Heather Hettrick PT, PhD, CWS, CLT-LANA, CLWT discusses different tissue textures that apply with pathologies that present and uses non-anatomical objects to help relate the textile relationship between the two.
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Pamela: Now Dr. Heather Hettrick is going to give you a Tissue Texture Lab where you get to play with your fruits and vegetables.
Hettrick: [Laughs] That’s right. Thank you, Pamela.
Pamela: You're welcome.
Hettrick: Can you hear me okay?
Pamela: Yeah, keep that closer to your mouth.
Pamela: Just a little bit, thank you.
Hettrick: Alright, great. Okay, you have the clicker [Laughs]. So as I said before, we know wound care is extremely visual, but it's also very kinesthetic, and I think one of the ways to appreciate it is by everyday common things that we can all relate to. And my students sometimes don’t appreciate this because I do a lot of food analogy, so just bear with me a little bit.
But, one of the things I want to talk about is how we can recognize what different edema feels like, and different types of edema are going to feel differently. So, when we have soft, pliable, very easy to manipulate, very easy to push that fluid around and you can see these little ziplock baggies, some of you’re at tables that don’t have the fruits, so you might need to move. But there are some ziplock baggies there with dough. This type of edema is very consistent with CHF edema or congestive heart failure edema, which is a very watery form of edema, very easy to push around, manipulate, leads to lot of pitting, but it refills pretty quickly. Okay, so dough, whether it's play dough, pizza dough, these were just the Pillsbury quick bake [Laughs] biscuits that we bought. Well, I put it in just so their fingers don’t smell like dough, but they can push it in, that’s finally going to be in the ziplock. But when you have a very doughy presentation of edema, you're probably dealing more with a watery form of edema, which could be pure venous or could be CHF, okay.
We’re going to get to some other ones. If you have a very ripe tomato or you have an onion -- see we have onion skins and we have tissue paper. Okay, this is very analogous to elderly skin or very fragile skin. Now remember, a lot of patients might have very fragile skin, maybe they’ve been on corticosteroids for very long time, but maybe they’re young.
So, fragile skin, we have to really be very careful with, particularly when we're thinking about our handling techniques. But also, if you want to play with the band-aids that are on there, just as an adhesive example. Depending on how you're putting on dressings and removing dressings, we could actually cause medical adhesive-related skin injuries with these patients or we can cause skin tears, we can cause denudement. There’s a lot of different things that can happen when we have elderly or fragile skin. So don’t just assume it's elderly skin, but any type of fragile skin. And so, it has a consistency much like onion skin or very, very ripe tomato and even like tissue paper, just to compare to normal paper.
Another thing that I think is important to appreciate are avocados. So, on each table you have a very unripe avocado and a very ripe avocado. Unripe avocados have a very similar texture and do not pit, okay. So the very hard lumpy-bumpy avocados, this is a lot like our patients with stage 3 lymphedema, okay, that hard lumpy-bumpy noncompressible tissue. And so it's very common and very similar to lymphedema with those skin changes that are fibrotic, okay. And again, it's fibrotic skin changes because the difference with lymphedema, it's a protein-rich edema, and protein when it's left behind in the tissues, kind of acts like a rancid butter. If it's left out too long, it starts to break down and it's going to wreak havoc with the extracellular matrix and this cause a whole host of reactions. You are going to end up getting a lot of collagen proliferation and a lot of extracellular matrix degradation, and it’s going to lead to that fibrotic tissue. So it feels like that unripe avocado. Ripe avocados though are soft and pliable and this represents kind of a similar pitting feel. So, this has got the type of pitting we feel sometimes with our stage 2 patients with lymphedema or phlebolymphedema. So it’s soft, it will pit, but the indentation is going to stay.
The other thing that I think is important to appreciate is that this is how fibrous lymphatic tissue feels as it starts to begin to soften. So, when we start doing complete decongestive therapy and part of that’s manual lymph drainage and compression of course, and we start doing maybe fibrotic techniques, manual techniques, you can start to change that unripe avocado into a ripened avocado because we’re breaking down that fibrotic tissue. And so what I’ll do in class is I’ll have that unripe avocado, I have a lot of people just handle it, massage it, work it a little bit, and at the end of the class, it's starting to feel a lot like a ripe avocado. And so that’s just how to appreciate some of those tissue texture changes. Because when you have that really unripe avocado, we’re dealing with kind of a classic lymphedema presentation, it’s how that tissue feels.
