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  1. 1. Keloid scars is made up of –a) Dense collagen b) Loose fibrous tissuec Granulamatous tissue d) Loose areolar tissueWhat is true about keloids – (JIPMER 95)a)It appears immediately after surgeryb)It appears a few days after surgeryc)It is limited in its distribution (grows beyond the limits of the original wound)d) it is common in old peopleKeloid is best treated by – (UPSC 95)a)Intrakeloidal injection of triamcinoloneb)Wide excision and graftingc)Wide excision and suturingd)Deep X-ray therapyThe following statement about keloid is true- A) They do not extend in normalskin (extreme overgrowth of scar tissue that grows beyond the limits of the originalwound)b)Local recurrence is common after excisionc) They often undergo malignant changed) They are more common in whites than in blacksThe best cure rate in keloids is achieved by –a)Superficial X – ray therapy (UPSC 2001)b)Intralesional injection of triamcinolonec)Shavingd)Excision and radiotherapyCombination is always better.Surgery:-Excision alone of keloids is subject to a high recurrence rate, ranging from45 to 100%. There are fewer recurrences when surgical excision is combined withother modalities such as intralesional corticosteroid injection, topical application ofsilicone sheets, or the use of radiation or pressureRadiation:-Poor results with 10 to 100% recurrence when used alone. It is moreeffective when combined with surgical excision. Given the risks ofhyperpigmentation, pruritus, erythema, paresthesias, pain, and possible secondarymalignancies, radiation should be reserved for adults with scars resistant to othermodalities.Combination therapies:- Intralesional corticosteroid injections decrease fibroblastproliferation, collagen and glycosaminoglycan synthesis, the inflammatory process,
  2. 2. and TGF levels. When used alone, however, there is a variable rate of responseand recurrence, therefore steroids are recommended as first-line treatment for keloidsand second-line treatment for HTSs if topical therapies have failed. Intralesionalinjections are more effective on younger scars. They may soften, flatten, and givesymptomatic relief to keloids, but they cannot make the lesions disappear nor canthey narrow wide HTSs. Success is enhanced when used in combination with surgicalexcision. Serial injections every 2 to 3 weeks are required.Sabiston:- Intralesional injection of steroids into a keloid scar can inactivate andshrink the scar; such therapy is not indicated for hypertrophic scars.Scars that are perpendicular to the underlying muscle fibers tend to be flatter andnarrower, with less collagen formation than when they are parallel to the underlyingmuscle fibers. The position of an elective scar can be chosen in such a way to make anarrower and less obvious scar in the distant future. As muscle fibers contract, thewound edges become reapproximated if they are perpendicular to the underlyingmuscle. If, however, the scar is parallel to the underlying muscle, contraction of thatmuscle tends to cause gaping of the wound edges and leads to more tension and scarformation.____________________________________________________________________________________________________________________________________________________________________________ WoundsPrimary closure of incised wounds must be done in –a) 2 hrs b) 4 hrsc) 6 hrs d) 12 hrse) 16 hrs(Because of the fear of bacterial invasion, primary wound closure beyond 6 to 8 hoursafter injury was historically proscribed. However, several scientific studies have sinceshown that when blood supply to a wound is adequate and bacterial invasion isabsent, wounds can be safely closed at any time after proper débridement andirrigation)The tensile strength of wound reaches that of normal tissue by – (PGI 88)) 6 weeksc) 4 monthsb) 2 monthsd) 6 monthsNEVERIn the healing of a clean wound the maximum immediate strength of the wound isreached by –a) 2 – 3 days b) 4 – 7 days10 – 12 days d) 13 – 18 days
