The International Journal of
Lower Extremity Wounds
Treatment in an Outpatient Setting
for a Patient With an Infected, Surgical
Wound With Hypergranulation Tissue
Nicole M. Stevens, DPT, Terry Shultz, MPT, Ryan L. Mizner, MPT, PhD,
and Meryl Gersh, PT, PhD
The purpose of this article is to describe a multifaceted
approach to wound care in an outpatient setting for a
patient with an infected, nonhealing surgical wound
with hypergranulation tissue following fasciotomy
for acute compartment syndrome. A 44-year-old male
underwent an anterior and lateral lower extremity com-
partment fasciotomy and developed a persistent right
anterolateral lower leg wound. Thirty-six days after fas-
ciotomy he came to the authors’ clinic after 2 failed skin
grafts with an infected wound covered in hypergranu-
lation tissue. Treatment included sharp debridement,
I
nfected surgical wounds have a profound effect
on a patient’s health. For example, surgical site
infections increase the length of stay in a hospi-
tal by 7.5 days, and treatment of an infected wound
ranges from $3000 to $26 000.1 Infection increases
the risk of mortality, causes delayed healing time,
and leads to extension of the inflammatory process.2-5
Surgical site infections are reported to occur after
approximately 2.7% of all operations,6 and following
fasciotomies, wound infection rates have been
reported to be as high as 25%.7
There is some evidence to support the use of sil-
ver when treating infected wounds.2-4,8-10 A study by
Schaller et al8 found that the use of a silver-based
hydrocolloid dressing was superior in reducing bac-
terial cells and edema in reconstituted human
epithelium when compared with a non-silver-based
From Rockwood Clinic, Spokane (NMS); Lourdes Medical
Center, Pasco (TS); Department of Physical Therapy, Eastern
Washington University, Spokane (RLM, MG), Washington.
Address correspondence to: Nicole M. Stevens, DPT, Rockwood
Clinic, 605 E Holland Ave, Ste 112, Spokane, WA 99218; e-mail:
neager@u.washington.edu.
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Volume 8 Number 1
March 2009 37-44
© 2009 SAGE Publications
10.1177/1534734608329684
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hosted at
http://online.sagepub.com
saline irrigation, patient education, and dressing
changes during 9 treatment sessions. The patient’s total
wound surface area decreased from 5.2 cm × 17.3 cm
to 4 cm × 15 cm with increased epithelialization from
approximately 40% to 85% after 29 days of treatment.
This article demonstrates the positive effect of a multi-
faceted approach for facilitation of wound healing in a
lower extremity wound following fasciotomy.
Keywords: wound healing; infection; granulation tis-
sue; silver application
hydrocolloid. They also noted minimal cytotoxic
effects with both dressings.
Sharp debridement is a generally accepted
method for the removal of devitalized tissue; however,
there is little evidence to support its efficacy.11,12
Patients who received sharp debridement were found
to have a total decrease in mean ulcer surface area of
7.4 cm2 compared with a 1.3 cm2 increase in the con-
trol group in a study by Williams et al.12
Hypergranulation tissue can delay wound heal-
ing impeding epithelialization across the wound
bed.13,14 In a study by Harris and Rolstad,15 a
polyurethane foam dressing was found to reduce
the presence of hypergranulation tissue in wound
beds and decrease the size of the subjects’ wounds
significantly.15 P value <0.01 Foam was also found
to be less painful and more cost effective when
compared with gauze.16 A large randomized control
study (n = 99) conducted by Andersen et al17 found that
wound healing time was similar when comparing a
polyurethane foam dressing with a hydrocellular dress-
ing. However, polyurethane foam managed drainage
better and therefore required less frequent dressing
changes.17
37
38 International Journal of Lower Extremity Wounds / Vol. 8, No. 1, March 2009
Few studies appear to have focused on non-
healing surgical incisions, which is surprising con-
sidering the reports on lower extremity wounds of
vascular etiology. The purpose of this case report is
to describe an evidence-based approach to wound
care in an outpatient setting for a patient with an
infected, nonhealing surgical wound with hyper-
granulation tissue status post fasciotomy secondary
to acute compartment syndrome of the lower leg
using the aforementioned treatment methods.