So, beef jerky is very representative of that dry leathery eschar, and we see this a lot of times and to Pamela’s point, which we’ll show you later, is, are we dealing with a stable or an unstable eschar. So that stable eschar we kind of want to leave it alone and monitor it, right? But, once it starts to soften or demarcate or separate from the edges, or get soft or squishy or fluctuant, then we need to start doing aggressive debridement depending on the perfusion and underlying arterial supply to our patients. But eschar is very characteristic when it's hard and dry to be like a leathery eschar quality or a beef jerky quality.
Other things to consider is when we talk about atrophic changes. So you know normally skin in hair-bearing areas is going to be soft, it's going to have some hair, and it will feel a lot like a peach or a kiwi, okay, but when we have those atrophic changes and we start to lose those epidermal appendages because there’s no perfusion, it's going to feel more like a lime or it's going to feel more like nectarine, because we’ve lost those epidermal appendages. So again, appreciating not just visually what you're seeing, but this is why it's important to palpate and feel for those changes as well.
Other things, the cantaloupe, now I apologize these were really heavy, and Pamela and I [Laughs] went to the store yesterday, and we had to carry these back. So I only bought 5 cantaloupes, but what I like about the cantaloupes and you can pass these around, is that this tissue represents that really dry hyperkeratotic tissue, you’ve all felt this before. These are the patients that have that lipodermatosclerosis that bound down tissue, again classic for a longstanding venous disease, but also for patients with lymphedema and this is how it feels. It kind of has that rough texture. It's hard, it's not soft, and it doesn’t feel like moist supple tissue.
Other things which I didn’t bring today is wax, so similar to callus, which I think everybody can appreciate, is, this is a lot how calluses or candles can present. So, it's a hyperkeratotic response, you get a building up of that callus, whether it's around an ulcer or just on a pressure weight-bearing area, and the waxy feel of a candle or wax can actually be very similar to indurated or hard fibrotic tissue that’s non-pitting or non-compressible. So again, just feeling for those qualities can be indicative of an underlying etiology for edemas.
And then, the other thing that I have here and I’ll pass this around. If you're familiar with lipedema, which is a condition, it's an adipose disorder. The one in the light brown is the beginning of how a lipedema feels and it's a progressive disease. It is a disease that happens primarily in women and it's a disease involving adiposity from basically the ankle bones, the feet are spared up to the iliac crests. And it's hard nodules basically in the tissue. And so lipedema is a fat disorder, but what it's commonly associated with -- unfortunately people are just usually told that they have an obesity problem and it's different, it's a disease in and of itself like obesity is a disease in and of itself.
Unfortunately, there is not lot that can be done, although some advancing technologies are coming out of the University of Arizona with Dr. Karen Herbst. But lipedema is a condition and often it can lead to a secondary lymphedema because the adiposity stretches and fatigues the lymphatic system. So, over time, these patients can develop a secondary lymphedema. But what you’ll notice for patients that do have pure lipedema is that it's not a fluid disorder, it's a fat disorder. So, they typically don’t have a pit response unless they have an underlying lymphedema, okay, but that’s kind of how the tissues present. The texture is very different than obese tissue because of the underlying pathophysiology.
So another thing I just want to touch on is wound geography and topography. Because like I said earlier the location of the wound and what's present in the wound is very indicative of underlying contributing factors or etiologies, and this can really help us with our differential diagnosis. So we’re kind of go through some interactive test questions here. So when you look at these different three types of granulation tissues, one is representative of hypergranulation, one is beefy red granulation, and one is hypogranulation. The beefy red granulation tissue is what we’re striving for right because that’s healthy. The other two are abnormal forms of granulation tissue/
So which is which? Hopefully you guys can see okay. What do think number one is? Which one?
Unknown Speaker: [Indecipherable] [0:09:31]
Hettrick: ‘A’ hyper, right. Because again in veterinary medicine that’s proud flesh. That’s that cauliflower like presentation of granulation tissue. It's exuberant, it's above and beyond the boundaries of the wound.
What about the middle one? Hypo, absence, right, where we would expect to see granulation tissue, so exactly. And that’s a good looking wound, right? That’s what we’re striving for, it’s that beefy red granulation tissue. So great, very good job.
Okay, so next one. Which wound base presents with fibrin? And then, what's the difference between fibrin and slough? Does anybody know?
We use these terms interchangeably all the time. Which one do you thing is fibrin?
