1. Wound ulcer
Rahul AP. BPT,MPT;MIAP.CVTP

2. • An injury to the tissue can be simply called as
a wound
• A pressure ulcer is a wound caused by
unrelieved pressure on the dermis and
underlying vascular structure, usually between
bone and support surface

3. Normal wound healing
• 3 overlapping phase
Inflammatory phase
• Characterized by vasodilatation, release of
histamine and stimulation of nociceptive
receptors
• This can be correlated with redness, heat,
swelling and pain

4. Proliferative phase
• Characterized by the formation of granulation
tissue
• Wound contraction starts
• Fibroblast in the wound develops in to
collagen matrix
Maturation /remodeling phase
• Remodeling of the new epithelium
• It is an ongoing processes even after wound
closure takes months to years
• Pt intervention starts at this stage

6. • In case of pressure wounds, when pressure is not
relieved damage happens which cannot be repair
or recover on their own
• When deeper vessels occluded decreased blood
flow leads to cell death next to necrosis and finally
a visible wound
• Superficial dermis can tolerate ischemia for 2-8hrs
• Deeper muscle fat tissue etc for 2hrs and less
• It occurs frequently who are immobilized for a long
period of time
• Can occur at any age depends on the period
• It increases the risk of death in elderly individuals

9. Clinical presentation
• First sign of pressure ulceration is blanchable
erythema with increased skin temperature
• Progression to superficial abrasion, blister
• Full thickness skin loss -bleeding is minimal
• Main areas – sacrum, coccyx, greater
trochanter, ischial tuberosity ,calcaneus and
lateral malleolus

10. Blanchable Erythema

11. Superficial abrasion

13. Full thickness skin loss

14. Wound examination
History
• It is taken to determine the primary problems
• History should include queries like mechanism
of injury, date of onset, progression
• How long has wound been present
• Treatment history to date
• What types of health-care providers have
been involved in the management of the
wound
• History of previous wounds

15. • Co-morbidities – Patient’s capacity to heal can be
limited by specific disease effects on tissue like
integrity and perfusion, mobility, compliance,
nutrition and risk for infection.
A. Diabetes
• abnormal glucose levels are not compatible with
wound healing
• decreased sensation in feet cause high risk for
breakdown

16. B. Vascular
• 1. Coronary Artery Disease – decreased circulating
oxygen
• 2. Congestive Heart Failure – edema in lower
extremities
• 3. Peripheral Vascular Disease – inadequate
vascular support
• 4. Peripheral Arterial Disease – inadequate arterial
support

17. C. Cancer
• 1. Radiation – high risk or may cause skin
breakdown
• 2. Antineoplastic medications impair wound
healing

18. Subjective examination
• It is to gather information about the current
symptoms
• He should be questioned about behavior and
characteristics of symptoms (pain associated
with wound or to any extremity, are there any
certain positions which keep symptoms better
or worse)

19. Objective examination
• Here observation is the important component of
data gathering
• Typically includes-type of lesion (ischemic arterial
ulcer, venous insufficiency ulcer, neuropathic,
rheumatoid ulcer etc)
• Stage of wound (stage 1 to 4)
• Type of drainage- will check the amount, color,
consistency, and odor,serous (clear, watery);
serosanguinous (clear red or reddish brown);
purulent (thick, yellow, cloudy)
• Presence of edema

20. ischemic arterial ulcer

21. venous insufficiency ulcer

22. Neuropathic ulcer

23. rheumatoid ulcer

24. Aims of treatment
• Teach the patient self-care of wound
management and identification of signs of
infections
• Provide a moist wound healing environment
• reduces the necrotic tissue at wound site
• Decrease pain associated with wound
• Decrease the risk of infection
• Improve physical functions (if decreased
secondary to wound)

25. Intervention
• Physical therapy intervention for wound
management includes verity of modalities and
appropriate wound dressing to promote healing
• the intervention plan should have a holistic view
eg: patient with signs and symptoms with venous
disease may also present with poor ankle ROMs.
• Wound must be cleansed and dressed but the
limb should get compression for optimum
healing.

26. Ultrasound therapy
• US can increase tissue temperature and it includes-acceleration
of metabolic rate, reduction or control
of pain and muscle spasm, increase circulation and
increase soft tissue extensibility.
• It heats smaller and deeper areas than most
superficial area. US heats tissue with high US
absorption coefficient- tissues with high collagen
content like tendon ligament joint capsule but not
for fat with water content.
• US is not ideal for muscle heating because of low
absorption but very effective in heating scar in
muscle area because of increased collagen content

27. • Application of ultrasound stimulates cell activity
and it accelerate inflammatory process.
• The skin repair and wound contraction will be
accelerated.
• US stimulates the collagen secretion and have an
affect on elastin properties which strengthen scar
tissue.
• Procedure is done by covering the wound by a
hydrogel and deliver US by a hand held applicator.
• Another option is apply US transmission gel over
periwound area and treat from this region instead
of the wound bed.