Case History
This case report describes a 44-year-old male who was
diagnosed in the emergency room with an acute onset,
nontraumatic compartment syndrome of the right
lower leg. The onset was thought to have been caused
by a bleed into the anterior compartment of the lower
leg, which increased compartment pressure and even-
tually led to arterial occlusion of the anterior tibial
artery. The patient was taken to the operating room
where he underwent an anterior and lateral compart-
ment fasciotomy. During the fasciotomy a skin incision
was made down the right anterolateral lower leg.
Following the initial surgery, the patient under-
went 3 surgical interventions: 2 split-thickness skin
grafts, one 8 days after surgery and the other 24 days
after surgery, and surgical debridement under anes-
thesia 22 days after surgery. These procedures were
unsuccessful; however, some portions of the skin
graft healed over approximately 40% of the wound.
The patient’s leg was placed in an Unna boot. Thirty-
six days after the fasciotomy, the patient presented
to our physical therapy clinic with an infected, non-
healing wound with hypergranulation tissue on the
right anterolateral lower leg.
The patient lived with his wife in an apartment.
He was retired and occasionally cared for his grand-
children. During the initial examination, the patient
was alert and oriented to person, place, time, and
situation and was able to follow multistep direc-
tions. The patient was independent in all activities
of daily living and instrumental activities of daily
living and was able to care for his grandchildren on an
as needed basis. He did not use any assistive devices
prior to his injury. He did not smoke, occasionally
consumed alcohol, and did not exercise regularly.
The patient had a past history of cocaine abuse, but
denied current drug abuse.
The patient’s medical history included thrombo-
cytopenia, hepatitis C, gunshot wounds to the right
leg and hip years prior to the recent surgery, a right
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total hip arthroplasty, and a cholecystectomy. His
platelet count on the date of the initial injury
was 65 000 (normal range, 150 000-350 000). A
Doppler ultrasound at the initial date of injury was
negative for deep vein thrombosis. The patient was
taking propoxyphene and acetaminophen (Darvocet;
Xanodyne Pharmaceuticals, Newport, KY) to help
relieve the pain. One of the side effects of aceta-
minophen is anticoagulation.18 The patient’s history
of thrombocytopenia necessitated vigilant attention
being paid to excessive blood loss during treatment.
Darvocet was replaced with hydrocodone approxi-
mately halfway through the treatment program after
it began giving the patient stomach pain.
The wound had a malodor that was noticeable
from a distance of approximately 60 cm. A culture of
the wound was taken following saline irrigation by
swabbing the wound surface with a sterile swab. The
wound culture was positive for Enterobacter cloacae
and Staphylococcus aureus infection. After receiving
results of a positive wound culture the patient started
taking antibiotics, sulfamethoxazole and trimetho-
prim (Bactrim DS; AR Scientific, Philadelphia, PA).
This class of drugs can lead to blood disorders, such
as thrombocytopenia, which increased the risk of
excessive blood loss during treatment.18
The periwound tissue was irritated and had non-
pitting edema. Girth measurements, measured by
circumferential tape measurements, of 26 cm and
35 cm, were taken at the malleoli and 15 cm above
the malleoli on the right, respectively.
Approximately 25% to 50% of the wound bed
showed loosely to firmly adherent yellow slough.
Under the slough, approximately 60% of the wound
bed was filled with bright, beefy red hypergranulation
tissue that was elevated 1 to 2 mm above the wound
bed. The remaining 40% was covered by epithelial
tissue that healed from the skin graft. The wound had
a moderate amount of serosanguinous and yellow
purulent drainage that required management. The
wound edges were raised and rolled under.
Measurements of the wound on the right antero-
lateral lower leg were 5.2 cm at the widest point and
17.3 cm at the longest point. Photo documentation
was also used as an objective way to document the
visual changes in the wound bed’s color and texture
over the course of treatment.5 Figure 1 shows a
photo of the wound on the right anterolateral lower
leg at the initial examination.
