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WOUNDS AND WOUND HEALING

It is a breech in the integrity of a tissue or a break in the continuity of a tissue. Aetiological factors 1. Mechanical factors 2. Thermal factors like frost bite, burns; dry or moist heat 3. Chemicals 4. Radiation 5. Ischemia 6. Infective causes (ab initio) Wound classification 1. Basic classification 2. Rank and Wakefield classification 3. Based on rate of infection 4. Based on rate of healing 5. Based on depth 6. Based on involvement of other structures/ severity 7. Based on time elapsing from trauma Basic classification or based on morphology This classifies wounds as: a. Open b. Closed Open wounds They are wounds in which there is a communication with the exterior. An open wound (as in a knife cut) is a break in the skin or mucous membrane. i. ii. iii. iv. v. vi. vii. Incised wounds Abrasion Friction burn Laceration Avulsion Puncture wounds Penetrating wound

Incised wounds- which are made under sterile conditions. Most surgical wounds are incised in type and there is little tissue damage or bruising around the operation site. A cut is made into tissues of the body by a scalpel to gain access to tissues usually to repair or remove a diseased organ or allow pus to drain from an abscess or boil. There is usually no risk of foreign material.

falls against a hard surface. The surgical equivalent of this is an incised wound.Abrasion also called a graze. Puncture wounds are generally caused by a sharp pointed object entering the skin. Most common examples are stepping on a nail. lacerations. Incomplete in which case tissue is still attached by a small tissue. Such objects as nails. There may be little to see on the surface. and bleeding is more of a slow ooze. needles.is similar to an abrasion but there is an element of thermal damage as well as abrasion. Once the cutting implement has gone deep to the dermis. Friction burn. These wounds are always contaminated by saliva and require extra care. They are usually caused by friction or rubbing against an abrasive surface. Avulsion. and the wound may be barely noticeable. Laceration.caused by tearing away of body structure from its point of attachment. Penetrating wounds Perforating wounds Human bites and animal bites can be puncture wounds. Bleeding is usually minimal. or contact with a sharp object are the most common causes of lacerations. They may occur as a result of injury or be performed as part of a surgical procedure. . It can be y y Complete in which tissue is completely wrenched from its attachment.found on the skin surface caused by scrapping or rubbing. Most are superficial and heal by epithelialisation but some may result in full-thickness skin loss. or a combination of both. The deeper skin layers are intact. They may be ingrained with dirt and if this is not removed at the time of primary treatment permanent tattooing of the skin will result. there is less resistance in the subcutaneous tissues and the cut may therefore penetrate to a considerable depth.It heals without scarring (healing without fibrosis). All puncture wounds require the attention of a health professional because of the danger of tetanus. there may be serious internal bleeding resulting from internal damage to an organ (as in a gunshot wound). Lacerations (cuts) go through all layers of the skin and into the fat or deeper tissues.a torn irregular wound caused by stretching of skin over bony prominences. Foreign materials and organisms are likely to be carried deeply into the underlying tissues. Puncture wounds. or being stabbed with a knife. Even if external bleeding is slight. tissues. ice picks and other pointed objects can produce puncture wounds.result from pointed objects such as nails and needles. Scrapes and abrasions are superficial (on the surface) There is denudation of superficial surface and only the epithelium is affected. Bleeding may be more brisk or severe. getting stuck with a needle or a tack. The point of entry is always small but may traverse numerous tissues. Severe blows by a blunt object. It is usually the result of contact with a sharp object although the force could be a blunt or a sharp force. It is a shearing injury of the skin in which the surface is rubbed off. There is torrential bleeding. It usually occurs when there has been a severe degree of tissue damage.

