2. Definition of a wound :
ANY break in the integrity of the skin or
tissues which may be associated with
disruption of structure or function
Etiology: - Trauma
- Radiation
- Infection
- Iatrogenic Etc
7. CLEAN WOUND
Clean wound is a nontraumatic, uninfected
operative wound in which neither the
respiratory, alimentary or genitourinary tracts
nor the oropharyngeal cavities are entered.
Clean wounds are elective, primarily closed,
and undrained wounds.
Infection rate is <2%
8. CLEAN CONTAMINATED WOUND
Gastrointestinal, respiratory or genitor-
urinary tracts entered without significant
spillage or wounds which are mechanically
drained.
Eg: appendicectomy, gallbladder, biliary,
pancreatic surgeries
Infection rate <10%
9. CONTAMINATED WOUND
Operative wound contaminated
Fresh traumatic wound from clean source
Gross spillage from the gastrointestinal tract
When infected urine or bile is present
Incision encountering acute non-purulent
inflammation.
Eg: penetrating abdominal injury, enterotomy
INFECTION RATE – 15 – 30%
12. WHAT IS WOUND HEALING???
Wound Healing Is the Physiologic
Response to Tissue Trauma
It is related to tissue reconstitution which is
the process by which the body replenishes
cells that are being lost
13. TYPES OF WOUND HEALING
WOUNDHEALING
PRIMARY
SECONDARY
TERTIARY
14. PRIMARY HEALING
Occurs in clean incised
wound
More epithelial
regeneration than
fibrosis.
Wound heals rapidly
Scar will be linear,
smooth & supple.
15. SECONDARY HEALING
Occurs in wounds
with extensive soft
tissue loss
Heals slowly with
fibrosis
Wide
hypertrophied and
contracted scar
16. TERTIARY / DELAYED PRIMARY
Intial wound
debridement and
control of local
infection
Wound closed with
sutures or covered
with skin graft
17. PHASES OF WOUND HEALING
Wound Heals In 3 Phases That Partially
Overlap:
Inflammatory Phase
Fibroplasia Phase
Remodelling Phase
21. VASCULAR RESPONSE
SECONDARY PHASE
Venular Vasodilatation - 10 X Increase In
Blood Flow
Increased Vascular Permeability - Aids In
Flow Of Chemical And Cellular Mediators
(PDGF) In Inflammation To Site Of Injury
Lymphatic Obstruction Leads To Tissue
Edema
22. CELLULAR RESPONSE
Increased Vascular Permeability During
Inflammatory Phase Facilitates Margination,
Extravasation And Migration Of Cellular Mediators
(Pmn’s And Macrophages)
PMN’S
Function Short Lived (0-48 Hours)
Attacks Bacteria, Then Leaves
Not Essential For Wound Healing Process
23. Macrophages
Monocyte–derived
Central Cell During Inflammatory Phase Of
Wound Repair
Activated By Lymphokines, Immune Complexes
Release Angiogenesis Factor
Phagocytosis Of Wound Debris
Essential For Wound Healing
CELLULAR RESPONSE
24. Factors Affecting Inflammatory Phase:
Pus
Contains Both Proteolytic And Collagenolytic
Enzymes; Prolongs Inflammatory Phase And
Retards Epithelialization
Necrotic Tissue, Foreign Body, Haematoma -
Prolongation Of Inflammatory Phase
Steroids - Inhibit Macrophage Function
29. EPITHELIALIZATION
Is A Requirement For Orderly Progression
Into The Proliferative Phase. It Starts In The
Inflammatory Phase.
It Requires De-differentiation, Mitosis,
Migration And Then Re-differentiation By
Basal Cells Of Epidermis
PROLIFERATIVE PHASE
30. WOUND CONTRACTION
“wounds heal from side to side but contract
from end to end”
Thought to be mediated by myofibroblast -
can produce collagen but also contains
smooth muscle filaments.
Highest rate of contraction from days 10-21
PROLIFERATIVE PHASE
31. Wound Contraction
Begins approximately 4-5 days after
wounding.
Represents centripetal movement of the
wound edge towards the center of the
wound.
Maximal contraction occurs for 12-15
days, although it will continue longer if
wound remains open.
32. Wound Contraction
The wound edges move toward each other at an
average rate of 0.6 to .75 mm/day
Wound contraction depends on laxity of tissues,
so a buttocks wound will contract faster than a
wound on the scalp or pretibial area.
Wound shape also a factor, square is faster than
circular.
33. Wound Contraction
Contraction of a wound across a joint can cause
contracture.
Can be limited by skin grafts, full better than split
thickness.
The earlier the graft the less contraction.
Splints temporarily slow contraction.
34. COLLAGEN DEPOSITION
Prior to collagen deposition fibroblasts deposit
“ground substance” composed mainly of
glycosaminoglycans.
Function of ground substance is to create
scaffold onto which collagen can be deposited,
aggregated, and oriented in appropriate fashion
PROLIFERATIVE PHASE
35. Starting at day 3 or 4 collagen is deposited,
net collagen deposition is positive until day
21.
It reaches a maximum at 60 days post-
injury (80% of tensile strength of normal
skin)
PROLIFERATIVE PHASE
37. MATURATION AND RE-
MODELLING PHASE
3 Weeks To 1-2 Years
Type III Collagen Is Replaced By Type I Collagen,
Creation Of More Stable Bonds Between Fibers -
Decreases The Amount Of Collagen Required To
Maintain Wound Integrity
Duration Of Phase Dependent Upon Patient Age
(Decreased Age - Increased Duration), Racial
Differences, Type Of Wound, Body Location And
Duration Of Inflammatory Phase
38.
39.
40.
41.
42. Incised wound
Caused by sharp cutting instruments.
Minimum loss to tissue tends to gap (the
extent of gaping depends upon elasticity
and tension).
Edges are regular.
Bleeds freely and painful.
Heals by primary intension healing.
43.
44. Lacerated wound
Caused by tearing of
tissues,
Wounds have irregular
jagged borders
Loss of tissue is limited
to skin and s/c tissue.
45.
46. DEGLOVING/AVULSION
INJURY
Occurs when skin &
subcutaneous tissue
are stripped from
underlying fascia
leaving
neurovascular
structures, tendons,
bone exposed.
47. What is the type of wound according to Rank & Wakefield classification?
50. LOCAL FACTORS
Infection & haematoma
Presence of necrotic tissues and foreign
body
Poor blood supply
Venous or lymph stasis
Tissue tension
Large defect or poor apposition
53. MANAGING ACUTE WOUND
HAEMOSTASIS
CLEANSING
EXPLORATION AND DIAGNOSIS
DEBRIDEMENT
REPAIR OF STRUCTURES
REPLACEMENT OF LOST TISSUES
54. SKIN COVER IF REQUIRED
SKIN CLOSURE WITHOUT TENSION
ALL THE ABOVE WITH CAREFUL
TISSUE HANDLING
55. WHEN DOES A WOUND BECOME
CHRONIC?
In healthy individuals with no underlying factors
an acute wound should heal within three weeks
with remodeling occurring over the next year or
so.
If a wound does not follow the normal trajectory
it may become stuck in one of the stages and the
wound becomes chronic.
56. Chronic wounds are thus defined as wounds,
which have “failed to proceed through an
orderly and timely process to produce anatomic
and functional integrity, without establishing a
sustained anatomic and functional result.