Complex Wounds
Wounds of the hand or upper limb that will not heal on their own, or that expose bone, tendon, joint or hardware and need durable coverage.
Most wounds heal. A complex wound is one that will not - because too much tissue is missing, because something that must not dry out is exposed, because the blood supply is poor, or because infection or previous surgery has changed the local conditions.
The distinction that matters is what lies at the base of the wound. A wound with a healthy bed can often be left to heal or covered with a skin graft. A wound with exposed tendon, bone, joint, nerve or hardware needs tissue with its own blood supply brought in to cover it.
Choosing the right form of coverage - and getting the timing right - is a core part of plastic and reconstructive surgery.
Loading anatomy
Common symptoms
- A wound that has not healed over several weeks
- Exposed bone, tendon or hardware within a wound
- A wound that repeatedly breaks down after appearing to heal
- Increasing pain, odour or discharge
- Surrounding skin that is thin, scarred or previously operated on
- A wound over an area that has previously been irradiated or grafted
Causes and contributing factors
- Trauma with tissue loss
- Infection, including deep hand infections
- Wound breakdown after previous surgery
- Poor blood supply, whether from vascular disease or from local tissue damage
- Diabetes and other conditions that impair healing
- Pressure, burns, and injection or extravasation injuries
- Exposed hardware from previous surgery
If you have already had surgery for this
Wounds that break down after previous surgery are assessed both as a wound problem and as a question about what happened underneath.
How it is evaluated
The assessment asks two questions: why has this wound not healed, and what is at the base of it. Both answers are needed before a plan can be made, because covering a wound without addressing the reason it is open tends to fail.
Where healing is impaired, the general factors matter as much as the local ones - circulation, nutrition, diabetes control, smoking and medication all affect whether reconstruction will succeed.
- Assessment of the wound bed and of what structures are exposed
- Assessment of the surrounding tissue and previous surgical scars
- Evaluation of blood supply to the limb
- Investigation for infection, including bone infection where relevant
- Review of general factors affecting healing
- Imaging where deep infection or hardware is a concern
Clinical detail
Planning follows the reconstructive principle of selecting the simplest option that meets the requirements of the defect - considering exposed structures, the need for gliding surfaces beneath tendons, the durability required and the eventual functional demand.
Adequate débridement, control of infection and optimisation of the patient generally precede definitive coverage. Attempting closure over an inadequately prepared bed is a recognised route to failure.
Nonsurgical treatment
Some complex wounds can be brought to healing without an operation, and almost all benefit from optimising the conditions around them first.
- Specialist wound dressings selected for the wound bed
- Negative-pressure wound therapy in selected cases
- Treatment of infection
- Improving general factors - glucose control, nutrition, stopping smoking, reviewing medication
- Offloading, elevation and swelling control
Surgical treatment
Surgical treatment usually begins with removing the tissue that will not heal, and then providing coverage appropriate to what is exposed.
The reconstructive options form a ladder of increasing complexity, and the right choice is the one that meets the needs of that wound and that patient - not necessarily the most complex one available.
- Débridement of non-viable and infected tissue
- Skin grafting where the wound bed will support it
- Local flaps, using nearby tissue with its own blood supply
- Regional flaps from elsewhere in the forearm or arm
- Free tissue transfer, where tissue is moved with its blood vessels and reconnected microsurgically
- Removal or exchange of exposed hardware where necessary
Recovery
Recovery depends on the reconstruction. Grafts and flaps need a protected period during which they establish a blood supply and settle, and movement is reintroduced progressively.
Reconstructed tissue continues to change for many months - softening, flattening and fading - and further minor adjustment is sometimes appropriate once things have settled.
- A protected period after grafting or flap reconstruction
- Careful monitoring of the reconstruction in the early days
- Scar management and hand therapy
- Graded return to activity
When to seek urgent care
Seek immediate medical attention - an emergency department - if you experience:
- Spreading redness, fever or feeling generally unwell - possible spreading infection
- A hand that is swollen, red and severely painful, particularly with a bent, stiff finger
- A rapidly enlarging or blackening wound
- Heavy bleeding from a wound
- Exposed bone or hardware following surgery
This list is not exhaustive. If something about your hand worries you, have it looked at.
Frequently asked questions
Why can this wound not simply be stitched closed?
Closing a wound under tension, over unhealthy tissue, or without addressing why it is open tends to result in it opening again. Where tissue is missing or something vital is exposed, coverage that brings in its own blood supply is more likely to heal and to stay healed.
What is the difference between a skin graft and a flap?
A skin graft is a thin layer of skin moved without its own blood supply - it survives by taking a new one from the wound bed, so it needs a healthy bed. A flap is tissue moved with its blood supply intact, which allows it to cover bone, tendon or hardware where a graft would not survive.
How long will a complex wound take to heal?
It varies widely with the wound, the reconstruction and general health. Complex wounds are usually a matter of weeks to months, sometimes with several stages. A specific timeline can only be given once the wound has been assessed.
Related conditions
Complex Hand Trauma
Severe injuries that damage more than one tissue system at once - bone, tendon, nerve, blood vessel and skin together.
Tendon Injuries
Cuts, ruptures or damage to the cords that connect muscle to bone and make the fingers and thumb move.
Peripheral Nerve Injuries
Damage to the nerves that carry signals between the brain and the hand, causing numbness, weakness or pain in the territory that nerve supplies.
Discuss complex wounds with Dr. Champagne
A consultation begins with understanding your symptoms, how they affect what you do, and what has already been tried.