The 2 donor graft areas on the right anterior
thigh were fully epithelialized and healing well. The
grafts were harvested 28 days and 12 days before the
 Infected Wound With Hypergranulation Tissue / Stevens et al
Figure 1. Photo of the wound on day 1 of treatment. The
photo taken was of the right anterolateral lower leg at the initial
examination. Wound bed was filled with hypergranulation tissue
and edema in the periwound tissue is apparent.
initial examination at our clinic. The patient’s toes
were warm, there was normal hair growth on the
right leg, and there were no signs of hemosiderin
staining. Other than the wound on the right antero-
lateral lower leg the rest of the skin was in good con-
dition and unremarkable. The patient’s toe nails
were yellow in color and brittle; however, the patient
stated this was regular for him. This issue was not
addressed during the course of treatment.
All manual muscle testing in bilateral lower
extremities revealed strength within normal limits,
and the patient did not present with any functional
weakness. Fortunately, sensation was intact to light
touch throughout the right lower extremity. Range
of motion in both lower extremities was also within
functional limits. Since the initial surgery the
patient reported having pain in the right lower leg at
night and during ambulation. Pain was relieved with
leg elevation during sleep and decreased with the
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39
use of a single-point cane during ambulation. The
patient favored the right leg slightly during ambula-
tion because of pain; otherwise his gait pattern was
unremarkable. Over the course of treatment the
patient reported that his pain lessened, and the
patient was able to tolerate sharp debridement with
minimal to no pain.
His balance was good while sitting, standing,
and during dynamic activities without the use of his
cane. The patient measured 5 ft 10 in. and weighed
230 pounds. He reported no history of cardiac dis-
ease, and his resting vital signs were as follows:
heart rate, 74 beats per minute; respiratory rate, 20
breaths per minute; and blood pressure, 109/72 mm
Hg. The patient had strong dorsalis pedis and poste-
rior tibial pulses on the right (2/3).
According to the World Health Organization’s
International Classification of Functioning, Disability
and Health,19 the patient’s functional impairments
included integumentary disruption, edema in the
periwound tissue, and pain in the right anterolateral
lower leg. His activity limitations included inability
to sleep at night secondary to pain and the need to
use a cane to decrease pain during ambulation.
His participation in social and recreational activities
was limited by pain and the bulkiness of his wound
dressings.
With an infected full-thickness lesion, the
patient was at risk of systemic infection and poor
scar formation. His history of thrombocytopenia also
placed him at higher risk of blood loss during sharp
debridement and during regular activities until the
wound closed. The patient was in need of wound
care in an outpatient setting to help the wound fully
close, reduce infection, and to achieve optimal scar
formation. He also required education on skin care,
edema reduction, correct gait pattern with a cane, and
risks involved with excessive blood loss. The patient
was a good candidate for wound healing once the
wound infection was controlled.
The patient’s prognosis for full wound closure
was good. He was also expected to maintain his
independence with all activities and discontinue the
use of the cane as the wound healed. This prognosis
was based on the patient’s presentation, impair-
ments at the time of examination, and clinical expe-
rience. Age and surrounding skin integrity were
determining factors in the prognosis for this patient.
As the patient was only 44 years old, had no signs of
vascular insufficiency, and had good skin integrity in
the lower extremities other than the wound site, his
40 International Journal of Lower Extremity Wounds / Vol. 8, No. 1, March 2009
chances for healing were predicted to be good.
Heemskerk and Kitslaar7 reported that subjects who
were less than 60 years were found to have signifi-
cantly better outcomes after fasciotomies than older
subjects. P value = 0.010
The goals of treatment set at initial examination,
to be achieved within 3 to 4 weeks, were
1. Complete removal of necrosis
2. Increased epithelialization to 75% to 100% of
the wound covered
3. Patient compliant with a home exercise program
of elevation and ankle range of motion exercises
The patient’s personal goal was to “Heal the
wound.” The discharge criterion for this case was
that the wound bed would be fully epithelialized.
Treatment Methods
The patient received a total of 9 treatment sessions
over the course of 29 days. At the initial examination
informed consent was obtained from the patient to
use his information for this case report. Photo doc-
umentation of the wound was given to the patient so
that he could provide his probation officer proof of
treatment. Pain medication was administered by the
patient prior to wound care treatments to decrease
pain during the treatment sessions and prevent a
pain cycle from beginning.20 During the course of
treatment, there was ongoing communication with
the patient’s physician regarding the plan of care.