Unknown speaker: [Indecipherable] [0:10:13]
Hettrick: Okay. Who said A? Who said A, who said A? Very good. Whoever said A, exactly.
Actually, this is fibrin, and pure fibrin is actually scaffolding for granulation tissue. It's not a necrotic tissue and you’ll often see this at the base of a venous ulcer, okay. Because, again, it's the scaffolding, it's kind of like the mortar. And fibrin is very adherent, very bound down, it can be a light yellow, it can be a light grey, it can be kind of white, but it's not stringy and sloughy, okay. Stringy and sloughy as shown in B and C is truly slough and that is a necrotic tissue, okay. So, fibrin does not need to be debrided from the wound, pure fibrin. Slough does, okay. And there has been a lot of debate for a long time about what's that yellow stuff, and there’s some papers coming out, and Dr. McGuire is going to talk about the different types of slough shortly. But, it's really important to know that fibrin itself is not a necrotic tissue, but slough is. And we do need to remove the slough from a wound bed. But I think sometimes what happens is people mistake true fibrin for a necrotic tissue in a venous ulcer when it's really not, okay.
Okay, so here different forms of eschar. How would you describe the first type of eschar? If you had to use just descriptive words. Looks a little bit like the beef jerky, right? [Laughs] So this is dry, hard, intact, leathery eschar and that’s the nice thing with wound care is we describe what we see, okay. How about the next one? This is also a form of eschar, but it's starting to lyse and break down. So, this would be soft lysing tan eschar, okay. How about this third one? Gangrene, I heard that. Is it wet or dry?
Unknown Speaker: Dry.
Hettrick: Right, it's dry and we want to leave it dry, okay. And how about the fourth?
Unknown speaker: [Indecipherable] [0:12:09]
Hettrick: Wet gangrene, medical emergency, right? Okay, and it's important to appreciate the difference because we’re going to monitor the dry gangrene, but we’re going to medically aggressively treat the wet gangrene, okay. It's all different types of eschar. And here these are -- it might be hard to see, but your choices are immature scar tissue, hemosiderin staining, or macules of repigmentation. Which one is hemosiderin staining?
Hettrick: Exactly. Again, biological tattoo -- oh! I just gave it all away [Laughs].
Biological tattoo, that’s very characteristic for venous disease, telltale for venous disease, which is great. Because that’s a really good characteristic we can pick up.
The second picture is actually of immature scar tissue, and you have to remember scar tissue can present in two ways. It's immature when it's red, sometimes it can be raised and it can be rigid. When it's immature and it can take up to 2 years for scar tissue to mature. We can do a lot to modify it. We can use compression, we can use silicone, we can do scar massage, we can manipulate it, we can use ultrasound. A lot of different things we can do to hasten this. We can do topical application of silicone, you’ve heard those products on TV.
But, when it's mature and, like I said, it can take up to 2 years to mature, it is pale, relative to the patient’s skin color, planar meaning it's flat in flesh, and it's pliable. It's going to move a lot more like normal tissue. And what's important with that, once it's mature, there’s nothing we can do to change it, okay. And it's important to remember, while it's immature, the tensile strength is never going to be normal. Even when it does get mature, we’re going to ever only hope to achieve 80% normal tensile strength. So when we have a newly epithelialized or newly closed full-thickness wound, that scar tissue is very fragile and we have to be very careful with it for about 4 months. After about 4 months, it's about 40% tensile strength.
So it can really take a long time for that integrity to get better. And this one what I wanted to show you is, this is an area that has re-epithelialized, but you’ll see this kind of purple macules of repigmentation. That’s the pigmentation returning, and it's important because sometimes in our darker-complected patients, after the wound resolves or closes or epithelializes, it might be hypopigmented. It might be white or kind of pink, and it can be a little disconcerting for patients sometimes, but you can just tell them over time it's going to normalize and it will refill in with those macules of repigmentation, and you can see that process happening.
Okay, this is an example of stable and unstable eschar and I gave you that answer, sorry. Oh, I didn’t actually give the answer. Which one do you think is stable?
Hettrick: Correct, A, and you can tell because the edges aren’t separating. If you were to touch that, it's firm, it's not soft, it's not boggy, it's not fluctuant, it's not draining, it's not separating. Compare that to this side here, B, which is that unstable eschar? So this is what we’re going to monitor and protect. This is what we’re going to actively debride and address, according to what the patient needs, okay.
And then, here we have looking at the edges of the wound, so we have one that’s diffuse and irregular. Which one do you think is diffuse and irregular?
