WOUNDS AND WOUND

HEALING
WOUNDS DEFINITON

A wound is a break in the integrity of skin or

tissues often which may be associated with the
disruption of structure and function
 Classification of wounds

RANK AND WAKEFIELD CLASSIFICATION

a) Tidy wounds
b) Untidy wounds

Tidy wounds
These are wounds like surgical incisions and wounds
caused by sharp objects
It is incised clean healthy wounds without any tissue loss
usually primary suturing is done. Healing is by
primary intention.
b) Untidy wounds
They are due to
 Crushing
 Tearing
 Avulsion
 Devitalised injury
 Vascular injury
 Multiple irregular wounds
 Burns
 Untidy..

 Fractures of the underlying bone may be present

 Wound infection, delayed healing are common
 Liberal excision of devitalised issue and allowing
to heal by secondary intention is the management
 Secondary suturing, skin graft or flap may be
needed.
Classification based o the thickness of the wound

1. Superficial wound: involving only the epidermis

and dermal papillae
2. Partial thickness wound: with skin loss up to
deep dermis with only deepest part of the
dermis, hair follicle shafts and sweat glands are
left behind
3. Full thickness wound: with loss of entire skin
and subcutaneous tissue causing spacing out of
the skin edges.
4. Deep wounds: are the ones extending deeper
across deep fascia into muscles or deeper
structures
5. Complicated wounds: associated with injury to
vessels and nerves
6. Penetrating wounds: ones which penetrate into
either natural cavities or organs
 Classification based on involvement of structures

1.Simple wounds: involving one organ or tissue

2. Combined wounds: involving mixed tissues
 Classification based on the time
elapsed
 Acute wound: up to 8 hours of trauma
 Chronic wound: after 8 hours of trauma
 Classification of surgical wounds

1. clean wounds
 Herniorraphy
 Excisions
 Surgeries of the brain, joints, heart, transplant
 Infective rate is less than 2%
 Cont..

2. Clean contaminated wound

 Appendicectomy
 Bowel surgeries
 Gall bladder, billiary and pancreatic surgeries
 Infective rate is 10%
 cont..

3. Contaminated wounds
 Acute abdominal conditions
 Open fresh accidental wounds
 Infective rate is 15 to 30%
 Cont..

4.Dirty infected wounds

 Abscess drainage
 Pyocele
 Empyema Gallbladder
 Fecal peritonitis
 Infective rate is 40 to 70%
 Wound healing
 Wound healing is a complex method to achieve
anatomical and functional integrity of disrupted
tissues by various components like; neutrophils,
macrophages, lymphocytes, fibroblasts, collagen; in
an organised staged pathways
 Hemostasis…inflammation…ploriferation…matrix
synthesis(collagen and proteogycan ground
substance)…maturation…remodelling…
ep)ithelialisation…wound contraction(by
myofibroblasts)
 Types of wound healing

Primary healing(First intention)

it occurs in a clean incised wound or surgical
wound Wound edges are approximated with
sutures There is more epithelial regeneration
than fibrosis Wound heals rapidly with complete
closure Scar will be linear and smooth
Secondary healing(second intention)

 It occurs in a wound with extensive soft tissue

loss like in tissue trauma, burns, and wounds
with sepsis
 It heals slowly with fibrosis
 It leads into a wide scar often hypertrophied an
contracted
 It may lead into disability
 Re epithelialisation occurs from remaining
dermal elements or wound margins.
 Healing by Third intention(Tertially wound
healing or delayed primary closure)

After wound debridement and control of infection

wound is closed with sutures or covered using
skin graft.
 Primary contaminated or mixed tissue wounds
heal by tertially intention.
 Stages of wound healing
1. Stage of Inflammation
2. Stage of Granulation tissue formation and
organization. Fibroblastic activity, synthesis of
collagen and ground substance occurs.
3. Stage of Epithelialisation
4. Stage of Scar formation and resorption
5. Stage of Maturation
 Phases of wound healing

Inflammatory phase (lag or substrate or exudative phase)

