Module 5-Healing and Repair

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LECTURE 4
Healing and Repair
Wound Assessment and Primary Care

 Patient History and Physical Exam
 Time and mechanism of injury.
 Neurological and vascular examination distal to the
sight of injury.
 Ensure tetanus shot is up to date.
 Anesthesia – Lidocaine/epinephrine; avoid
epinephrine in fingers and toes.
 Tourniquet – Used for extremities and digits only
in cases of excessive and life-threatening
hemorrhage.
GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO
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ANDREW

 Wound preparation
 Cleanse surrounding skin with a surgical solution
but use only a physiologic solution, such as normal
saline, on wound itself to prevent further tissue
damage.
 Remove, by careful scrubbing, any dirt, gravel or
other foreign materials that may lead to traumatic
tattooing.

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 Wound exploration and hemostasis
 Explore wound carefully for any foreign bodies
and to determine extent of injury by assessing
tissue injury, amount of tissue lost, and the degree
of injury to deeper structures.
 Hemostasis by means of direct pressure, elevation,
electrocautery, or suture ligation.

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 Débribement
 After viability of wound margins are assessed,
remove all devitalized tissue and excise ragged
edges to prepare for realignment.
 The goal of débribement is to produce a clean,
bleeding margin of viable tissue.

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 Antibiotic usage
 Antibiotics can be used prophylactically, before a
surgical wound is made, or empirically, in the case
of a traumatic wounds.
 In either case, the location and age of the wound, as
well as the mechanism of injury/surgical incision
should be considered to determine the microbes
most likely of concern for infection.

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Types of Wounds
 Lacerations
 Injury where tissue is cut or torn. For treatment,
tissue is first cleansed of any blood clots and
foreign material, débribed and irrigated. Local
anesthetic is administered and atraumatic technique
of wound closure is employed, where wound
margins are realigned with careful regard to
prevention of any further crush injury to tissues.
Sterile dressings are applied and immobilization is
recommended for complex extremity wounds.

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Types of Wounds
 Abrasions
 Injury where a superficial layer of tissue is removed, as
seen with 1st degree burns. The wound is cleansed of
any foreign material, sometimes employing a scrub
brush to prevent traumatic tattooing by dirt and gravel,
and should be performed within the first day of injury.
Local anesthetic can be used for pain, however
treatment of the wound is non-surgical, using moist
dressings and a topical antibiotic to protect the wound
and aid healing.
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Types of Wounds
 Contusions
 Injuries resulting from a forceful blow to the skin
and soft tissue, however leaving the outer layer of
skin intact. These injuries generally require
minimal care as there is no open wound. However,
contusions should be evaluated for possible
hematoma deep to the surface or other tissue
injuries that may indicate more severe morbidity.
An expanding hematoma can damage overlying
skin and demands evacuation.

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Types of Wounds
 Avulsions
 Injuries where a section of tissue is torn off, either
partially or in total. In partial avulsions, the tissue is
elevated but remains attached to the body.
 A total avulsion means that the tissue is completely
torn from the body with no point of attachment.
 In the case of a partial avulsion where the torn tissue is
still well-vascularized and viable, the tissue is gently
cleansed and irrigated and the flap is reattached to its
anatomical position with a few sutures.
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Types of Wounds
 Avulsions
 If the torn tissue is non-viable, it is often excised and
the wound closed using a skin graft or local flap.
 In the case of a total avulsion, the tissue is often very
thick and demands debulking and defattening
methods before it can be regrafted.
 Major avulsions describe amputation of extremities,
fingers, ears, nose, scalp or eyelids and require
treatment by a replant team.

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Wound Closure
1.) Factors determining method of wound closure:
 Type of wound
 Size of wound
 Location
 Age of wound
 Presence of infection
 General condition of the patient
 Urgency of closure
 Antibiotics needed
 Follow-up needed and achievable for patient

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Wound Healing
 Regeneration – Replacement of a single type of
parenchymatous cells by production of more cells
of the same kind.
 Somatic cells may be divided into three types:
1) Labile cells – Can continue to multiply
throughout life e.g. epidermis, alimentary,
respiratory and urinary tract epithelium, uterine
endometrium and heamatopoietic bone marrow
and lymphoid cells.