Skin wounds will usually be single and clean cut. Untidy Tidy wounds are inflicted by sharp objects and contain no devitalised tissue.a bruise that is visible through the skin. A closed wound (a contusion or internal bleeding) is a bruise that damages the underlying tissue without breaking the skin (as in a black eye). nerves and muscles. Ecchymosis. Tissue damage and contamination is minimal and they include: a. Abrasions Such wounds are closed immediately with expectation of quiet primary healing. and then the breakdown of haemoglobin turns the bruise yellow. Tidy 2.results from injury of tissues subjacent to surface epithelium usually as a result of blunt trauma. Serious types include extradural and subdural haematoma. At first. Rank and wakefield classification This is the most useful classification from a practical point of view.a localized collection of blood (usually clotted) caused by bleeding from a ruptured blood vessel. Bruise. iv. Fractures are not common in tidy wounds. Skin wound are multiple and irregular. Surgical incisions undertaken under aseptic techniques b.a discoloured area under the skin caused by leakage of blood from damaged capillaries. Haematoma. Less serious types of haematoma include those found under the nails or in tissues of the outer ear (cauliflower ear). There is liquification within a few days after formation of the clot. Untidy wounds indicate irregular skin damage with possible skin loss. Most disappear without treatment in a few days but if they are painful they may be drained.Closed wounds: There is no communication with the exterior. It results from . they may be indications of a bleeding disorder. i. iii. ii. Lacerations from clean glass and knife c. It is therefore a closed blunt injury. external contamination and damage to underlying tissues such as blood vessels. the blood appears blue or black. Fractures are common and may be multifragmentary. If they appear for no apparent reason or are severe after only a minor injury. There is disruption of connective tissue with extravasation of blood and tissue discolouration. It can occur anywhere in the body and vary from a minor to a potentially fatal condition. Contusion Haematoma Bruise Ecchymosis Contusion . They include 1. It usually fades after one week.

At worst. It could involve incision through an abscess. Dirty wounds are traumatic wounds from a dirty source. d. Such wounds are not inflammed and does not involve a site that is associated with heavy commensal flora. and urinary tracts not entered. where there is delayed treatment or when significant bacterial contamination or release of pus is encountered. biliary. The correct management of an untidy wound is wound excision.a. b. In biliary surgery. Penetrating traumatic wounds <4 hours. Examples. thyroidectomy. biliary. gastrointestinal. Elective entry into respiratory. interval appendectomy. Infection rate of such wounds is between 15-20%. Superficial wounds: involving only the epidermis and dermis up to the dermal papillae .are non-traumatic wounds with a minor break in technique or with contaminated entry into a viscus but with minimal spillage. Less than 10% of such wounds become contaminated. Based on risk of infection (if no antibiotics used) i. Lacerations with marginal necrosis Avulsion injuries with skin loss Crush injuries Vascular injuries or burns If such wounds are closed immediately. Respiratory. It occurs at sites with a heavy commensal load. c. Wound infection rate is less than 40% but may be 60% or more before prophylaxis. Clean contaminated iii. Based on depth I. At best. mastectomy. Example Herniorapy. urinary tracts. Closed drainage used if necessary. Closed primarily. Purulent inflammation present. prostatectomy. infection and delayed healing. lumpectomy. Contaminated wounds-are traumatic wounds with a major break in surgical techniques with significant spillage from an open viscus. Clean contaminated wounds. Example in emergency appendectomy. but may be up to 60% before prophylaxis. Preoperative perforation of viscera. Acute inflammation is often encountered in such wounds. cholecystectomy. infection rate can be as high as 20% before prophylaxis. There is no sign of leakage from microbially colonised sites. Penetrating traumatic wounds >4 hours. In gastric surgery infection rate may be up to 30% before prophylaxis. Clean wounds ii. healing is unlikely to occur and if it does there will be complications. gastrointestinal. gas gangrene may result and death may result. no septic focus and no viscus opened. Contaminated iv. Example in emergency surgery for faecal peritonitis. Less than 2% of clean wounds become infected. Dirty wounds Clean wounds are non-traumatic wounds with no break in the surgical technique (good surgical practise has been maintained). there may be wound dehiscence.

