Case Studies & Self-Assessment

✅ Correct answer: 4 points. Site forefoot 0, ischemia 0 (pulse palpable), neuropathy 1, infection 1 (local erythema ≤2 cm = mild infection still scores 1), area ≥1 cm² scores 1, depth to tendon 1 → 0+0+1+1+1+1 = 4. A score ≥3 falls in the poorer-prognosis group. (Monteiro-Soares 2023)

✅ Correct answer: Offloading. IWGDF Offloading 2023 explicitly states that first-line care for plantar ulcers is a non-removable knee-high offloading device; no dressing can replace offloading. Mild infection is managed with oral antibiotics plus debridement — silver dressings are not core therapy. (Bus 2023, DOI:10.1002/dmrr.3647)

✅ Correct answer: Stage 3 — full-thickness loss with visible fat but no exposed fascia/tendon/bone. Slough covers only part of the wound and depth can be determined, so it is not Unstageable. (EPUAP/NPIAP/PPPIA 2019)

✅ Correct answer: Calcium alginate. Specific guideline statements: Stage 3–4 with moderate exudate → calcium alginate; low exudate → hydrogel; moderate-to-heavy → foam. Dry gauze is not moist wound healing. Also never forget the core measures: offloading + support surfaces + nutrition. (EPUAP 2019; Gould 2024)

✅ Correct answer: ABI. Every lower-leg ulcer requires exclusion of significant arterial disease before compression, to avoid compression worsening ischemia. Venous ultrasound guides later intervention planning — it is not the safety gate before compression. (Marston 2016; WOCN)

✅ Correct answer: Compression therapy (multilayer bandaging / compression stockings). Combine with highly absorbent dressings for exudate management and periwound skin protection; after healing, long-term compression stockings prevent recurrence (C5→C6r risk). Antibiotics only for infection; walking engages the calf muscle pump and is actually beneficial. (Franks 2016; Lurie 2020)

✅ Correct answer: Revascularization assessment. WIfI I3 (ABI <0.40), severe ischemia: stable dry necrosis should be kept dry and protected; before perfusion is restored, debridement or hydrogel-promoted autolysis can enlarge the necrosis and convert it to wet gangrene; compression is contraindicated. (Federman 2024; Conte 2019 GVG)

✅ Correct answer: Pyoderma gangrenosum. Clues: inflammatory bowel disease + severe pain + violaceous undermined borders + worsening after debridement (pathergy phenomenon). Necrotizing fasciitis presents with toxic appearance and rapid systemic deterioration; calciphylaxis is mostly seen in dialysis patients. (Maverakis 2020)

✅ Correct answer (the incorrect option): Aggressive debridement. Debriding active Pyoderma gangrenosum triggers pathergy and enlarges the ulcer — this case worsening after outside-hospital debridement is classic. Correct approach: biopsy for diagnosis, immunomodulation, atraumatic wound care. (Isoherranen 2019 EWMA)

✅ Correct answer: Tdap, no TIG. Contaminated puncture wound = high-risk wound; primary series ≥3 doses completed with the last dose 5–10 years ago → booster vaccine, no TIG (TIG is only for high-risk wounds with "<3 doses or unknown history"). Adults who have never received Tdap should preferentially get Tdap. (CDC)

✅ Correct answer: Irrigation + exploration + leave open. A contaminated deep puncture wound is high infection risk: irrigate thoroughly, confirm no retained foreign body (imaging if needed), and do not perform tight primary closure. For plantar punctures, beware of Pseudomonas osteomyelitis — return promptly if worsening. (Nicks 2010; WHO)

✅ Correct answer: Severe infection. Fever + tachycardia = systemic inflammatory response (SIRS ≥2 criteria) → severe by IWGDF/IDSA definition: admission, IV antibiotics, surgical evaluation for drainage/debridement and deep cultures. (Senneville 2023)

✅ Correct answer: 31.5%. Rule of Nines: anterior chest (anterior trunk) 18%, each upper extremity 9% (both arms 18%), anterior right thigh approximately 4.5% (the whole leg is 9%, anterior half is half of that). 9% + 9%×2 + 4.5% = 31.5%. (ABA 2023)

