Wound & Wound Healing
Definition of a wound :
ANY break in the integrity of the skin or
tissues which may be associated with
disruption of struc...
CLASSIFICATION OF WOUNDS
RANK & WAKEFIELD CLASSIFICATION
 Tidy Wounds
 Surgical incisions,
 wounds by sharp objects,
 keloid,
 Untidy Wounds
...
BASED ON TYPE OF WOUND
 Bruising & contusion
 Haematoma
 Clean Incised Wound
 Lacerated Wound
 Abrasion
 Crush injur...
CLASSIFICATION OF SURGICAL
WOUNDS
 Clean Wound
 Clean Contaminated Wound
 Contaminated Wound
 Dirty Infected Wound
CLEAN WOUND
 Clean wound is a nontraumatic, uninfected
operative wound in which neither the
respiratory, alimentary or ge...
CLEAN CONTAMINATED WOUND
 Gastrointestinal, respiratory or genitor-
urinary tracts entered without significant
spillage o...
CONTAMINATED WOUND
 Operative wound contaminated
 Fresh traumatic wound from clean source
 Gross spillage from the gast...
DIRTY WOUND
 Traumatic wound from dirty source
 Fecal contamination
 Foreign body, Retained devitalized tissue
 Operat...
WOUND HEALING
WHAT IS WOUND HEALING???
 Wound Healing Is the Physiologic
Response to Tissue Trauma
 It is related to tissue reconstitu...
TYPES OF WOUND HEALING
WOUNDHEALING
PRIMARY
SECONDARY
TERTIARY
PRIMARY HEALING
 Occurs in clean incised
wound
 More epithelial
regeneration than
fibrosis.
 Wound heals rapidly
 Scar...
SECONDARY HEALING
 Occurs in wounds
with extensive soft
tissue loss
 Heals slowly with
fibrosis
 Wide
hypertrophied and...
TERTIARY / DELAYED PRIMARY
 Intial wound
debridement and
control of local
infection
 Wound closed with
sutures or covere...
PHASES OF WOUND HEALING
Wound Heals In 3 Phases That Partially
Overlap:
 Inflammatory Phase
 Fibroplasia Phase
 Remodel...
INFLAMMATORY PHASE
INFLAMMATORY PHASE
 (aka. lag phase or substrate phase) 0-48 hrs
INFLAMMATORY
PHASE
VASCULAR
RESPONSE
CELLULAR
RESPONSE
VASCULAR RESPONSE
PRIMARY PHASE –
Haemostasis
• Vasoconstriction
• Platelet Aggregation
And Degranulation
• Fibrinous Clot...
VASCULAR RESPONSE
SECONDARY PHASE
 Venular Vasodilatation - 10 X Increase In
Blood Flow
 Increased Vascular Permeability...
CELLULAR RESPONSE
Increased Vascular Permeability During
Inflammatory Phase Facilitates Margination,
Extravasation And Mig...
Macrophages
 Monocyte–derived
 Central Cell During Inflammatory Phase Of
Wound Repair
 Activated By Lymphokines, Immune...
Factors Affecting Inflammatory Phase:
 Pus
Contains Both Proteolytic And Collagenolytic
Enzymes; Prolongs Inflammatory Ph...
PROLIFERATIVE PHASE
PROLIFERATIVE PHASE
(Aka. Fibroplasia Phase) Day 2 To ~ 6 Weeks
CLINICAL SIGNS:
 Disappearance Of Inflammatory Signs,
 R...
KEY-ELEMENTS:
 Net Collagen Synthesis,
 Increase In Wound Tensile Strength,
 Scar Formation
PROLIFERATIVE PHASE
PROLIFERATIVE PHASE
EPITHELIALISATION
WOUND CONTRACTION
C COLLAGEN DEPOSITION
EPITHELIALIZATION
 Is A Requirement For Orderly Progression
Into The Proliferative Phase. It Starts In The
Inflammatory P...
WOUND CONTRACTION
 “wounds heal from side to side but contract
from end to end”
 Thought to be mediated by myofibroblast...
Wound Contraction
 Begins approximately 4-5 days after
wounding.
 Represents centripetal movement of the
wound edge towa...