but within a few hours they dilate following the release of vasodilators such as serotonin.g.e.II. etc. The edges of the wound become sealed with platelet clot and then fibrin clot. the process probably serves to raise the metabolic rate of the wound preparatory to its repair. polymorphoneuclear leucocytes. Based on involvement of other structures I. a properly co-apted and sutured wound.5-38. These include coagulation. Immediately after trauma there is a clotting cascade which involves the intrinsic and extrinsic pathways and results in the formation of thrombin and fibrin and other proteins such as fibronectin. with laceration of blood vessels and nerves). IV. The . It also brings together the materials necessary for the subsequent stages of repair i. histamine. Partial-thickness wounds: involving skin loss up to the lower dermis (part of the skin remains and shafts of hair follicles and sweat glands are leftover. wounds penetrating into natural cavities. epithelialisation. Combined wounds: as seen in mixed tissue trauma Based on rate of healing I. plasma. remodelling and scar maturation. kinins and histamine and neural reflexes. Acute wounds: II. A narrow zone of granulation tissue forms and union occurs rapidly with minimal scar formation. inflammation. Old wounds: after 8 hours from trauma or skin discontinuity Wound healing It is the process through which injured tissue is replaced by damaged tissue. and wounds penetrating into an organ or tissue. The adjacent capillaries constrict and are plugged with clot. These are followed by angiogenesis. fibroplasias. Full-thickness wounds: involving the skin and subcutaneous tissue. Wounds may heal by primary or secondary intention. Fresh wounds: up to 8 hours from trauma II. Tissue loss occurs and the skin edges are spaced out. The aggregation and activation of platelets and release of chemotactic factors are initiated and promoted by exposure of blood to fibrillar collagen of the injured tissues. which results in platelet aggregation. fibrin.50C. III. The body temperature is raised usually to 37. Exposure of type IV and V collagen also disturbs the balance of platelet thromboxane A and intimal prostacyclin I2. Simple wounds: comprise only one organ or tissue II. and deposition. contraction. Deep wounds: include complicated wounds (e. First intention healing: this is the process of healing a clean incised wound with the edges in apposition. It is the summation of a number of processes that follow injury. matrix synthesis. Chronic wounds: Based on time elapsing from trauma I. and is accompanied by vessel contraction and secretion of serotonin. Haemostasis is promoted.

sutures staples or glue. Wound breakdown is the result of poor technique during this phase. Third intention healing also called healing or delayed primary suture is done in a heavily contaminated wound. In contrast to first intention healing. Wound strength depends on the materials used for wound apposition e. by which time the wound is cleaner and so an early growth of granulation tissue would have commenced. The scab is gradually lifted at its edges until it falls off. Under the scab re-epithelialization begins from wound edges. EGF. There is fibrinous adhesion only of the edged in this phase. Acute inflammation includes a. This is accompanied by vascular permeability and neutrophil margination and diapedesis. This can account for the majority of closure of larger wounds.IL-6 and TNF. Preparation phase (4-6 days)which is prolonged by development of bacterial infection b. Demolition phase concerned with removal of dead and dying tissues from the wound by neutrophils and monocytes which migrate into the wound. It follows the clotting. ICAM).ground substance of the connective tissue undergoes depolymerisation and granules disappear from most cells. oxygen free radicals. pro-inflammatory cytokines (principally IL-1. Capillary loops bud and fibroblasts proliferate to form collagen-rich granulation tissue. The wound is then closed secondarily. integrins.IGF-II. It is now common practise to delay primarily closing a heavily contaminated wound for 4 to 5 days. IGF-I. healing by second intention is slow and results in a large distorted scar. Phases of wound healing There are three phases in first intention healing: Inflammatory or lag phase (0-3 days). FGF. In larger wounds the advancing epithelial edge can be more easily seen. PMN s and macrophages release nitric oxide. TGF and TGF ) . fibrinolytic and complement cascades. Neutrophils and macrophages invade the wound and clear necrotic tissue and debris.) and growth factors(PDGF. controlled by expression of selectins. The wound gapes because of the elastic pull of the dermis on each side and/or tissue loss.g. The influx of polymorphonuclear white cells (PMN) is followed by macrophages and lymphocytes. depending on surrounding skin laxity. Some fibroblasts acquire contractile properties (myofibroblasts) and cause wound to contract. The defect initially fills with blood clot which dries to forms a scab. Second intention healing: this is the process of healing a wound with separated edges. Wounds heal from below upwards. with prostaglandins. and other antimicrobials. and adhesion molecules changes (VCAM.

