(CS-110) Management of chronic wound in teenaged patient with severe self-injurious behaviors, Soto Syndrome and Autism

Katharine Finney, MSN, CRNP

Introduction: This case presentation discusses the clinical management of a 12 year old girl with severe self-injurious behavior which resulted in a non-healing, traumatic wound to her right heel. The patient had the diagnoses of autism, Soto Syndrome, intellectual disability, and was blind due to repeated self-inflicted eye trauma. She admitted to our specialty neurobehavioral unit from an acute hospital with a 1 cm wide x 0.5 cm long x 1 cm wound to her right heel. By 2 months into the admission, the wound deteriorated. The wound was difficult to heal due to self-injurious behaviors with repetitive local trauma. The patient would strike her heel against the ground or other objects repeatedly. This behavior would happen throughout the day without any triggering events.

Methods: A variety of wound care modalities were employed including debridement with Santyl, Mepilex, and Aquacel Ag, The wound had persistent serosanguinous drainage which would soak through dressings several times a day.

Soft multi-podus boots and other protective gear were used to prevent additional injury. Attempts were made by behavioral staff to block patient from performing additional self-injurious behaviors. However, not all behaviors were able to be blocked. This resulted in continued worsening of the wound with significant callous formation around the wound and ultimately tunneling. Wound grew to 4 cm x 2 cm x 1 cm deep with tunneling of 2 cm.

As a result of worsening wound status, consultation with orthopedic surgery was requested. They recommended debridement and casting post operatively.

Photos of the progression of the wound will be included in the presentation.

Results: Operative debridement of the wound and placement in a long, full contact leg cast with a window was the key to healing. The weight of the cast decreased mobility of the leg making attempts to block behaviors successful. Additionally, the foot was positioned in the cast in 30% dorsiflexion. This made the patient unable to strike her heel to cause recurrent damage. The cast was removed 47 days post operatively at the time of the patient's discharge to a distant residential treatment facility.

Discussion: Treatment of a non-healing wound in youth with severe self-injurious behaviors can be achieved but requires collaboration, planning, and innovative care strategies.