✅ Correct answer: 8820 mL. Parkland = 4 mL × 70 kg × 31.5% TBSA = 8820 mL, given over the first 24 hours, with the first half infused within 8 hours. Note that only adult burns ≥10% TBSA require formula-based resuscitation, and titration to urine output (target 0.5 mL/kg/h) is required. (ABA 2023; Jevsevar 2024)

✅ Correct answer: Deep incisional SSI. Involvement of the fascia/muscle layer, purulent exudate, within 30 days postoperatively, with fever → meets deep incisional infection criteria. Superficial involves only skin and subcutaneous tissue; organ/space involves organs or spaces manipulated during surgery. (CDC NHSN 2023; Berríos-Torres 2017)

✅ Correct answer: Open drainage + empiric antibiotics + imaging. Deep incisional infection requires suture removal and open drainage, obtaining cultures, covering staphylococci and enteric flora (especially enteric organisms after rectal surgery), and CT to exclude deep fluid collection or organ/space infection. Prophylactic antibiotics should not be extended, and the contaminated wound should not be immediately closed. (Banoub 2023; Bratzler 2013)

✅ Correct answer: Long-term compression stockings. After healing, long-term graduated compression stockings (30–40 mmHg) are first-line to prevent recurrence. Multiple randomized studies show that continued compression after healing reduces 1-year recurrence to 15–20% (vs 30–50% without). Antibiotics and silver dressings are not for recurrence prevention. (Nelson 2014; Franks 2016)

✅ Correct answer (the incorrect option): Stop compression after healing. Lifelong or at least long-term compression is still required after healing; recurrence risk rises significantly when compression is discontinued. Venous intervention can address the underlying venous hypertension, but compression stockings should still be maintained after intervention. (Nelson 2014; Lurie 2020)

✅ Correct answer: Moderate. Surrounding erythema >1 but ≤2 cm (or erythema/induration >0.5–2 cm), depth only to subcutaneous tissue: meets IWGDF/IDSA moderate. Mild is erythema ≤2 cm with no systemic symptoms but limited to skin and subcutaneous; severe requires systemic inflammatory response (SIRS). (Senneville 2023; Lipsky 2012)

✅ Correct answer: Outpatient oral antibiotics + debridement + offloading. Moderate infection without systemic symptoms and with normal perfusion → outpatient oral antibiotics covering gram-positive organisms (e.g., cephalexin or clindamycin), with appropriate debridement and offloading. Admission and IV antibiotics are reserved for severe infection or poor perfusion; silver dressings are not anti-infective therapy; hyperbaric oxygen is only for select severe ischemic lesions. (Senneville 2023; Bus 2023)

✅ Correct answer: Alternating-pressure reactive mattress. For high-risk bedridden patients, guidelines recommend an alternating-pressure/reactive pressure-redistributing support surface, superior to standard foam or a simple static air overlay. Air-fluidized beds are reserved for severe existing pressure injuries or multiple lesions requiring postoperative care. (EPUAP 2019; NPUAP 2021)

✅ Correct answer: Heel offloading. The heel is a common high-pressure point; guidelines recommend a heel suspension boot to keep the heel off the bed, and heel protectors while in a wheelchair. Elastic bandages actually increase pressure; massage of broken skin is contraindicated. (EPUAP 2019; NPIAP 2019)

✅ Correct answer: W2. WIfI perfusion grading: W2 is ABI 0.40–0.79 or toe pressure 40–60 mmHg or skin perfusion pressure 30–50 mmHg. This case has ABI 0.45 and toe pressure 30 mmHg, consistent with W2. W3 is ABI <0.40 or toe pressure <30 mmHg. (Conte 2019 GVG; Federman 2024)

✅ Correct answer: Refer for revascularization. Rest pain plus ABI 0.45, toe pressure 30 mmHg, dry necrosis → chronic limb-threatening ischemia (CLTI), requiring vascular imaging and revascularization evaluation. Compression is contraindicated; delay may lead to irreversible ischemic deterioration; hyperbaric oxygen is not first-line. (Conte 2019; GVG 2024; TASC II)

✅ Correct answer: Pathergy. Pyoderma gangrenosum (PG) is characterized by a hypersensitivity reaction to trauma (including surgery, needle sticks, debridement) that enlarges the ulcer, termed pathergy. Köbner is the appearance of psoriasis lesions along lines of trauma, which does not cause ulcerative necrosis. (Maverakis 2020; ISO/BSR 2024)