fibroblasts also aid wound closure by a process of contraction involving secreted actin and myosin fibres. At first. The endothelial cells divide and migrate to form a new capillary network in the wound. The fibroblasts from the cells surrounding the wounds are also activated and migrate into the wound. In connective tissue defects. Matrix degradation is blocked. The tensile strength of the wound increases rapidly. This is the stage of granulation tissue formation. Systemic . laminin and other glucosaminoglycans (GAG) in the extracellular space in the wound as the scaffolding matrix. Inadequate refashioning and formation of collagen causes wound disruption or anastomotic leak. excessive production may lead to hypertrophic and keloid scars or stenosis. The scar. hyaluronic acid. Thus damage is repaired. Collagen is a triple helical molecule and as it cross-links. The entire process is sometimes called cicatrisation. the fibre-cell ratio increases until in the adult scar tissue only a few elongated fibroblasts are visible. in which fibroblasts divide and mature with the formation of endothelial buds from damaged blood vessels. They aid in bringing nutrition and oxygen to the wound and facilitate the demolition of dead tissue and removal of foreign material. This phase follows the acute inflammatory response. Wound strength progresses with the formation of granulation tissue and collagen(fibroplasias). the number of fibroblasts in relation to collagen fibres rapidly falls so that there is progressive increase in tensile strength which is in the fasciae of the body goes on for many months. the collagen fibrils are fine and few in relation to the cells but as healing proceeds. synthesis of protease inhibitors is increased at the same time. which up to this time has remained elevated and congested. There is continous reorientation and maturation of collagen fibres. The ground substance now shows striking metachromasia indicating depolymerisation and increasing quantities of mucopolysaccharides. Histologically. over a period of weeks or months thins out and flattens and becomes progressively less conspicuous. Remodelling phase(3weeks-1year). These buds become canalized and new capillaries grow into the dead space of the wound. the blood vessels gradually disappear (Endarteritis obliterans). Factors affecting wound healing They include 1. During this phase there is a fine balance between breakdown of old damaged collagen by matrix metalloproteinases and tissue inhibitors.in this phase collagen is formed by fibroblasts which forms scar tissue. Fibroblasts now deposit collagen on the fibronectin and GAG scaffolding. scar tissue becomes stronger and binds the wound together( but scar is never as string as unwounded tissue). Local 2. Maturation phase (6months -2years) is soon followed by gradual shrinkage and maturation of connective tissue in the wound.Proliferative phase (3 days-3weeks). The endothelial cells and fibroblasts use fibronectin.

