A chronically infected wound may be months or years old, and so scarred that you cannot bring its edges together by suture. The fibrous tissue at its base may be so dense that you have to excise it first. A chronic tropical ulcer (Chapter 29) is an extreme example of a wound of this kind.
Don’t forget: (1) Neurological causes for chronic ulcers, particularly leprosy (test for anaesthesia and feel for thickened nerves). (2) In Uganda, Buruli ulcer.
WOUND TOILET Give the patient a bath, clean his wound well with soap and water and shave the skin round it. Examine it to find out exactly which structures are involved. If there are extensive sloughs or any sequestra, do a thorough wound toilet (54.1).
If the granulations are unfavourable, prepare them, as in Section 57.3 before you then graft them. Change the dressings at least every day, taking care to avoid cross infection. Change them twice daily in the few days before grafting.
Pad the wound and bandage it. A plaster back slab may make the patient more comfortable.
If scar tissue has had time to develop (3 weeks or more), excise it and the subcutaneous layers until you have exposed healthy fascial planes. Wait 3 days for new granulations to form and then graft. You can graft immediately, but the graft will be more likely to take if you wait a few days. A large infective wound will cause the patient to lose much weight. So feed him up (58.12).
CAUTION! (1) If he is anaemic, treat him. (2) Have you considered the possibility that his ulcer might be tuberculous? These ulcers are often multiple, and there may be a sinus. Antituberculous drugs cure tuberculous ulcers rapidly.