Wounds And Wounds Healing

Department of Medicine, University of Georgia

MD4120E: Surgery I
Dr. Nino Gabunia
Juma Awar
22/06/2022

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Introduction

A wound is defined as disruption of the normal anatomic relations of tissues due to trauma. The trauma
may be intentional (elective surgical incision) or unintentional. It is important to appropriately clean and
dress wounds to limit the spread of infection and further injury. (Herman & Bordoni, 2022)

Wounds can be acute or chronic. Acute wound is any surgical wound that heals by primary intention or
any traumatic or surgical wound that heals by secondary intention. An acute wound is expected to
progress through the phases of normal healing, resulting in the closure of the wound. Meanwhile
chronic wound is a wound that fails to progress healing or respond to treatment over the normal
expected healing time frame (4 weeks) and becomes "stuck" in the inflammatory phase. This pathologic
inflammation is due to a postponed, incomplete or uncoordinated healing process. Wound healing is
delayed by the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-
morbidities or inappropriate dressing selection.

Pathophysiology of Wound Healing

There are three phases in wound healing which are: Inflammatory or substrate phase, proliferation, and
remodeling or maturation phase.

1. Substrate (Inflammatory) Phase

This phase includes hemostasis and inflammation. An injury to the skin immediately initiates clotting
cascades which provide a temporary fibrin blood clot plug to the injury site. Meanwhile, 5- to 10-minute
vasoconstriction is triggered in the wounded area. This temporary reactions prevent further bleeding
and protect the wound. Vasodilatation occurs after this brief vasoconstriction response which will cause
local hyperemia and edema. The exposed sub-endothelium, collagen, and tissue factor due to injury
stimulate platelet aggregation and activate platelet degranulation. The released chemotactic factors and
growth factors complete hemostasis and start inflammation.

Neutrophils are recruited to the wounded area within the first 24 hours and stay for 2 to 5 days. They
initiate phagocytosis which is continued by macrophages later. These phagocytic cells release reactive
oxygen species (ROS) and proteases for killing local bacteria and debriding necrotic tissues. Neutrophils
also act as a chemoattractant for other cells and augment the inflammatory response by releasing many
pro-inflammatory cytokines. Macrophages arrive approximately 3 days after the injury. Similarly, they
release numerous growth factors, chemokines, cytokines which promote cell proliferation and synthesis
of extracellular matrix (ECM) molecules.

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 2. Proliferation
The proliferative phase is characterized by granulation tissue formation and vascular network
restoration. This phase starts approximately 3 to 10 days after injury and takes days or weeks
to complete. Various cytokines and growth factors have a role in this phase such as transforming growth
factor-beta family (TGF-beta, including TGF-beta1, TGF-beta2, and TGF-beta3), interleukin (IL) family and
angiogenesis factors. The predominate proliferating cells are fibroblasts and endothelial cells in this
phase. During the cell proliferation, a requirement for an adequate blood supply occurs. Therefore, an
angiogenic response is initiated simultaneously. This response is mainly stimulated by local hypoxia,
vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), fibroblast growth
factor-basic (bFGF) and the serine protease thrombin and as a result, new vascular network is formed
which provides nutrient delivery, gas and metabolite exchange.

Local keratinocytes that are found at the edge of the wound and epithelial stem cells in the bulbs of the
hair follicles and apocrine glands take part in epithelization. Stem cells differentiate into keratinocytes
and keratinocytes begin to migrate over the wound edge until a physical contact with each other.

The last step of the proliferation phase is the granulation tissue formation. Fibroblasts migrate to the
wound site and proliferate within the wound. Then they begin to synthesize a provisional matrix
containing collagen type III, glycosaminoglycans and fibronectin. The granulation tissue is composed of
fibroblasts, granulocytes, macrophages, capillaries, and loosely organized collagen bundles. Also, this
new classic red tissue is highly vascular because the angiogenesis is not completed yet.

3. Maturation Phase (Remodeling)

Remodeling is the last phase of the wound healing, begins from day 21 and continues up to 1 year. In
this phase, there is a precise balance between synthesis and degradation of the new tissue that needs to
be strictly preserved. Any disruption ends up with a chronic wound formation. This phase is
characterized by the remodeling and strengthening of collagen in the wound by intermolecular cross-
linking. (Ozgok & Regan, 2022)

Wound classification

To correctly classify the cleanliness and condition of wounds, the CDC has established classification
definitions composed of four classes of wound statuses:

Class 1 wounds are considered to be clean. They are uninfected, no inflammation is present, and are
primarily closed. If the draining of these wounds is necessary, a closed draining method is necessary.

