WOUND CARE IN

ORTHOPAEDIC TRAUMA

BIMO SASONO, Dr. Sp.OT, FICS

BATU, 6 FEBRUARI 2005

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 PENDAHULUAN
1. A wide range of material is now available for
cleansing closing and covering wounds, allowing
ideal conditions to be created for undisturbed
healing

2. Wounds and injuries heal according to certain

laws nature does not follow you, you must follow
nature
Paracelsus (1493-1541)

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 STAGE OF WOUNDS
HEALING

 BIOCHEMICAL AND PHYSIOLOGICAL

 PROCESS

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 STAGE OF WOUNDS HEALING

1. BIOCHEMICAL AND PHYSIOLOGICAL

 VASCULAR RESPONSE
 COAGULATION
 INFLAMATION
 FORMATION OF NEW TISSUE

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Stage Of Wounds Healing…
2. PROCESS

a. INFLAMATORY PHASE
 Immediate to 2-5 days
 Hemostasi
 Vasoconstriction
 Platelet aggregation
 Thromboplastin make clot
 Inflation
 Vasodilatasi
 Phagocytosis
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 Stage Of Wounds Healing
2. PROCESS
b. PROLIFERATIVE PHASE
 2 days to 3 weeks
 Granulation
 Fibroblast lay bed of collagen
 Ful defect and produces new capillaries
 Contraction
 Wound edges pull together to reduce defect
 Epithelization
 Crosses moist surface
 Cell travel about 3 cm from point of origin in
all directions
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Stage Of Wounds Healing
2. PROCESS

c. REMODELING PHASE
 3 weeks to 2 years
 New collagen forms which increases
tensile stength to wounds
 Scar tissue is only 80 percent as
strong as original tissue

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 PRIMARY OR SCONDARY HEALING
PREFERABLE?

PRIMARY HEALING
 More rapid healing
 Better cosmetic result

SCONDARY HEALING
 Contaminated, infected wound
 Highly lacerated wound margin
 Large tissue defect
 Extensive necrosis and ulcerations
 Injuries >6 hours old

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 AIM OF WOUND CARE

 To eliminate interfering factors

 To created the environtment necessary
for the various biochemical reactions
allowing the bodys self healing powers to
come fully into effect

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 THE FOUR SEGMENTS OF
WOUND CARE

 WOUND CLEANSING
 WOUND CLOSURE

 STIMULATION

 COVERAGE

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 AIM OF WOUND CLEANSING:

 Removal of factors that interfere with

healing:
 Foreign bodies
 Germs

 Tissue debris

 Necrotic materials

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 METHODS:

 MECHANICAL CLEANSING
 DESINFECTION WITH ANTISEPTIC
 SURGICAL WOUND REVISION
 ENZYMATIC WOUND DEBRIDEMENT
 WOUND CONDITIONING WITH SPECIAL
DRESSING MATERIAL

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 Mechanical cleansing
 Preparation of area
surrounding the wound
 Cleansing the skin
 Removal of hair
 Desinfection of intact skin

 Swabs/brush
 Irrigation
Fisiological saline

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Ringer solution
 H2O2 ?

 Extraction of foreign
bodys
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 Desinfection with antiseptic
 Requirments for wound desinfectant
 Minimal tissue irritation
 No ipairment of wound healing
 Low systemic absorbtion
 Broad spectrum activity
 Rapid onset of action
 The most widely used antiseptics
 Water and alcohol
 Triphenylmethane dyes gentian violet B or brillant green
 Hydrogen peroxide 1-3 %
 Mercury compounds (Merbromine)
 Iodoform (PVP Iodine)
 Cation compounds (Bensalconiumchloride, Chlorhexidine)

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 Surgical Wound Revision

 To maintain blood flow in the wound area,

all necrotic debris and tissue inadequately
perfused due to contusions should be
excised

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 Enzymatik debridement
Enzymatic debridemant is based on the hydrolitic
cleavage of biological macro molecules resulting
in ul liquefaction of necroses and coagula
Enzyme:
 Proteases (e.q. Trypsin, plasmin, papain)

 Deoxyribo nucleases (e.q. Streptodonase)

 Fibrinolysin

 Streptokinase

 Collagenases

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 Indication:

 Soft tissue lessions not amenable to

immediate surgical management (e.q.
Venous leg ulcers, Burns)
 Poorly healing, inflamed wounds
 Skin graft

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 WOUND CONDITIONING WITH SPECIAL
DRESSING MATERIAL

 In ‘soft debridement’ excess exudate,

contaminants, germs and tissue debris
are absorbed by the dressing pad

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Absorbent gauze (bandages, compresses)

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 POLYURETHANE SOFT COMPRESSES

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Hydroactive wound dressing (e.g. hydrocolloids,
alginates and polyurethane gels) swell inside
the wound and bind tissue debris and
contaminants

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 THE FOUR SEGMENTS OF WOUND
CARE

 WOUND CLEANSING
 WOUND CLOSURE
 Suturing
 Stapling

 Wound closure strips

 Tissue glue

 STIMULATION
 COVERAGE
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 Suturing
Indication Suitable for all wounds, including those
under great tension
Restrictions on use The cosmetic results are often
unsatisfactory
Traumatilization Relatively little tissue injury only if fine
threads and needles are used
Tissue tolerance Suture material can provoke foreign
body reactions in tissues
Behavior in wound Sutures are non-elastic, i.e. do not give
oedema way to swellings and constrict the wound
edges, sutue marks are common
Cosmetic result Satisfactory to good depending on suture
technique and material used
Time requered Very time consuming
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 Stapling
Indication Can be used for almost all wounds if they have
moveable edges and a distance of 2-5 mm can be
maintained in relation to bones, tendons, nerve etc
Restrictions on Cannot be used in all regions of the body, especially not
use on which the patient lies and on bony prominences

