Wound

Defination:
Wound may be defined as a break of anatomical continuity of
any lining tissue due to any violence.
Classification:
A. According to contamination (Rank and wakefield classification)
a. Tidy wound/ Clean
b. Untidy wound / Dirty
B. According to duration
a. Acute wound
i. Closed
1. Bruise/contusion
2. Haematoma
ii. Open
1. Incised
2. Abrasion
3. Laceration
4. Puncture – by neddle
5. Penetration – by knife
6. Avulsion
iii. Complex
1. Crush injury
2. War wound
3. Gun shot wound
iv. Injury to special tissue
1. Fat, muscle, bone, vein, nerve

b. Chronic wound
i. Ulceration
ii. Pressure sore
INITIAL STEPS
1. Patient Comfort and Safety
2. Initial Hemostasis
Most bleeding can be stopped with simple pressure and
compression dressings.
Clamping is reserved for the actual exploration and repair of the
wound under controlled, well-lighted conditions
3. Jewelry Removal
4. Pain Relief
Pain relief begins with gentle, empathic, and professional
handling of the patient
5. Wound Care Delay
If there is going to be a delay from initial wound evaluation to
repair, the wound is covered with a saline-moistened dressing to
prevent drying. The dressing need not be soaked and dripping
wet.
 Delays that extend beyond 1 hour require that the wound be
thoroughly cleansed and irrigated before the saline dressing is
applied.
6. Tetanus immunization:
severe soft tissue wounds are more likely to be at risk for tetanus
7. Antibiotic prophylaxis

WOUND EVALUATION AND DOCUMANTATION:

A. Wound History
Mechanism of injury—what happened, possible foreign body
Age of wound—when it happened
Associated symptoms—systemic, numbness, loss of function
B. Past/Social History
Underlying disorders—diabetes, seizures
Allergies—drugs, anesthetics
Date of last tetanus
Medications—anticoagulants, corticosteroids
Vocation/avocation
Handedness
C. Physical Examination
Vital signs
General/system findings as appropriate
D. Wound description
Location
Length/extent
Depth
Condition—clean, contaminated, sharp, irregular
Functional examination—as appropriate

WOUND MANAGEMENT:

Wound excision:
Carefully planned operation to remove all devitalized and
contaminated tissues which might predispose to infection.
Wound debridement:
Removal of any devitelised skin tags and necrotic tissue along with
foreign body and debreis

Wound healing
Definition:
Wound healing is a cellular response (/mechanism) to injury in an
attempt to restore normal structure and function of the body.
2 distinct processes
Regeneration – Restoration, no scar formation.
Process: Proliferation and maturation
Repair – Healing by fibrous tissue, scar formation
Process: Granulation tissue formation and wound
contraction
At a time both the processes take place simulatinaously
Regeneration depends on
PMN – Survive <24 hrs
Cell cycle – the period between two successive cell division↑ Contamination (+) PMN
Cells are 3 type depending on their capacity to divideIf controlled PMN migration stopped
1. Labile Not essential for wound healing
2. Stable
Macrophage
3. Permanent Survive 24-48
Mechanism/ Phase/ sequence of wound healing
Most commonly agreed being: Activity Mediator
Phagocytosis Reactive O2 specis
1. The inflammatory phase
Nitric oxide
a. begins immediately after wounding Debridement Colagenase, Elastase
and lasts Cellrecruitme GF- PDGF, EGF, IGF
2–3 days nt and Cytokines – TNF, IL 1,
b. 1st vasoconstriction activation IL 6
nd Fibronectin
c. 2 blood clot formation
Matrix GF – TGF, PDGF, EGF
d. 3rd platelet aggregation synthesis Cytokines TNF IL1
e. 4th platelet degranulation Enzyme - collagenase
f. 5th vesodilation Prostaglandin
g. 6th Chemotaxis Nitric oxide
Angiogenesis GF – VEGF, FGF
i. PMN Leucocyte Cytokines – TNF
ii. Neutrophil Nitric oxide
iii. Macrophage
2. The proliferative phase Lymphocytes peak at 7th day
a. from the third day to the third week Affects fibroblast
st
b. 1 – angiogenesis
c. 2nd fibroblast migration ECM – scaffold for cellular migration
d. 3rd formation of granulation tissue Composed of – fibrin, fibrinogen,
e. 4th reepithelialization fibronectin
f. Fibronectin & Type 3 collagen =
early matrix
3. the remodelling phase (maturing Type 1 Collagen – wound strength
phase) later
a. from Weeks to years Collagen synthesis ↓ at 4 weeks after
b. Fibroblast starts to disappear injury
Collagen 25 % of total protein
c. Collagen type III is gradually
Type 1 = skin and bone
replaced by stronger type I collagen Adults – 80% type 1, 20% type 3
d. Tensile strength of the scar tissue Neonates – type 3 predominates
gradually increases Vitamin C – (+) collagen synthesis
Occasionally, a haemostatic phase is referred to as occurring Interferon
beforegamma,
the steroid - ↓
synthesis
inflammatory phase, or a destructive phase following inflammation consisting
**Excessive deposition – Keloid ,
of the cellular cleansing of the wound by macrophages

A. The inflammatory phase

Begins immediately after wounding and lasts 2–3 days.
Bleeding is followed by
 vasoconstriction and
thrombus formation to limit blood loss.

 Platelets stick to the damaged endothelial lining of vessels, releasing

adenosine diphosphate (ADP), which causes thrombocytic aggregates
to fill the wound.
 When bleeding stops, the platelets then release several cytokines from
their alpha granules.
 These are platelet derived growth factor (PDGF), platelet factor IV and
transforming growth factor beta (TGF_).
 These attract inflammatory cells such as polymorphonuclear
lymphocytes (PMN) and macrophages.
 Platelets and the local injured tissue release vasoactive amines, such
as histamine, serotonin and prostaglandins, which increase vascular
permeability, thereby aiding infiltration of these inflammatory cells.
 Macrophages remove devitalised tissue and microorganisms while
regulating fibroblast activity in the proliferative phase of healing.
 The initial framework for structural support of cells is provided by fibrin
produced by fibrinogen.

B. The proliferative phase

Lasts from the third day to the third week,
Consisting mainly of fibroblast activity with the production of collagen
and ground substance (glycosaminoglycans and proteoglycans),
 The growth of new blood vessels as capillary loops (angioneogenesis)
and the re-epithelialisation of the wound surface.
 Fibroblasts require vitamin C to produce collagen.
 The wound tissue formed in the early part of this phase is called
granulation tissue.
 In the latter part of this phase, there is an increase in the tensile
strength of the wound due to increased collagen, which is at first
deposited in a random fashion and consists of type III collagen.

C. The remodelling phase is characterised by

Maturation of collagen (type I replacing type III until a ratio of
4:1 is achieved).
 There is a realignment of collagen fibres along the lines of tension,
 decreased wound vascularity and
 Wound contraction due to fibroblast and myofibroblast activity.

Surgical wound are controlled form of trauma creating in the operative room
environment
According to degree of bacterial load/ contamination
 Clean
 Clean contaminated
 Contaminated
 Dirty
DIDN’T HEAL
D - DM
I - Infection
D - Drugs
N – Nutrional problem
T – Tissue necrosis
H - Hypoxia
E – Excessive tension on
wound edge
A – Another wound
L – Low temparature