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Factors Affecting Wound Healing
- 1. By: Dr. Dinesh kumar Assistant Professor of Surgery Rama Medical College Kanpur
- 2. • Wound definition • Classification of wounds • Wound healing • Types of wound healing • Stages of wound healing • Phases of wound healing • Factors affecting wound healing
- 3. A wound is a break or breach in the integrity or continuity of the skin or tissues, which may be associated with disruption of the structure and function. Note: An ulcer is a type of wound
- 4. I. Rank and Wakefield Classification a.Tidy wounds (Incised,Clean,Healthy,Seldom tissue loss) b.Untidy(Crushed or avulsed, Contaminated, Devitalised tissues,Often tissue loss)
- 5. a. Clean incised wound b. Lacerated wounds c. Bruising and contusion d. Hematoma e. Closed blunt injury f. Abrasion g. Avulsion and degloving h. Penetrating injury i. Crush injury
- 7. a.Superficial wound b.Partial thickness c.Full thickness d.Deep wounds e.Complicated wounds f.Penetrating wounds
- 8. IV. Classification based on Involvement of Structures a. Simple wounds b. Combined wounds V. Classification based on the Time Elapsed Acute wound is up to 8 hours of trauma. Chronic wound is after 8 hours of trauma.
- 9. a. Clean wound b. Clean-contaminated wound c. Contaminated wound d. Dirty infected wound
- 12. Wound healing is a complex method to achieve anatomical and functional integrity of disrupted tissue by various components
- 13. 1)PRIMARY INTENTION 2)SECONDARY INTENTION 3)TERTIARY INTENTION (also called as Delayed Primary Intention)
- 14. It occurs in a clean incised wound, surgical wound or uninfected wounds. Without much loss of tissue. Wound edges are approximated with sutures. More epithelial regeneration than fibrosis. Wound heals rapidly with complete closure. Scar will be linear, smooth and supple.
- 15. It occurs in a wound with extensive soft tissue loss like in major trauma, burns and wound with sepsis. Inflammatory reaction is more intense. Much larger amount of granulation tissue is formed It heals slowly with fibrosis. It leads into a wide scar, often hypertrophied and contracted. It may lead into disability. Re-epithelialisation occurs from remaining dermal elements or wound margins.
- 16. Features Primary Secondary Cleanliness Clean Not clean Infection Not infected Infected Margins Clean , Regular Irregular Sutures Used Not used Healing Small granulation Large granulation Outcome Linear scar Irregular scar Complication Not frequently Frequent
- 17. After wound debridement and control of local infection, wound is closed with sutures or covered using skin graft. Used in Primary contaminated or mixed tissue wounds
- 18. 1.Stage of inflammation. 2.Stage of granulation tissue formation and organisation. 3. Stage of epithelialisation. 4.Stage of scar formation and resorption. 5.Stage of maturation.
- 19. 1. Inflammatory Phase-Lasts for 4-6 days a. Clot formation b. Early Inflammation c. Late Inflammation 1. Proliferative Phase- begins in 7 days and lasts for 6 weeks 2. Maturation phase- begins at 6 weeks and lasts for 2 years
- 20. Features of inflammation are seen Macrophases secrete fibroblastic growth factor which enhances angiogenesis Polymorphonuclear leukocytes (PMN leukocytes) appear after 48 hours which secrete inflammatory mediators and bactericidal oxygen derived free radicals These cells also remove clots, foreign bodies and bacteria. Within 24-48 hrs spurs of epithelial cells from both edges migrate and grow along the cut margins
- 22. • Characterized by production of polymorphonuclear neutrophils(PMNs) • Begins to enter the wound site within 6 hours of clot stabilization • The number of PMNs increases steadily, peaking at about 24- 48 hours after the injury • Three key steps in PMNs migration into the wound site 1.Pavementing 2.Emigration 3. Migration • Main role of PMNs is wound decontamination by phagocytosis • The number of PMNs drop rapidly after third day
- 24. •Presence of Macrophages •Reaches peak concentration by third or fourth day •They have longer life span than PMNs and remain in wound till healing is complete •More bioactive than PMNs--Secrete a vast array of cytokines—leads to initiation of proliferative phase of wound healing
- 25. Major functions of Macrophages are • Wound decontamination through phagocytosis and digestion of microorganisms and tissue debris • Ingestion and processing of antigen for presentation to T lymphocytes • Regulation of wound healing
- 28. Formation of granulation tissue in the wound 2 key cell types ( Fibroblasts and Endothelial cells) It begins in 7 days and lasts for 6 weeks. Collagen and glycosamines are produced by fibroblasts. Hydroxyproline and hydroxylysine are synthesised by specific enzymes using iron, alpha ketoglutarate and vitamin-C. Tropocollagen is produced which aggregates to form collagen fibrils.
