Joy Tickle, Tissue Viability Specialist, Shropshire Community NHS Trust, Telford

INTRODUCTION

The management of cavity wounds frequently pose a number of clinical and practical challenges to healthcare professionals. They often need debridement, in addition to biofilm, infection and exudate management. The hidden nature of some cavities can present practical challenges in terms of visualising and managing the wound bed, and documenting the wound’s condition, and may therefore require adaptation of the approaches used for non-cavity wounds.
 
 

DEFINING CAVITY WOUNDS

A lack of a standardised definition for cavity wounds can prevent the delivery of evidenced-based care. Having an ambiguous definition and one that is not agreed by all, can hold back understanding and research within the field (Ousey et al, 2017). Since the 1990s there have been various attempts to define what a cavity wound is with definitions ranging from a relatively shallow cavity wound of less than 2cm to wounds that are more than 2cm deep (Chaloner and Poole, 1995) to deep wounds that expose underlying structures such as fascia, tendons, muscle and bone (Williams, 1997).

 
Cavity wounds have also been defined as a wound that extends beneath the dermis (Timmons and Cooper, 2008), and more recently in surgical wound dehiscence, a very clear grading system was developed based on the tissue layers involved and the presence of clinical signs and symptoms of infection (WUWHS, 2018). For pressure ulcers there is a categorisation system based on the depth of tissue loss or suspected tissue loss that outlines the structures that may be exposed (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance, 2019).
 

PREVALENCE OF CAVITY WOUNDS

Owing to the number of definitions that exist, the prevalence of cavity wounds is difficult to determine. Cavity wounds are frequently not captured as seen in large audits that have taken place in England (Guest et al, 2015), Wales (Phillips et al, 2015) Northern Ireland (Skerritt and Moore, 2014) and also in Sweden (Lindholm et al, 1999). In some audits, however, wound aetiologies have been recorded that are strongly linked to a cavity presentation such as surgical wound dehiscence. For example, a study by Srinivasaiah et al (2007) reported that surgical wound dehiscence accounted for 9.7% of wounds in an audit of acute and secondary care settings.  
 

CAUSES AND TYPES OF SHALLOW AND DEEP CAVITY WOUNDS


A cavity can exist in most wound aetiologies including chronic wounds (e.g. leg ulcers, pressure ulcers, malignant wounds [Figure 1] and diabetic foot ulcers), traumatic wounds (e.g. gun shot or stabbing), surgical wounds (e.g. wound dehiscence [Figure 2], sinus/fistula formation) and abscess drainage and excision (Timmons and Cooper, 2008; Wounds UK, 2016). A poor nutritional state can also result in a poor quality of wound healing and the development of a cavity wound (Smith et al, 2015).

 
Figure 1 Figure 1. A malignant cavity wound.
Figure 2 Figure 2. A dehisced surgical cavity wound.

There are several different presentations of cavity wounds (Figures 3a-f) and these include (Williams, 1997; Wounds UK, 2016):
 
Figure 3a
Figure 3a. A regular-shaped cavity, with uniform shape and sloping sides 
Figure 3b
Figure 3b. A cavity with undermining (tissue destruction underneath intact skin around the wound margins
Figure 3c
Figure 3c. A cavity with a tunnel (a pathway extending from the cavity) or pocket (an area of dead space) 
Figure 3d
Figure 3d. A sinus (a blind-ended tunnel leading to a cavity which commonly contains a collection of infected matter) 
Figure 3e
Figure 3e. A fistula (an abnormal tunnel connecting two organs or an organ to the skin) 
Figure 3f
Figure 3f. A cavity wound with bridging (tissue that bridges one side on the cavity to another)
Figure 4 shows an abdominal, dehisced, surgical cavity wound with a fistula at the base.

Identifying the cause of the chronic wound and any associated cavity is a vital starting point (Williams, 1997) in ensuring correct assessment and management.
 

ASSESSMENT


The principles that apply to the assessment of wounds in general are all relevant in the case of a cavity wound but should also include a specific review of the cavity itself (Vowden, 2016). Holistic assessment should be carried out in order to provide the patient with individualised and tailored management (Wounds UK, 2018). If possible, the patient should be an integral part of the assessment and their ability and willingness to participate in their management should be considered (Wounds UK, 2018).

Holistic assessment should aim to determine wound aetiology, identify any underlying comorbidities or factors that may delay healing, followed by a detailed wound assessment. This should consider wound location, dimensions, tissue types present, exudate volume, signs of infection or biofilm, and the condition of the surrounding skin (Vowden, 2016, Wounds UK, 2018).

