5.4 Mixed Disease, Atypical, Surgical, Traumatic, and Burn Wounds

5.4 Mixed Disease, Atypical, Surgical, Traumatic, and Burn Wounds

Quick Answer: Mixed venous-arterial disease looks like a gaiter ulcer with an ABI often in the 0.5–0.8 band; reduced compression is a vascular collaboration, not a default wrap. Phlebolymphedema shows a positive Stemmer sign. Atypical ulcers (pyoderma gangrenosum, calciphylaxis, vasculitis, Marjolin) need specialty work-up and, for pyoderma, restraint on aggressive debridement. Surgical wounds fail from dehiscence, infection, and dead space. Burns are described by depth; full-thickness injury belongs on a surgical pathway. MASD, MARSI, and skin tears are not pressure injuries.

Blueprint 010302 still has etiologies after venous, arterial, and neuropathic disease. 010303 asks you to classify moisture damage, adhesive injury, skin tears, and to use Wagner where it belongs (the foot—already covered) rather than stretching pressure-injury stages onto every denuded patch.

Mixed venous-arterial disease

The limb tells two stories at once: irregular ruddy gaiter ulcer, edema, and hemosiderin plus claudication, weak pulses, elevational pallor, or a cool foot. ABI commonly lands around 0.50–0.80. High-level compression (about 30–40 mmHg) is not the opening move. Reduced or modified compression is considered only when edema is genuinely venous, perfusion is judged adequate for a lower pressure dose, and vascular clinicians are in the plan. If ABI is below 0.50, skip compression and refer. If ABI is incompressible, obtain TBI before any wrap. Document both etiologies in the assessment; treating only the wetness or only the pulses leaves the other process to enlarge the ulcer.

Phlebolymphedema and Stemmer sign

Long-standing venous hypertension can overwhelm lymphatics. Phlebolymphedema is combined venous and lymphatic edema: square toes, mossy or cobblestoned dorsal foot skin, recurrent cellulitis, and swelling that includes the toes rather than stopping at the gaiter. Stemmer sign is positive when you cannot pinch and lift a fold of skin at the base of the second toe (or sometimes a finger in upper-extremity disease). A positive Stemmer sign supports lymphedema overlay; a negative sign does not fully exclude it. Compression and skin care still matter, but the program looks more like complete decongestive therapy than a two-layer wrap applied once in clinic. Do not chart “refuses elevation” as the whole diagnosis when the toes will not pinch.

Atypical ulcers: stop rules

If location, age of wound, edge color, or pain is wrong for the “big four” (pressure, venous, arterial, neuropathic), change the team, not only the dressing.

Pyoderma gangrenosum (PG) is a painful ulcer with an undermined violaceous border, often on the legs, sometimes after trauma or surgery. Pathergy means trivial injury or debridement enlarges the wound. Avoid aggressive wide surgical debridement as “wound bed preparation.” Coordinate biopsy and immunosuppression with dermatology; gentle conservative care protects the edge. A CWCN who unroofs every violaceous overhang as if it were pressure undermining can double the ulcer overnight.

Calciphylaxis (calcific uremic arteriolopathy) appears in end-stage renal disease and sometimes in other calcifying states: livedo, retiform purpura, and extremely painful ischemic plaques that ulcerate. These are microvascular thromboses, not ordinary pressure injuries on the abdomen or thighs. Involve nephrology and wound/surgical colleagues; local care is supportive and pain-focused while the systemic plan is built. Do not treat it as a routine ischemic toe that will wait for elective clinic.

Vasculitis presents as palpable purpura, livedo, or crops of punched-out ulcers, often on the legs. Biopsy of an early lesion (not only the oldest necrotic center) and a systemic work-up belong with dermatology and medicine. Cropping lesions that ignore bony landmarks are a clue.

Marjolin ulcer is a squamous cell carcinoma (or other malignancy) in a chronic wound or scar, often after years of ulceration or a burn scar. The edge is heaped, rolled, or cauliflower, drainage may be foul, and the story is “this wound has been here since the injury in 1998.” Recommend biopsy rather than another year of silver foam. Chapter 3 already flagged biopsy indications; here the etiology name is Marjolin.