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Healing
2) Stable cells – Ceases multiplication when
growth ceases but retain mitotic ability
during adult life e.g. liver, pancreas, renal
tubular epithelium and adrenal cortex
3) Permanent cells – Lose their mitotic ability
in childhood e.g. the neuron

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Healing….
 Most healing of an organ or tissue occurs by
regeneration, the cells lost being replaced by
proliferative activity of those remaining
 When damage involves a cell type incable of
regeneration or due to other factors like interuption
of blood supply, healing occurs by formation of
fibrous tissue.

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Types of Wound Healing
Healing by first intention
 Also called primary wound healing or primary closure
 Describes a wound closed by approximation of wound
margins or by placement of a graft or flap, or wounds

created and closed in the operating room.
 Best choice for clean, fresh wounds in well-
vascularized areas
 Occurs in uninfected surgical incisions and other
clean wounds without loss of tissue
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Healing by first intention
 Characterized by minimal amounts of granulation
tissue
 Indications include recent (<24h old), clean wounds
where viable tissue is tension-free and approximation

and eversion of skin edges is achievable.
 Wound is treated with irrigation and débribement and
the tissue margins are approximated using simple

methods or with sutures, grafts or flaps.
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Healing by first intention…
 Final appearance of scar depends on: initial injury,
amount of contamination and ischemia, as well as

method and accuracy of wound closure, however
they are often the fastest and most cosmetically
pleasing method of healing.

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Healing of skin wounds
 Sequence of events include: First two days
Blood clots between the wound edges and
on the surface where it clots to form a scab
Removal of clot and dead tissue by action
of polymorphs and later macrophages
Rapid spread of epithelium beneath scab to
bridge the wound surface within the first
two days
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Healing of skin wounds….
 Next 3-5 days:
 Capillaries and fibroblasts grow in beneath
the epithelium
 Collagen formed by the fibroblasts begin to
bind the wound edges together by the end of
the first week reaching a maximum in two
or three weeks
 Wound strength slowly increases over many
months
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Healing by second Intention
 Also called secondary wound healing or spontaneous
healing
 Describes a wound left open and allowed to close by
epithelialization and contraction.
 It occurs by formation of granulation tissue which
grows from the base of the wound to fill the defect.
 The vascular and fibroblastic proliferation
(granulation tissue) are usually much more abundant
and healing takes longer than by first intention.

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 Commonly used in the management of contaminated
or infected wounds.
 Wound is left open to heal without surgical
intervention.
 Indicated in infected or severely contaminated
wounds.
 Unlike primary wounds, approximation of wound
margins occurs via re-epithelialization and wound
contraction by myofibroblasts.

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 Complications include late wound contracture and
hypertrophic scarring
 To speed the healing skin grafts are increasingly
used.

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Healing by third intention
 Also called tertiary wound healing or delayed
primary closure
 Useful for managing wounds that are too heavily
contaminated for primary closure but appear clean
and well vascularized after 4-5 days of open
observation. Over this time, the inflammatory
process has reduced the bacterial concentration of the
wound to allow safe closure.
 Subsequent repair of a wound initially left open or
not previously treated.

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Healing by third intention
 Indicated for infected or unhealthy wounds with high
bacterial content, wounds with a long time lapse
since injury, or wounds with a severe crush
component with significant tissue devitalization.
 Often used for infected wounds where bacterial count
contraindicates primary closure and the inflammatory
process can be left to débribe the wound.
 Wound edges are approximated within 3-4 days and
tensile strength develops as with primary closure.