 It begins immediately after wound formation, it lasts for 4
to 6 days
Features of inflammation are: Red, pain, swelling, Hot, loss
of function
 Macrophages secrete fibroblastic growth factor which
enhances angiogenesis
 Polymorphonuclear leukocytes appear after 48 hours
which secrete inflammatory mediators
 These cells also remove clots, foreign bodies and bacteria
 Chemical factors involved in wound
healing
1. Growth factor..platelet derived, epidermal, and
transforming
2. Interleukin
3. Tumor necrosis factor
4. Prostaglandins
5. Collagenase
6. Elastase
 Here, Hemostasis, coagulation, and chemotaxis
occur.
 Coagulation begins in wound hematoma…
formation of platelet fibrin thrombus….release of
cytokines, PDGF, TGF/p, Platelet Activating Factor,
fibrin, serotonin
 Proliferative phase(collagen/fibroblastic
phase)
 It begins in 7 days and lasts for 6 weeks.
 Collagen and glycosamines are produced by
fibroblasts
 Hydroxyproline and hydroxylysine are synthesised by
specific enzymes using iron, alpha ketoglutarate, and
vitamin c
 Tropocollagen is produced which aggregates to form
collagen fibrils
 80 to 90% of their final strength in post operative
wounds) is achieved in 30 days.
Remodeling phase(maturation phase)

 It begins at 6 weeks and lasts for 2 years

 There is maturation of collagen by cross linking which
is responsible for tensile strength of the scar
 Collagen production is not present after 42 days of
wound healing
 Initially, fibrin, fibronectin, proteoglycan deposition
occurs; later collagen protein develops to form scar.
 Normal dermal skin contains 80% type 1, & 20 % type
3 collagen; granulation tissue contains mainly type 3
collagen; scar contains both type 1 and type 3 equally
Factors affecting wound healing
Local factors
1. Infection
2. Presence of necrotic tissue and foreign body
3. Poor blood supply
4. Venous or lymph stasis
5. Tissue tension
6. Hematoma
7. Large defect or poor apposition
8. Recurrent trauma
9. X-ray irradiated area
 Factors affecting wound healing
10. Site of wound e.g wound over the joint and back
has poor healing
11. Underying diseases e.g osteomyelitis and
malignancy
12.Mechanism and type of wound..
incised/ lacerated /crush
13.Tissue hypoxia locally reduces macrophage and
fibroblast activity
 General factors

1. Age
2. Obesity
3. Smoking
4. Malnutrition. Zinc, copper, manganese, Vit C, vit A
5. Anaemia
6. Malignancy
7. Immunosuppresive dz e.g HIV, Diabetes etc
8. Use of Steroids and cytotoxic drugs
Complications of wound healing

 Infection
 Hypertrophic scars and contractures
 Shock
 Air/fat embolism
 Pneumothorax
 Effects of to vital organs e.g brain,heart, lungs
 Management of Wounds
 Antibiotics, fluid and electrolyte balance, blood transfusion,
tetanus toxoid, (0.5 ml intramuscular to deltoid muscle) or
antitetanus globulin (ATG) injection.
 Wound debridement (wound toilet, or wound excision) is
liberal excision of all devitalized tissue at regular intervals (48-72
hours) until healthy, bleeding, vascular tidy wound is created.
Primary suturing means suturing the wound immediately
within 6 hours. It is done in clean incised wounds.
Delayed primary suturing means suturing the wound in
48 hours to 10 days. It is done in lacerated wounds.
This time is allowed for the oedema to subside.
 Management of Wounds
Secondary suturing means suturing the wound in
10-14 days or later. It is done in infected wounds.
After the control of infection, once healthy
granulation tissue appears, secondary suturing is
done.
Principles of wound suturing

--Primary suturing should not be done if there is

oedema I infection/ devitalised tissues I haematoma
--Always associated injuries to deeper structures like
vessels I nerves or tendons should be looked for before
closure of the wound
--Wound should be widened by extending the incision
whenever needed to have proper evaluation of the
deeper structures - proper exploration.
 Principles of wound suturing

-- Proper cleaning, asepsis, wound excision/ debridement

-- Any foreign body in the wound should be removed
--Skin closure if it is possible without tension
-- Skin cover by graft /flap - immediate or delayed
-- Untidy wound should be made tidy and clean before
suturing
-- Proper aseptic precautions should be undertaken
-- An tibiotics/analgesics are needed
-- Sutured wound should be inspected in 48 hours
-- Sutures are removed after 7 days