2. Wound & Wound Healing
Definition:
Breach in continuality of epithelial lining
surface due to injury & trauma.
Classification of wound:
Depend on degree of contamination.
Depend on causal agents/morphology.
3. Depend on degree of contamination.
Clean wound
Wound without contamination.
(e.g. Clean surgical wound under aseptic condition;
Thyroid, Breast, Lipoma Surgery.)
Clean contaminated wound
Wound with minimal or potential contamination.
(e.g. Surgical wound made on potentially
contaminated area (upper GI surgery-stomach,
biliary)
Traumatic clean wound within six hours after
trauma.)
4. Contaminated wound
Wound with gross contamination.
(e.g. Surgical wound made on contaminated area
(colonic surgery)
Traumatic wound > six hours, with
contaminated soil)
Dirty/ Septic wound
Wound contaminated with pathogenic organisms
(e.g. Wound made on gross sepsis-peritonitis,
abscess)
5. Depend on Causal agents/
Morphology
Incised wound
Due to sharp weapon
Minimal tissue loss, edge opposed together & even
Rapid healing when wound is clean & closed
primarily, increased tensile strength, minimal scar
Lacerated wound
Due to blunt object
Variable amount of tissue loss, haematoma, edge is
uneven & rages
More time need to heal (because of increase tissue
loss & presence of haematoma) reduced tensile
strength, increased scar
6. Depend on Causal agents/
Morphology
Crush wound
Tissue crush between two hard objects
Large amount of tissue loss, haematoma,
unexpected amount of devitalised tissue at
first, and then loss of tissue depend on force
& extend of crush injury
Delay wound healing, reduced tensile
strength, increased scar
Penetrating wound
Due to sharp & pointed weapon
7. Types of Wound Healing
First intention
In clean surgical wound/incised wound, wound edge
opposed together by suture wound healing is
rapid from edges as well as base, increased tensile
strength & minimal scar formation
Second intention
In case of contaminated/dirty wound with variable
amount of tissue loss- healing arise from base
(contained all 3 elements of wound healing)- healing
is delayed & need long time- reduced tensile strength,
increased scar formation
8. Third intention
In case of contaminated wound with minimal tissue
loss, wound wait to clean as open wound ( due to
infection more susceptible in close wound)- closed
the wound with suture when the wound is clean (
delay primary closure) or secondary closure. Wound
healed as first intention and known as third intention.
9. Elements of Wound Healing
1. Epithelialization
Migration, proliferation of epithelial tissue from the
edges & epidermal layer of wound to cover the
wound
2. Wound contraction
In open wound, the size of wound become smaller
by contraction of myofibroblast to wound healing
3. Connective tissue formation
Main body of wound is united by synthesis & lysis of
collagen tissue from fibroblast & new capillary
formation ( granulation tissue)
10. Phase of Wound Healing
1. Lag (or) Preparatory phase
First few hours to days of wound- infiltration of
neutrophil & macrophages- demolition of
inflammatory exudate & devitalised tissue
2. Repair (or) Proliferated (or) Fibroblastic phase
First few days of wound- macrophages- attract the
fibroblast & synthesis of collagen tissue &
intercellular ground substance & new formation of
blood vessels ( granulation tissue) filled up the
wound wound healing.
11. 3. Maturation (or) Differentiation phase
Reduced activity of fibroblast & increasing tensile
strength of wound need months to years until
normal tensile strength regained (very rare).