Some wounds are difficult to measure in an accurate and reproducible way and having a wound cavity can make this even more problematic, especially if undermining, tunnels and bridging are present (Timmons and Cooper, 2008). However, it is important to implement the most objective measurement possible, as this will enable the clinician to have a baseline against which to measure wound progress or deterioration. Table 1 provides guidance on how to measure cavity wounds.
 
Figure 4
Figure 4. Reproduced with permission from Clare Morris, Tissue Viability Nurse Specialist
Table 1 - How to measure a cavity wound  
Step 1 – take two photographs with the first showing wound location
Step 2 – measure and/or probe with caution (see below), especially if the full depth is not visible. Beware of causing trauma, discomfort, pain or contamination
Step 3 – document accurately  
A regular-shaped cavity Use a ruler-based disposable measurement device/tape or a probe to record length, width and depth 
A cavity with undermining
 		 Palpate and use a probe – sterile/plastic/metal/wound swab
A cavity with a tunnel or pocket
 
 		 Use a probe 
A sinus Use of a probe
Sinogram X-ray may be needed to diagnose and assess the size and shape of sinuses 
A fistula Fistulogram X-ray may be used to diagnose and assess the size and shape of fistulas or MRI
A cavity wound with bridging Measure in a consistent place using a probe but avoiding the bridged area 
A cavity with a narrow opening A cannula with the needle removed can be used which will bend into the cavity, unlike a metal probe (Cooper, 2006)

Good documentation is vital to enable an assessment of wound progression (Wounds UK, 2016) and to ensure consistent methods of measurement are used. Cavity wounds should be accurately described and where possible a digital photograph used, although it is acknowledged that isn’t always possible with a cavity wound due to poor visualisation of all or some aspects of the cavity.

A minimum of two photographs should be taken with the first showing the location of the wound (Wounds UK, 2018). Using a clock face as a reference, where 12 o’clock is the patient’s head, can be a useful way of describing what can be seen in a cavity wound and in wound assessment in general (Mahoney, 2020). The use of a sterile, plastic probe or cotton-tipped applicator can be used to measure the depth of the cavity. In addition, the use of a commercial measuring system may also be an option which can give both area and volume measures, but accuracy is still limited (Vowden, 2016).

It is important to remember that a cavity wound will heal by filling with granulation tissue from the base upwards, until the deficit is filled to just below the level of intact skin. At this point, epithelial cells from healthy peri-wound skin will migrate across the granulation tissue to contract the wound, which can be observed as a reduction in wound dimensions. Therefore, a reduction in wound size will not be seen in the width and length of the cavity until it has filled (Williams, 1997). 

The presence of devitalised tissue such as slough or necrosis may obscure full assessment and measurement of the cavity (Wounds UK, 2016) therefore debridement should be performed as soon as possible by using an appropriate technique. If a full assessment is not possible, this should be documented and then performed once the cavity can be fully visualised (Vowden, 2016).
 
Cavity wounds are often associated with a high risk of infection and so assessment should proactively look for signs and symptoms. Generally, local wound infection can be identified by the presence of erythema(redness), inflammation(swelling), local warmth, odour, discharge, delayed healing and pain (Brown, 2018). There are also clinical signs that may indicate a biofilm is delaying healing in the wound. The presence of wound ‘slime’ that can be removed easily but which reforms quickly and continues to be a problem despite debridement in addition to no improvement of the wound following the use of topical antimicrobials can point to the presence of biofilm (Metcalf et al, 2014).

A large volume of exudate can be produced by some cavity wounds and assessment should record the volume, colour, type and viscosity (consistency) (WUWHS, 2019a). Exposure of the skin to wound exudate, particularly if chronic in nature, carries the risk of periwound moisture-associated dermatitis, one of the four clinical manifestations of moisture-associated skin damage (Young, 2017). The skin area around the wound can become white and soggy (maceration) or red and inflamed (excoriation)(Figure 5) (Young, 2017; Mahoney, 2020).
 
Figure 5
Figure 5. Maceration.

