Chapter 6 Wounds

(1) Define wound. What are types of surgical wound.

(2) Classify wounds. Discuss each of them briefly.
(3) Describe phases of wound healing.
(4) What are factors affecting wound healing?
(5) Describe wounds in medicolegal aspect.
(6) Outline management of facial wounds.
(7) What are complications of wound healing?

1. Wound

Break in continuity of lining surface epithelium is defined as wound. Wound is seen in a wide variety of situations, e.g. after an accident, assault, surgery
and even self-inflicted wound. Wounds are classified into tidy and untidy wounds.

Types of surgical wounds

i. Clean Wound of elective surgery where hollow viscera* are not entered, e.g. lymph node biopsy.
ii. Clean contaminated Wound where hollow viscera* are entered with minimal contamination.
iii. Contaminated Wound where hollow viscera* are entered with uncontrolled spillage.
iv. Dirty Wound with pus in operative field, e.g. abscess drainage.
*Hollow viscera—gut, respiratory tract, genitourinary tract

2. Classification of wounds

From practical point of view

Tidy Wounds Untidy Wounds

These are clean wounds caused by sharp Soiled wounds caused by crushing and avulsion injuries. The
instruments and can be closed primarily. If underlying underlying structures (nerves, vessels, etc.) are crushed to
structures (nerves, vessels, etc.) are damaged, they variable extent. They cannot be closed primarily because in
can be repaired at the same sitting before wound presence of foreign bodies and devitalized tissues. High
closure. chances of wound infection, wound dehiscence, septicemia
and even death. Tx - wound toilet and excision of all dead
tissues so that it gets converted to a tidy

TYPES OF WOUND
Abrasion  Irregular tearing of only superficial layers of skin as body skids on a rough surface.
 Severe pain(Exposed Bleeding points and sensitive nerve endings)
 Dirt gets embedded in the wound.
 Wound toilet, dressing for management.
 Abrasions of face may be left uncovered. Healing occurs in about 10 day’s time.
In case of infection full thickness skin loss may occur.
Contusion • Skin surface remains intact and subcutaneous bleeding occurs, leading to swelling and
skin discoloration.
• The color- red, gradually > blue > black, fades > greenish yellow > normal skin color.
• No treatment is required
Hematoma • More severe injury leading to collection of large volume of blood in tissue planes.
• Large hematomas need intervention -
• requires incision and drainage (Abscess formation)
• can be aspirated with a wide bore needle to liquefied hematoma(a cystic swelling (seroma))
• A large hematoma producing pressure effects (e.g. intracranial hematoma) > Surgery
• A hematoma in a muscle may organize into fibrous tissue producing a very firm swelling.
may be replaced by calcifying osteoid tissue (myositis ossificans), quadriceps femoris muscle
Incised wound • caused by sharp knife, metal and glass.
• Clean wounds and injury occurs along the track of penetration.
• Ideal for primary closure if done within 6 hours of injury.
Lacerated wound • irregular and untidy wounds caused by crushing and tearing forces
• Contusion and abrasion of surrounding area.
• Nerves and vessels may be stretched and torn rather than cleanly divided.
• Grossly contaminated with dust and foreign materials, rapid proliferation of bacteria in dead
and devitalized tissues > infection.
• Tx - wound toilet, excision of dead tissue, primary closure within 6 hours.
• If delayed, the wound should be left open and repaired after a few days when edema and inflammation has subsided.
Punctured wound • Deeper than their length, caused by stabbing action of a long, thin weapon
• A punctured wound can be:
• Penetrating wound: It is an entry wound only.
• Perforating wound: It has both entry and exit wound.
• potentially lethal
• High velocity bullets create shock waves while passing through the tissues,
causes widespread tissue destruction due to cavitational effect

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 Avulsion wound • Caused by shearing force that detaches the skin from its underlying structures.
• The raised skin flap may remain attached at one edge; degloving injury.
(separation is between subcutaneous fat and deep fascia)
• Tx - thorough cleansing of the wound, excision of obvious dead tissues and
reposition of skin flap with a few stitches.
• Risk - devascularized skin flap will slowly necrose and become dead.
• Skin flap is completely detached and crushed > wound requires skin grafting after
thorough toilet and debridement of dead tissues.
Crushed wound • Severe blunt injury to the tissues leading to inflammation, edema and bleeding within closed fascial compartments.
• Rise in interstitial pressure leading to decreased blood flow and muscle ischemia that further adds to interstitial edema
• a vicious cycle starts leading to progressive ischemia of muscles and nerves and then limb loss
(Compartment syndrome), can cause acute renal failure.
• Tx - urgent fasciotomy. Longitudinal incisions are given on skin and deep fascia, compressed muscles are released
and restored circulation.