28. • The parameters that have been found to be
effective for healing wound is 20% duty cycle,
0.8-1.0 W/cm² intensity, 3MHz frequency, for
5-10 minutes
• Treatment duration depends on the area of
the wound

30. Electrical stimulation
• Electrical stimulation has effectiveness in
facilitating healing in both acute and chronic
wounds.
• It is used to eliminate bacterial load, promote
granulation, reduce inflamation,edema,reduce
wound related pain
• Electric stimulation has a galvanotoxic effect
on the cells needed for healing
• By using high volt pulsed current (HVPC)
directly in the wound can create these
changes –attraction of neutrophils,
macrophages, and epidermal cells which
facilitate debridement and reepithelialization.

31. Method of application
Direct method of application-it includes an ES unit
treatment and non treatment electrodes and a
saline soaked gauze or hydrogel dressing over
wound bed to enhance electrical conductivity.
Indirect method of application-here electrodes are
placed around the periwound skin using gel.

32. Radiant heat
Infrared red radiation increases local wound and skin
temperature facilitating metabolic rate and
improving circulation to the wound site.
This technique is effective in treating chronic wounds
even in the presence of vascular compromise.
Normothermia can be accomplished by warm up
wound therapy system which includes, delivering
moist heat through a non contact dressing.
Using a warming card which is placed in a sleeve on
top of the sterile wound cover giving warmth up to
38degree C.

34. Negative pressure wound therapy(NPWT)
Npwt is a wound healing technique used to facilitate
wound closure in acute surgical and challenging
slow healing wounds.
VAC or vacuum assisted closure is the device used to
provide negative pressure treatment.
An open cell foam dressing is placed in the wound
and a suction tube is connected from the foam to
the portable pump, an air tight seal is created over
the foam and suction tube with a film.
A controlled amount of negative pressure (sub
atmospheric) is applied through the foam to the
wound bed.

35. For the first few days 48hrs pressure applied
continuously via portable pump, after the
withdrawal of significant amount of wound fluids it
is done intermittently.
The foam is changed in every 12 hrs(infected wounds)

38. Short wave diathermy
• PSWD and CSWD have been used to treat chronic
open wounds
• It provides radio waves to produce thermal and non
thermal effect by facilitating one phase of healing to
next.
• PSWD heats superficial tissues and CSWD heats
deep muscle and joint tissue
• It increases fibroblast proliferation, collagen
formation and tissue perfusion
• Treatment is delivered usually with out touching the
skin, but with newer units pad can be placed over
the wound dressing, compression garments etc..

39. Ultraviolet radiation
• It is a form of energy between x ray and visible light
• It is divided in to wavelength and bands
• Three bands useful for human skin are UVA,UVB
and UVC
• It has bactericidal effects and it increases blood
flow, enhance granulation tissue formation,
stimulation of vitamin D
• Procedure is done on a clean wound with dressing
removed using UVB or UVC lamp
• Treatment distance dosage frequency will vary on
the status of the wound

40. Hyperbaric oxygen therapy
• HBO delivers 100% o2 to an individual who rest
inside a sealed chamber at a pressure greater than
atmosphere (full body chamber)
• It increases the amount of o2 available for cell
metabolism, increase o2 in hypoxic tissue
• Topical hyperbaric o2 therapy THBO is used now a
days Instead of full body chamber, localized limb
chambers are used, so THBO delivered o2 directly
to the surface of the wound through a portable
unit.
• It is also used in combination therapy along with
stimulation or with cold laser

41. Hyperbaric oxygen therapy

42. Hyperbaric oxygen therapy

43. Topical hyperbaric o2 therapy

44. Compression therapy
• The concept of compression therapy is based on a
simple and efficient mechanical principle consisting
of applying an elastic garment around an area of
the body to control edema
• Edema not only inhibit wound healing by affecting
perfusion of the tissue but also inactivates the
ability of the skin to manage Bactria
• It should apply as soon as signs of swelling appears
when leg wounds are present

45. Elevation
• It is not a compression technique but used to
reduce some type of swelling (mild acute swelling)
and is a precursor to compression
• Proper positioning and active ROM exercise should
teach the patient in corporate with other means of
swelling controlling technique like compression etc
Four layer bandage system
• Four-layer bandaging is a high-compression
bandaging system (sub-bandage pressure 35-
40mmHg at the ankle) that incorporates elastic
layers to achieve a sustained level of compression
over time. Since the development of the four-layer
system over 15 years ago.