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Partial Thickness Wounds
 Wound is superficial, not penetrating the entire
dermis.
 Type of healing seen with 1st degree burns and
abrasions.
 Healing occurs mainly by epithelialization from
remaining dermal elements.
 Less contraction than secondary healing in full-
thickness wounds
 Minimal collagen production and scar formation.
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Infected wounds
 Healing is by second intention
 Repair is accomplished by the production of
granulation tissue
 There is a more pronounced inflammatory process
and formation of larger and more numerous blood
vessels
 Some wounds require through cleaning called
surgical toilet to hasten healing ie. Removal of
dead tissue
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Infected wounds….
 Granulation tissue is a good defence against
bacterial infection because of its rich blood supply
and ability to mount an effective immune response
 Infection inhibits both epithelial regeneration and
proliferation of fibroblasts and delays healing.

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Skin grafting
 When a skin graft is placed on a recipient site it adheres to the
new bed by fibrin and is nourished by diffusion of plasma
from the raw surface.
 Within 3 days capillary buds grow from the recipient area and
begin to unite with those on the undersurface of the graft;
ingrowing fibroblasts produce collagen which anchors the
graft more firmly.
 Rapid take is encouraged by: Good vascularity of the bed with
no heamatoma formation, control of pathogenic infection,
close undisturbed contact with the graft.

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Skin grafting….
 Grafts from the same individual (autografts) persist
indefinately.
 Grafts from another individual (homografts) are
accepted initially but are destroyed within a month
or so by immune reaction; They provide temporary
cover of extensive raw surfaces e.g. large burns;
They also help to control excessive contraction of
the area

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Physiological stages of Wound Healing
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Physiological Stages of Wound Repair
 1.) Inflammatory Phase

 Initial response to injury
 Day 1-4 post injury
 Characterized by rubor, tumor, dolor, calor
 Platelet aggregation and activation
 Leukocyte (PMNs, macrophages) migration,
phagocytosis and mediator release

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 1.) Inflammatory Phase…

 Venule dilation
 Lymphatic blockade
 Exudative
 In wounds closed by primary intention, lasts 4
days
 In wounds closed by secondary or tertiary
intention, continues until epithelialization is
complete
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 2.) Proliferative Phase

 Day 4-42
 Fibroblast proliferation stimulated by
macrophage-released growth factors

 Increased rate of collagen synthesis by
fibroblasts
 Granulation tissue and neovascularization
 Gain in tensile strength

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 3.) Remodeling Phase

 6wks-1 year
 Intermolecular cross-linking of collagen via
vitamin C-dependent hydroxylation

 Characterized by increase in tensile strength
 Type III collagen replaced with type I
 Scar flattens

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Factors that Impair Healing
 Local factors
 Infection
 Poor local blood supply
 Defects in collagen formation e.g. deficiency
of vitamin C or sulphur containing aminoacids
or excess glucocorticoids or zinc deficiency
 Precence of heamatoma
 Contaminated wounds

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Factors that Impair Healing
 Systemic factors
 Metabolic disorders like diabetes mellitus
and cushings syndrome
 Immunosuppressive disorders
 Ureamia
 Zinc deficiency – Zinc is necessary for the
synthesis of collagen

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Dressings
 Dressings protect the wound from further trauma and
provide a moist, antibacterial environment for healing.
 Sometimes in addition to moist or medicated bandage,
splinting or casting is performed on the affected limb.
 If aberrant scarring is suspected, pressure bandages can
be used to suppress scar hypertrophy.
 Dressing changes at regular intervals is paramount to
preventing infection and optimizing wound healing.

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The Ideal Dressing
 Provides protection from further injury or
infection
 Permits movement of joints and body parts
proximal to the wound

 Exercises some compression on the wound
site to control bleeding and scarring

 Absorbs fluids draining from the wound
 Ultimately contributes to an improved esthetic
outcome for the resulting scar

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The Ideal Dressing
 2.) Wound Care Options
 Ointments
 Impregnated gauze
 Gauze packing
 Hydrocolloids
 Hydrogels
 Alginates
 Adhesive films

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Abnormal Wound Healing
 1.) Hypertrophic scars
 Remain within boundaries of original scar
 Common areas of occurrence are back,
shoulders or sterum
 Red, raised and often pruritic
 Can resolve with time and often treated
conservatively

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 2.) Keloid scarring
 Extend beyond boundaries of original scar
 Common areas of occurrence are sternum, deltoid
and earlobe
 More frequently occur in darkly-pigmented
people
 Do not spontaneously heal and demand treatment
with pressure bandages, surgery, radiation or
topical steroids; reoccurrence is common.

