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ABC of Wound Healing

ABC of Wound Healing

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David J Leaper
Traumatic and surgical wounds
These include: 
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on 9 March 2006bmj.comDownloaded from 
 ABC of wound healin
 Traumatic and surgical wounds
David J Leaper, Keith G Harding 
Management of traumatic and surgical wounds has had achequered history. For example, in 1346 at the Battle of Crécy,France, foot soldiers were issued with cobwebs to staunchhaemorrhage caused by trauma. Two centuries later, theeminent surgeon Ambroise Paré (1510-1590) rejected boiling oil as a primary dressing after amputation, preferring a mixtureof oil of turpentine, rosewater, and egg.
Surgical incisions
Surgical incisions cause minimal tissuedamage. They are made with precision in an environment  where aseptic and antiseptic techniques reduce the risk of infection, with the best of instruments and the facility to controlhaemostasis. Penetrating trauma may involve minimal damageto skin and connective tissue, though deeper damage to vessels,nerves, and internal organs may occur.
Lacerations are caused when trauma exceedsintrinsic tissue strength
for example, skin torn by blunt injuryover a bony prominence such as the scalp. Tissue damage maynot be extensive, and primary suturing (see below) may bepossible. Sterile skin closure strips may be appropriate in somecircumstances
for example, in pretibial laceration, as suturing causes increased tissue tension, with the swelling of earlyhealing and inflammation leading to more tissue loss.
Contusions are caused by more extensive tissuetrauma after severe blunt or blast trauma. The overlying skinmay seem to be intact but later become non-viable. Largehaematomas under skin or in muscle may coexist; if they aresuperficial and fluctuant they can be evacuated with overlying necrosed skin. Ultrasound scanning or magnetic resonanceimaging may help to define a haematoma amenable toevacuation. Extensive contusion may lead to infection (antibioticprophylaxis should be considered in open wounds) andcompartment syndromes (fasciotomy will be needed topreserve a limb).
 Large open wounds
Such wounds may be left to heal “bysecondary intention” (that is, the wound heals from the baseupwards, by laying down new tissue) or with delayed skingrafting, depending on the extent of the residual defect.Exploration of a traumatic wound is needed if there is asuspicion of blood vessel or nerve damage, with attention tofractures and debridement of devascularised tissue and removalof foreign material.
 Abrasions are superficial epithelial woundscaused by frictional scraping forces. When extensive, they may be associated with fluid loss. Such wounds should be cleansed tominimise the risk of infection, and superficial foreign bodiesshould be removed (to avoid unsightly “tattooing”).
Surgical wounds are made in optimum conditions with fullanaesthetic and operating theatre support; traumatic woundsare not, and they may be associated with much more seriousunderlying injury. Triage and resuscitation may be needed before definitive wound management is started.
Although the 16th century Frenchsurgeon Ambroise Paré couldsuccessfully dress a wound, he felt that only God could heal it 
Wounds usually involve some loss or damage to anepithelial surface (usually skin) but may also includedamage to underlying connective tissue,which mayoccur without epithelial loss
Pretibial laceration showing treatment with sterileskin closure strips
Types of traumatic and surgical woundsType of wound Result Cause
Incision Penetrating Surgical (rarely, trauma)Laceration Torn tissue Usually traumaContusion Extensive tissuedamageUsually trauma; skin may beintact  Abrasion Superficial epithelial Usually traumaCombination Usually severe trauma Life threatenin
In England,triage and resuscitation should be donefollowing the Advanced Trauma Life Support guidelines of the Royal College of Surgeons of England(www.rcseng.ac.uk)This is the fifth in a series of 12 articles
VOLUME 332 4 MARCH 2006 bmj.com
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 Arterial bleeding is easy to recognise
pulsatile and bright red
provided it is overt, but if it is hidden from view (for example, the result of a penetrating injury of the aorta) it maylead to profound unexpected haemorrhagic shock. Earlyexploration and repair or ligation of blood vessels may berequired. Venous haemorrhage is flowing and dark red, and can be controlled by adequate direct pressure. Even large veins mayspontaneously stop bleeding after this measure. Capillary bleeding oozes and is bright red; it can lead to shock if injury isextensive and it should not be underestimated. The risk of infection in traumatic wounds is reduced byadequate wound cleansing and debridement with removal of any non-viable tissue and foreign material. If severecontamination is present, broad spectrum antibiotic prophylaxisis indicated and should be extended as specific therapy asrecommended for surgical wounds that are classed as “dirty” or  when there are early signs of infection. Traumatic wounds needtetanus prophylaxis (parenteral benzylpenicillin and tetanustoxoid, depending on immune status). Strong evidence supportsthe use of antibiotic prophylaxis and treatment for surgical wounds that are classed as “clean contaminated” or “contaminated.” The value of antibiotic prophylaxis in “clean” wounds is controversial but is widely accepted in prostheticsurgery (such as hip and knee replacement and synthetic vascular bypass surgery).
