dressings, and a compression garment deserves further investigation, perhaps in other types of wounds.

Conclusion

The dehisced traumatic hand wound is uncommon and could be difficult to treat. In this patient, the combined treatments utilizing HVPC, a low concentration of hydrogen peroxide, silver, and compression dressings were effective. Further research into the combined use of these products and therapies is warranted. 

Acknowledgments

The authors thank the John R. Oishei Foundation and James H. Cummings Foundation for funding the Daemen College Physical Therapy Wound Care Clinic; Dr. Corstiaan Brass, MD for his generous donation to the clinic and guidance in the management of patients; and various suppliers for wound care dressings. 

Affiliations

Dr. Zhou is a clinical assistant professor, Department of Health Care Studies, Daemen College; and a physical therapist, Daemen College Physical Therapy Wound Care Clinic, Cheektowaga, NY. Dr. Krug is a wound care specialist, Daemen College Physical Therapy Wound Care Clinic. Dr. Brogan is an associate professor, Department of Physical Therapy, Daemen College. Please address correspondence to: Kehua Zhou, MD, DPT, LAc, Daemen College, 4380 Main Street, Amherst, NY 14226; email: kzhou@daemen.edu.