Wound Assessment: Think Like a Detective

Comprehensive wound assessment is analogous to a detective processing a crime scene. The scene is secured (patient scheduled for an evaluation); the scene is processed (patient history is established); evidence is collected and identified (tests, measures, special tests and/or diagnostics are performed) and a working theory and report is generated to ascertain what transpired and what next steps need to be taken. This is akin to establishing a differential diagnosis, determining contributing factors and creating a plan of care to manage the wound and the patients’ medical needs.

This goes well beyond just looking at the wound. As Carrie Sussman says, “Look at the whole patient, not just the hole in the patient.” In fact, looking at the wound should be the final piece of wound assessment, not the first. Global assessment should involve: taking a history, conducting a physical exam and systems review, determining the need for skin/wound biopsies, assessing lab values, performing non-invasive vascular tests, acquiring radiographs if a deep infection is suspected, and establishing a working diagnosis and treatment plan.^1-5

Once the clues have been collected, the provider can focus on the differential diagnosis. In clinical practice, most chronic wounds present on the lower extremity. The majority are of venous origin, representing 45–75% of all lower extremity wounds. Arterial ulcers account for 4–20% and up to 26% are mixed venous and arterial etiologies. Including the foot, 15–25% are neuropathic/diabetic ulcers and the remaining 7–14% are atypical such as vasculitis, vasculopathy, infections, cancers, etc.^1,3,4,6,7 Atypical wounds are zebras, as many present with characteristics similar to the most common wound etiologies.

This is where a detailed investigation is warranted, paying attention to the clues, asking good questions, actively listening to the patient and other providers, and paying attention to the wound geography and topography. Collectively, these elements of your investigation will guide you to proper diagnosis so an appropriate plan of care can be established for the patient.

Conducting an Effective Global Assessment

Global assessment will guide your investigation and it should involve understanding the patient’s chief complaint and symptoms, as well as how the symptoms behave. This can readily help you narrow down the differential diagnosis. For example, venous wounds are typically uncomfortable and worsen over time in a dependent position but symptomatically improve with elevation of the lower extremity. Arterial wounds tend to be exquisitely painful, especially with elevation and have minimal relief in the dependent position of the lower extremity. Patients with arterial pathology often report sleeping with their legs hanging off the side of the bed or in a recliner due to ischemic or rest pain.

The global assessment should also involve taking vital signs and assessing pain. Ask about the history of the present illness/condition and how the wound(s) developed or occurred. What current and past treatments have been rendered? This includes asking about various forms of compression, dressings, footwear, biophysical agents, surgery, topical and/or systemic medications, etc. This, too, can assist with your differential diagnosis as certain interventions are cornerstone or considered the gold standard for certain wound etiologies.  

Insights on the Systems Review

From here, a thorough systems review should be conducted inclusive of past medical history and the patient’s current health status. Information should be collected about current or previous illnesses, comorbid conditions, allergies and sensitivities, as well as a family medical history. Pay attention to disorders that are inherited as these often contribute to integumentary dysfunction and can be readily missed.

Make sure to ask about all medications whether topical, systemic, over the counter, prescribed or supplemented. This should also include smoking, alcohol, and drug use, whether current or in the past. Appreciating the patient’s social support network is also essential so resources, referrals and/or additional education can be provided.

Focusing Attention on the Patient’s Wounds

Once the global assessment/investigation has been completed, specific attention can be directed toward the wound or wounds. This is analogous to investigating the room in detail where a crime occurred, then focusing in on the specific location where key evidence resides. Using all your senses and paying careful attention to the clues, will assist with homing in on the diagnosis and contributing factors surrounding the wound etiology. Start by looking at the general appearance of the patient, then focus in on the body region or extremity/extremities involved.

