Al-Azhar University

Faculty of Medicine
General Surgery Department
 Wound management,
hypertrophic scar, keloid
 ILOs
By the end of this topic, you have to;
Enumerate types of closed wounds
Enumerate types of open wounds
Differentiate between contusion & hematoma
Compare between incised & lacerated wound
How to manage wounds?
Describe missile injury
How to mange patient comes with missile injury
Indications of amputation as a line of wound management
Define keloid & hypertrophic scar
Compare between keloid & hypertrophic scar
How to manage a patient comes with keloid or hypertrophic scar
 Types of wounds
Management of wound depends on types of wounds;
Types of wounds;
A) Closed wounds
1- Abrasions
2- Contusions
3- Hematoma
B) Open wounds
1- Incised wounds
2- Lacerated wounds
3- Crushed wounds
4- Penetrating wounds
5- Missile injuries
 Management of wounds

Abrasions; partial injury of superficial layer of the

skin.
Painful

Treatment: not more repeated dressings using

antiseptic solutions & non adherent dressings.
Abrasions
 Management of wounds
Contusions (Ecchymosis); extravasation of
blood through damaged small blood vessels (blunt
trauma),
Painful, swollen, discoloration of the skin (first red,
then blue & later green).
Treatment:
1- Cold fomentation in the first 24 hs
2- Local antiseptics & local anti-inflammatory cream
3- Elevation of contused area, to decrease pain &
oedema
4- Systemic anti-oedematous & analgesics
Contusions
 Management of wounds
Hematoma; localized collection of blood due to
rupture sizable blood vessel (subcutaneous,
subfacial, intramuscular, subperiosteal)
Painful swelling, discoloration of the skin may be
present if it is subcutaneous.

Treatment:
1- Cold fomentation
2- Antibiotics to guard against infection
3- If large; open surgery evacuation
4- If small; aspiration
 Management of wounds
Incised wound; caused by sharp cutting
instrument,
Clean cut edges, not much tissue damage, severe
bleeding due to clean cutting blood vessels
Lacerated wound; caused by blunt heavy
instrument,
Crushed edges, severe tissue damage, little bleeding
due to crushed blood vessels
Crushed wound; more extensive type of lacerated
wound,
Clean incised wound
Lacerated wound
Crushed wound
 Management of wounds
Penetrating wounds; may be;
Perforating; inlet & outlet.
Punctured; inlet only.
 The wound is small on surface but usually deep,
severe external bleeding due to clean cutting
blood vessels.
 Drainage is poor due to small external wound

 Internal organs and deep vessels may injured

 Management of wounds
Missile injuries; the amount of tissue damage
caused by missiles depends on the kinetic energy
(K) released by the missiles as it traverses: K= ½
(mass)*(Velocity)2
 Low velocity missile produces injury by its direct
effects
 High velocity missile produces tissue necrosis
several cm on either side of the missile track due
to associated shock wave & cavitation
phenomenon
 Internal organs and deep vessels may injured
Management of wounds
Missiles injury
 Management of open wounds
I- First aid;
1- Ensure a patent airways
2- Temporary control of bleeding
3- Immobilize the bone fracture
4- Sterile dressing to prevent contaminations
5- Anti-shock measures
6- Prophylaxis against tatanus
7- Antibiotics
II- In the operating room
1- Cleaning the wound by saline & antiseptic
solutions
2- Removal of foreign bodies
 Management of open wounds
III- Further management; depends on, nature of
wound, timing of the repair, degree of
contaminations
A) Wounds without skin loss:
1- Within 6-8 hours:
Clean incised wounds; (primary sutures),
including tendons & nerves
Lacerated wounds; (wound excision & primary
sutures)
Crushed wounds; (wound excision then daily
dressing & delayed primary sutures after 4-5 days)
 Management of open wounds
2- From 8-24 hours:
Clean incised wounds; (Daily dressing then
delayed primary sutures after 4-5 days),
Lacerated & Crushed wounds; (wound excision
then daily dressing & delayed primary (4-5 days) or
secondary (10-14 days) sutures)
3- After 24 hours:
(Debridement then daily dressing & secondary
sutures)

Wound excision; removal of devitalized tissues

Debridement; surgical cleaning of wound
 Management of open wounds
B) Wounds with skin loss: plastic
reconstructions according to time of wound (flaps or
grafts)
C) Wounds due to missiles:
 Carful surgical debridement & the wound is left
open
 Fasciotomy of all compartments of the limb in
case of high velocity injuries
D) Specific types of treatment:
 Microsurgery in hands & foots
 Amputation; in severely crushed limb,
uncontrolled infection, gangrene
 Hypertrophic scar
 Exaggerated normal maturation process
especially in children & deep burns
 Raised red firm scar never to continue to worsen
after 6 months

Treatment:
 Elastic pressure

 Steroid injection

 Silicon gel

 NOT to be excised
Hypertrophic scar
 Keloid
 Scar continues to enlarge after 6 months & invade
neighboring uninvolved skin especially in the
upper chest, shoulder & black men

Treatment: as hypertrophic scar, but if fail:

 Excision to be followed immediately by low dose
of radio-therapy.
Keloid
 Quiz
Enumerate types of closed wounds
Enumerate types of open wounds
Differentiate between contusion & hematoma
Compare between incised & lacerated wound
Describe missile injury
Patient comes with incised / lacerated wound within 6-8
hour/ 8-24 hour/ after 24 hour; how to manage
How to mange patient comes with missile injury
Indications of amputation as a line of wound
management
Define keloid & hypertrophic scar
Compare between keloid & hypertrophic scar
How to manage a patient comes with keloid or
hypertrophic scar