  3. 3. 21 days is ansThe tensile strength of the wound starts and increases after – (MAHE 05)a)Immediate suture of the woundb)3 to 4 daysc)7-10 daysd 6 monthssee figureWhen is the maximum collagen content of woundtissue – (PGI 81, ROHTAK 87)a)Between 3rd to 5th dayb)Between 6th to 17th dayC) Between 17th to 21st day d) None of the aboveIn a sutured surgical wound, the process of epithelialization is completed within –(UPSC 07)a) 24 hours b) 48 hoursc) 72 hours d) 96 hoursRef schwartz Epithelialization:- While tissue integrity and strength are being re-established, the external barrier must also be restored. This process is characterizedprimarily by proliferation and migration of epithelial cells adjacent to the wound Theprocess begins within 1 day of injury and is seen as thickening of the epidermis at thewound edge.Re-epithelialization is complete in less than 48 hours in the case ofapproximated incised wounds, but may take substantially longer in the case of largerwounds, in which there is a significant epidermal/dermal defect.Sabiston : – Finally, adequate dressing of the closed wound isolates it from theoutside environment. Providing an appropriate dressing for 48 to 72 hours candecrease wound contamination. However, dressings after this period increase thesubsequent bacterial count on adjacent skin by altering the microenvironmentunderneath the dressing.Following are required for wound healing except – a) Zincb) Copper c) Vitamin C d) CalciumCopper is also a component of ferroprotein, a transport protein involved in thebasolateral transfer of iron during absorption from the enterocyte. As such, copperplays a role in iron metabolism, melanin synthesis, energy production,neurotransmitter synthesis, and CNS function; the synthesis and cross-linking ofelastin and collagen :- HarrisonCopper Deficiency:- Anemia, growth retardation, defective keratinization andpigmentation of hair, hypothermia, degenerative changes in aortic elastin, osteopenia,mental deterioration.Patient has lacerated untidy wound of the leg and attended the casualty after 2 ‘hours.His wound (AIIMS 84)should be –
  4. 4. a) Sutured immediately b) Debrided and sutured immediately c) debrided andsutured secondarily d) Cleaned and dressedWound healing is worst at –(ALL INDIA 93) a) Sternum b) Anterior neckc) Eyelid d) LipsAfter closing deep tissues and replacing significant tissue deficits, skin edges shouldbe reapproximated for cosmesis and to aid in rapid wound healing. Skin edges may bequickly reapproximated with stainless steel staples or nonabsorbable monofilamentsutures. Care must be taken to remove these from the wound before epithelializationof the skin tracts where sutures or staples penetrate the dermal layer. Failure toremove the sutures or staples by 7 to 10 days after repair will result in a cosmeticallyinferior wound(Anatomic areas where tension is excessive are avoided if possible. The shoulders,back, and anterior chest are high tension and mobile areas where wide scarringis difficult to avoid. Patients are also questioned as to propensity for development ofhypertrophic scars or keloid formation. Ears, anterior chest, and shoulders are areasprone to these problematic scars)Sabiston :-Wound strength increases rapidly within 1 to 6 weeks and then appears toplateau up to 1 year after the injury .When compared with unwounded skin, tensilestrength is only 30% in the scar. An increase in breaking strength occurs afterapproximately 21 days, mostly as a result of cross-linking.The rate of collagensynthesis declines after 4 weeks and eventually balances the rate of collagendestruction by collagenase (MMP-1). At this point the wound enters a phase ofcollagen maturation.Taylor:-The tensile strength of the young scar is only about 10% that of normal skin.Scar strength increases to about 30–50% of normal skin by 4 weeks and to 80% afterseveral months.Robbins:-We now turn to the questions of how long it takes for a skin wound toachieve its maximal strength, and which substances contribute to this strength. Whensutures are removed, usually at the end of the first week, wound strength isapproximately 10% of the strength of unwounded skin, but it increases rapidly overthe next 4 weeks. This rate of increase then slows at approximately the third monthafter the original incision and then reaches a plateau at about 70 to 80% of the tensilestrength of unwounded skin, which may persist for life.Schwartz:-Wound strength and mechanical integrity in the fresh wound aredetermined by both the quantity and quality of the newly deposited collagen. Thedeposition of matrix at the wound site follows a characteristic pattern: Fibronectin andcollagen type III constitute the early matrix scaffolding, glycosaminoglycans andproteoglycans represent the next significant matrix components, and collagen type I isthe final matrix. By several weeks postinjury the amount of collagen in the woundreaches a plateau, but the tensile strength continues to increase for several moremonths.20 Fibril formation and fibril cross-linking result in decreased collagensolubility, increased strength, and increased resistance to enzymatic degradation of the
