WOUNDS

DR AKMED
MARU
WOUND- IS A DISCONTUNITY OR BREAK IN THE SURFACE

07/12/2024
EPITHELIUM.
• represents a disruption of the normal structure and function

Abdominal trauma
of the skin and soft tissue structure and may be due to a
variety of mechanisms and etiologies
• Simple wound when only skin is involved.
• Complex wound when it involves underlying nerve ,vessels
and tendon

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Classification

 TIDY / UNTIDY

07/12/2024
 ACUTE/CHRONIC

Abdominal trauma
 CLOSED/OPEN

 Based on clinical healing pattern

 Based on risk for tetanus

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Tidy wound
By sharp instrument E.g: surgical incisions, cut from
glass or knives
Skin would be sharp and clean
Tendons,arteries and nerves can be involved but repair is
usually possible.
Fragments are not common
Contain no devitalized tissue
Can be closed immediately with expectation of primary
healing(Well vascularized edges)

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 Untidy wound
 Result from crushing, tearing, avulsion or
burn
 Skin wounds would be multiple and
irregular
 Fractures are common
 Contain devitalized tissue
 Healing is unlikely to occur and if it does
there will be wound complications

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 Acute and chronic wound
• Acute wounds
Heal in a predictable manner and time frame – E.g stab injuries
• Chronic-wounds
That have failed to proceed through the orderly process that produces
satisfactory anatomic and functional integrity
or
That have proceeded through the repair process without producing
an adequate anatomic and functional result.
The majority of wounds that have not healed in 3 months are
considered chronic.

Skin ulcers, which usually occur in traumatized or vascularly

compromised soft tissue, are also considered chronic in nature 6

E.g, Pressure ulcer, leg ulcer

CLOSED/ OPEN
CLOSED
 Contusion
 Hematoma
 Abrasion
OPEN
 Incised
 Lacerated
 Penetrated
 Crushed etc...

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 Contusion and hematoma
Contusion is caused by internal
bleeding into the interstitial
tissues at different levels, usually
initiated by blunt trauma which causes
damage through physical
compression
When the amount of blood is sufficient to
create a localized collection Hematoma

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9
ABRASION
They are made by a scraping
injury to the skin surface,
typically in an irregular fashion

Usually the epidermis is

scrapped away exposing the
dermis

Most are superficial and will

heal by epithelialisation
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 Incised wound
• An incision is defined as a very
regular cut made by a sharp
object such as a knife, glass or
blade.
• Has sharp edge and is less
contaminated.
• Primary suturing is ideal for
these wounds as it gives a neat
and clean scar.

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 Laceration
 Lacerations are made when a
surface is cut in an
irregular fashion down to
the underlying tissue.

 Lacerations are deeper than

abrasions and more
irregular than incised
wounds.

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• They are caused by blunt injuries like fall on a stone and
RTA.
• It may involeve only the skin and subcutaneous tissue
• It is important to ascertain from the history the amount
of force involved.
• The clinical examination must assess the integrity of all
structures in the area: arteries, nerves, muscles, tendons
and ligaments.

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 Penetrating wound
- A wound in w/c the skin is
broken and the agent
causing the wound
entering subcutaneous
tissue or deeply lying
structure or cavity. Eg. Stab
injuries, bullet injuries
- Internal organs like liver,
mesenteries, spleen and
intestine may be involvoved.
So all patients should be
admitted. 14
Crushing wound
• Caused by a blunt injury due to vehicle, earthquake, wall
collapse and indurstrial accidents.
• Dangerous as they may cause severe hemorrhage, death
of tissue and crushing of bloodvessels.
• They are associated with degloving and compartment
Syndrome.

• Compartment syndrome can occur in an open injury if

the wound does not extend into the affected
compartment.
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 Some specific wound
Puncture wounds
A puncture wound - is an open injury in
which foreign material and organisms
are likely to be carried deeply into the
underlying tissues.
Standing on a nail
Needle stick injury

Needs radiography to rule out

retained foreign bodies

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 Bite

Most bites involve usually either

puncture wounds or avulsions.
There is high incidence of
infection.

