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.

It is a shearing injury of the skin in which the surface is rubbed off.It heals without scarring (healing without fibrosis). or a combination of both. Such objects as nails.result from pointed objects such as nails and needles. There is torrential bleeding. The surgical equivalent of this is an incised wound. Penetrating wounds Perforating wounds Human bites and animal bites can be puncture wounds. Bleeding is usually minimal. getting stuck with a needle or a tack. Avulsion. Severe blows by a blunt object. It usually occurs when there has been a severe degree of tissue damage.caused by tearing away of body structure from its point of attachment. The deeper skin layers are intact. The point of entry is always small but may traverse numerous tissues. Incomplete in which case tissue is still attached by a small tissue. needles. Even if external bleeding is slight. They are usually caused by friction or rubbing against an abrasive surface. 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. Friction burn. They may occur as a result of injury or be performed as part of a surgical procedure. Scrapes and abrasions are superficial (on the surface) There is denudation of superficial surface and only the epithelium is affected. Laceration. Foreign materials and organisms are likely to be carried deeply into the underlying tissues. All puncture wounds require the attention of a health professional because of the danger of tetanus. or being stabbed with a knife. .found on the skin surface caused by scrapping or rubbing. there is less resistance in the subcutaneous tissues and the cut may therefore penetrate to a considerable depth. Puncture wounds are generally caused by a sharp pointed object entering the skin.Abrasion also called a graze. Puncture wounds. Lacerations (cuts) go through all layers of the skin and into the fat or deeper tissues. or contact with a sharp object are the most common causes of lacerations. It is usually the result of contact with a sharp object although the force could be a blunt or a sharp force. falls against a hard surface. ice picks and other pointed objects can produce puncture wounds. These wounds are always contaminated by saliva and require extra care. and bleeding is more of a slow ooze.a torn irregular wound caused by stretching of skin over bony prominences. Bleeding may be more brisk or severe. It can be y y Complete in which tissue is completely wrenched from its attachment.is similar to an abrasion but there is an element of thermal damage as well as abrasion. lacerations. Most common examples are stepping on a nail. Most are superficial and heal by epithelialisation but some may result in full-thickness skin loss. there may be serious internal bleeding resulting from internal damage to an organ (as in a gunshot wound). tissues. and the wound may be barely noticeable. Once the cutting implement has gone deep to the dermis. There may be little to see on the surface.

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

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

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

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

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

may mark the onset of a long-term. may heal surprisingly well despite unfavorable circumstances. local pain and tenderness may necessitate removal.such as fragments of steel. Haematoma Ischaemia: Tissue necrosis. which has a borderline blood supply. It impairs blood flow and increases local need for oxygen in the wound. So injury to the scalp where the scalp is torn off the bone with the peripheral attachment intact. The vessels and nerves of the scalp enter the scalp from the periphery. Ischaemia ii.If wounds are not correctly apposed. 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. Wounds in characteristically well-perfused areas. Sutures may be safely removed from the face and scalp by 3days. Healing is in effect by secondary intention. the scalp will not only survive but also heal. Denervation ix. Any kind of foreign body retained in a wound will delay healing if infection is present. Foreign bodies. Infection iv. 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. Foreign bodies (including sutures) potentiate wound infection. Blood supply and location iii. glass. Foreign bodies vi. nonhealing ulcer. Infection potentiates collagen lysis. a dead space soon forms which becomes filled with tissue fluid or blood and is subsequently replaced by granulation tissue. 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.Local factors i.can delay wound healing by compressing blood vessels and separating the edge of the wound. Mechanical factors such as immobilization and trauma. A susceptible host and wound environment are also required. However . It is the single most important cause of delay in wound healing. Bacterial contamination is a necessary condition but is not sufficient for wound infection. impairs wound healing. Size and type of wound viii. Conversely. even a minor wound involving the foot. The face is richly supplied with blood as the arteries anastomose freely. Infection-results in persistent tissue injury and inflammation. Mechanical factors v. resulting from local or systemic ischemia or radiation injury. such the face and neck. or even bone constitute impediments to healing. Surgical technique. Surgical technique vii. Excessive . Hence injury to the face bleeds profusely and heals quickly. Venous ulcers also heal poorly because of impairment of local circulation. Excessive tension on wound edges: This leads to local tissue ischemia and necrosis.