  5. 5. collagen matrix. Scar remodeling continues for many (6 to 12) months postinjury,gradually resulting in a mature, avascular, and acellular scar. The mechanical strengthof the scar never achieves that of the uninjured tissue.Factors That Inhibit Wound HealingInfectionIschemiaCirculationRespirationLocal tensionDiabetes mellitusIonizing radiation
  6. 6. Advanced ageMalnutritionVitamin deficiencies:- Vitamin C Vitamin AMineral deficiencies:-Zinc IronExogenous drugs:-Doxorubicin (Adriamycin) Glucocorticosteroidssuture marks are to be avoided, skin sutures should be removed by - a) hours b) 1week2 weeks d) 3 weeksEpidermal skin sutures function for fine alignment of skin edges. Interrupted suturesare less constrictive than running sutures. The needle enters and exits the skin at 90degrees in order to evert the skin edges. These skin sutures are removed as soon asadequate intrinsic bonding strength is sufficient. Skin sutures left in place too longresult in an unsightly track pattern. On the other hand, sutures removed prematurelyrisk wound dehiscence. Nonabsorbable sutures on the face are typically removedafter 5 days. Sutures in the hand, foot, or across areas that are acted on bymotion are left for 14 days or longer .Alternatively, by employing the runningintradermal suturing technique, the time constraints of suture removal may bedisregarded, and these sutures may be left in place for a longer time without risking atrack pattern scar. Finally, epidermal approximation can be achieved without sutureusing a medical-grade cyanoacrylate adhesive such as Dermabond. Such adhesivesare applied across the coapted skin edges only and contribute no tensile strength. Tapeclosure strips such as Steri-Strips can be applied at the completion of wound closureto help splint the coapted skin edges.Guidelines for Day of Suture Removal by AreaBODY REGION REMOVAL (DAYS)Scalp 6-8Ear 10-14Eyelid 3-4Eyebrow 3-5Nose 3-5Lip 3-4Face (other) 3-4Chest, abdomen 8-10Back 12-14Extremities 12-14Hand 10-14
  7. 7. BODY REGION REMOVAL (DAYS)Foot, sole 12-14A patient with grossly contaminated wound presents 12 hours after an accident. Hiswound should be managed by – (UPSC 96)a)Thorough cleaning and primary repairb)Thorough cleaning with debridement of all dead and devitalised tissue withoutprimary closurec)Primary closure over a draind)Covering the defect with split skin graft after cleaningManagement of an open wound seen 12 hrs. afterthe injury – (AIIMS 87)a)Suturingb)Debridement and suturec)Secondary suturingd)Heal by granulationDelayed wound healing is seen in all except-(AP 96)a) Malignancy b) Hypertensionc) Diabetes d) InfectionAll of the following favour postoperative wound dehiscence except – (Karnat 05)a)Malignancyb)Vitamin B complex deficiencyc)Hypoproteinaemiad)JaundiceFibroblast in healing wound derived from –a) Local mesenchyme b) Epithelium (PGI 98)c) Endothelial d) Vascular fibrosis(Sabiston) Fibroplasia:- Fibroblasts are specialized cells that differentiate from restingmesenchymal cells in connective tissue; they do not arrive in the wound cleft bydiapedesis from circulating cells. After injury, the normally quiescent and sparsefibroblasts are chemoattracted to the inflammatory site, where they divide andproduce the components of the ECM.The primary function of fibroblasts is tosynthesize collagen, which they begin to produce during the cellular phase ofinflammation. The time required for undifferentiated mesenchymal cells todifferentiate into highly specialized fibroblasts accounts for the delay between injuryand the appearance of collagen in a healing wound. This period, generally 3 to 5 days,depending on the type of tissue injured, is called the lag phase of wound healing.Therate of collagen synthesis declines after 4 weeks and eventually balances the rate ofcollagen destruction by collagenase (MMP-1). At this point the wound enters a phaseof collagen maturation. The maturation phase continues for months or even years.Glycoprotein and mucopolysaccharide levels decrease during the maturation phase,and new capillaries regress and disappear. These changes alter the appearance of thewound and increase its strength.