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 3.) Chronic Wounds
 Lacerations and open injuries older than 24h
 Require débribement, irrigation, and healing
by secondary or tertiary intention

 Wound sepsis is determined by the total
bacterial load per gram tissue (>105

bacteria/gram tissue)

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 Systemic antibiotics not useful, however
topical antibiotic creams (silver sulfadiazine,

bacitracin, Neosporin) for areas of partial
thickness loss may be useful.
 Be aware that some of these agents inhibit
epithelialization and the initial stages of

wound healing
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 Biological dressings can be used
 Final closure should be performed only after
bacterial contamination is controlled

 Deep sutures should be kept to a minimum
and monofilament. If any signs of infection

seen on reevaluation, portion of wound is
opened by removing sutures
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Healing of Fractures
 Problem
 A fracture is defined as a disruption in the
integrity of a living bone, involving injury to

the bone marrow, periosteum, and adjacent
soft tissues.
 Many types of fractures exist, such as
pathologic, stress, and greenstick fractures.

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 Etiology
 Fractures occur when the force applied to a bone
exceeds the strength of the involved bone.
 Both intrinsic and extrinsic factors are important
with respect to fractures.
 Extrinsic factors include the rate at which the
bone’s mechanical load is imposed and the
duration, direction, and magnitude of the forces
acting on the bone.
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 Etiology
 Intrinsic factors include the involved bone’s
energy-absorbing capacity, modulus of

elasticity, fatigue, strength, and density.
 Bones can fracture as a result of direct or
indirect trauma.

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 Etiology
 Direct trauma consists of direct force applied
to the bone; direct mechanisms include

tapping fractures (eg, bumper injury),
penetrating fractures (eg, gunshot wound), and
crush fractures.
 Indirect trauma involves forces acting at a
distance from the fracture site such as tension

(traction), compressive, and rotational forces.
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 Pathophysiology
 The 5 phases of fracture healing are the
following:
 Fracture and inflammatory phase
 Granulation tissue formation
 Callus formation
 Lamellar bone deposition
 Remodeling

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 Actual fracture injuries to the bone include insult
to the bone marrow, periosteum, and local soft
tissues.
 The most important stage in fracture healing is
the inflammatory phase and subsequent
hematoma formation.
 It is during this stage that the cellular signaling
mechanisms work through chemotaxis and an
inflammatory mechanism to attract the cells
necessary to initiate the healing response.
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 Within 7 days, the body forms granulation
tissue between the fracture fragments.
 Various biochemical signaling substances are
involved in the formation of the granulation

tissue stage, which lasts approximately 2
weeks.
 During callus formation, cell proliferation and
differentiation begin to produce osteoblasts

and chondroblasts in the granulation tissue.
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 The osteoblasts and chondroblasts,
respectively, synthesize the extracellular
organic matrices of woven bone and cartilage,
and then the newly formed bone is
mineralized.
 This stage requires 4-16 weeks.

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 During the fourth stage, the meshlike callus of
woven bone is replaced by lamellar bone,
which is organized parallel to the axis of the
bone.
 The final stage involves remodeling of the
bone at the site of the healing fracture by

various cellular types such as osteoclasts.
 The final 2 stages require 1-4 years.

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 Patient factors that influence fracture healing
include:
 Age
 Comorbidities
 Medication use
 Social factors and
 Nutrition.

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 Other factors that affect fracture healing
include:
 The type of fracture
 Degree of trauma
 Systemic and local disease, and
 Infection.