3. Phases of wound healing

- If wound edges are approximated as is done in a clean incised wound, called as healing by primary intention.
- If wound edges cannot be approximated due to presence of devitalized tissue, called as healing by secondary intention.

1. Phase of inflammation (Day 1-4) • “Lag phase”

• Bleeding d/t injury contact with collagen tissue and activates kinins, complement cascade,
clotting factors activated and platelets aggregate. (blood clot formation)
• RBC and WBC escape into the wound ( capillary permeability)
• Polymorphs remove dead tissues during initial 48 hrs.(as scavengers)
• Monocytes act as scavengers.(3rd to 5th day)
• 5th day, capillary budding and fibroblast proliferation starts  granulation tissue formation.
2. Phase of granulation tissue (Day 5-20) • The granulation tissue is rich in fibroblasts that secrete collagen and ground substance.
• The fibroblasts  protocollagen (immature form)  collagen (mature form), hydroxylation.
• mature collagen fiber gives strength to the tissues
• Ground substance = a thin gel like binding agent (binds the collagen fibers)
3. Phase of scar formation (Day 20 onwards) • haphazardly arranged collagen fibers takes place
• New collagen fibers synthesized in an orderly fashion along lines of tension in the scar.
• Vascularity becomes less and ingrowth of nerve fibers and lymphatics takes place.
• imperceptible scar remodeling and gain in strength continues up to 2 years
• scar revision for cosmetic reasons should not be done before 1 year.

4. Factors affecting wound healing

General factors Local factors

Old age Wound hematoma
Anemia Wound infection
Hypoproteinemia Necrotic tissue in wound
Uremia Foreign material in wound
Diabetes Poor blood supply
Jaundice Tension on suture line
Malignancy Faulty wound closure
Chemotherapy Lack of rest to the sutured area
Steroids Local radiotherapy
Immunodeficiency
(HIV infection)

5. Wounds in medicolegal aspect

 First examine the patient as a whole and look for vital signs—pulse, blood pressure, respiration, consciousness level, temperature, etc.
 Examine the wound

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  Examine structures deep to the wound viz:

In limbs Look for major vessel injury by feeling peripheral pulses.

Look for tendon injury by testing movements.
Look for nerve injury by testing sensations and movements.
Look for any fractured bones
In head Look for injuries to skull, brain, eyes and ears.
In chest Look for injuries to lungs, heart and great vessels.
In abdomen Look for injury to solid and hollow viscus.

6. Management of facial wounds

 Facial wounds bleed profusely due to high vascularity.

 Facial artery can be tied safely without ischemic tissue damage (rich collateral circulation).
 Careful clinical examination
 Examine inside of the mouth
 X-ray is indicated
 Ragged skin edges need minimum trimming
 Deep tissues are repaired with absorbable sutures
 Skin is accurately approximated with several, fine, non-absorbable sutures.
 Wounds crossing linear features must accurately approximated (e.g. lips)
 A wound inside mouth should be sutured first
 Skin sutures are removed on 4th day since wound heals (rich blood supply and less cross marks)

7. Complications of wound healing

Wound infection • complains of throbbing pain

• the wound is tense and inflamed
• The skin sutures need to be removed, wound laid open to allow free drainage of pus
• Pus culture sensitivity, wound dressed regularly, antibiotics
• secondary suturing
Hypertrophic scar • The stages in formation of scar-
• Healing (0-4 weeks): The scar is fine, soft, not contracted and not strong.
• Remodeling (4-12 weeks): The scar is red, raised, itchy, tender and starts contracting.
• Maturation (12-40 weeks): The scar becomes soft, supple and white and tends to
relax.
• If the scar remains in remodeling stage for a longer time, it is called as hypertrophic scar
Keloid (like a Claw) • Excessive growth of the scar tissue
• spreads like a claw into adjoining normal tissues
• itching, erythematous and spreading margins.
• continues to grow even after 1 year or 5-10 years
• Treatment is extremely difficult.
• Use of pressure garments and intralesional injection of triamcenolone with hyalase
(Control Growth)
Skin pigmentation • Pigments
Contractures • final scar is always shorter than original wound.
• The scar should be placed parallel to the line of wrinkle (looks like another wrinkle)
• On face and neck, the lines of wrinkles are at right angles to the direction of fibers of
underlying muscles
• Linear scars cutting the lines of wrinkles, can restrict mobility
• More common if healing occurs with secondary intention, e.g. post-burn contractures.
• The treatment is by doing plastic procedures like Z plasty, Y-V plasty or scar excision with
skin grafting.
Marjolin’s ulcer • Squamous cell carcinoma developing in long-standing scar is called as Marjolin’s ulcer

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