46. • The four-layer bandage system is primarily used in the
treatment of venous ulceration and achieves healing in
patients with both deep, superficial and combined
venous incompetence. Four-layer bandaging can also
be used to prevent recurrence in patients who are
unable to wear elastic stockings.
• The short-stretch, elastic effect noted in four-layer
bandaging has made this a useful treatment.
Indications
Primary uses
• Treatment of venous ulceration
• Prevention of ulcer recurrence if hosiery is not
tolerated
• Symptomatic relief of superficial thrombophlebitis

47. Other uses
• Traumatic wounds with local oedema, for example
pretibial lacerations
• Venous/lymphatic disorders
• Ulceration of mixed aetiology with an oedematous
component
Contraindications
• Patients with heart failure should not receive high-compression
therapy. In this instance high
compression will redistribute blood towards the
centre of the body, thereby increasing the pre-load
of the heart and possibly causing further overload
and death

48. • patients with severe obliterative arteriosclerosis
should not receive compression therapy.
Application
Layer 1: orthopaedic wool: Orthopaedic wool
provides a layer of padding that protects areas at
risk of high pressure
Layer 2: crepe bandage: This is the least effective layer
as it simply adds extra absorbency and smooths
down the orthopaedic layer prior to the application
of the two outer compression bandages.
Layer 3: elastic extensible bandage: It is a highly
extensible bandage that provides a sub-bandage
pressure of approximately 17mmHg when applied
at 50% overlap using a figure-of-eight technique.

49. Layer 4: elastic cohesive bandage: A frequent
misconception is that the outer cohesive layer
within the four-layer system is there simply to
maintain the bandage position. In fact, this layer
provides the higher level of compression (sub-bandage
pressure approximately 23mmHg)

51. Long and short stretch bandages
• This both bandages are used to control edema and
provide compression to support the lymphatic
system
• Long stretch bandages provide a high resting
pressure means they constrict when the wearer is
resting.
• They do not provide significant working pressure.
they are readily available and easy to wear.
• Short stretch bandages provide low resting pressure
but provide high working pressure
• They are less stretchy, provide rigid appearance
after application and this make more appropriate
for edema treatment

52. • Working pressure increases the work of muscle like
pumping activity and lower resting pressure make
bandage more tolerable
• It need special training to apply like no: of layers,
age condition and tension of the bandage etc…

53. Lymphedema bandage
• This is highly specialized bandage with multiple
layers of padding materials and short stretch
bandage which provide support to the lymph
edematous body part.
• It provides support to the tissues with elasticity loss
and facilitates a mild tissue pressure to empty the
lymph vessels.
• It is applied to head and neck, chest, abdomen,
genital area and back.

56. Compression garments
• It is widely used by clients all over the world, it is
designed to venous blood flow in Les.
• Now it is designed to manage burns surgical scars to
provide support to venous circulation ant to
prevent reaccumulation of fluids It is not used as a
treatment to remove excess fluids
• Another one is quilted garment which provide
compression which is used by person who cannot
apply support garment and whose skin is fragile.
• Venous return and lymphatic drainage is attained by
altering the stitching channels

59. Guidlines for compression bandaging
• Arterial wound- no compression or very light long
stretch bandage in 12-25mmhg is used
• Venous wounds-compression is essential,short
stretch bandage with high working preassure
40mmhg
• Neuropathic wounds-if no arterial involvement
compression with short stretch wrap
• Lymphedema-short stretch compression wrap untle
limb reduction then modarate to high compression
20-30mmhg 30 -40 mmhg
• Edema-same as lymphedema short stretch
compression 23hours/day.

60. Wound dressing
• A dressing is an adjunct used by a person for
application to a wound to promote healing or to
prevent further harm. A dressing is designed to be
in direct contact with the wound, which makes it
different from a bandage.
• Choosing appropriate dressing should be on the
basis of wound and periwound tissue. A product
that preserves wound hydration limit fluid loss is
ideal
• In moist wound dressing the following wound
characteristics must be considered.

61. • Infection-present /absent
• Necrosis-remove/not
• Drainage-dry, adequate or excessive
• Granulation-present/not
• Epithelielization-present/not
• Periwound area-intact/at risk
• Odor-minimal/need reduction
Primary dressing- that applied directly to the wound
Secondary dressing-that applied over primary one