Wound Contraction
 The wound edges move toward each other at an
average rate of 0.6 to .75 mm/day
 Wound contraction dep...
Wound Contraction
 Contraction of a wound across a joint can cause
contracture.
 Can be limited by skin grafts, full bet...
COLLAGEN DEPOSITION
 Prior to collagen deposition fibroblasts deposit
“ground substance” composed mainly of
glycosaminogl...
 Starting at day 3 or 4 collagen is deposited,
net collagen deposition is positive until day
21.
 It reaches a maximum a...
MATURATION &
REMODELLING
MATURATION AND RE-
MODELLING PHASE
 3 Weeks To 1-2 Years
 Type III Collagen Is Replaced By Type I Collagen,
Creation Of ...
Incised wound
 Caused by sharp cutting instruments.
 Minimum loss to tissue tends to gap (the
extent of gaping depends u...
Lacerated wound
 Caused by tearing of
tissues,
 Wounds have irregular
jagged borders
 Loss of tissue is limited
to skin...
DEGLOVING/AVULSION
INJURY
 Occurs when skin &
subcutaneous tissue
are stripped from
underlying fascia
leaving
neurovascul...
What is the type of wound according to Rank & Wakefield classification?
FACTORS AFFECTING
WOUND HEALING
FACTORS
WOUND
HEALING
LOCAL
SYSTEMIC
LOCAL FACTORS
 Infection & haematoma
 Presence of necrotic tissues and foreign
body
 Poor blood supply
 Venous or lymp...
LOCAL FACTORS
 H/O IRRADIATION
 Underlying diseases lie malignancy /
osteomyelitis
 Tissue hypoxia
GENERAL/SYSTEMIC FACTORS
 Age
 Obesity, smoking
 Malnutrition
 Vitamin deficiency
 Anaemia, uremia, jaundice
 Diabet...
MANAGING ACUTE WOUND
 HAEMOSTASIS
 CLEANSING
 EXPLORATION AND DIAGNOSIS
 DEBRIDEMENT
 REPAIR OF STRUCTURES
 REPLACEM...
 SKIN COVER IF REQUIRED
 SKIN CLOSURE WITHOUT TENSION
 ALL THE ABOVE WITH CAREFUL
TISSUE HANDLING
WHEN DOES A WOUND BECOME
CHRONIC?
 In healthy individuals with no underlying factors
an acute wound should heal within th...
 Chronic wounds are thus defined as wounds,
which have “failed to proceed through an
orderly and timely process to produc...
Wound
Wound
Wound
Wound
Wound
Wound
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Wound

  1. 1. Wound & Wound Healing
  2. 2. Definition of a wound : ANY break in the integrity of the skin or tissues which may be associated with disruption of structure or function  Etiology: - Trauma - Radiation - Infection - Iatrogenic Etc
  3. 3. CLASSIFICATION OF WOUNDS
  4. 4. RANK & WAKEFIELD CLASSIFICATION  Tidy Wounds  Surgical incisions,  wounds by sharp objects,  keloid,  Untidy Wounds  Avulsion  Crush injury  Devitalised injury
  5. 5. BASED ON TYPE OF WOUND  Bruising & contusion  Haematoma  Clean Incised Wound  Lacerated Wound  Abrasion  Crush injury  Penetrating wounds
  6. 6. CLASSIFICATION OF SURGICAL WOUNDS  Clean Wound  Clean Contaminated Wound  Contaminated Wound  Dirty Infected Wound
  7. 7. CLEAN WOUND  Clean wound is a nontraumatic, uninfected operative wound in which neither the respiratory, alimentary or genitourinary tracts nor the oropharyngeal cavities are entered.  Clean wounds are elective, primarily closed, and undrained wounds.  Infection rate is <2%
  8. 8. CLEAN CONTAMINATED WOUND  Gastrointestinal, respiratory or genitor- urinary tracts entered without significant spillage or wounds which are mechanically drained.  Eg: appendicectomy, gallbladder, biliary, pancreatic surgeries  Infection rate <10%
  9. 9. CONTAMINATED WOUND  Operative wound contaminated  Fresh traumatic wound from clean source  Gross spillage from the gastrointestinal tract  When infected urine or bile is present  Incision encountering acute non-purulent inflammation.  Eg: penetrating abdominal injury, enterotomy  INFECTION RATE – 15 – 30%
  10. 10. DIRTY WOUND  Traumatic wound from dirty source  Fecal contamination  Foreign body, Retained devitalized tissue  Operative wound w/ acute bacterial inflammation or perforated viscus  Presence of pus Eg: abscess drainage, pyocoele INFECTION RATE : 40 – 70 %
  11. 11. WOUND HEALING
  12. 12. WHAT IS WOUND HEALING???  Wound Healing Is the Physiologic Response to Tissue Trauma  It is related to tissue reconstitution which is the process by which the body replenishes cells that are being lost
  13. 13. TYPES OF WOUND HEALING WOUNDHEALING PRIMARY SECONDARY TERTIARY
  14. 14. PRIMARY HEALING  Occurs in clean incised wound  More epithelial regeneration than fibrosis.  Wound heals rapidly  Scar will be linear, smooth & supple.