Size and type of wound viii. the scalp will not only survive but also heal. Excessive tension on wound edges: This leads to local tissue ischemia and necrosis. Haematoma Ischaemia: Tissue necrosis. nonhealing ulcer. Hence injury to the face bleeds profusely and heals quickly. A susceptible host and wound environment are also required. Foreign bodies (including sutures) potentiate wound infection. Foreign bodies vi. The face is richly supplied with blood as the arteries anastomose freely. Bacterial contamination is a necessary condition but is not sufficient for wound infection. Hypoxia and excessive tension on the wound edges Blood supply and location -wounds in richly vascularised areas such as the face and scalp heal faster than those in poorly vascularised areas such as the foot. Healing is in effect by secondary intention. even a minor wound involving the foot.Local factors i. The vessels and nerves of the scalp enter the scalp from the periphery. Foreign bodies.such as fragments of steel. It impairs blood flow and increases local need for oxygen in the wound. local pain and tenderness may necessitate removal. Mechanical factors such as immobilization and trauma.can delay wound healing by compressing blood vessels and separating the edge of the wound. may mark the onset of a long-term. Blood supply and location iii. Infection iv. Ischaemia ii. Surgical technique. such the face and neck. or even bone constitute impediments to healing. Infection potentiates collagen lysis. Excessive . Wounds in characteristically well-perfused areas. However . which has a borderline blood supply. Sutures may be safely removed from the face and scalp by 3days. resulting from local or systemic ischemia or radiation injury. Rough handling of tissues and excessive trauma also delays healing not only because of increased tendency to infection but also from production of much tissue necrosis. impairs wound healing. Infection-results in persistent tissue injury and inflammation. Venous ulcers also heal poorly because of impairment of local circulation. So injury to the scalp where the scalp is torn off the bone with the peripheral attachment intact. may heal surprisingly well despite unfavorable circumstances. Conversely. On the other hand a clean object such as a piece of glass may be buried in a wound which will heal without significant complication. Denervation ix. It is the single most important cause of delay in wound healing. Surgical technique vii. Mechanical factors v.If wounds are not correctly apposed. glass. a dead space soon forms which becomes filled with tissue fluid or blood and is subsequently replaced by granulation tissue. Any kind of foreign body retained in a wound will delay healing if infection is present.

Drugs viii. until bone and joint deformities become marked. The result is a convex foot with a rocker-bottom appearance. Metabolic status v. starvation or deficient blood supply. Size and type of wound. Hormones vii. Delay is probably due to deficiency state. Wounds sutured with catgut heal more slowly and are initially weaker than silk sutured wound but the end results are essentially the same. C. Hypoxia xi. neuropathic osteoarthropathy) and is observed most commonly in people with diabetes mellitus. The type of suture has little effect on the rate of wound healing. Radiation and cytotoxics ix. Malnutrition. Malignant disease / neoplasms Age.small injuries heal faster and with less scar formation than large excisional wounds or wounds caused by blunt trauma Denervation: Neuropathy: Sensory neuropathy involving the feet may lead to unrecognized episodes of trauma caused by ill-fitting shoes. Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A. Metabolic status iv. affecting approximately 2% of persons with diabetes. Type of tissue Dressings or protection Hematoma Systemic factors i. Nutritional status. Low temperature x. This is compounded by motor neuropathy causing intrinsic muscle weakness and spaying of the foot on weight bearing. Nutritional factors iii. and zinc impair normal wound-healing mechanisms. Vitamin C or ascorbic acid is a cofactor in the hydroxylation of procollagen to collagen .oddly enough wounds heal well in old people. Multiple fractures go unnoticed.has a profound effect on wound healing. The sutures strangulate and eventually cut through the skin and subcutaneous tissues. Age ii.tension in the wound from unduly tight sutures applied in an effort to close a gaping wound has the effect of delaying the healing of the wound. obesity and trace metal deficiency also retard wound healing. This is termed a Charcot foot (ie. Circulatory status vi.

