Resolved Chronic Non-Healing Ulcer After Distal Radius Giant Cell Tumor Resection: Nursing Experience and Wound Care

Introduction

Giant cell tumors of bone almost invariably (97–99%) occur when the growth plate has closed, and are therefore typically seen in early adulthood. Most cases (80%) are reported in patients between the ages of 20 and 50 years, with a peak incidence between 20 and 30 years of age [1]. Among these cases, the distal radius accounts for 10% to 12% of the cases, making it the second most common location affected, following the distal femur and proximal tibia [2]. Intralesional curettage with adjuvant treatments (eg, high-speed burr, cryotherapy, phenol, hydrogen peroxide) can provide good local control, with recurrence rates ranging from 0% to 28% [3]. The distal radius has a rich blood supply, and complications of poor soft tissue healing are rare, particularly in young, healthy individuals. However, bone cement tamponade can affect the local blood supply, and the intralesional curettage procedure requires pulling the soft tissues for a long period of time. In our case, our patient presented with a rare dorsal skin defect (4×3 cm) postoperatively, and we were able to achieve satisfactory healing through chronic wound management. The paradigm for managing pressure wounds like this is widely applicable.

Case Report

A 24-year-old woman with no significant medical history received a diagnosis of giant cell tumor of the radius and underwent tumor scraping, bone cement filling, and plate internal fixation for treatment at a local hospital. During the regular postoperative wound dressing changes, the third dressing change (7 days after surgery) revealed that the palmar side of the surgical incision was healing well. However, on the dorsal side of the wrist, there was a 4×3-cm area of flushed skin color, with a small blister and reduced local sensation. The origin of the wound was pressure from the bandage of the cast, which had been applied after the distal radius giant cell tumor resection. There was no obvious pressure pain, fever, or other discomforts. Laboratory examination, including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein levels showed no abnormalities, and bacterial culture of the secretion was negative. The dressing change treatment at our hospital’s surgical outpatient clinic did not yield satisfactory results, as the skin gradually necrotized. The patient was then referred to our hospital’s medical aesthetic treatment area for following treatment. On examination, a longitudinal surgical scar of approximately 12 cm in length was visible on the palmar side of the right wrist, which had healed well, with the stitches removed. On the dorsal side of the radius, there was a skin defect of irregular oval shape measuring 2.5×1.8 cm (Figure 1). The base of the wound appeared dark red and was covered by yellow necrotic tissue, with poor granulation growth and obvious surface exudation. There was also a dorsal tendon exposure of approximately 0.5×1 cm. The diagnosis was postoperative soft tissue necrosis of the skin of the right distal radius, with a giant cell tumor of the bone.

For patient wound management, we used a stepped dressing change strategy (Figure 2). Debridement and freshening were conducted in the early stage of wound healing (d0 & d4), using a sterile blade for sharp debridement. This involved removing the upper layer of yellow putrefactive flesh, followed by cleaning with 0.9% saline. We then applied dry sterile gauze and topically applied Ag yogurt SSD (lipid hydrocolloid silver sulfate dressing) and Allevyn adhesive foam dressing externally. We provided the patient with guidance for a high-quality protein diet to help her maintain the wound microenvironment. One week after debridement (day 10), we found that the patient had less exudation, with a drier surface, and better granulation growth, and we replaced the URGO dressing with a silver ion gel to enhance breathability. However, after 2 weeks (day 24), exudation from the wound increased but was not purulent, and we used Mesalt dressing to enhance exudation management. Mesalt consists of a soft viscose/polyester, non-woven material impregnated with sodium chloride. When the wound exudate comes into contact with Mesalt, the sodium chloride is released, making the dressing hypertonic. This helps draw out exudate, bacteria, and necrotic material from the wound, facilitating the natural wound healing process. At day 35, the wound had healed (100% epithelial growth), and obvious scar tissue was visible, with a slightly dark red color and no obvious bulge. A self-adhesive soft poly-silicone scar dressing (Comfeel Plus) was prescribed to be applied externally for 6 months, attention was paid to moisturizing the skin around the wound, avoiding excessive friction, strict sun protection, and pharmacological or phototherapeutic interventions were feasible to improve the local appearance if necessary. Six months later, the wound showed satisfactory healing (Figure 3).

Discussion

A removable splint or brace is commonly applied to stabilize the wrist and allow for proper healing and rehabilitation after distal radius internal fixation [4]. Removal of a giant cell tumor results in a large amount of bone loss that can easily lead to pathological fractures; therefore, early postoperative stabilization is necessary [5]. Pressure ulcers are a common complication of cast immobilization and often occur on the lower extremities, a common location in patients with underlying medical conditions, such as diabetes, and are less commonly found in patients without these conditions [6]. In this case report, we presented the management of a chronic non-healing postoperative pressure ulcer that occurred after resection of a giant cell tumor of the distal radius.