  8. 8. Degloving injury is – (KERALA 2K)a) Surgeon made wound b) Lacerated woundc) Blunt injury d) Avulsion injurye)Abrasive woundAvulsion injuries are open injuries where there has been a severe degree of tissuedamage. Such injuries occur when hands or limbs are trapped in moving machinery,such as in rollers, producing a degloving injury. Degloving is caused by shearingforces that separate tissue planes, rupturing their vascular interconnections andcausing tissue ischaemia. This most frequently occurs between the subcutaneous fatand deep fascia. Degloving injuries can be open or closed. Degloving can be localisedor circumferential. It can occur only in the single, subcutaneous plane, but wherepresent in multiple planes, such as between muscles and fascia and between musclesand bone, is an indication of a severe high-energy injury with a limited potential forprimary healing. Similar injuries occur as a result of runover road traffic accidentinjuries where friction from rubber tyres will avulse skin and subcutaneous tissuefrom the underlying deep fascia (Fig. 3.11). The history should raise the examiner’ssuspicion and it is often possible to pinch the skin and lift it upwards revealing itsdetachment from the normal anchorage. The danger of degloving or avulsion injuriesis that there is devascularisation of tissue and skin necrosis may become slowlyapparent in the following few days. Even tissue that initially demonstrates venousbleeding may subsequently undergo necrosis if the circulation is insufficient.Treatment of such injuries is to identify the area of devitalised skin and to remove theskin, defat it and reapply it as a full-thickness skin graft. Avulsion injuries of hands orfeet may require immediate flap cover using a one-stage microvascular tissue transferof skin and/or muscle.In treatment of hand injuries, the greatest priority is – (A1 96)a)Repair of tendonsb)Restoration of skin coverc)Repair of nervesd) Repair of blood vesselsDuring the surgical procedure – (AIIMS 83)a)Tendons should be repaired before nervesb)Nerves should be repaired before tendonsc)Tendons should not be repaired at the same timed)None is trueIn hand injuries first to be repaired is – (A195)a) Bone b) Tendonc) Muscle d) NerveIn the case of injuries, treatment is directed at the specific structures damaged:skeletal, tendon, nerve, vessel, and integument. In emergency situations, the goals oftreatment are to maintain or restore distal circulation, obtain a healed wound, preservemotion, and retain distal sensation. Stable skeletal architecture is established in theprimary phase of care because skeletal stability is essential for effective motionand function of the extremity. This also results in reestablishing skeletal length,straightening deformities, and correction of compression or kinking of nerves
  9. 9. and vessels. Arteries are also repaired in the acute phase of treatment to maintaindistal tissue viability. Additionally, extrinsic compression on arteries must be releasedemergently such as in compartment pressure problems. In clean-cut injuries, tendonscan be repaired primarily. In situations in which there is a chance that tendonadhesions may form, such as when there are associated fractures, it is nonethelessbetter to repair tendons primarily with preservation of their length and if necessary ata later date to perform tenolysis. However, when there are open and contaminatedwounds or a severe crushing injury, it is best to delay repair of both tendon andnerve injuriesPrevention of wound infection done by –a)Pre-op shaving (PGI 05)b)Pre-op antibiotic therapyc)Monofilament suturesd)Wound appositionSSIs are the most common nosocomial infection in our population and constitute 38%of all infections in surgical patients. By definition, they can occur anytime from 0 to30 days after the operation or up to 1 year after a procedure that has involved theimplantation of a foreign material (mesh, vascular graft, prosthetic joint, and so on).Incisional infections are the most common; they account for 60% to 80% of all SSIsand have a better prognosis than organ/space-related SSIs do, with the latteraccounting for 93% of SSI-related mortalities.Preoperative shaving has been shown to increase the incidence of SSI after cleanprocedures as well. This practice increases the infection rate about 100% as comparedwith removing the hair by clippers at the time of the procedure or not removing it atall, probably secondary to bacterial growth in microscopic cuts. Therefore, thepatient is not shaved before an operation. Extensive removal of hair is notneeded, and any hair removal that is done is performed by electric clippers withdisposable heads at the time of the procedure and in a manner that does nottraumatize the skin1.Basic principles include size of the OR, air management (filtered flow, positivepressure toward the outside, and air cycles per hour), equipment handling(disinfection and cleansing), and traffic rules. All OR personnel wear clean scrubs,caps, and masks, and traffic in and out of the OR is minimized.2.The CDC recommends the use of