Nocturnal leg elevation and elastic wraps or support hose are appropriate adjuncts to the treatment of recalcitrant wounds in edematous extremities. complex decongestive physiotherapy is a useful treatment option. Diabetes: The long-term effects of diabetes impair wound healing by diminishing sensation and arterial inflow. particularly in patients with hereditary coagulation abnormalities. The effect in acute phase is not only on rapidly dividing tumour cells but also on normal cells with a high turnover. poor peripheral perfusion. or breasts. even acute loss of diabetic control can affect wound healing by causing diminished cardiac output. It may occur with heparin or warfarin. Therefore. Anticoagulant-induced skin necrosis is an unusual complication of anticoagulant therapy.Zinc deficiency uncommon except in children in the middle east retards healing by preventing cellular mitosis. during the first several days of warfarin therapy.the effects of radiation on tissues may be studied in acute. This complication is often attributable to hereditary coagulation abnormalities. Hormones. These agents also inhibit collagen synthesis. usually in an area having abundant adipose tissue. Diabetes mellitus is associated with delayed healing. as a consequence of the microangiopathy that is a frequent feature of this disease. extremity ulcers may fail to heal because of untreated lymphedema. Radiation and cytotoxics. Warfarin (Coumadin) depletes vitamin K dependent coagulation factors. though it is more common with warfarin. which impairs capillary blood flow or traps growth factors. and impaired polymorphonuclear leukocyte phagocytosis. Venous insufficiency: Patients with varicose veins or nonfunctional venous valves after deep vein thrombosis develop ambulatory venous hypertension. For advanced and nonresponsive lymphedema. The adverse effects of prolonged or excessive electromagnetic radiation vary with the wavelength. The female-to-male ratio is 4:1. Circulatory status. Warfarin-induced skin necrosis manifests as painful hemorrhagic skin lesions.such as glucocorticoids have well documented anti-inflammatory effects that influence various components of inflammation. antithrombin 3 deficiency. Drugs: Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis. such as protein C deficiency or protein S deficiency. In addition. such as the thighs. a period of transient hypercoagulability may occur.inadequate blood supply usually caused by arteriosclerosis or venous abnormalities such as varicose veins that retard venous drainage also impair healing. Excess zinc level hinders macrophage migration and phagocytosis and thus impairs wound healing. Wavelengths of electromagnetic radiation are as follows: .can change wound healing. abdomen. intermediate and chronic phases. Macromolecules pass into the dermis and eventually cause the hemosiderin deposition and brawny induration in the distal leg (gaiter area) characteristic of chronic venous insufficiency. that is. such as protein C. Metabolic status. Lymphedema: Although not typically a cause of ulceration. This constant venous hypertension seems to cause white cell and fibrin buildup. or activated protein C resistance. The changes take the form of desquamation. distal venous pressure remains elevated despite ambulation.

Malignant disease/Neoplasms: Neoplasms strongly suggest malignancy in any chronic nonhealing wound. progeria. particularly if the wound appeared to occur spontaneously.Less than 0. and hyperpigmentation. Patients with cutaneous lymphoma present with a single nodule or a . Werner s syndrome(progera/progressive ageing). Ehlers-Danlos syndrome. cutis laxa. whereas squamous cell cancer is often somewhat erythematous and scaly and almost always occurs on sun-exposed areas. which induces repeated or persistent skin hyperthermia of 43-47°C. squamous cell carcinoma. Genetic disorders such as osteogenesis imperfect. such as a burn scar or sinus tract. unrelieved pain. with atrophy of hair follicles and a paucity subcutaneous fat.01 nm X-rays . elastoderma. Marfan syndrome. pseudoxanthoma elasticum Uraemia Low temperature: The relatively low tissue temperature in the distal aspects of the upper and lower extremities (a reduction of 1-1.Excessive exposure to infrared radiation. Patients with this skin condition present with telangiectasia. The long-term result is inhibition of regeneration of skin cells from dividing basal cells.) Particularly pertinent in wound care is the so-called Marjolin ulcer. acrodermatitis epithotica. The surrounding skin is atrophic.760 nm to 1 mm Microwave .01-10 nm Ultraviolet C . or hypothermia.1 mm to 30 cm Radio waves . may cause erythema ab igne. a squamous cell carcinoma originating in a chronic wound. epidermolysis bullosa. erythematous patches.y y y y y y y y y Gamma rays . Basal cell carcinoma appears smooth. Gamma and x-ray radiation also spawn ionized oxygen that adversely affects DNA. and elevated above the skin surface. (See image below and Image 5. in which local blood supply is impaired by coagulative necrosis due to thrombotic occlusion of smaller arteries.320-400 nm Visible light .Ultraviolet radiation exposure.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites. Patients with Kaposi sarcoma typically present with multifocal violaceous lower extremity lesions.0. melanoma). Hypoxia: Inadequate tissue oxygenation due to local vasoconstriction resulting from sympathetic overactivity may occur because of blood volume deficit. especially involving the distal extent of the extremities.280-320 nm Ultraviolet A . This implies that even a wound that is decades old is not necessarily benign. basal cell carcinoma.10-280 nm Ultraviolet B .400-760 nm Infrared . This may cause recalcitrant painful skin ulcers. pearly. particularly ultraviolet B. causes sunburn initially and subsequently conveys a continuing risk of skin malignancy (eg.Centimeters to meters Gamma radiation and x-ray exposure cause a zone of stasis.