Surgical, traumatic, and burn wounds

Surgical complications the exam expects you to name:

• Dehiscence: the incision separates. Causes include tension, ischemia of the edges, hematoma, infection, malnutrition, steroids, and coughing on an abdominal closure. Document how much of the incision is open, whether fascia is intact (if you can know), and drainage.
• Surgical site infection (SSI): increasing pain, erythema, purulence, fever, or dehiscence with infection. Culture per protocol from tissue or a properly obtained sample, not a casual swab of every staple hole.
• Dead space: a cavity under a closed or nearly closed incision that collects fluid. Unfilled dead space becomes a seroma or abscess. Gentle filling of the cavity (not tight packing that causes ischemia) and addressing why the space exists are the assessment points.

Trauma ulcers follow the injury pattern: pretibial skin tears in older adults after a bumper or wheelchair footrest, crush injuries, and road rash. Etiology is mechanical; ischemia and contamination decide healability. Pretibial wounds in people on steroids behave like skin tears with poor dermal anchors—handle flaps, do not shred them.

Burns are described by depth, not by a dressing brand.

• Superficial: intact epidermis, erythema, pain, no blisters (classic sunburn physiology).
• Partial-thickness: blisters or a moist pink/red bed; painful; superficial partial can re-epithelialize from appendages; deep partial is paler, less painful, and slower.
• Full-thickness: dry, leathery, waxy, or charred; painless in the destroyed dermis; will not epithelialize from the center and needs a surgical pathway (excision and grafting in appropriate patients).

TBSA (total body surface area) drives fluid resuscitation and burn-center triage; it is not the CWCN’s entire job, but you should recognize that a large or full-thickness burn is not a community foam-dressing project. Know depth well enough to escalate. Electrical and circumferential burns have additional emergency rules (compartment, cardiac) outside a typical outpatient wound clinic, but they still are not “stageable pressure injuries.”

MASD, MARSI, and ISTAP skin tears — do not stage them as pressure injuries

Moisture-associated skin damage (MASD) is inflammation and erosion from prolonged moisture. Subtypes you must separate from pressure injury:

• Incontinence-associated dermatitis (IAD): patchy diffuse denudement, irregular edges, burning or itching, often with scale or satellite irritation, in the distribution of urine or stool. There is no discrete bony-prominence pattern and typically no necrosis. A round necrotic ulcer over the sacrum is not IAD even if the patient is incontinent.
• Intertrigo: inflammation in skin folds (under pannus, groin, submammary) from heat, moisture, and friction; secondary yeast is common.
• Periwound maceration: white, waterlogged skin at a dressing edge from unmanaged exudate—etiology is moisture plus the wound, not unrelieved pressure on bone.

Medical adhesive-related skin injury (MARSI) includes skin stripping when tape shears epidermis, tension blisters from stretched adhesive, and folliculitis under occlusive tape. The shape often matches the dressing or tape. Removing adhesive daily from fragile skin is the mechanism; the answer is technique and product change, not a pressure-injury stage.

ISTAP skin tears (International Skin Tear Advisory Panel):

• Type 1: no skin loss; a flap can be approximated to cover the bed.
• Type 2: partial flap loss; the flap cannot fully cover the bed.
• Type 3: total flap loss; the entire bed is exposed.

Reapproximate a viable Type 1 flap; do not discard it as “loose skin.” Skin tears follow shear on fragile, often steroid or aged skin of the arms and pretibial legs. They are not Stage 2 pressure injuries.

Do not stage MASD, MARSI, or skin tears as pressure injuries. If a true pressure injury and IAD coexist, document two processes. Forcing one NPUAP/NPIAP stage onto a tape injury or a diaper rash misdirects offloading and under-treats moisture or adhesive technique.

Scenario: three labels that are not Stage 2

A 72-year-old woman in long-term care is referred for “Stage 2 buttocks and arm wounds.” Exam shows (1) irregular, moist, non-necrotic denudement across the gluteal folds matching incontinence, (2) a linear flap on the right forearm after a blood-pressure cuff and tape removal, flap fully repositionable, and (3) a separate round ulcer with slough directly over the left ischial tuberosity in a wheelchair user. The CWCN records IAD (MASD), an ISTAP Type 1 skin tear, and a pressure injury over bone. The tape injury is not staged. The fold rash is not staged. Only the ischial wound enters pressure-injury staging. A second patient in the same wing has a violaceous, exquisitely painful pretibial ulcer that enlarged after bedside “wide cleanup”; the CWCN stops further aggressive debridement and flags possible pyoderma gangrenosum rather than another pressure stage.

When the map does not match bone, moisture, adhesive, flap anatomy, mixed ABI, or an atypical edge, name the real etiology. That naming is the assessment skill this chapter is built to teach.