- 32. It is a pink or red fragile structure composed of an extracellular matrix of fibrin, fibronectin, glycosaminoglycans, proliferating endothelial cells, new capillaries and fibroblasts mixed with inflammatory macrophages and lymphocytes
- 33. •It begins at 6 weeks and lasts for 2 years. •There is maturation of collagen by cross-linking which is responsible for tensile strength of the scar. •Collagen production is not present after 42 days of wound healing. •Normal dermal skin contains 80% type I (20% type III) collagen • Granulation tissue contains mainly type III collagen •scar contains both
- 37. •Local factors • Infection • Presence of necrotic tissue and foreign body •Poor blood supply •Venous or lymph stasis •Tissue tension • Haematoma •Large defect or poor apposition •Recurrent trauma •X-ray irradiated area • Site of wound, e.g. wound over the joints and back has poor healing • Underlying diseases like osteomyelitis and malignancy • Mechanism and type of wound —incised /lacerated / crush/avulsion • Tissue hypoxia locally reduces macrophage and fibroblast activity
- 38. • Age, obesity, smoking • Malnutrition, zinc, copper, manganese • Vitamin deficiency (Vit C, Vit A) • Anaemia • Malignancy • Uraemia • Jaundice • Diabetes, metabolic diseases • HIV and immunosuppressive diseases • Steroids and cytotoxic drugs • Neuropathies of different causes
- 39. Questions?
Editor's Notes
- III. Classif cation based on Thickness of the Wound Superf cial wound involving only epidermis and dermal papillae. Partial thickness wound with skin loss up to deep dermis with only deepest part of the dermis, hair follicle shafts and sweat glands are left behind. Full thickness wound with loss of entire skin and subcuta- neous tissue causing spacing out of the skin edges. Deep wounds are the one extending deeper, across deep fascia into muscles or deeper structures. Complicated wounds are one associated with injury to vessels or nerves. Penetrating wound is one which penetrates into either natural cavities or organs.
- IV. Classif cation based on Involvement of Structures Simple wounds are one involving only one organ or tissu Combined wounds are one involving mixed tissues. V. Classif cation based on the Time Elapsed Acute wound is up to 8 hours of trauma. Chronic wound is after 8 hours of trauma.
- VI. Classif cation of Surgical Wounds a. Clean wound Herniorrhaphy. Excisions. Surgeries of the brain, joints, heart, transplant. Infective rate is less than 2%. b. Clean contaminated wound Appendicectomy. Bowel surgeries. Gallbladder, biliary and pancreatic surgeries. Infective rate is 10%. c. Contaminated wound Acute abdominal conditions. Open fresh accidental wounds. Infective rate is 15-30%. . Dirty infected wound Abscess drainage. Pyocele. Empyema gallbladder. Faecal peritonitis. Infective rate is 40-70%.
- It occurs in a clean incised wound or surgical wound. Wound edges are approximated with sutures. There is more epithelial regeneration than fi brosis. Wound heals rapidly with complete closure. Scar will be linear, smooth, and supple.
- It occurs in a wound with extensive soft tissue loss like in major trauma, burns and wound with sepsis. It heals slowly with fi brosis. It leads into a wide scar, often hypertrophied and contracted. It may lead into disability. Re-epithelialisation occurs from remaining dermal elements or wound margins.
- Healing by Third Intention (Tertiary Wound Healing or Delayed Primary Closure) After wound debridement and control of local infection, wound s closed with sutures or covered using skin graft. Primary ontaminated or mixed tissue wounds heal by tertiary intention.
- Stages of Wound Healing Stage of infl ammation. Stage of granulation tissue formation and organi sation. Here due to fi broblastic activity synthesi sation of collagen and ground substance occurs. Stage of epithelialisation. Stage of scar formation and resorption. Stage of maturation.
- It begins immediately after wound healing. It lasts for 4-6 days. Features of infl ammation are rubor, calor, tumour, dolor and loss of function. Macrophages secrete fibroblastic growth factor which enhances angiogenesis. Polymorphonuclear leukocytes (PMN leukocytes) appear after 48 hours which secrete infl ammatory mediators and bactericidal oxygen derived free radicals. These cells also remove clots, foreign bodies and bacteria.
- Proliferative Phase (Collagen/Fibroblastic Phase) Collagen and glycosamines are produced by fi broblasts. It begins in 7 days and lasts for 6 weeks. Hydroxyproline and hydroxylysine are synthe sised by specifi c enzymes using iron, alpha ketoglutarate and vitamin C. Tropocollagen is produced which aggregates to form collagen fi brils. 80–90% of their fi nal strength (in postoperative wounds) is achieved in 30 days. Here proliferation of venular endothelial cell with fi broblast at wound margin and bed occurs by the action of cytokines and released growth factors. This angiogenesis and f broplasia
- Remodelling Phase (Maturation Phase) It begins at 6 weeks and lasts for 2 years. There is maturation of collagen by cross-linking which is responsible for tensile strength of the scar. Collagen production is not present after 42 days of wound healing.