Wounds from explosions and gunshot 
 When the source of the wound is high velocity (for example, anexplosion or gunshot), it causes more damage because of thedissipation of kinetic energy (kinetic energy =
, where m isthe mass of the bullet or shrapnel and v its velocity). In additionto gross skeletal injury, soft tissues (such as muscles of the thigh)develop cavitation ahead of the bullet track. These tissues arerendered ischaemic and there may be a large exit wound.Behind the missile there is a sucking action that depositsclothing or dirt in the wound. Together with ischaemia, thiscontamination provides an ideal culture medium for anaerobicorganisms (such as
Clostridium perfringens
, which can lead to gasgangrene). These wounds need extensive debridement down to viabletissue and should be left open until healthy granulation tissue hasformed;repeated debridement may be necessary.Even after extensive debridement,infection may develop,requiring antibiotic treatment.Where there is doubt or an obvious crushinjury,fasciotomy can prevent systemic complications,including infection.After debridement,delayed primary or secondarysuturing may be done,with or without reconstructive surgery (seeeighth article in this series).Alternatively,if the combination of  wound contraction and epithelialisation will leave an acceptablecosmetic appearance,a wound may be left to heal by secondaryintention.Human and animal bites are traditionally managed inthis way,but primary closure can be done after wounddebridement and excision of non-viable tissue.
Methods of wound closure
For primary closure, the technique of closure, the suturematerial, and the type of needle or appliance all need to beconsidered. Various suturing techniques exist. Skin may be closed withsimple or mattress sutures using interrupted or continuoustechniques. Knots should not be tied tightly, to allow swelling asa result of inflammation and to prevent necrosis at the skinedge. Mattress sutures ensure optimal eversion at the skin edgeand appose deeper tissue, reducing the risk of formation of haematoma or seroma. The subcuticular suture is the most  widely favoured technique for closing surgical skin wounds and
A tourniquet is rarely needed in traumatic bleeding—control by direct pressure prevents irreversibleischaemia and nerve damageCategories of surgical woundsCategory ExampleRecommendationfor antibiotics
Clean Hernia, varicose veins, breast NoneProsthetic surgery: vascular,orthopaedic implantsProphylaxisCleancontaminatedElective cholecystectomy ProphylaxisContaminated Elective colorectaloperationsProphylaxisDirty Drainage of abscess Treatment if spillageFaecal peritonitis Treatmen
Bomb blast and gunshot injuries should not besutured—primarily because of the high risk of infection
Streptococcal cellulitis complicating a leg wound (wound not shown)
Wounds to consider for open management 
Severe contamination (during laparotomy for faecal peritonitis)
Old laceration (>12-24 hours; depends on amount of contusion)
Shock (of any cause but usually haemorrhagic)
Devitalisation (local poor tissue perfusion)
Foreign body (either external or known dead tissue)
Kinetic energy (in wounds caused by explosions; implies presenceof dead tissue and foreign material)
InterruptedsimpleContinuoussimpleContinuousblanketInterrupted andcontinuoushorizontalmattressInterruptedlongitudinalmattressHalsted's stitch
Left: Suture techniques in skin. Top right:Simple and mattress closure. Bottom right: Subcuticular closure
VOLUME 332 4 MARCH 2006 bmj.com
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