  15. 15. SECONDARY HEALING  Occurs in wounds with extensive soft tissue loss  Heals slowly with fibrosis  Wide hypertrophied and contracted scar
  16. 16. TERTIARY / DELAYED PRIMARY  Intial wound debridement and control of local infection  Wound closed with sutures or covered with skin graft
  17. 17. PHASES OF WOUND HEALING Wound Heals In 3 Phases That Partially Overlap:  Inflammatory Phase  Fibroplasia Phase  Remodelling Phase
  18. 18. INFLAMMATORY PHASE
  19. 19. INFLAMMATORY PHASE  (aka. lag phase or substrate phase) 0-48 hrs INFLAMMATORY PHASE VASCULAR RESPONSE CELLULAR RESPONSE
  20. 20. VASCULAR RESPONSE PRIMARY PHASE – Haemostasis • Vasoconstriction • Platelet Aggregation And Degranulation • Fibrinous Clot • Fibrinolysis
  21. 21. VASCULAR RESPONSE SECONDARY PHASE  Venular Vasodilatation - 10 X Increase In Blood Flow  Increased Vascular Permeability - Aids In Flow Of Chemical And Cellular Mediators (PDGF) In Inflammation To Site Of Injury  Lymphatic Obstruction Leads To Tissue Edema
  22. 22. CELLULAR RESPONSE Increased Vascular Permeability During Inflammatory Phase Facilitates Margination, Extravasation And Migration Of Cellular Mediators (Pmn’s And Macrophages) PMN’S  Function Short Lived (0-48 Hours)  Attacks Bacteria, Then Leaves  Not Essential For Wound Healing Process
  23. 23. Macrophages  Monocyte–derived  Central Cell During Inflammatory Phase Of Wound Repair  Activated By Lymphokines, Immune Complexes  Release Angiogenesis Factor  Phagocytosis Of Wound Debris  Essential For Wound Healing CELLULAR RESPONSE
  24. 24. Factors Affecting Inflammatory Phase:  Pus Contains Both Proteolytic And Collagenolytic Enzymes; Prolongs Inflammatory Phase And Retards Epithelialization  Necrotic Tissue, Foreign Body, Haematoma - Prolongation Of Inflammatory Phase  Steroids - Inhibit Macrophage Function
  25. 25. PROLIFERATIVE PHASE
  26. 26. PROLIFERATIVE PHASE (Aka. Fibroplasia Phase) Day 2 To ~ 6 Weeks CLINICAL SIGNS:  Disappearance Of Inflammatory Signs,  Reduction Of Swelling,  Reduction Of Wound Size (Contraction),  Itching
  27. 27. KEY-ELEMENTS:  Net Collagen Synthesis,  Increase In Wound Tensile Strength,  Scar Formation PROLIFERATIVE PHASE
  28. 28. PROLIFERATIVE PHASE EPITHELIALISATION WOUND CONTRACTION C COLLAGEN DEPOSITION
  29. 29. EPITHELIALIZATION  Is A Requirement For Orderly Progression Into The Proliferative Phase. It Starts In The Inflammatory Phase.  It Requires De-differentiation, Mitosis, Migration And Then Re-differentiation By Basal Cells Of Epidermis PROLIFERATIVE PHASE
  30. 30. WOUND CONTRACTION  “wounds heal from side to side but contract from end to end”  Thought to be mediated by myofibroblast - can produce collagen but also contains smooth muscle filaments.  Highest rate of contraction from days 10-21 PROLIFERATIVE PHASE
  31. 31. Wound Contraction  Begins approximately 4-5 days after wounding.  Represents centripetal movement of the wound edge towards the center of the wound.  Maximal contraction occurs for 12-15 days, although it will continue longer if wound remains open.
