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
- Iatrogenic Etc
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%
CLEAN CONTAMINATED WOUND
Gastrointestinal, respiratory or genitor-
urinary tracts entered without significant
spillage or wounds which are mechanically
Eg: appendicectomy, gallbladder, biliary,
Infection rate <10%
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
Eg: penetrating abdominal injury, enterotomy
INFECTION RATE – 15 – 30%
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
TYPES OF WOUND HEALING
Occurs in clean incised
Wound heals rapidly
Scar will be linear,
smooth & supple.
Occurs in wounds
with extensive soft
Heals slowly with
TERTIARY / DELAYED PRIMARY
control of local
Wound closed with
sutures or covered
with skin graft
PHASES OF WOUND HEALING
Wound Heals In 3 Phases That Partially
Venular Vasodilatation - 10 X Increase In
Increased Vascular Permeability - Aids In
Flow Of Chemical And Cellular Mediators
(PDGF) In Inflammation To Site Of Injury
Lymphatic Obstruction Leads To Tissue
Increased Vascular Permeability During
Inflammatory Phase Facilitates Margination,
Extravasation And Migration Of Cellular Mediators
(Pmn’s And Macrophages)
Function Short Lived (0-48 Hours)
Attacks Bacteria, Then Leaves
Not Essential For Wound Healing Process
Central Cell During Inflammatory Phase Of
Activated By Lymphokines, Immune Complexes
Release Angiogenesis Factor
Phagocytosis Of Wound Debris
Essential For Wound Healing
Factors Affecting Inflammatory Phase:
Contains Both Proteolytic And Collagenolytic
Enzymes; Prolongs Inflammatory Phase And
Necrotic Tissue, Foreign Body, Haematoma -
Prolongation Of Inflammatory Phase
Steroids - Inhibit Macrophage Function
(Aka. Fibroplasia Phase) Day 2 To ~ 6 Weeks
Disappearance Of Inflammatory Signs,
Reduction Of Swelling,
Reduction Of Wound Size (Contraction),
Net Collagen Synthesis,
Increase In Wound Tensile Strength,
C COLLAGEN DEPOSITION
Is A Requirement For Orderly Progression
Into The Proliferative Phase. It Starts In The
It Requires De-differentiation, Mitosis,
Migration And Then Re-differentiation By
Basal Cells Of Epidermis
“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
Begins approximately 4-5 days after
Represents centripetal movement of the
wound edge towards the center of the
Maximal contraction occurs for 12-15
days, although it will continue longer if
wound remains open.
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
Contraction of a wound across a joint can cause
Can be limited by skin grafts, full better than split
The earlier the graft the less contraction.
Splints temporarily slow contraction.
Prior to collagen deposition fibroblasts deposit
“ground substance” composed mainly of
Function of ground substance is to create
scaffold onto which collagen can be deposited,
aggregated, and oriented in appropriate fashion
Starting at day 3 or 4 collagen is deposited,
net collagen deposition is positive until day
It reaches a maximum at 60 days post-
injury (80% of tensile strength of normal
MATURATION AND RE-
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
Caused by sharp cutting instruments.
Minimum loss to tissue tends to gap (the
extent of gaping depends upon elasticity
Edges are regular.
Bleeds freely and painful.
Heals by primary intension healing.
Caused by tearing of
Wounds have irregular
Loss of tissue is limited
to skin and s/c tissue.
Occurs when skin &
are stripped from
What is the type of wound according to Rank & Wakefield classification?
MANAGING ACUTE WOUND
EXPLORATION AND DIAGNOSIS
REPAIR OF STRUCTURES
REPLACEMENT OF LOST TISSUES
SKIN COVER IF REQUIRED
SKIN CLOSURE WITHOUT TENSION
ALL THE ABOVE WITH CAREFUL
WHEN DOES A WOUND BECOME
In healthy individuals with no underlying factors
an acute wound should heal within three weeks
with remodeling occurring over the next year or
If a wound does not follow the normal trajectory
it may become stuck in one of the stages and the
wound becomes chronic.
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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