WOUNDS AND THEIR

MANAGEMENT
Dr. Solomon Mamo
Dept. of Surgery, APH
 INTRODUCTION
• Majority of surgical patients have wounds as any
elective surgical intervention will result in a wound.
• In some cases, e.g. in the traumatic patient the
wound is the primary pathology.
• In both situations the task of the surgical team
(including doctors, nurses, ward assistants, orderlies)
is to minimise the adverse effects of the wound,
remove or repair damaged structures and harness
the process of wound healing to restore function
 INTRODUCTION
• A wound can be caused by almost any
injurious agent:
– physical trauma,
– dry/wet heat as occurs in burns
– chemicals.
 CLASSIFICATION OF WOUNDS
(Rank and Wakefield)

• TIDY WOUNDS:
– Usually inflicted by sharp instruments and contain
no devitalized (dead) tissue. E.g. surgical incisions,
cuts from glass and knife wounds.
– Can be closed and allowed to heal by primary
intension.
– Tendons, arteries and nerves are commonly
injured in tidy wounds. Repair of such injuries is
usually possible.
– Fractures are uncommon in tidy wounds.
 CLASSIFICATION OF WOUNDS
(Rank and Wakefield)

• UNTIDY WOUNDS:
– Result from crushing, tearing, avulsion, vascular
injury or burns and contain devitalised tissue.
– Tendons, arteries and nerves may be exposed, and
might b injured in continuity.
– Fractures are common and often occur in multiple
fragments.
– Must not be closed primarily as healing is unlikely
to occur without complications if it is so done.
 CLASSIFICATION OF WOUNDS
(Rank and Wakefield)

• UNTIDY WOUNDS:
– If closed primarily, wound dehiscence, infection
and delayed healing may occur.
– In severe cases, wet gangrene and subsequent
death may result.
– Managed by debridement first to make it clean.
Afterwards it can be closed primarily or allowed to
heal by secondary intention.
 WOUND DEBRIDEMENT
(a.k.a. Wound Excision or Wound toilet)

• The most important step in the management

of untidy wounds.
• Excision of devitalised tissues. When
devitalised;
– The dermis becomes pink rather than white
– Fat becomes pink rather than yellow
– Muscle becomes dark, loses its usual sheen and
turgor and does not twitch when picked up with
forceps.
 TYPES OF WOUND
• Bruise, contusion and haematoma
• Puncture wounds and bites
• Abrasions and friction burns
• Laceration
• Traction and avulsion
• Crush
BRUISE, CONTUSION AND HAEMATOMA

• Bruise and contusion results from a closed

blunt injury. There is no break in the skin.
• There is bleeding into the tissues and visible
discolouration.
• A haematoma results when the there is
sufficient bleeding leading to accumulation of
blood.
• Accumulated blood usually clots but liquefies
again within a few days.
BRUISE, CONTUSION AND HAEMATOMA

• There is a danger of secondary infection.

• Bruises require no specific management, and
no treatment is of proven value.
• A haematoma should be evacuated by open
surgery if large or causing pressure effects
(e.g. intracranial haematoma), or aspirated by
a large-bore needle if smaller or in a
cosmetically sensitive site.
 PUNCTURE WOUNDS AND BITES
• A puncture wound is an open injury in which
foreign material and organisms are carried
deeply into underlying tissues. E.g. nail prick.
• Treatment is essentially by wound irrigation,
antibiotic treatment and tetanus prophylaxis.
• Large foreign bodies should be removed.
• May result in abscess formation deep within the
tissues which would require an incision and
drainage.
 PUNCTURE WOUNDS AND BITES
• Bites are puncture wounds associated with a
high incidence of infection from mouth
organisms.
• The wounds may be
– Small, sharp and incised in nature
– Moderate with some avulsion (dog bites)
– Large with severe tissue crushing. (??horse bites)
• Depending on the size of the wound, surgical
exploration may be needed.
ABRASIONS AND FRICTION BURNS
• An abrasion is a shearing injury of the skin in
which the surface is rubbed off.
• Usually superficial and heal by epithelialization;
others may result in full thickness skin loss.
• Usually has dirt ingrained in it. This must be
removed at the time of primary treatment
otherwise permanent tattooing of the skin may
result.
ABRASIONS AND FRICTION BURNS
• Treatment is by cleaning with a scrubbing
brush, gently brushing along the grain of the
scratch lines.
• A friction burn is similar but may include an
element of a thermal burn as well as abrasion.
• Should be managed as a burn.
 LACERATION
• Results from contact with a sharp object.
• Like a surgically incised wound.
• The integrity of arteries, nerves, muscles tendons
and ligaments in the area must be assessed.
• Ideally, the wound should be surgically
inspected, cleaned and closed by suturing.
• Damaged structures must be repaired during
closure.
 TRACTION AND AVULSION
• Avulsion injuries are open injuries in which
there is associated severe tissue damage.
• Occurs when limb is trapped in a moving
machinery such as rollers, producing a
degloving injury.
• The danger of avulsion injuries is that there is
devascularisation of tissue and skin necrosis
may result in a few days.
 TRACTION AND AVULSION
• Treatment of such injuries involve
– Removal devitalized skin
– Defat the skin and reapplly as full thickness skin
graft.
 CRUSH
• Associated with degloving and compartment
syndrome.
• There is injury to tissues with a closed fascial
compartment leading to bleeding , exudation and
swelling of these tissues and ↑sed interstitial
pressure.
• Eventually, if no interceptive measures are instituted,
muscle and nerve ischeamia will result which will
lead to necrosis of muscle and skin and limb loss.
OTHER WOUNDS
 CHRONIC WOUNDS
Ulcers
• An ulcer is a breach in an epithelial lining.
• Chronic ulcers are wounds that fail to heal
• Commonest sites are lower third of the lower
limb and foot.
• Ulcers often result from the non-healing of
wounds.
 CHRONIC WOUNDS
Ulcers
• Delay in the wound healing is a result of
– infection
– mechanical irritation
– ischemia
– other metabolic factors.
• Ulcers are common in patients with diabetes
and rheumatoid arthritis
 CHRONIC WOUNDS
Ulcers
• An ulcer is managed by
– First, treating the underlying cause
– Dressings as frequent per day as may be necessary
to allow healing by secondary intention, or by
secondary suturing or skin grafting.
 CHRONIC WOUNDS
Pressure Sores
• These are chronic wounds that result from tissue
necrosis from pressure.
• Occur over bony prominences.
• Usually occur in
– Patients who are paraplegic and who lack the ability to
move themselves. (sacral and trochanteric sores)
– Bed bound (sacral and trochanteric sores) or chair bound
patients (ischial sores)
– Patients with peripheral vascular disease. (heal pressure
sores)
 CHRONIC WOUNDS
Pressure Sores
• Prevention is better than cure
• This depends on
– Awareness of pressure sore risk in all patients
– Implementation of appropriate measures
• Turning or lifting the patients frequently
• Treatment of pressure areas.
• Pressure-relieving mattresses and beds
• Special seating and cushions
• Educating the patient and carers in taking responsibility
for pressure relief.
 CHRONIC WOUNDS
Pressure Sores
• Urinary and faecal incontinence should be
managed appropriately
• Nutritional support should be provided If
needed.