Hettrick: Exactly. Which one shows a pebbly or those invaginated edges or rolled over edges?
Hettrick: One, exactly. And then, this one which is not a great picture, but what I wanted to show you here is how in darker-complected patients, we need to look for instead of an erythema, which is the redness, we’re looking for a darkening or dyschromia of their natural skin tones. Not that you won't see some redness, but it's going to be a lot more subtle, okay, and Leider [phonetic] has done some research and found that we tend to miss the stage one’s and the two’s and even the deep tissue injuries in our darker complected patients because we’re looking for things that we may not readily see.
So, it's important to visually screen these patients, but we need to touch those areas as well because you can pick up tissue temperature discrepancies and tissue quality or consistency discrepancies.
And then, this one too we’re looking at the periwound. So if you had to describe this as being intact, macerated or indurated, which would your choice be? The periwounds like 3-4 cm extending from the wound edge. It's hard to tell from that picture. It's not indurated, so it's intact, okay. So that’s a pretty healthy looking periwound area, so we want to protect that.
Here we have choices of induration, maceration, erythema, or all of the above.
Hettrick: Exactly, because it's showing signs of induration, which is that hardness. You can actually even see that from this picture. It is macerated, you can see the white tissue here, it is red and erythematous, so it is all of the above. And you can have periwounds with multiple presentations. Here we have choices of moisture associated skin damage, excoriation, which again is the scratch marks, signs of infection or macerated. What do you think your choice is? Or best choice?
Hettrick: C, signs of infection. Do you see the streaking? And it's going to be extending beyond the 3-4 cm of that periwound area. And usually when you see streaking, it’s like a lymphangitis, okay, and that’s telltale for infection.
Here we have -- again, we’ve already seen this picture, but the arrows are pointing to what?
Hettrick: C, excoriation. Again, very important, because it’s a trauma usually induced by the patient to themselves due to pain or due to itching, and so that shouldn’t be called a stage 2 pressure injury, it shouldn’t be called moisture associated skin damage, that’s truly excoriation. So, again it's like Pamela said we’re using our words properly in describing truly what the etiology is.
Now this is the lower leg, just to orient you a little bit. So do we have moisture associated skin damage, lymphorrhea, inflamed erythema? Is it denuded or is it all of the above?
Hettrick: It is all of the above, right. And the primarily cause behind this is actually the lymphorrhea. So this is lymphedema that is just having the fluid come out into the tissues and inducing the chemical burn leading to basically all of these complications. Okay.
So geography, we’re kind of go through this quickly, again. Here, what happens when you have too much tension on a wound? What type of wound does that lead to?
Hettrick: Dehiscence, right. We see this a lot in the abdomen, we can see this in the lower leg, so dehiscence can be big problem. It's usually due to too much tension; or sometimes you have too much edema and it's going to just pull those edges apart.
What's this condition? Cell cycle reduced from 311 hours to 36 hours.
Hettrick: Psoriasis, absolutely, and it's very common on the flexor surfaces of the body. It's treatable, okay, but we’ve to recognize it for what it is.
How about this condition? Discovered after seeing a bloody foot print. Typically, what's the cause?
Hettrick: Neuropathy, right? Absolutely. How many patients have come in and said, “You know what? I noticed blood on my sock, I didn’t feel anything.” I’ve had patients come in to the clinic with their nails sticking out of their foot, right? So again, the neuropathic process is pretty telling and it can lead to some pretty severe wounds. What about this?
Hettrick: Who says venous? Okay. Who says arterial? This is mixed. [Laughs] This is a mixed presentation because it's classically in the location of the venous ulcer, right.
But, do you see there’s necrotic tissue? You're not going to typically see that in a venous ulcer unless there is an arterial component. The bulk of lower extremity wounds are venous in origin, 70% are venous in origin, 10–15% are going to be arterial, but the remaining are going to be mixed. And those are the challenging wounds, because the venous component needs the compression, the arterial component doesn’t necessarily need the compression, but we need to be able to provide compression appropriately for patient like this. So that’s a mixed progression. This is when really good intentions go wrong. What do you think caused these complications?
Hettrick: Yeah, [Laughs] improper compression. So, this patient got put in compression, but in a plantar flexed position. We’ve to make sure when we’re putting on compression, they’re in neutral. We need to facilitate gait, right? So they got pressure necrosis. And patients do this sometimes to themselves inadvertently. So again, it's just when the compression isn’t utilized properly, we can actually cause more problems.