✅ Correct answer: Systemic immunomodulation. PG is an autoinflammatory skin disease; core therapy is systemic immunomodulation (corticosteroids, cyclosporine, TNF-α inhibitors such as infliximab). During the acute phase, surgical debridement or skin grafting should be avoided to prevent pathergy exacerbation. (Maverakis 2020; Isoherranen 2019 EWMA)

✅ Correct answer: Tdap + TIG. Incomplete primary series (<3 doses or unknown) + high-risk contaminated wound → both vaccine and TIG are required. TIG provides passive immunity; the vaccine initiates active immunity; the two should be injected at separate sites. Those who completed ≥3 doses with the last dose <5 years ago do not need a booster. (CDC 2023; WHO 2017)

✅ Correct answer: Admission + IV TIG + intensive care. Difficulty opening the mouth (trismus/lockjaw) is an early neurotoxin manifestation of tetanus → requires admission, IV TIG (3,000–6,000 IU), moderate or long-term intensive care with airway maintenance, mechanical ventilation if necessary. Delayed treatment significantly increases mortality. (CDC 2023; WHO 2017; Thwaites 2018)

✅ Correct answer: It damages new tissue. Wet-to-dry gauze adheres to and strips granulation and new epithelium on removal, causing repeated trauma, pain, and delayed healing; it is no longer recommended as standard. Modern moist wound healing is the guideline first-line. (O'Donnell 2014; WUWHS 2020; WUWHS 2024)

✅ Correct answer: Hydrocolloid or foam. Partial-thickness shallow wound with light exudate → hydrocolloid or thin foam to maintain moisture balance, promoting epithelialization and comfort. Dry gauze and alcohol disrupt the moist environment; silver dressings are only for infected or high-bioburden wounds and are not first-line without infection. (WUWHS 2020; Ovington 2023)

✅ Correct answer: Glycemic control and corticosteroids. Preoperative HbA1c >8% and long-term corticosteroids are the main modifiable/adjustable risk factors for wound dehiscence. Obesity is also a major risk factor. Guidelines recommend HbA1c <8% (some guidelines <7.5%) before elective surgery, and corticosteroid dose should be evaluated. (Wilson 2018; Ban 2017; Tang 2024)

✅ Correct answer: Operating-room evaluation. Acute full-thickness wound dehiscence with visible fascia → requires operating-room evaluation, debridement, source control, delayed closure or VAC (negative-pressure) therapy; the contaminated wound cannot be managed by taping or immediate tight closure alone. (Wilson 2018; Banoub 2023; Tang 2024)

✅ Correct answer: Skin atrophy and telangiectasia. Late radiation skin changes appear months to years later and include atrophy, telangiectasia, pigment change, fibrosis, and chronic non-healing ulcers. Acute erythema is an acute-phase reaction. (Leventhal 2019; NCCN 2024; BC Cancer 2023)

✅ Correct answer: Biopsy + flap reconstruction. Chronic radiation ulcers require biopsy to exclude radiation sarcoma or recurrent malignancy, then referral to plastic surgery for vascularized flap (e.g., free or local myocutaneous flap) reconstruction, because surrounding fibrosis and poor blood supply make simple dressing changes unlikely to heal. Hyperbaric oxygen is adjunctive, not first-line. (Leventhal 2019; NCCN 2024)

✅ Correct answer: Small-vessel vasculitis. Bilateral symmetric purpura, stellate violaceous-black ulcers, leukocytoclastic vasculitis on biopsy + hematuria and arthralgia → IgA vasculitis (HSP) and other small-vessel vasculitides. Infectious ulcers are usually unilateral cellulitis-like erythema; arterial/venous ulcers are usually unilateral and distal. (Jennette 2013; Wick 2020; Ishiguro 2024)

✅ Correct answer: Immunomodulation and systemic evaluation. The core therapy for vasculitic ulcers is immunomodulation targeting the underlying vasculitis (corticosteroids, combined with immunosuppressants if needed), with evaluation of renal, joint, and gastrointestinal involvement. Debridement or skin grafting is contraindicated because it can trigger pathergy; compression is not primary for vasculitic ulcers. (Jennette 2013; Wick 2020; Ishiguro 2024)