Maintaining a moist, cell incubator-like microenvironment is critical for accelerating wound healing and reducing scar formation [7]. The skin plays a vital role in maintaining a stable environment and normal physiological function within the body. Skin defects can lead to chronic delayed wound healing, impairing appearance and physiological function. Ideal dressings should have good biocompatibility, safety, and no immune response and should be able to maintain a moist wound microenvironment that is favorable for gas exchange and exudate absorption. They should also have sufficient physico-mechanical strength to prevent pathogen invasion, along with appropriate microstructural and biochemical properties to support local cell proliferation, migration, and extracellular matrix synthesis. Furthermore, ideal dressings should be able to adhere to tissues and granulation while being easily removable, without causing secondary damage upon removal [8]. Functional dressings not only have the basic properties mentioned above but also have additional functions, such as anti-inflammatory, antioxidant, hemostatic, accelerated wound healing, and scar preventive functions. Some common dressings are made of chitosan, alginate, and hydrogel. Hydrogels provide a moist healing environment, with a 3-dimensional network structure, appropriate degradation rates, and high-water content. They have similar properties to the natural extracellular matrix, are soft and stable, and are virtually painless to remove.

Allevyn adhesive dressing is a convenient adhesive presentation that adheres well to intact skin but not to the wound itself. The low-allergy adhesive is designed to be non-irritating. A hydrocellular structure allows for a moist wound environment to promote healing, while the breathable outer surface allows excess moisture to evaporate. The Allevyn adhesive dressing is also able to remain in place for up to 7 days, reducing the need for frequent dressing changes, which helps prevent skin stripping and irritation.

Silver ion is a widely used antimicrobial material, and its antimicrobial activity stems from changes in bacterial membrane permeability, inhibition of bacterial DNA replication/RNA transcription, and the ability to inactivate bacterial enzymes [9]. The multifunctional antimicrobial mechanism of silver ions inhibits gram-positive and gram-negative bacteria. The addition of silver ion gels to wound management can prevent wound infections and promote healing. We achieved satisfactory results by using a combination of the silver dressing/gel together with the Allevyn dressings, primarily during dressing changes.

In addition, high-protein diets are reported to play a crucial role in wound healing, especially for pressure wounds [10]. Protein is essential for tissue repair, protease synthesis, and collagen formation. Collagen, in turn, is vital for wound healing and maintaining skin integrity. Protein requirements significantly increase when a person has a wound. For patients with chronic wounds, it is recommended to consume 1.2 to 1.5 g of protein per kg of body weight per day. This translates to 96 to 120 g for an 80-kg man and 82 to 102 g for a 68-kg woman. Some patients with poor nutritional status can require up to 2 g of protein per kg of body weight, especially if they have severe wound exudates. High-protein foods include lean meats, poultry, fish, eggs, dairy products, legumes, and nuts. Adequate calorie and protein intake, along with a balanced diet, are essential for wound healing. In contrast, a recent preclinical study suggests that a low-protein diet can accelerate wound healing more effectively than the high-protein diets commonly used in clinical practice [11]. The study found that mice benefited the most from a low-protein diet combined with a balanced intake of carbohydrates and fats. However, there is still a lack of high-quality clinical studies to confirm this. In conclusion, it is believed that a high-protein diet plays a vital role in wound healing by providing essential nutrients for collagen synthesis, enzyme production, and immune system function. However, the optimal protein intake for wound healing can vary depending on an individual’s nutritional status, the size and number of wounds, and the patient’s overall health. It is important to include the assessment and recommendations of a dietitian and utilize multidisciplinary teamwork.

In addition to the technical aspects mentioned above, management of chronic wounds is a long-term process, and nurse-patient communication plays an essential role in wound healing. Empathy is a key component of effective communication and is crucial for building trust and rapport between patients and healthcare professionals. Empathy promotes pro-social behaviors, which fosters rapport and trust between patients and nurses, ultimately improving patient outcomes [12]. Clear and direct communication is vital for wound management as it ensures that patients receive accurate information about chronic wound care and understand the importance of adhering to the treatment plan. Poor communication can lead to complications and poor outcomes [13]. Nurses who demonstrate empathy for the patient’s experience of illness can strengthen the nurse-patient relationship and provide high-quality care. Studies have found that empathy helps promote positive responses to treatment programs, such as alleviating patient discomfort, enhancing emotional expression, and reducing anxiety, depression, and hostility. In a qualitative study, researchers analyzed empathic words and phrases used in nurse-patient communication to demonstrate how empathy is constructed by both the nurse and patient in a particular interactive setting [14]. Effective nurse-patient communication requires understanding patients’ needs, respecting their beliefs and culture, maintaining their dignity, establishing a friendly relationship, and encouraging patients to express their true feelings, needs, and concerns [15]. In conclusion, nurse-patient communication, especially empathy, plays an integral role in wound healing by building trust and rapport, ensuring clear and direct communication, and providing high-quality care based on patients’ needs and concerns.

Conclusions

Chronic non-healing of postoperative wounds in giant cell tumors of the distal radius is relatively rare, and this case report discusses the course of wound management. In managing rare complications, such as postoperative soft tissue necrosis in giant cell tumors of the distal radius, it is crucial to ensure appropriate dressing techniques, provide nutritional support, and maintain effective nurse-patient communication. Early recognition and a multidisciplinary approach can significantly improve outcomes and serve as best practices for similar cases. This case serves as an example of best practices for managing these types of wounds.