  32. 32. Wound Contraction  The wound edges move toward each other at an average rate of 0.6 to .75 mm/day  Wound contraction depends on laxity of tissues, so a buttocks wound will contract faster than a wound on the scalp or pretibial area.  Wound shape also a factor, square is faster than circular.
  33. 33. Wound Contraction  Contraction of a wound across a joint can cause contracture.  Can be limited by skin grafts, full better than split thickness.  The earlier the graft the less contraction.  Splints temporarily slow contraction.
  34. 34. COLLAGEN DEPOSITION  Prior to collagen deposition fibroblasts deposit “ground substance” composed mainly of glycosaminoglycans.  Function of ground substance is to create scaffold onto which collagen can be deposited, aggregated, and oriented in appropriate fashion PROLIFERATIVE PHASE
  35. 35.  Starting at day 3 or 4 collagen is deposited, net collagen deposition is positive until day 21.  It reaches a maximum at 60 days post- injury (80% of tensile strength of normal skin) PROLIFERATIVE PHASE
  36. 36. MATURATION & REMODELLING
  37. 37. MATURATION AND RE- MODELLING PHASE  3 Weeks To 1-2 Years  Type III Collagen Is Replaced By Type I Collagen, Creation Of More Stable Bonds Between Fibers - Decreases The Amount Of Collagen Required To Maintain Wound Integrity  Duration Of Phase Dependent Upon Patient Age (Decreased Age - Increased Duration), Racial Differences, Type Of Wound, Body Location And Duration Of Inflammatory Phase
  38. 38. Incised wound  Caused by sharp cutting instruments.  Minimum loss to tissue tends to gap (the extent of gaping depends upon elasticity and tension).  Edges are regular.  Bleeds freely and painful.  Heals by primary intension healing.
  39. 39. Lacerated wound  Caused by tearing of tissues,  Wounds have irregular jagged borders  Loss of tissue is limited to skin and s/c tissue.
  40. 40. DEGLOVING/AVULSION INJURY  Occurs when skin & subcutaneous tissue are stripped from underlying fascia leaving neurovascular structures, tendons, bone exposed.
  41. 41. What is the type of wound according to Rank & Wakefield classification?
  42. 42. FACTORS AFFECTING WOUND HEALING
  43. 43. FACTORS WOUND HEALING LOCAL SYSTEMIC
  44. 44. LOCAL FACTORS  Infection & haematoma  Presence of necrotic tissues and foreign body  Poor blood supply  Venous or lymph stasis  Tissue tension  Large defect or poor apposition
  45. 45. LOCAL FACTORS  H/O IRRADIATION  Underlying diseases lie malignancy / osteomyelitis  Tissue hypoxia
  46. 46. GENERAL/SYSTEMIC FACTORS  Age  Obesity, smoking  Malnutrition  Vitamin deficiency  Anaemia, uremia, jaundice  Diabetes  Steroids & cytotoxic drugs
  47. 47. MANAGING ACUTE WOUND  HAEMOSTASIS  CLEANSING  EXPLORATION AND DIAGNOSIS  DEBRIDEMENT  REPAIR OF STRUCTURES  REPLACEMENT OF LOST TISSUES
  48. 48.  SKIN COVER IF REQUIRED  SKIN CLOSURE WITHOUT TENSION  ALL THE ABOVE WITH CAREFUL TISSUE HANDLING
  49. 49. WHEN DOES A WOUND BECOME CHRONIC?  In healthy individuals with no underlying factors an acute wound should heal within three weeks with remodeling occurring over the next year or so.  If a wound does not follow the normal trajectory it may become stuck in one of the stages and the wound becomes chronic. 
  50. 50.  Chronic wounds are thus defined as wounds, which have “failed to proceed through an orderly and timely process to produce anatomic and functional integrity, without establishing a sustained anatomic and functional result.
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