How about this? What's this?
Hettrick: Absolutely, a skin tear, a very classic type of skin tear. And how about this? It’s often subject to mistaken identity and subject to pathergy.
Hettrick: Pyoderma, absolutely. So lot of time this is diagnosed as a venous wound, but it’s actually not. And pathergy is what happens with pyoderma, and that any time you manipulate this to debridement, it worsens the condition, it’s what pathergy is. So usually pyoderma gangrenosum is ruled out or ruled in. So it's a diagnosis usually of exclusion and it requires medical management, because it's very difficult to treat, but it's not venous.
And how about this? What's this classic for? So it's fairly painful with elevation. They tend to be distal.
Hettrick: Arterial exactly. Mm-hmm, arterial. How about this?
Hettrick: Notice the location, it's fairly clean, irregular borders, hemosiderin staining.
Hettrick: Right. This is a lot like your cantaloupe. So it's the lipodermatosclerosis that bounding down hardening of the tissues. And this is truly phlebolymphedema, okay, this is the combination of lymphedema and venous disease. And what about this, on the heel?
Hettrick: Deep tissue injury, exactly. And these are actually myocutaneous infarctions and what's interesting, what I’ll say about pressure injuries, particularly DTIs, is that the area underneath the bony muscle tissue interface, remember muscles are going to die out first, it has the highest demand for oxygen, and so when it's compromised which can be 20 minutes, it's going to die. Now in a living person what happens in deep tissue injury is that tissue is going to behave as if it's dead. It's going to actually release all the enzymes that happen when somebody dies. That tissue is going to become locally a rigor mortis, and we can see this.
And these are those wounds that start small, but seem to get really big. It's because locally that tissue is behaving as if it’s dead. So it's releasing all those enzymes, and it's going to increase the shear that’s happening internally, from like an engineering kind of standpoint. What happens is that shear is actually going to increase and extend that wound. So the tissue is going through a local rigor mortis, which will pass over time, but it’s why sometime these wounds start small and end up getting bigger. It's because they are behaving like dead tissue, even in a living person, so it's kind of an interesting pathology that we see. So this is classic deep tissue injury.
And what about this?
Hettrick: Callus, absolutely, you guys see that all the time. Again, we can’t ignore callus, especially in our patients with neuropathy.
And then, how about this? This is the lateral aspect of the foot and what is this erythematous response called in darker complected skin, do you remember? I mentioned it a couple of times.
Hettrick: This is dyschromia. It's that dark. So instead of seeing an erythema per se, you're going to see a darkening of that natural skin tone. And you could feel for this too. It could be warmer, it could be cooler, but this why palpation is critically important, okay.
And what about this? This is often misdiagnosed as an ankle sprain.
Hettrick: Charcot, yes. So lot of times we’re going to pick this up because you're going to start to see the changes in the shape of the foot, the rocker bottom foot. You're going to have temperature discrepancies between the two extremities. It looks like an ankle sprain, but it's not, it's Charcot arthropathy. Okay, we need to recognize this early so we can hopefully move it through that quiescence stage quickly.
And the last one, what do you think this is?
Hettrick: Melanoma, absolutely. And we’re going to see this in a lot of patients. One thing that I’ll say is patients -- again, darker complected patients -- if you see a changing nail lesion, okay, and so if they have a lesion in the nail, whether it's the toenail or the fingernail and it's evolving, you need to get it biopsied, because 20% of melanomas in darker complected skin are in the nail beds. Okay, so any nail lesion that’s evolving or changing, particularly in darker complected patients, we need to biopsy for. But melanomas can happen anywhere on the body, but they often do can happen in the nail beds as well. Okay, so melanoma is important to pick up as well.
What about this?
Hettrick: Yes, onychomycosis [Laughs]. So definitely need to address that. And we’ve to discern the difference between hyperkeratotic nails, dystrophic nails or true fungal infection. And as you all know it's pretty difficult to treat, but they do need to be monitored and it can be managed. And dermatophytes can reside dormant for up to a year under the nail bed, so we need to really make sure we’re treating this properly.
And this last one is really what I was talking about with respect of lipedema, okay, and you can see how the feet are spared and it really involves the ankles to the hip bones. So this is lipedema, that abnormal fat disorder that’s characteristic particularly for women and they’ll also have very hypermobile knees that’s another telltale sign, okay. But they often lead to secondary lymphedema.
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