Zebras not horses: the atypical wound

This issue of Wound Central was complied by our guest editor

Perhaps you've heard this saying before: ‘When you hear hoofbeats, look for horses, not zebras’. What does that mean for the wound specialist? In determining the aetiology of the wound, the most common causes are most likely the culprit. In lower extremity management, the big three are arterial wounds, venous-related wounds and diabetic related wounds.¹ While managing our patients, zebras should always be lurking in the back of our minds.

There are many wounds that masquerade as one of the ‘Big Three’. These are atypical wounds. How many times have you looked at a patient's wound and said to yourself, ‘That one just doesn't look right?’ That's the first clue that the zebra has arrived. At that time our focus turns to proving it is NOT a commonly observed wound or skin disorder.

The patient's history can raise an eyebrow or two. During the initial physical assessment or in obtaining a history of current or past illnesses, be aware of red flags that might suggest an atypical ulcer. Something as innocuous as a burn that occurred thirty years ago, that healed in a normal course, can subsequently develop a wound in the scarred area — often malignant.² When managing lower extremity wounds, a suspicion for squamous or basal cell cancer must always be pursued early during patient management. If the wound is not improving in four weeks or if the wound looks out of character, it's time to look for an answer.