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Additionally, these wounds do not enter respiratory, alimentary, genital, or urinary tracts. The risk for an
infection in this type of wound is usually 3%.

Class 2 wounds are considered to be clean-contaminated. These wounds lack unusual contamination.
Class 2 wounds enter the respiratory, alimentary, genital, or urinary tracts. However, these wounds have
entered these tracts under controlled conditions. The risk for an infection is usually 8%.

Class 3 wounds are considered to be contaminated. These are fresh, open wounds that can result from
insult to sterile techniques or leakage from the gastrointestinal tract into the wound. Additionally,
incisions made that result in acute or lack of purulent inflammation are considered class 3 wounds. The
risk for an infection is usually 15%.

Class 4 wounds are considered to be dirty-infected. These wounds typically result from improperly cared
for traumatic wounds. Class 4 wounds demonstrate devitalized tissue, and they most commonly result
from microorganisms present in perforated viscera or the operative field. The risk for an infection in
these cases is usually 35%. (Herman & Bordoni, 2022)

Types of healing

Healing by Primary Intention:

The term applies to all surgical incisions and lacerations that are closed with sutures, staples, adhesive,
or any technique by which the surgeon intentionally approximates the epidermal edges of a wound. The
one major disadvantage of primary closure of a wound is the risk of wound infection

Healing by Secondary Intention:

Deep layers are closed but superficial layers are left to heal from the inside out. Healing by second is
appropriate in cases of infection, excessive trauma, tissue loss, or imprecise approximation of tissue. The
disadvantages of leaving a wound open are that daily dressing changes are required until the wound is
healed.

Healing by Tertiary Intention:

Also referred to as delayed primary closure. the wound is initially managed as a secondary intention
wound, that is, left open with dressing changes. After a matter of about 5 days or so, when the wound is
clean and granulation tissue is abundant, the wound edges are actively approximated. Delayed primary

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closure combines the advantages of primary wound closure in terms of final cosmetic result and rapid
return to function while significantly reducing the risk of wound infection.

Skin grafting:

For large surface area full-thickness wounds that cannot be closed primarily. Split-thickness skin grafts
consist of epidermis and a portion of the underlying dermis and are harvested using a dermatome.
Before it is placed on the open wound, the graft may be meshed with a device that creates fishnet-like
perforations or interstices in it. The perforations allow the graft to expand to cover an irregularly shaped
wound and also prevent pooling of blood or serum underneath the graft, which would prevent take.

Factors affecting wound healing

A number of local and general factors can delay or impair wound healing. These may include:

Local:

Wound management practices: the goal is to optimize the wound environment so healing progresses.

Moisture balance: dressings are designed to promote moist wound healing.

Wound temperature and PH: a constant temperature of approximately 37’C has been shown to have a
significant effect on healing along with the impact of maintaining a neutral or acidic pH to reduce the
risk of bacterial colonization and opportunistic infection.

Infection: replication of organisms within a wound with subsequent host injury.

Presence of foreign bodies.

General:

Underlying disease: diabetes, autoimmune disorders, anemia and malignancy. The reason these
conditions impair healing include impaired collagen, impairment of angiogenesis, delayed infiltration of
inflammatory cells, macrophages and lymphocytes, due to decreased host resistance, poor cutaneous or
epidermal vasculature.

Impaired perfusion and hypoxia: cardiac conditions, shock and hemorrhage.

Malnutrition: inadequate supply of protein, carbohydrates, lipids and trace elements and vitamins
essential for all phases of wound healing.

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Body mass index: a major concern of obesity is the increased workload of the heart to supply
oxygenated blood to body tissues. If the heart is unable to perfuse these tissues, ischemia can occur and
thus contribute to necrosis and impaired wound healing.

Medications: NSAIDs, chemotherapy, immunosuppressive drugs, corticosteroids, glucocorticoids are

known to have dermal effects that can impact wound healing, including inhibition of fibroblast
proliferation and decreased collagen production. 

Radiation therapy: radiation-induced damage to the epithelium can result in skin breakdown, lower
tensile strength, atypical fibroblasts and delayed healing rates.