To begin each treatment session the patient’s
wound was cleansed with saline solution to help
remove debris from the wound bed and soften
necrosis.2 Following irrigation, sharp debridement
was performed during 6 out of 9 treatment ses-
sions.11,12 Debridement was performed very gently
and minimal bleeding was allowed secondary to the
patient’s history of thrombocytopenia. During occa-
sions of bleeding, gauze and pressure were applied
until hemostasis occurred. The majority of debride-
ment was performed with forceps to remove yellow
necrosis from the wound bed. During treatments 7
and 8, a scalpel was used to remove small areas of
excessive hypergranulation tissue. We angled the
blade slightly so that it would remove only the top
layer of hypergranulation tissue and not cut deeply
into the wound bed.
Prior to treatment at our clinic on the day of the
ninth visit the patient had a follow-up examination
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with his physician. During this visit the patient
received silver nitrate cauterization to the remaining
open areas of the wound. For this reason, only dress-
ing changes were performed on the ninth visit.
We paid careful attention to the moisture level
in the wound bed because the patient had moder-
ate amounts of exudate that required absorption.
However, areas of epithelialization were at risk of
becoming too dry. To adjust the moisture level in the
wound, we used a combination of petrolatum
impregnated gauze, silver-based hydrogel (SilvaSorb;
Acrymed, Inc, Beaverton, OR) and polyurethane
foam.
To combat desiccation and infection, a silver-
based hydrogel was applied during all 9 treatments to
areas of epithelialization that were too dry and to the
hypergranulation tissue.8,21 During treatments 4
through 8, the wound still produced a fair amount of
exudate, although it was becoming progressively less,
most likely because of infection control and increased
epithelialization. At this point the petrolatum- impreg-
nated gauze was applied to retain moisture over the
areas that were becoming dry. The polyurethane
foam was applied over the gauze and silver-based gel
during all 9 treatment sessions. The foam was used
to absorb exudate and help reduce hypergranulation
tissue.2,15-17
Finally, the 4-layer bandage system (Profore;
Smith and Nephew, London, UK) was wrapped from
the base of the patient’s toes to just below the knee
with the bandages stretched to approximately 50%
of their elastic capacity. Compression was offered to
help wound healing and to reduce edema in the
lower limb. The 4-layer bandage was also used to
help protect the wound, keep the dressings in place,
and provide stability to areas of the skin graft that
were viable.22-27 The 4-layer compression wrap and
polyurethane foam made it possible to have
biweekly dressing changes because this dressing
wrap absorbed the exudate and stayed in place for
long periods of time.17 This was preferable to daily
dressing changes, which would have been necessary
had a gauze and compression stocking bandage sys-
tem been used. This schedule permitted the patient
to continue to care for his grandchildren regularly
during the course of treatment.
The patient was given instructions to perform
ankle range of motion exercises and elevate the leg
at home to reduce edema.28,29 He received education
regarding the choice of dressing materials, moisture
levels in the wound bed, keeping the dressings dry,
 Infected Wound With Hypergranulation Tissue / Stevens et al 41

and the need to watch for signs of excess compres-

sion from the bandage system. We also educated
him to be aware of blood loss and the need to seek
medical attention should this became a problem.
Finally, the patient was instructed on the correct gait
pattern using a single-point cane in the left hand to
help relieve pain in the right leg during gait. This
pattern would allow the patient to shift his weight
away from the right leg and onto the left arm during
stance, thereby relieving pressure on the right leg.
The patient was aware of the correct technique but
said that he preferred using the cane on the right
because he felt more comfortable that way.
During the course of wound care treatments, the
patient returned for follow-up visits with his physi-
cian. After 14 days of treatment in our clinic, he had
a follow-up visit during which his physician per-
formed sharp debridement with a scalpel to remove
hypergranulation tissue. Twenty-nine days after the
initial examination, he had a second visit with his
physician where the remainder of the open wound
was cauterized with silver nitrate to reduce the
height of the hypergranulation tissue.