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Degloving
Degloving occurs when the skin and subcutaneous fat are
stripped by avulsion from its underlying fascia, leaving
neurovascular structures, tendon or bone exposed.
 A degloving injury may be open or closed.
 An obvious example of an open degloving is a ring avulsion
injury with loss of finger skin.
 A closed degloving may be a rollover injury, typically caused by
a motor vehicle over a limb.
 Tissue that is determined to be devascularized, on the basis of
either physical examination or fluorescein testing, should be
debrided
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19
ACS-BASED ON INFECTION RATE

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Based on clinical healing pattern

1.Healing by primary intention

wound is closed by direct approximation of the wound
margins or by placement of a graft or flap
Leaves minimal scar
Occurs in clean wound primarily closed
Assisted by suturing, clips , stapels and adhesive materials
Takes place epithelialization
Epithelialization of surgical incisions occurs within 24 hrs of
closure
Cont’d
2. Healing by secondary intention
Occurs in wide contaminated wounds which are left
open
beyond the initial 6-hour “golden period”
bacterial count of greater than 105 per/gram of tissue.
Healing takes place by granulation tissue formation,
contraction and epithelialization
An ulcer heals by this way
 Differs from 10 by
Large tissue defects

07/12/2024
New “filler” tissue needed (skin graft)
Intense inflammation

Abdominal trauma
Abundant granulation tissue
Longer course
Wound contraction by ‘myofibroblasts’
Substantial scar & thinning of the epidermis

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Cont’d

3 .Healing by tertiary intention

 delayed primary healing
Occurs in wounds which are left open initially and
closed later
 too heavily contaminated for primary closure but
appear clean and well vascularized after 4 to 5 days of
open observation
more rapid closure could be achieved rather than
waiting healing by secondary intention.
Based on risk for tetanus
Wound Healing
Phases of wound healing
1 Hemostasis and inflammation

Hemostasis precedes and initiate inflammation.

 this phase represents an attempt to limit damage by stopping
bleeding; sealing the wound surface; and removing necrotic tissue,
foreign debris, and bacteria.
 is characterized byincreased vascular permeability, migration of cells
into the wound by chemotaxis, secretion of cytokines and growth
factors into the wound, and activation of the migrating cells
 Hemostasis includes vasoconstriction by the smooth muscle of the
blood vessels, platelets adhesion and aggregation and activation of
coagulation cascade.
CONT…
The component of injured tissue , fibrillar collagen and tissue
factor , act to activate the extrinsic clotting cascade and prevent
ongoing hemorrhage.
The end result of coagulation cascade is fibrin matrix ,which
provides scaffold for cell migration required during a later phase
of wound healing.
Cellular infiltration after injury follows a characteristic
predetermined sequence.
 CONT…
• For the first two days PMNs infiltrate into the fibrin matrix ,whose
primary role is to remove dead tissue by phagocytosis and prevent
infection by oxygen dependent and independent killing mechanism. N
• By the third day monocytes & macrophages are
predominant ,involved in phagocytosis of debris,& bacteria. Also
produce growth factor important for production of extracellular
matrix by fibroblast and new blood vessels. M
• The lymphocyte , the last cell to enter wound L between 5 to 7 days,
although its function is not clear , declares the start of the
proliferative phase.
ROLE OF MACROPHAGES
2.PROLIFERATIVE PHASE
The second phase of wound healing , occurring day 4 to 12
In this phase a balance between scar formation and tissue
regeneration occurs.
In this phase angiogenesis , granulation tissue formation ,
epithelialization and contraction occurs. AGEC
Fibroblasts and endothelial cells are important cell population
CONT…
In this phase the fibrin matrix is replaced by granulation tissue ,
which is composed of fibroblasts, macrophages and
endothelial cells which form extracellular matrix and new
blood vessels. During this phase tissue continuity
reestablished.
Fibroblasts from the wound syth. more collagen , proliferate
less and carry out matrix contraction
• Endothelial cells also proliferate and participate in
angiogenesis.
3.Maturation and remodeling of scar

• This began during the fibroblastic phase , chac. by reorganization of

previously synthesized collagen.
• This phase begins with programmed regression of blood vessels and
granulation tissue described above.
• In human remodeling is characterized by the process of wound
contraction by myofibroblasts and collagen remodeling i.e type ІІІ
collagen initially laid down by fibroblast will be changed to type І
collagen in few months.
• This is the longest and list understood phase of wound healing,which
aim to maximize the strength and structural integrity of wound.
• Strength and integrity of new wound is determined by both quality
and quantity of collagen.
• By several weeks posti njury the amount of collagen in the wound
reaches its plateau , but tensile strength continue increase for several
month.
 Chronic Wound Healing
• Fails to heal in a reasonable amount of time (> 4-6wks)