chlorhexidine showers, and it is reasonable toimplement such a policy, particularly in patients who have been in the hospital for afew days and in those in whom an SSI will cause significant morbidity (cardiac,vascular, and prosthetic procedures). Skin preparation of the surgical site is done witha germicidal antiseptic such as tincture of iodine, povidone-iodine, or chlorhexidine.An alternative preparation is the use of antimicrobial incise drapes applied to theentire operative area. Traditionally, the surgical team has scrubbed their hands andforearms for at least 5 minutes the first time in the day and for 3 minutes everyconsecutive time.3.As many as 90% of an operative team puncture their gloves during a prolongedoperation. The risk increases with time, as does the risk for contamination of the
  10. 10. surgical site if the glove is not changed at the moment of puncture. The use of doublegloving is becoming a popular practice to avoid contamination of the wound, as wellas exposure to blood by the surgical team. Double gloving is recommended for allsurgical procedures.Instruments that will be in contact with the surgical site aresterilized in standard fashion, and protocols for flash sterilization or emergencysterilization, or both, must be well established to ensure the sterility of instrumentsand implants.Local Wound Related:-Intraoperative measures include appropriate handling of tissueand assurance of satisfactory final vascular supply, but with adequate control ofbleeding to prevent hematomas/seromas. Complete débridement of necrotic tissueplus removal of unnecessary foreign bodies is recommended, as well as avoiding theplacement of foreign bodies in clean-contaminated, contaminated, or dirty cases.Monofilament sutures have proved in experimental studies to be associated witha lower rate of SSI. Sutures are foreign bodies that are used only when required.Suture closure of dead space has not been shown to prevent SSI. Large potentialdead spaces can be treated with the use of closed-suction systems for short periods,but these systems provide a route for bacteria to reach the wounds and may cause SSI.Open drainage systems (e.g., Penrose) increase rather than decrease infections insurgical wounds and are avoided unless used to drain wounds that are alreadyinfected.In heavily contaminated wounds or wounds in which all the foreign bodies ordevitalized tissue cannot be satisfactorily removed, delayed primary closureminimizes the development of serious infection in most instances. With thistechnique, the subcutaneous tissue and skin are left open and dressed loosely withgauze after fascial closure. The number of phagocytic cells at the wound edgesprogressively increases to a peak about 5 days after the injury. Capillary budding isintense at this time, and closure can usually be accomplished successfully even withheavy bacterial contamination because phagocytic cells can be delivered to the site inlarge numbers. Experiments have shown that the number of organisms required toinitiate an infection in a surgical incision progressively increases as the interval ofhealing increases, up to the fifth postoperative day.Finally, adequate dressing of the closed wound isolates it from the outsideenvironment. Providing an appropriate dressing for 48 to 72 hours can decreasewound contamination. However, dressings after this period increase the subsequentbacterial count on adjacent skin by altering the microenvironment underneath thedressing.Elective cholecystectomy is – (APPG 06)a) Clean contaminated b) CleanDirty d) ContaminatedWhich one of the following surgical procedures is considered to have a clean-contaminated wound ?a),Elective open cholecystectomy for cholelithiasisb)Hemiorrhaphy with mesh repair
  11. 11. c)Lumpectomy with axillary node dissectiond)Appendectomy with walled off abscessThe accepted range of infection rates has been 1% to 5% for clean, 3% to 11% forclean-contaminated, 10% to 17% for contaminated, and greater than 27% for dirtywounds.Table 14-2 – Surgical Wound Classification According to Degree ofContaminationWOUNDCLASS DEFINITIONClean An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or infected urinary tract is not entered. Wounds are closed primarily and, if necessary, drained with closed drainage. Surgical wounds after blunt trauma should be included in this category if they meet the criteriaClean- An operative wound in which the respiratory, alimentary, genital,contaminated or urinary tract is entered under controlled conditions and without unusual contaminationContaminated Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this categoryDirty Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operationStaphylococcus aureus remains the most common pathogen in SSIs, followed bycoagulase-negative staphylococci, enterococci, and Escherichia coli. However, forclean-contaminated and contaminated procedures, E. coli and otherEnterobacteriaceae are the most common cause of SSI.The Vitamin which has inhibitory effect on wound healing is – (MAHE 05)a) Vitamin-A b) Vitamin-Ec) Vitamin-C d) Vitamin B-complex