Traumatilization More tissue damage with U-staples, less tissue damage

with D- and B-staples

Tissue tolerance The staple material (implant steel) rarely causes

rejection reactions

Behavior in Staples yield flexible to wound oedema, traumatic marks

wound oedema are thereby avoided

Cosmetic result Good when using B-staples

Time requered Time-saving, up to 5 times faster than suturing,

especially on long wounds
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 Wound closure strips
Indication As sutureless wound closure especially suitable for cosmetically critical
sites and in children and sensitive patients. Also after early removal of
stitches/staples and for stepwise closure of wounds healing by
secondary intention
Restrictions on Cannot be used for wounds under great tension or located
use on surfaces subject to friction.
Do not adhere to moist and very hairy surfaces
Traumatilization Absolutely atraumatic and painless application

Tissue Excellent tolerance because non-invasive

tolerance

Behavior in Wound closure strips yield elastically to swellings and

wound oedema contract again after the swelling has subsided, tissue is not
strangulated
Cosmetic result Excellent

TimeBatu,
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6-2-2005 Time-saving, faster
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 Defect coverage
 Skin grafting
 Thiersch
 Split-thickness skin graft
 Full thickness skin graft

 Skin flap
 Local skin displacement by extension
incision
 Rotation flap
 Distant flap
 Free pedicle flap
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THE FOUR SEGMENTS OF WOUND
CARE

 WOUND CLEANSING
 WOUND CLOSURE

 STIMULATION

 COVERAGE

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Stimulation of wound healing
 If wound do not heal despite adequate
therapy curative topical agent are
frequenly used
 A few of them which have an objectively
veryfieble promoting effect on healing and
a mechanism of action that is now largely
explained

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  NUTRIEN SOLUTION
 Electrolytes
 Amino Acids

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  GROWTH FACTORS
 Produced by macrophage platelets
 PDGF (platelet derived growth factor)
 Stimulate proliferation of fibroblast
 TGF (transforming, growth factor )
 Stimulate fibroblast
collagen+fibronectin
 EGF (epidermal growth factor)
 To promotes proliferation of
fibroblast and epithelical cells
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 OINTMENT COMPRESSES
 Panthotenic acid and dexpanthenol
Important for all regeneration and
repair resposes
Promotes epithelialization
 Zinc

Essential for anabolic cell metabolism

Influences the granulation of wound

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 DIRECT CURRENT / ELECTRIC
STIMULANT
 The use of direct current to promote healing is
based on the finding that the anode placed on
the wound attracts the white blood cells and
that the exudation and self-cleansing of
wound improve as a consequence

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Electrical stimulation effect:
1. Inflammation phase
 Initiate the wound repair process by it effect
on the current of injury
 Increase blood flow
 Promots phagocytosis
 Enhances tissue oxygenation
 Reduces edema perhaps from reduced
microvascular leakage
 Attract and stimulates fibroblast and epitelial
cells
 Stimulates DNA syntesis
 Controls infection
 Solubilizes blood products including necrotic
tissue
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Electrical stimulation effect:
2. Proliferation phase
 Stimulates fibroblasts and epithelial
cells
 Stimulates DNA and protein synthesis
 Increases ATP generation
 Improves membrane transport
 Produces better collagen matrix
organization
 Stimulates wound contraction

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Electrical stimulation effect:
3. Epithelialization phase
 Stimulates epidermal cell
reproduction and migration
 Produces a smoother, thinner scar

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 HYPERBARIC OXYGEN THERAPY
 Increase in tissue oxygenation
 It influences the rate of collagen deposition,
angiogenesis, and bacterial clearance in wound
 HBO therapy may be useful:
 Diabetic wound
 Venous statis ulcers
 Pressure ulcers
 Osteomyelitis
 Arterial insufisiensi ulsers

 Treatment:
 performed at 2.0 to 25 ATA for 90 to 120 minutes
 Treated twice daily or once daily

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 ULTRASOUND
 Ultrasound is a mechanical
vibration delivered at a frequency
above the range of human hearing
 Frequencies of 1 and 3 MHz

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 WHIRLPOOL
 Objectives of whirlpool treatment
include:
 Vasodilatation
 Increased blood flow
 Softening and loosening of necrotic tissue
 Mechanical debridement
 Wound cleansing: debris and topical agents
 Exudate removal reduced infection
 Pain management

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THE FOUR SEGMENTS OF WOUND
CARE

 WOUND CLEANSING
 WOUND CLOSURE

 STIMULATION

 COVERAGE

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 The main aim of wound care is to
create optimal conditions for
undisturbed healing.
 This also means that the dressing
assumes the functions of the injured
skin during the healing process.

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 Protecting the wound against
 Invading microorganisms
 Mechanical factors
 External thermal influences and
loss of heat
 Dehydration
 Contamination and chemical factors
 Manipulations

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  DRESSING
 READY TO USE DRESSING
 TUBULAR DRESSING
 FILM DRESSING
 SPECIAL DRESSING

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 Dressing
 The dressing should:
 Absorb exudate
 Allow gas exchange

 Be sterile

 Be stable

 Be chemically inert

 Maintain the undisturbed state of the

wound

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 Prevent
microbial
transmission

Not restrict
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Be safe to use

Be transparent or
semitransparent
if possible
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 Film dressing

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