• Slowed or arrested in the inflammatory or proliferative

phases

• have marked increased levels of matrix metalloproteinases,

which bind up or degrade the various cytokines and growth
factors at the wound surface

• Most often, there are definable causes of the failure of these

wounds to heal
Factors affecting wound
healing
Solomon bekele

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Normal healing is affected by systemic and local
factors

Systemic Local
Age Mechanical injury
Nutrition Infection
Trauma Edema
Metabolic diseases Ischemia/necrotic tissue
Immunosuppression Topical agents
Connective tissue disorders Ionizing radiation
Smoking Low oxygen tension
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Foreign bodies
• Site of the wound
• Structures involved
• Mechanisms of wounding
• Incision
• Crush
• Contamination (bacteria/foreign bodies)
• Loss of tissue

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Advanced age
• Intrinsic physiologic changes that result in delayed or
impaired wound healing
• Decreased supply of cutaneous nerves and blood vessel
• Loss of collagen and ability to produce more collagen
• Significant delay of 1.9 days in epithelialization of
superficial skin

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 Hypoxia, anemia and
hypoperfusion
• Low oxygen tension has significant effect on all aspects of
wound healing
• Optimal collagen synthesis requires oxygen
• Hypoperfusion due to systemic or local causes result in
decreased oxygen delivery
• Rate of wound infection increases

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 Steroids and
Chemotherapeutic Drugs
• Large doses or chronic usage reduce collagen synthesis and
wound strength
• Chemotherapeutic anti metabolite drugs inhibit inflammatory
phases of wound healing

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Metabolic disorders
• Diabetes is associated with vasculopathy, neuropathy and
immunopathy
• Severe peripheral artery disease with diabetic neuropathy
contributes to higher rates of non-healing ulcer
• Higher rates of wound infection

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Nutrition
• Poor nutritional intake or lack of individual nutrients
significantly alters many aspects of wound healing
• Deficiency of vitamin C and Vitamin A also impairs wound
healing
• Zinc is known element in wound healing
• Screen for malnourishment with prealbumin and albumin

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Infections
• Impair and delay the process of wound healing
• Wound dehiscence
• Source of pathogens is usually the endogenous flora
• Staphylococcus aureus, CoNS, enterococci, and E.coli
• Bacteria produce inflammatory mediators that inhibit the
inflammatory phase of wound healing and prevent
epithelialization

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Management of wounds
Approach to acute wound Mx
Assessment of wounds
 Determination of the mechanism of injury.
 Age of injury.
 Identification of possible contamination & foreign bodies.
 Extent of wound & configuration of the wound.
 Ass. neurovascular or tendon injury.
 need of tetanus px.
identification of risk factors that might affect healing.
Wound preparation

1. Anesthesia
• Lidocaine (0.5 to 1%) or bupivacaine (0.25 to 0.5%) combined
with a 1:100,000 to 1:200,000 dilution of epinephrine provides
anesthesia and hemostasis
• Epinephrine should not be used in wounds of the fingers, toes,
ears, nose, or penis due to the risk of tissue necrosis (end
arterioles)
2. Irrigation
• to visualize all areas of the wound and remove foreign material
• best accomplished with normal saline (without additives).
• Iodine, povidone-iodine, hydrogen peroxide, and organically
based antibacterial preparations should not be used (Injury to
Ns & Ms).
•
3. hemostasis
A bleeding wound should be elevated and a pressure pad
applied.
Do not put Clamps blindly
All hematomas within wounds carefully evacuated and any
remaining bleeding sources controlled with ligature or cautery.
4. debridement
Removal of nonviable tissues and any remaining foreign bodies
Irregular, macerated, or beveled wound edges should be
débrided in order to provide a fresh edge for re-approximation.
Wound closure

Timing - The choices are:

1. Close at the time of initial presentation

2. Delay closure until after a period of healing or wound care,
3. Allow the wound to heal on its own.

 Methods - The closure methods available include:

1. Primary closure by direct approximation
2. Delayed primary closure, in which the wound is closed
after a healing period;
3. secondary closure - left to heal on its own.
4. skin grafting
5. the use of local or distant flaps.
Wound dressing
- maintaining a moist clean environment.
- prevent pressure and mechanical trauma.
- hemostasis and reduce edema
- stimulates repair.
- comfort and aesthetic apperance.
Absorbent Dressings
- Dressing
that absorb without getting soaked through, as this
would permit bacteria from the outside to enter the wound.
Non-adherent Dressings
- Impregnated with paraffin, petroleum jelly, or water-soluble
jelly for use
as non-adherent coverage.
- A secondary dressing must be placed on top to seal the
edges and prevent
desiccation and infection.
Occlusive and Semi occlusive Dressings
-provide a good environment for clean, minimally exudative
wounds.
- These film dressings are waterproof and impervious to microbes,
but permeable to water vapor and oxygen.
Hydrophilic and Hydrophobic Dressings
- Hydrophilic dressing aids in absorption, whereas a hydrophobic
dressing is waterproof and prevents absorption
Alginates
- derived from brown algae and contain long chains of
polysaccharides.
- Processed as the calcium form & turn into soluble sodium
alginate through ion exchange in the presence of wound
exudates.
- The polymers gel, swell, and absorb a great deal of fluid.
- used when there is skin loss, in open surgical wounds with
Adjunctive Wound Treatment

Antibiotics

Must be based on - organisms suspected

- patients immune status.
- location of the wound.
- quality of tissue perfusion.

 Antibiotics should be used only when there is an obvious

wound infection - erythema, cellulitis, swelling, and purulent
discharge.

 Indiscriminate use of antibiotics should be avoided to prevent

emergence of multidrug-resistant bacteria
Tetanus Prophylaxis
• Tetanus is a nervous system disorder that is caused by Clostridium tetani and
is chacracterized by muscle spasm.
• Accordingly, all wounds, regardless of cause or severity, must be considered
tetanus prone, and the patient's tetanus immunization status must always
be considered.
Wounds > 6hrs
Puncture wounds with devitalized tissue
Wounds contaminated with soil,manure or other FBs
Extensive burns
Rabies Prophylaxis
• Rabies is an acute progressive encephalitis that is caused by viruses from the
family Rhabdoviridae
• Bite wounds in which the animal's saliva (carnivores and bats) penetrates
the dermis are the most common cause of exposure.
• Postexposure treatment consists of wound care, infiltration of rabies
immune globulin into the wound, and administration of vaccine.
Recommendations for Tetanus
Immunization
 Recommandations for Postexposure Rabies
Prophylaxis

If the isolated animal shows symptoms of rabies, postexposure prophylaxis is started

immediately, and the animal is euthanized for laboratory testing. Vaccination
prophylaxis is stopped if laboratory tests are negative for rabies
 SPECIFIC WOUND MANAGEMENT

• Abrasion
• An abrasion is rubbing or scraping of skin or mucous
membrane.
• Mx - Cleanse using scrubbing brushes
- Analgesic
• Punctures
• These may be compound wounds which involve deeper
structures.
• Mx - Evaluate the depth of damage
- Remove foreign bodies
- Excise damaged tissue
- Tetanus prophylaxis & PEP accordingly
• Lacerations
• These are open wounds caused by sharp objects which slice
with minimal energy, like a knife, or glass, but can also be due
to high-energy impact.
• Mx - Adequate cleansing & debridement
- Closure, if feasible,
- Tetanus Prophylaxis
- Analgesics as needed
• Crush and avulsion wounds
• These are compound complicated wounds.
• Degloving may occur. (open or closed)
• Mx - Correct associated life threatening conditions
- Assess nerovascular damages & fracturs
- Proper wound debridement
- Appropriate antibiotics
- Tetanus Prophylaxsis.
A patient with a complex wound must be treated in the OR
under general anesthesia because the injury is extensive or
because there is a need for exploration of tissues, removal of
foreign bodies, and debridement of nonviable tissue

Large open wounds resulting from avulsion can be either left to

heal by secondary intention or treated with delayed skin
grafting.