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

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

Excessive exposure to infrared radiation. elastoderma. Hypoxia: Inadequate tissue oxygenation due to local vasoconstriction resulting from sympathetic overactivity may occur because of blood volume deficit. basal cell carcinoma. Patients with this skin condition present with telangiectasia.10-280 nm Ultraviolet B . causes sunburn initially and subsequently conveys a continuing risk of skin malignancy (eg. Genetic disorders such as osteogenesis imperfect.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites.y y y y y y y y y Gamma rays .Ultraviolet radiation exposure. may cause erythema ab igne. Patients with cutaneous lymphoma present with a single nodule or a . particularly ultraviolet B. Patients with Kaposi sarcoma typically present with multifocal violaceous lower extremity lesions. erythematous patches. Malignant disease/Neoplasms: Neoplasms strongly suggest malignancy in any chronic nonhealing wound.01 nm X-rays . especially involving the distal extent of the extremities. in which local blood supply is impaired by coagulative necrosis due to thrombotic occlusion of smaller arteries. pearly. cutis laxa. whereas squamous cell cancer is often somewhat erythematous and scaly and almost always occurs on sun-exposed areas. with atrophy of hair follicles and a paucity subcutaneous fat. Gamma and x-ray radiation also spawn ionized oxygen that adversely affects DNA. and elevated above the skin surface.400-760 nm Infrared . particularly if the wound appeared to occur spontaneously. and hyperpigmentation. which induces repeated or persistent skin hyperthermia of 43-47°C.0. (See image below and Image 5.1 mm to 30 cm Radio waves . Marfan syndrome. Werner s syndrome(progera/progressive ageing). This may cause recalcitrant painful skin ulcers. The surrounding skin is atrophic. melanoma).) Particularly pertinent in wound care is the so-called Marjolin ulcer. 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. progeria.320-400 nm Visible light . epidermolysis bullosa. such as a burn scar or sinus tract. a squamous cell carcinoma originating in a chronic wound. squamous cell carcinoma. Ehlers-Danlos syndrome.Centimeters to meters Gamma radiation and x-ray exposure cause a zone of stasis. This implies that even a wound that is decades old is not necessarily benign.Less than 0. The long-term result is inhibition of regeneration of skin cells from dividing basal cells. or hypothermia.760 nm to 1 mm Microwave . unrelieved pain.280-320 nm Ultraviolet A . Basal cell carcinoma appears smooth. acrodermatitis epithotica.01-10 nm Ultraviolet C .

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

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

11. 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. The deformity so produced is frequently gross with untoward effects on function e.3. Implantation cysts: are the result of epithelial elements penetrating the wound and proliferating in situ to form epidermoid cysts. intestine and urethra. 5. no clot forms and epithelial migration is hindered. They are particularly liable to occur in the scars of burns. Age is important. It results in deformities of the wound and surrounding tissues. Marjolin s ulcer of burns. In effect inection converts healing by primary to healing by secondary intention. They are commonly seen after serious burns and can compromise the movements of joints. Discharge is profuse. the embryonic status is temporary.oesophagus. Tissue death occurs and sloughs accumulate. 6. Such may occur along stitch tracts. The neck is a frequent site for such lesions. They are particularly prone to develop in the palms. soles and anterior aspect of the thorax. 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. . Hyperpigmentation: frequently occurs at sites of chronic scars. stricture formation in important organs. 12. Only when this is shed would adequate granulation tissue form. The exact cause is unknown. 10.g. Cicatrisation: continued thickening and shortening of collagen may on occasion produce contractures which later embarrass function. Deposition of degraded products of haemoglobin probably contributes but the exact cause is uncertain. the condition occurring more often in younger people. 9. arresting state is soon induced presumably by contact inhibition and remodelling ensues. distortion of limbs. 8. In a healing wound. 7.g. Wounds produced by radiant energy are particularly liable to malignant change e. 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. Neoplasia: the intense cellular proliferation and migration that characterizes healing tissues is reminiscent of embryonic activity or the uncontrolled growth of a neoplasm. 4. The important difference is the factor of control. Negroes or dark skinned people are predisposed to this and there may be a genetic basis.

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