A 58-year-old diabetic man with a 10-day-old surgical abdominal wound presents with dehiscence (partial separation of the incision). The wound edges are erythematous, with purulent drainage and surrounding cellulitis. Vital signs: temperature 38.5°C, heart rate 110/min. What is the most appropriate next step in management?

Question

Accepted Answer

C. Immediate surgical exploration, debridement, and re-closure under general anaesthesia. ## Infected Wound Dehiscence: Management Strategy

**Key Point:** Infected dehiscence with systemic signs (fever, tachycardia) and purulent drainage requires urgent surgical intervention—debridement and re-closure—not conservative management.

### Clinical Assessment of This Case

| Feature | Finding | Significance |
|---------|---------|---------------|
| **Timing** | 10 days post-op | Early dehiscence; high infection risk |
| **Appearance** | Erythema + purulent drainage | Active infection present |
| **Systemic signs** | Fever 38.5°C, HR 110 | Systemic inflammatory response |
| **Comorbidity** | Diabetes | Impaired wound healing, immunocompromise |
| **Diagnosis** | Infected dehiscence | Requires surgical intervention |

### Why Surgical Intervention Is Mandatory

```mermaid
flowchart TD
  A[Wound dehiscence at day 10]:::outcome --> B{Signs of infection?}:::decision
  B -->|No fever, no purulence| C{Partial or complete?}:::decision
  B -->|Fever, purulence, cellulitis| D[Infected dehiscence]:::urgent
  C -->|Partial, clean| E[Conservative: dressing + observe]:::action
  C -->|Complete| F[Surgical re-closure]:::action
  D --> G[Urgent surgical exploration]:::action
  G --> H[Debride necrotic/infected tissue]:::action
  H --> I[Irrigate copiously]:::action
  I --> J{Infection controlled?}:::decision
  J -->|Yes| K[Re-close in layers]:::action
  J -->|No| L[Leave open, plan delayed closure]:::action
```

### Pathophysiology of Infected Dehiscence

1. **Bacterial colonization** at the incision site (often S. aureus, E. coli, or anaerobes)
2. **Impaired collagen synthesis** in the proliferative phase (especially in diabetics)
3. **Enzymatic degradation** of collagen by bacterial proteases and neutrophil elastase
4. **Loss of wound integrity** → mechanical separation
5. **Systemic spread** if untreated → sepsis, necrotizing fasciitis

**High-Yield:** At day 10, the wound is still in the **proliferative phase**. Collagen cross-linking is incomplete, making re-closure technically feasible if infection is controlled. Waiting >14 days risks progression to necrotizing infection and loss of re-closure opportunity.

**Clinical Pearl:** Infected dehiscence with systemic signs is a surgical emergency. The presence of fever + purulence + cellulitis indicates bacterial invasion beyond the incision—conservative management will lead to sepsis and tissue necrosis.

### Why Immediate Surgery?

- **Debridement removes infected/necrotic tissue** that antibiotics cannot penetrate
- **Irrigation dilutes bacterial load** and removes foreign material
- **Re-closure in layers** restores anatomic integrity and prevents further contamination
- **Tissue viability assessment** is only possible under direct visualization
- **Systemic signs** (fever, tachycardia) indicate infection has crossed the incision boundary

**Mnemonic: FIRE** — **F**ever, **I**nfection, **R**equires **E**xploration (and debridement, re-closure)

Answer

A. Topical antiseptic application and observation for 48 hours before deciding on re-closure

Answer

B. Negative pressure wound therapy (NPWT) alone without surgical intervention

Answer

D. Oral antibiotics and outpatient wound care with daily dressing changes

Explanation

Infected Wound Dehiscence: Management Strategy

Clinical Assessment of This Case

Why Surgical Intervention Is Mandatory

Pathophysiology of Infected Dehiscence

Why Immediate Surgery?

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Feature	Finding	Significance
Timing	10 days post-op	Early dehiscence; high infection risk
Appearance	Erythema + purulent drainage	Active infection present
Systemic signs	Fever 38.5°C, HR 110	Systemic inflammatory response
Comorbidity	Diabetes	Impaired wound healing, immunocompromise
Diagnosis	Infected dehiscence	Requires surgical intervention