a bloodless field aids identification of structures. It is helpful to use a skin-marking pen to plan the skin excision and any wound extensions. MANAGEMENT OF WOUNDS Wound excision is the most important step in the management of any untidy wound. dealing with each tissue layer in turn. Smaller haemostats should be employed so as to reduce the amount of tissue crushed while clamping vessels. carry out fasciotomy as appropriate and dress the wound. the wound should resemble an anatomical dissection. Strict asepsis should be observed routinely using gowns. Normal bleeding should be observed in each layer. further serial wound excisisons until a tidy wound is achieved. devitalized muscle is a dark colour. Immobilization and elevation of the injured part are essential for they promote venous and lymphatic drainage and thus prevent congestion and pain. . For superficial wounds the use of local anaesthetic with 1:200000 adrenaline gives good homeostasis of skin edges. nerves and tendons are identified and exposed but left in continuity. an hence minimizs infection thus promoting early healing. has lost its usual sheen and turgor.group of papules from one to several centimeters in diameter. devitalized fat is pink rather than yellow. usually starting with the superficial and moving to deeper structures. it is reasonable to excise what is definitely non-viable. Occasionally. regional or general) must be provided. Where radical wound excision would threaten the viability or function of the limb. Sharp dissections should be preferred to blunt dissection except where safety demands otherwise. In the limbs. Blood deficit should be controlled adequately by blood transfusion. exudation. Longitudinal structures such as blood vessels. in very extensive wounds this very radical approach must be modified. Tissue must be protected from dessication by moistening with warm packs. adequate dose of broad spectrum bactericidal antibiotic should be instituted. bruising. because the entire wound is excised with an appropriate margin back to healthy tissue. In order to excise a wound. and does not twitch when picked up with forceps. Excision should proceed in a systematic fashion. and these almost always occurs above the waist. Bone fragments with no soft tissue attachment or non-vital soft tissue attachments are also discarded. At the end of the wound excision. a pneumatic tourniquet is used mainly in massive injuries attended by profuse bleeding and where amputation might be required. The approach to radical wound excision is sometimes called pseudotumour approach. with a view to returning 48hrs later for a second look and thereafter. caps and efficient masks for all major surgical procedures with the usual skin preparation and draping to prevent break in technique. Where possible. Prophylaxis against tetanus by active or passive immunization should be instituted and where significant wound contamination is suspected. adequate anaesthesia (local. Devitalized dermis is pink rather than white. Gentleness in handling tissues is ideal for it reduces trauma.