MANAGEMENT

The management of complex and challenging cavity wounds may require the skills and knowledge of specialist clinicians such as surgeons, radiographers, stoma nurses, tissue viability and nutritional support teams. Less complex, shallow cavities can be managed effectively through local dressing use.
The aims of treatment for a cavity wound include (Cooper, 2006; Timmons et al, 2008; Vowden, 2016):
 
Wound debridement where applicable
If devitalised tissue is present within the cavity it is important to remove this as soon as possible as it is a focus for infection, will potentially be the cause of increased exudate production and will delay healing (Vowden, 2016). A modified method may be required for a cavity wound as the devitalised tissue may be difficult to access and remove safely (Vowden, 2016). The use of antiseptic surfactants and debridement products that can fit inside the cavity may assist with cleansing and debriding cavities and undermining tissue. In addition, dressings can also facilitate autolysis and debridement.
Maintaining a moist wound environment by ensuring dressing materials are absorbent and conform to the cavity contours
It is important to prevent or eliminate dead space within the cavity (Morgan-Jones et al, 2019) since dead space, such as a pocket, is thought to be responsible for increasing the risk of wound infection (WUWHS, 2019b) and chronicity of wound infection by allowing bacteria to collect (Maddineni et al, 2015). For this reason, the ability of a primary wound dressing to conform to the wound bed is very important to stop pooling of exudate which may lead to an increase in bioburden (EWMA, 2007), even in shallow cavities.

Gelling fibre dressings, which transform into a gel on contact with exudate, are ideal primary dressings since they conform to the contours of the wound bed while absorbing excess exudate (Smet, 2015; Chadwick and McCardle, 2016), promoting the optimal environment for healing.

The primary cavity filler will require a bordered secondary dressing to secure it in position (WUWHS, 2019b). The secondary dressing should also conform closely to the skin, so that the primary cavity dressing can transfer exudate into the secondary dressing and support the objectives of management (Timmons et al, 2008). 


 
Absorb and control exudate while allowing free drainage
Cavity wounds should be gently packed, and dressings not forced in too tightly as this causes a ‘plug’ to form and will discourage free draining of exudate (Vowden, 2016). Packing too tightly could also cause the local blood flow to be restricted (Timmons et al, 2008), and may hinder granulation. 

Dressing selection will very much depend on the outcome of the wound assessment and the objectives set for management. Although there is no clear evidence that wounds heal faster when they are packed, it is generally accepted that they should be (Vowden, 2016) and the selection of the dressing should meet the priorities of treatment, such as absorbing a high volume of exudate, rehydrating dry wounds or delivering a topical antimicrobial. When selecting a cavity dressing, properties such as the ability to retain a high volume of exudate and lock it away can help to protect the wound and surrounding skin from leakage and potential maceration/excoriation, while maintaining a moist wound healing environment.
Periwound skin protection
Periwound skin protection and the prevention of maceration is achieved by preventing the leakage of exudate from the cavity onto the surrounding area through the use of an appropriate primary dressing, and by applying a secondary dressing to the cavity wound that is atraumatic on removal. The use of skin barrier products for some patients may also be necessary in order to protect the peri-wound skin.             

 
Pain free application and removal
Historically ribbon gauze soaked in an antiseptic was used to pack cavity wounds, but this practice is now considered detrimental to wound healing causing severe pain and trauma (Smith et al, 2015). Gauze and other dressing types that are not designed for cavity use or that are not designed to be cut can shed fibres in the wound (Jones, 2006). These can provide a physical barrier to healing and also act as a focus for infection.

Products specifically designed for use in cavity wounds should be used, that facilitate one-piece removal, and do not shed fibres into the cavity. The secondary dressing used should also be atraumatic to apply/remove. Dressings containing Safetac technology have been shown in numerous studies to be atraumatic and pain free on removal (White 2005; 2008).

Prevention of infection
As previously mentioned, the risk of wound infection is increased in cavity wounds and proactive prevention may be required in those assessed as being at risk. This may include the use of topical antimicrobial dressings and dressings that do not leave residual fibres in the cavity, in addition to debridement to remove devitalised tissue.
 
Other considerations
When managing a cavity wound where the depth cannot be viewed, it is important to record the number of dressings used to ensure dressings are not retained within the cavity (Vowden and Vowden, 2014) If the wound has a small opening, it is important to ensure the end of the primary dressing protrudes from the opening and is secured in place to aid removal (Cooper, 2006). This will also ensure that the wound edges do not close before the cavity has healed from the base upwards. Wound dressings that stay intact when they have absorbed exudate and can be removed in one piece should ideally be used.   

Nutrition and hydration should be optimised since having a wound can increase the metabolic demands on the body and protein can be lost through the production of copious amounts of wound exudate (Quain and Khardori, 2015). The presence of a chronic wound can increase protein requirement by 250% and calorie requirement by 50% (Quain and Khardori, 2015).

