Types of wounds and the
basic principles of wound
healing
Types of wounds
Wound: loss of continuity of skin or mucous membrane(road traffic accidents, at home or at work)
Surgical wounds
Accidental wounds
Open, Closed
Types of wounds (accidental
wounds)
Incised, slashed wounds (vulnus scissum at caesum)
Puncture wounds (v. punctum)
Contused wounds (v. contusum)
Lacerated wounds (v. lacerum)
Gunshot wounds
Bites (v. morsum)
Incised wounds
Caused by sharp cutting edges
(knife, glass or metal)
Linear in appearance – all surgical wounds
Gap formation
Much bleeding
Less painful
No infection
Underlying structures should be examined
Puncture wounds
Caused by pointed instruments (nails, knives, thorns of plants, flying fragments of explosion)
Damage of deep structures
Severe haemorrhage
No severe tissue damage
Apt for infection
Jeopardy of anaerobic infection
Gunshot wounds
Caused by weapons gunshot splintersPerforating wounds: entry wound, wound
track, exit wound Entry wound is smaller Blind wound: no wound exit bullet or
splinters get stuck Life threatening injuries Major bleeding Apt for infectionLow velocity bullet – less damageSplinter of bomb – more tissue damage
Bites
Caused by animals, humans, insects
Liable to infect
Considerable tissue damage (horses, cows, bears, etc.)
Apt for anaerobic infection
Typical human bite injury teeth cause to metacarpaphalangeal joint suppurative arthritis
Types of wounds
(classification according to cleanless –
bacterial contamination)
Clean wounds (operation or strile conditions, normal skin bacteria are detectable)
Clean-contaminated wounds (the contamination of clean wounds is endogenous or comes from the enverioment)
Contaminated wounds (severe contamination by purulent area or leakage GI tract)
Dirty wound (due to nonviable tissues, crhronic wounds)
Types of wounds (depending on
the time since the trauma)
Acute wounds
- fresh wounds: treatment within 8 h
- old wounds:> 8 h after trauma
Chronic wounds
(they do not heal within 4 weeks after the wound menegament or within 8 weeks)
Wound management
Anamnesis (When did it occur?, Contamination? Tetanus vaccination? Associated diseases?..)
Diagnostic procedure
- accompayning injury
- examination of circulatory, sensitivity and motor functions
- bone fractures?
Treatment of wounds
Anaesthesia: field, regional block
Torniquet: bloodless operation
Pneumatic torniquet
300 mmHg thigh
200 mmHg arm
Not more than 45 minutes
Cleansing: degreasing agent water, detergent, iodine,
Wound: physiologic salt, H2O2
Surgical treatment
Exploration, toilet, repair
Surgical toilet: to remove all foreign material and devitalized tissue
Surgical treatment
Irregular, devitalized skin edges should be removed by knife
Subcutan tissue and muscle removed by scissors
Smaller bone fragment could be removed
Deep tissues should be approximated by absorbable suture material
Do not excise wounds on the face
Surgical treatment
Fascia and subcutaneous layer: interrupted stiteches
Skin: accurate approximation of the skin edges. Tension and ischaemia of the skin edges are to be avoided.- interrupted stitch, Donati vertical mattress suture, Allgöwer, continous intrcutenous, steri-strips,.
Dressing: should be removed on the second postoperative day, regular changing
Sutures are usually removed after 4-6 days (5-14 days)
Surgical treatment
Early complications of wound closure
- haematoma
- seroma
- wound infections
usually Staphylococcus aureus
culture
treatment: removal of sutures, saline or H2O2 bathing, drainage
Surgical treatment
Dressing should be checked regularly
Drains
Timing
Primary closure within 12 hours
Delayed closure within 24 hours (clean)
> 24 hours toilet, exploration (left open)
Surgical treatment
Primary wound management is contraindicated:
- infectious signs
- severe contamination
- an incompletely removed foreign body
- bite, shot or deep incised wounds
Cleansing, covering, primary delayed suturing (3-8 days)
Surgical treatment
Early complications of wound closure
- haematoma
- seroma
- wound infections
usually Staphylococcus aureus
culture
treatment: removal of sutures, saline or H2O2 bathing, drainage
Phases of wound healing
Inflammatory phase
Vascular response
Vasoconstriction response to bleeding
Activation coagulation cascade
Platelet adhesion, aggregation clot formation
Inflammatory phase
Vasodilation, increased permeability
Histamin, serotonin liberation
Kinin – kallikrein activation
Classic sign of inflammation erythemia, warmth vasodilaton oedema increase in cells and plasmapain tension due to oedema
Inflammatory phase
Cellular response
Leukocytes (few hours)
Macrophages (1-2 days)
Proliferative phase (5 days to 3rd
week)
Epithelial repair
Collagen synthesis (fibroblast transformation)
Wound contraction
Maturation or remodelling phase
(within 3 months)
Wound flatter, softer, lighting colour
Collagen thicker, denser
Blood vessels constrict, disappear
Primary healing
Simple surgically closed wound
No soft tissue lost
No infection and contamination
No foreign body
Secondary healing
Not closed surgically
More granulation tissue
Wound contraction
Epithelialization
Scar wider, weaker
Tertiary healing
Combination of the first two
Open wound
Delayed suture (4 to 5 days)
Classic example:„ruptured appendix”
Factors affecting the wound healing
process
Nutrition Vitamin C (cofactor of collagen synthesis) Vitamin A (role in epithelialization) Zink Oxygen – blood supply tissue necrosis
infection Contamination – infection Nature of wound Chronic disease
diabetescancerimmundeficiency
Adrenal corticosteroids
Scars
Factors influencing scar formation • Individual genetic make up • Race • Anatomical site • Wound tension • Age • Placement of incision • Surgical technique
To minimise the degree of postoperative scarring: • Incisions should run along Langer's lines • The finest suture possible should be used • Tension should be avoided • Sutures should be removed as soon as possible • Traumatic wounds should be clean and edges excised • Exposure to sunlight should be avoided in the early postoperative
period
Problematic scars
Contractures Result if scars shorten Particularly seen in badly aligned scars not
corresponding to Langer's lines Can reduce joint mobility May require a z-plasty or skin graft
Depressed scars Result if skin becomes attached to deep tissue Can be treated by release of normal skin from
margins of scar Scar is then de-epithelialised and skin edges
closed over the top
Terminology related to abnormal
wound healing
Hypertrophic scars – wound healing excessive (epithelium raised, wide, radder) All scars become red and thickened during the normal healing process After several months maturation results in flattening of the wound In some scars collagen formation is excessive Results in elevated and red scar If confined to wound = hypertrophic scar
Terminology related to abnormal
wound healing
Keloid (tumor like moliferation of well vascularized connective tissue) If extends beyond wound into normal tissue = keloid scar
Seen particularly in patients of Afro-Caribbean origin Particularly affects scars on the presternal and deltoid areas Treatment is often difficult Treatment options include: Intra-lesional steroid injections (e.g. triamcinolone) Compression dressings with elasticated compression garments Silastic gel therapy Excision and radiotherapy Laser therapy