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 Patients who have poor prognostic factors in
terms of fracture healing are at increased risk
for complications of fracture healing such as:
 Nonunion (a fracture with no possible chance of
healing)
 Malunion (healing of bone in an unacceptable position
in any plane)
 Osteomyelitis, and
 Chronic pain.

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Healing of fractures
 Resembles healing in soft tissue
 Initial heamorrhage and mild inflammation is
followed by proliferative or productive stage in
which osteogenic cells play a major role.
 Continuity of the two fragments is first established
by a mass of new bone trabeculae and sometimes
cartilagenous tissue (provisional callus).
 This then undergoes remodelling with resorption
and replacement of callus to achieve bony union.
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Types of fractures
 Compound fractures – When a bone fragment has
torn the overlying skin and mucous membrane
 Comminuted fracture – When there is fracture with
splintering of bone

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Factors Impairing Fracture Healing
Factors Ideal Problematic
Age, y Youth Advanced age (>40 y)
Comorbidities None Multiple medical comorbidities (eg,

diabetes)
Medications None Nonsteroidal anti-inflammatory drugs

(NSAIDs), corticosteroids
Social factors Nonsmoker Smoker
Nutrition Well nourished Poor nutrition
Fracture type Closed fracture, neurovascularly intact Open fracture with poor blood supply
Trauma Single limb Multiple traumatic injuries
Local factors No infection Local infection
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ORGANISATION
 Replacement, by fibrous tissue, of solid, non-living
material such as fibrin, clotted blood, intravascular
thrombus and dead tissue.
 Involves the gradual digestion of material by
macrophages.
 Removal of more than a small amount of dead
material requires the ingrowth of capillaries and
fibroblasts similar to that in healing.
 The term organization is used only when inanimate
material is replaced by it.
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ANDREW
Examples of Organization
 the removal of fibrin deposited in acute
inflammation.
 Removal of blood clot
 Removal of a thrombus blocking a vessel
 A patch of necrotic tissue in an organ

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Process of Organization
 Continued migration of monocytes into site of
acute inflammation.
 Digestion of the fibrin by combination of
phagocytosis and release by lysosomal enzymes.
 Capillary sprouts grow into the spaces created by
macrophages and anastomose to form a network of
capillaries, some of which enlarge and develop into
arterioles and venules.
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ANDREW
Process of Organization……
 The capillaries are accompanied by proliferating
fibroblasts which produce collagen and ground
substance leading to granulation tissue formation.
 Fibrin is replaced by granulation tissue en replaced.
 The granulation tissue slowly changes to less
vascular, firm fibrous tissue.

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1 PETER 4:11

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

 General condition of the patient

 Follow-up needed and achievable for patient

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

 Describes a wound closed by approximation of wound

margins or by placement of a graft or flap, or wounds

where viable tissue is tension-free and approximation

the tissue margins are approximated using simple

amount of contamination and ischemia, as well as

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

 1.) Inflammatory Phase

 Day 1-4 post injury

 Characterized by rubor, tumor, dolor, calor

 Platelet aggregation and activation

 Leukocyte (PMNs, macrophages) migration,

phagocytosis and mediator release

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

 1.) Inflammatory Phase…

 2.) Proliferative Phase

 Fibroblast proliferation stimulated by

macrophage-released growth factors

 Gain in tensile strength

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

 3.) Remodeling Phase

 Intermolecular cross-linking of collagen via

vitamin C-dependent hydroxylation

 Type III collagen replaced with type I

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

proximal to the wound

site to control bleeding and scarring

 Ultimately contributes to an improved esthetic

outcome for the resulting scar

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

 Common areas of occurrence are back,

 Can resolve with time and often treated

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

 Require débribement, irrigation, and healing

by secondary or tertiary intention

bacterial load per gram tissue (>105

GREAT LAKES UNIVERSITY OF KISUMU - DR OTIENO

topical antibiotic creams (silver sulfadiazine,