free tissue transfers. however predispose to infection and drains must be left in place for only as long as is necessary as they provide possible routes of wound contamination. These aberrations can be grouped into three categories which include    1. The individual components or layers of tissues should be apposed as accurately as possible to each other. For this reason. Dead space should be avoided in the wound as this collects blood and serum suitable pabulum for bacterial growth. neovascularisation and fibroblasts which fills the dead space of wound and provides a temporary barrier. appropriate tissue needs to beimported. fibroblasts and collgen replace the initial fibrin clot. Most tidy wounds that do not involve loss of tissue can be closed directly. relieving excisions may be made. There is a tendency to necrosis. The use of the word is confusing whn talking about excision as it is this very excision that is designed to avoid the formation of laudable pus. Complications of wound healing They can arise from abnormalities in any of the basic components of the repair process. Reconstructive plastic surgical techniques can range from simple skin grafts to complex. This makes for minimal fibrosis and improves the resultant scar. Granuloma is a collection of macrophages which form in response to chronic inflammation or infecgtion such as TB or foreign body. Deficient scar formation Excessive formation of repair component Formation of contractures Infection Keloid formation . Where there is tissue loss. Dead space may be eliminated by judicious use of buried absorbable sutures and where indicated closed exterior drainage. It comes from the French unbridling or letting loose. It forms the basis for healing in connective tissues. DEFINITION OF TERMS Granulation tissue is defined as the combination of macrophages. which is the most important process. It refers to the concept of releasing laudable pus. Tension in the wound interferes with local blood flow and hence the healing process in the wound. 2.Wound toilet implies washing Debridement implies laying open or fasciotomy. Organisation is the process whereby capillary loops. The above two processes may be important in wound mamangement but do jnot describe the excision of devitalised tissue. Where tension is expected as a result of tissue loss. epithelium to epithelium and mesothelial structures in similar fashion. Wound closure. the cutting through of sutures and wound dehiscence. composite. th term wound excision is preferred. Excessive use of buried catgut may.

In effect inection converts healing by primary to healing by secondary intention. soles and anterior aspect of the thorax. The important difference is the factor of control. Implantation cysts: are the result of epithelial elements penetrating the wound and proliferating in situ to form epidermoid cysts. Marjolin s ulcer of burns. Keloid formation: is due to excessive fibroblastic activity with marked granulation tissue formation resulting in a markedly raised scar which grows beyond the boundaries of original wound and does not regress. They are particularly liable to occur in the scars of burns. They are particularly prone to develop in the palms. arresting state is soon induced presumably by contact inhibition and remodelling ensues. 8. Contractures: an exaggeration of the normal process of contraction in the size of a wound which is an important part of the normal healing process. 11. no clot forms and epithelial migration is hindered. The neck is a frequent site for such lesions.3. 4. 12. the condition occurring more often in younger people. 10. Neoplasia: the intense cellular proliferation and migration that characterizes healing tissues is reminiscent of embryonic activity or the uncontrolled growth of a neoplasm. In a healing wound.g. Only when this is shed would adequate granulation tissue form. intestine and urethra. Tissue death occurs and sloughs accumulate. Such may occur along stitch tracts. Deposition of degraded products of haemoglobin probably contributes but the exact cause is uncertain. Hyperpigmentation: frequently occurs at sites of chronic scars. distortion of limbs. It results in deformities of the wound and surrounding tissues. Negroes or dark skinned people are predisposed to this and there may be a genetic basis.g. They are commonly seen after serious burns and can compromise the movements of joints. Hyperpigmentation Implantation cysts Neoplasia Wound dehiscence Hypertrophic scar Proud flesh or exuberant granulation Contracture Weak scars Cicatrisation Traumatic neuroma Infection: enters via the primary wound and interferes with the healing process. Age is important. stricture formation in important organs. Wounds produced by radiant energy are particularly liable to malignant change e. 9. Discharge is profuse. Cicatrisation: continued thickening and shortening of collagen may on occasion produce contractures which later embarrass function. 6. 5. The deformity so produced is frequently gross with untoward effects on function e. the embryonic status is temporary. The exact cause is unknown. 7. .oesophagus.

Wound closure Primary wound closure is done 5-6 hours after surgery Secondary wound closure .