When focusing on the wound, think of geography and topography. Wound geography is the location of the wound on the body and wound topography is the appearance of the wound inclusive of the wound bed, wound edge and periwound tissues. This can be extremely helpful as certain wound etiologies are distinctive with respect to their location and clinical characteristics. For instance, wounds on the lower calf around the malleoli are typically a venous problem. Wounds on the distal foot are often of arterial etiology, though arterial ulcers and atypical wounds may occur anywhere on the leg given the underlying pathophysiology. Wounds on the plantar foot are commonly neuropathic in origin whereas ulcers on the heel or ankle may be related to pressure injury.

It is important to keep in mind, however, that some etiologies may be coexisting. This is where topography can be useful. Wound topography pays attention to the clinical characteristics of the wound bed, wound edge and periwound tissues. Venous ulcers are typically red, shallow, and granular with irregular wound edges and moderate to copious amounts of exudate. Hemosiderin staining, atrophie blanche, venous changes and edema are common at the periwound. Arterial ulcers tend to be dry and necrotic with a punched-out appearance, with little to no exudate. The surrounding skin tends to be cool, pale, hairless and dry given arterial wounds are related to a perfusion or ischemic problem. This can negatively impact the adnexal structures (sebaceous glands, sweat glands, and hair follicles) which require oxygen and nutrients to function and survive.

Neuropathic or diabetic foot ulcers typically occur on the first, third, or fifth metatarsal head, and often present with a callus or hyperkeratotic rim at the wound edge. Due to lack of sensation, motor and autonomic changes, these wounds develop due to unrelieved pressure or trauma, which may be compounded by biomechanical changes of the foot. The wound base may be hypogranular and dry if associated peripheral arterial disease is present, or if a significant amount of exudate is present, it may indicate the presence of osteomyelitis or a deep tissue infection.

With respect to pressure injuries, these typically occur on bony prominences, but they can develop anywhere there is unrelieved pressure. They take on the shape of the pressure-causing agent and can present with variable topographical characteristics depending upon the tissues involved.

Therefore, paying attention to the clinical clues is paramount. If the topography is funny-looking or exuberant, it is likely atypical and warrants a biopsy. Is it a weird geographical location for a “typical” chronic wound? Has the wound failed the standard of care? Does something not seem right? These are instances where a biopsy or referral may be warranted for a deeper dive into your investigation to ascertain the etiology.

In Conclusion

Thinking like a detective and working your wound scene will help you gather the proper evidence to support the differential diagnosis process. Pay attention to the clues, even those that seem insignificant and remember to employ the concepts of wound geography and topography. It is OK to question everything and when in doubt, refer out! It is also important to biopsy wounds that look suspicious or just do not respond to the plan of care. Chronic wounds can have carcinogenic changes that will only be picked up through a biopsy.

A systematic approach to wound assessment will help you determine the etiology of the wound as well as contributing factors; this will support a plan of care centered around the clinical needs of the wound as well as the patient.  

Heather Hettrick, PT, PhD, CWS, AWCC, CLT-LANA, CLWT, CORE, is a Professor in the Department of Physical Therapy at Nova Southeastern University.

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References
1. Adam DJ, Naik J, Hartshorne, et al. The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic. Eur J Vasc Endovasc Surg. 2003;25(5):462–468.
2. Harding K. Simplifying venous leg ulcer management: consensus recommendations. Wounds International. Published May 8, 2015.
3. O’Donnell TF Jr, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg. 2014;60(2 Suppl):3S-59S.
4. Pannier F, Rabe E. Differential diagnosis of leg ulcers. Phlebology. 2013;28(Suppl 1):55–60.
5. Singer AJ, Tassiopoulos A, Kirsner RS. Evaluation and management of lower-extremity ulcers. N Engl J Med. 2017;377(16):1559–1567.
6. Hedayati N, Carson JG, Chi YW, Link D. Management of mixed arterial venous lower extremity ulceration: A review. Vasc Med. 2015;20(5):479–486.
7. Mekkes JR, Loots MA, Van Der Wal AC, Bos JD. Causes, investigation, and treatment of leg ulceration. Br J Dermatol. 2003;148(3):388–401.