Results
After 29 days of wound care treatment, the patient’s
wound showed increased epithelialization and a
decrease in total surface area. The original size of
the wound bed measured 5.2 cm wide × 17.3 cm
long and was approximately 40% epithelialized. At
the eighth appointment, the total surface area of the
wound bed decreased to 4 cm wide × 15 cm long and
was approximately 85% epithelialized. The wound was
of similar shape and size during the ninth appoint-
ment; however, the remaining open areas were
covered by silver nitrate.
At the eighth appointment, only 2 sites remained
open within the wound bed: an inferior site and a
superior site. The inferior site was pear shaped, with
a length of 4 cm and a width of 2.5 cm in the widest
dimension of the pear shape and 1.2 cm at the peak
of the pear shape. The superior site measured 0.8
cm wide and 2.5 cm long. Both open areas were
covered by beefy red hypergranulation tissue.
Over the course of treatment the periwound tis-
sue became less irritated. In the end the wound
edges were slightly elevated even around areas of
epithelialization but were only rolled under around
the inferior site, which was still open. There was no
yellow slough or yellow purulent drainage and
Figure 2. Photo of the wound on day 7 of treatment shows
increased epithelialization but continued edema, hypergranula-
tion tissue, and yellow slough.
only minimal amounts of serosanguinous drainage.
Figures 1 to 5 show the progress in wound resolu-
tion that occurred during the healing process.
At the time of discharge the patient continued to
use pain medication and walk with a single-point
cane. He was unable to wear his regular pants or
jeans because of the bulk of the wound dressings.
However, the pain had decreased to permit the
patient to sleep at night.
During the ninth treatment session the patient
reported that he and his physician had discussed
the option of a skin graft to close the remainder of
the open wound. However, the patient reported that
he was pleased with the progress he made and the
treatments he received at our clinic and was unsure
of what he was going to do. The patient was lost to
follow-up after he did not attend his tenth appointment.
A phone call to the patient revealed that he and his
physician decided to try a third, full-thickness skin
graft over the inferior site in the wound bed. Therefore,

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42 International Journal of Lower Extremity Wounds / Vol. 8, No. 1, March 2009
Figure 3. Photo of the wound on day 11 of treatment shows
increased epithelialization.
final girth measurements were not recorded.
However, visual observation at his last appointment
revealed decreased edema in the right ankle and
periwound area.
Discussion
This case report described a comprehensive treatment
approach for a patient with an infected, nonhealing
surgical wound with hypergranulation tissue. With
the use of sharp debridement, 4-layer compression
bandaging, petrolatum-impregnated gauze, a silver-
based hydrogel, saline irrigation, polyurethane foam,
and patient education, the patient’s wound decreased
in total surface area and epithelialized from approxi-
mately 40% to 85%.
Factors that complicate clear explanations of
outcomes in this case were the numerous types of
treatments and treatment agents used. This includes
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Figure 4. Photo of the wound on day 15 of treatment shows
the remaining open areas of the wound following debridement.
the treatments at our facility and treatments the
patient received from his referring physician during
his course of care. Although practical and realistic,
this multifaceted set of treatment protocols compli-
cates the evaluation of which treatments were
the most beneficial. It also hinders insight into
which treatments may have prolonged healing of the
patient’s wound.
It is worthwhile reflecting on the possible bene-
fits of other adjuvant therapies such as electrical
stimulation that has been reported to reduce infection,
thereby helping to heal recalcitrant wounds.5,30-33
Vacuum-assisted closure is also another treatment
method that could have been helpful.34
In summary, there is limited research about the
treatment of wounds that occur following fasciotomy
in the current literature. This case report demon-
strates the positive effect of a multifaceted approach
for facilitation of wound healing in a lower extremity
wound following fasciotomy.
 Infected Wound With Hypergranulation Tissue / Stevens et al
Figure 5. Photo of the wound on day 22 of treatment (the
final photo taken at our facility). The wound appears to have
increased epithelialization and no necrosis.
Acknowledgments
The authors thank Luther C. Kloth, PT, MS, FAPTA,
CWS, FCCWS, Emeritus Professor, Department
of Physical Therapy, Marquette University, and
Brandee Gregory, student laboratory assistant, Eastern
Washington University, Department of Physical
Therapy, for their help.
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