Following initial assessment and implementation of the management plan, the cavity wound should be reassessed at each dressing change and monitored for signs of improvement or deterioration. Full holistic assessment should take place at least every four weeks (Wounds UK, 2018), however, if there are signs of deterioration, it will need to be undertaken sooner. When the current management plan is no longer relevant, e.g. once the cavity is filled with granulation tissue, it will need to be updated so that it is appropriate for the wound’s current condition (Mahoney, 2020), with all changes to the regimen fully documented in the patient’s notes.
 

CLINICAL CASE STUDY

 
Patient history
  • An 85-year old female presented with a one-week old abscess
  • The patient had a current medical history of cerebrovascular accident, dementia and hypertension
  • The patient was dependent for the majority of activities of daily living and was receiving enteral nutrition via a nasogastric tube. 
Wound history
  • The abscess located on the right thigh, measured 20.36cm2 (5.2cm length x 4.3cm width) with a depth of 5 cm after debridement (Figure 6) and appeared following the intramuscular administration of an anti-inflammatory agent
  • The wound was initially covered with dry eschar (sloughy tissue was observed at subsequent visits)
  • Exuberant signs of inflammation were also noted (swelling, redness, pain, and raised peri-wound temperature)
  • No exudate was present before surgical debridement. After eschar removal, a moderate volume of odourless viscous exudate was present. 
Treatment regimen
  • To manage wound exudate and assist with wound bed preparation, Exufiber® was applied (Figure 7), with Mepilex® Border Flex used as a secondary dressing
  • After 10 days, Granulox® was applied to the debrided wound (Figure 8), before the application of the dressings
  • Dressing changes were initially undertaken every three days for two weeks until major growth of the granulation tissue was observed. Subsequently, dressings were changed once weekly. 
Follow-up assessments
  • Over the treatment period, the ulcer area and depth steadily decreased
  • The condition of the wound bed tissue steadily improved, with 100% granulation tissue present
  • No clinical signs of local wound infection were observed
  • Wound exudate volume reduced from moderate to low
  • The peri-wound skin remained dry without maceration, despite the high volume of exudate at the outset (Figures 9, 10 and 11)
  • Treatment-associated pain was present at the start of the evaluation period but started to decrease in the early stages of follow-up when it was reported as low to none. 
Clinical outcome
  • At the final evaluation, the wound had healed (Figure 12)
  • The clinicians commented that Exufiber could be easily removed from the wound intact and facilitated autolytic debridement due to good exudate management.
Figure 6
Figure 6. Day 1.
Figure 7
Figure 7. Day 4.
Figure 8
Figure 8. Day 10.
Figure 9
Figure 9. Day 23.
Figure 10
Figure 10. Day 63. 
Figure 11
Figure 11. Day 74. 
Figure 12
Figure 12. Day 103.

COST OF INAPPROPRIATE MANAGEMENT

Inadequate assessment or management of cavity wounds can have a detrimental impact upon the patient as a consequence of skin damage caused by maceration, failure to heal, and an increased risk of infection. In an exploratory study of dressing-related trauma, Charlesworth et al (2014) found that between £56 and £175 could be attributed to such trauma, including wound adherence and plugging, and maceration, and described this as a hidden cost. Guest et al (2015) also suggested that better wound care, including diagnosis, treatment and the prevention of wound complications, could minimise costs and improve outcomes.

A cavity wound may also have an impact on a patient’s ability to be independent, work, interact socially, sleep and can generally reduce quality of life (Smith et al, 2015). They can also suffer from psychological problems such as anxiety and depression, altered body image, low self-esteem, anger and frustration and loneliness (Smith et al, 2015). This in turn has cost implications for the Health Service or health care system (Smith et al, 2015) and places ever increasing demands on an already struggling work force.
 

CONCLUSIONS

It is now recognised that inappropriate wound management is costly for both patients and healthcare organisations (Guest et al, 2015). In order to provide effective management of a cavity wound, holistic assessment should be carried out, the findings of which should inform the development of an individualised treatment plan, with re-assessment being carried out at regular intervals to measure progress. Patients with a cavity wound are often complex, requiring optimal medical management of concurrent illness and nutrition and hydration, in addition to wound care. Local wound management can be optimised by the use of dressings which promote a moist wound healing environment by absorbing excess exudate and conforming to the wound, to prevent pooling and leakage, which can otherwise result in an increased risk of infection and maceration, respectively. Dressings that are designed for one-piece removal and do not shed fibres within the wound are also of benefit for reducing infection risk in cavity wounds. Dressing selection should be based on the conditions of the wound, and should be acceptable to the patient, with minimal pain and trauma resulting at dressing change.


Mepilex Border Flex is marketed as Mepilex Border Comfort in the United Kingdom.

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