Degloved tissue that is determined to be devascularized, on the

basis of either physical examination or fluorescein testing,
should be debrided. If the viability of a tissue segment is in
doubt, the segment may be sewn back into its anatomic
location and allowed to define itself as viable or nonviable over
time.
 Abnormal Wound Healing
• Abnormal Wound Healing may result in loss of function or poor cosmetic
outcome.
• Delayed healing is characterized by
- decreased wound-breaking strength in comparison to wounds that
heal at a normal rate
- eventually achieve the same integrity and strength as wounds that
heal normally with correction of the underlying pathophysiology.
- caused by conditions such as nutritional deficiencies, infections, or
severe trauma
• Impaired healing is characterized by
- failure to achieve mechanical strength equivalent to normally
healed wounds
- Patients with compromised immune systems (diabetes), chronic
steroid usage, or tissues damaged by radiotherapy
Factors affecting wound healing
 Abnormal “over-healing” wounds important to note include

Keloid formation
 A keloid scar is defined as excessive scar tissue
that rise above the skin level & extends beyond
the boundaries of the original incision or wound.
 Its etiology is unknown, but it is ass. with
- elevated levels of growth factor
- darker-pigmented ethnicities (15x )
- inherited tendency (autosomal dominant)
 Tend to occur 3 months to years after traumaor
may arise spontaneously
 Involves certain areas of the body the earlobe
the deltoid, presternal, and upper back regions. (a
triangle whose points are the xiphisternum and
each shoulder tip).
 High recurrence rate after excision 45-100%
Hypertrophic Scars
 A hypertrophic scar is defined as excessive
scar tissue that does not extend beyond the
boundary of the original incision or wound.
 It results from a prolonged inflammatory
phase of wound healing and from
unfavourable scar siting (i.e. across the lines
of skin tension).
 HTSs usually develop within 4 weeks after
trauma.
 Usually occur across areas of tension and
flexor surfaces, which tend to be at right
angles to joints or skin creases. They also
commonly occur in sternum & neck.
 Hypertrophic scars improve spontaneously
with time, whereas keloids do not.
• Treatment is directed toward inhibiting
collagen overproduction which includes:
• Intralesional steroid injection
(Serial injections every 2 to 3 weeks)
• Surgical correction
(Often combined with othe Rx -
reccurence)
• Topical application of silicone sheets
(for 24 hours a day for about 3 months )
• Cryotherapy
• Compression therapy
• Irradiation
• Surgical Techniques
Excision
Z-plasty
W-plasty
Geometric broken line closure
Excision
• Lesions of the skin can be excised with
elliptical,
wedge,
circular, or
serial excision.
• Simple elliptical excision is the most
commonly used technique
- short ellipse may yield “dog-ears,” which
consist of excess skin and subcutaneous
fat at the end of a closure.
- length of ellipse should be at least three
times the width.
- excision of lesions are planned to make
the final scars will be parallel to the
relaxed skin tension lines / Langer lines.
Z-plasty
• Can be used for:
• Scar elongation
• Release of scar contractures
• To change direction of the scar
(from perpendicular to parallel
to the relaxed skin tension
lines )
• To change a displaced anatomic
point, raising or lowering it.
• Long scars can be broken up with
a series Z-plasties
Avoiding scars
• A dirt in grained (tattooed) scar prevented by
- proper initial scrubbing and cleansing of the wound
• Poorly contoured scars are caused by
- poor alignment of deep structures such as muscle or fat
- failure to recognize normal landmarks such as the lip
vermilion /white roll interface, eyelid and nostril free
margins and hair lines such as those relating to eyebrows
and moustache.
• Suture marks may be minimized by using
- monofilament sutures that are removed early (3–5 days).
- Fine sutures (6/0 or smaller) placed close to the wound
margins
- Subcuticular suturing avoids suture marks
CONTRACTURES

• Where scars cross joints or flexion creases, a

tight web may form restricting the range of
movement at the joint.

• can cause hyperextension or hyperflexion

deformity.

• In the neck, it may interfere with head

extension.

• Treatment may be simple involving multiple Z-

plasties or more complex requiring the inset of
grafts or flaps.

• Post op Splintage and intensive physiotherapy

References
• Bailey & love’s short practice of surgery 25th Ed.
• Schwartz's Principles of Surgery, 9th Edition.
• sabiston_textbook_of_surgery_18th_edition
• ACS surgery principles & practice
• Grab & Smith’s,Plastic surgery,6th Ed.
• Uptodate 19.1

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