Smoking: nicotine, an alkaloid poisonous substance present in all tobacco products, reduces cutaneous
blood flow by vasoconstriction, stimulates release of proteases that may accelerate tissue destruction,
suppresses the immune response and leads to an increased risk of infection. (Guo & Dipietro, 2010)

Chronic wounds and their management

If someone has a wound for more than eight weeks without any signs of it healing, it’s considered to be
a chronic wound. The management of chronic wounds include the following:

1. Cleaning the wound

The wound is often cleaned when the dressing is changed, normally using a saline (salt) solution. Overall,
though, not enough is known about the advantages and disadvantages of the various solutions that are
used to clean wounds, and how they affect the healing process. It’s also not yet clear whether tap water
could be used for the medical cleaning of wounds.

2. Debridement
When treating chronic wounds, doctors or nurses often remove dead or inflamed tissue. This is known
as debridement. The tissue is removed using instruments such as tweezers, a sharp spoon-like
instrument called a curette, or a scalpel. An enzyme-based gel is sometimes applied too, to help clean
the wound.

The wound can also be cleaned using a high-pressure water jet. Another form of debridement  involves
the use of a certain species of maggots (fly larvae) that are specially bred for medical purposes. The
maggots are placed on the wound, either as they are or in a pouch. They remove dead tissue and fluid
from the wound.

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Because debridement is often painful, a local anesthetic such as lidocaine is used to numb the wound
beforehand, for instance using an ointment. If more severe pain is expected, painkillers can also be
taken before treatment. Larger wounds are sometimes cleaned under general anesthetic. There is not
enough good research on the advantages and disadvantages of the various debridement techniques to
be able to say how effective they are.

3. Wound dressings
Once the wound has been cleaned, it is covered with a dressing. Most wounds are kept moist, for
instance with moist compresses. The dressings are used to remove excess fluid from the wound and
protect it from infection. They are usually left on the wound for several days. Dressings should be
changed if it’s clear that they can’t soak up any more wound secretions, if they slip out of place, or if
fluid leaks out of the bandage. It’s not yet possible to tell which types of wound dressings are most
suitable for different kinds of wounds because there isn’t enough good research in this area.

There are also dressings that contain substances called growth factors. These hormone-like substances
are meant to help the healing process by promoting the growth of the body’s cells. But there aren’t
enough good studies to be able to say whether treatment with growth factors is more effective than
conventional wound care for diabetic foot ulcers and other kinds of chronic wounds.

4. Antibiotics
Wounds are even less likely to heal well if they are infected with bacteria. Depending on how severe the
infection is, antibiotics may be considered. They can either be applied to the wound using an ointment
or placed on the wound using a compress. Initial study results show that wounds in people with diabetic
foot syndrome heal faster as a result. It’s not yet clear whether this also applies to wounds caused by
other underlying diseases.

5. Hyperbaric oxygen therapy

In hyperbaric oxygen therapy, the person with the wound goes into a special chamber to breathe in
oxygen under high pressure. This is meant to increase the oxygen concentration in their blood and
improve the blood supply to the wound area.

Research suggests that hyperbaric oxygen therapy can improve the healing of wounds in people with
diabetic foot syndrome.

6. Ultrasound and electromagnetic therapy

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Ultrasound therapy involves treating chronic wounds using sound waves. The sound waves make the
tissue warmer. But ultrasound therapy hasn't been proven to help the wound heal faster.

The same is true of electromagnetic therapy, where weak electromagnetic waves are applied to the
wound using pillows or mats that have magnets in them.

7. Negative pressure wound therapy

In negative pressure wound therapy (also called vacuum-assisted closure or VAC therapy), the wound is
covered with an airtight dressing that is connected to a pump by a thin tube. The pump continuously
sucks fluid out of the wound, creating negative pressure across the surface of the wound. The aim is to
increase the flow of blood to the wound. It helps keep the wound moist too, which is also meant to
improve the healing process. Pump systems are used in some hospitals to treat chronic or large open
wounds, for example following skin grafts. But they can also be used at home. The negative pressure is
either applied to the wound around the clock or at regular time intervals.

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References:

Anderson, K., & Hamm, R. L. (2014). Factors That Impair Wound Healing. The journal of the American

College of Clinical Wound Specialists, 4(4), 84–91. https://doi.org/10.1016/j.jccw.2014.03.001

Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of dental research, 89(3), 219–

229. https://doi.org/10.1177/0022034509359125

Herman TF, Bordoni B. Wound Classification. [Updated 2022 Apr 28]. In: StatPearls [Internet]. Treasure

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InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care

(IQWiG); 2006-. What are the treatment options for chronic wounds? 2006 Oct 17 [Updated 2018 Jun

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Kirsten Davidson. (2019). Wound assessment and management retrieved June 22, 2022 from

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