50% to 70% of tensile strength regained by the end
of six months
12. Process of wound healing
Epidermal events
Dermal events
Collagen production
13. Epidermal events
Particularly in surgical wd, incised wd within few
hrs
Primary single layer of epithelial cell starts to migrate
from edge to form delicate covering over wd
Followed by epithelial cell proliferation from epidermal
cells
(Implantation dermoid – In small penetrating wd(
needle prick) down growth of epidermal cell –keratin
forming cyst within dermis known as implantation
dermoid
14. Dermal events
Within few hrs, mild acute inflammatory
infiltration of neutrophil into and aroundwd
followed by migration of macrophages (1-2)after
wound
Demolition and removal of inflammatory exudate and
tissue debris
Restoration of tensile strength of sub epithelial
connective tissue
• Chemoattraction of fibroblasts synthesis secretion of collagen
and ground substance
• Expansion of fibroblast population
• Secretion of extracellular connective tissue protein for
fibroblast
15. Ingrowth of new small bld v/s
Budding of new endothelial cell from intact bld
v/s of edges
Chemoattraction of these new bld vs into
connective tissue of wd
16. Collagen production
Over half of collagen made up with 3 amino
acids; lysine, hydroxyprolene, prolene
Fibroblast ; synthesis new collagen intercellular
ground substance production of 3 main amino
acids and cross linkage of each other >
connective t/s formation> tensile strength of wd
a/acid precursor---hydroxylation-- collagen
(protocollagen) O2, vite, Fe++
17. Tensile strength depends on production of
amount of collagen and their orientation. This
process is maintained by production and
destruction of collagen (collagen synthesis and
lysis)
Inbalance between this process>wd
complication
Decrease synthesis ,increase lysis > impaired wd
healing and dehiscence
Increased synthesis, decrease lysis > hypertrophic
scar keloid formation
18. Factors affecting wound healing
General factors
(1) Age - young age - increased blood supply- good
wound healing
- old age - reduced blood supply & associated
diseases- impair wound healing
(2) Nutritional status
(1) Overnutrition - (2) Undernutrition
19. (1) Overnutrition - obesity- increased fatty tissue-
(a) reduced supportive tissue to blood vessels-
fragile, easy to bleed
(b) retraction of blood vessel- difficult to control
healing
(c) increased tissue destruction, dead space
(2) Undernutrition
hypoproteinaemia- impair amino acid synthesis
hypovitamin C (surgery) – impair collagen
synthesis (hydroxylation)
hypovitamin A – epidermal growth reduced
zinc – impair wound healing- because of decrease
collagen synthesis
20. (3) Associated diseases
-jaundice
-uraemia
-anaemia-reduced Hb – decreased oxygen carrying
capacity
-diabetes mellitus – decreased immunity, reduced
blood supply, increased infection
-impaired cardiopulmonary status- reduced oxygen
supply to tissue
(4) Immunity
-reduced immunity- increase infection-
due to disease - burn, DM, HIV, trauma, Ca
due to drugs - steroid, chemotherapy,
immunosuppressive therapy
Increased collagen breakdown
21. Local factors
1. Site- face- increased blood supply- increased
wound healing
2. Presence of foreign body + contamination-
increased infection- reduced oxygen supply-
impaired wound healing
3. Underlying vascular diseases –artery-
reduced blood supply, venous stasis-
reduced oxygen supply
4. Presence of tension- reduced blood supply-
to wound- haematoma, dead space
oxygenation
infection
24. Hypertrophic Keloid
Time factor Regress after 6 months Continue after 6 months
Tendency No previous Previous tendency
Site Any site Over the bony
prominent
e.g. sternum
Extend beyond
the margin of
wound
Never Presence
Treatment No active treatment required Active treatment
required – injection
steroid, pressure
dressing, R/T
Complication - Malignant change –
Marjolin’s ulcer
25. Principle of wound management
Clean wound – closed by primary intention
Contaminated wound – change to clean wound
– closed
Depend on - amount of contamination
- type of wound
26. A. Specific treatment
Contaminated wound- change to clean wound by-
1. “wound toilet”- irrigation of wound with sterile water
including antiseptic solution - to reduce contamination
& remove foreign body
2. “wound debridement”- excision of dead & devitalised
tissue[pseudo tumour approach] under appropriate
GA/LA/Reagional
Skin – as little as possible (easy to close the wound)
Subcut :fat & tls – as much as possible
Mls – till bleed ( viable mls )
Tendon – color suture for delayed repair
Nv – primary repair / delayed repair mark with
suture
27. Bld v/s -Small v/s – haemostasis
-Major v/s – primary repair / graft
Bone - detached bone & pieces from periosteum
removed
- Reduction & traction by external fixator or POP
with windows for dressing
Care of internal organ damage - chest tube for 10
haemothorax
Wound not closed primarily ( left open until clean )
Daily dressing untill clean
28. B. Supportive / symptomatic treatment
- Analgesic & antiinflammatory drugs - for pain &
inflammation
- Antipyretic drugs – pt with febrile reaction
- Antibiotic – according to possible organ ( or ) C&S
result
- tetanus prophylaxis – tetanus toxoid – active for
regular immunized person
– both active & passive in pt
who has no regular immmunization
- Nutritional support
- Correct the factors which delayed the wd healing
e.g Correction of Anaemia, Diabetes mellitus
29. C. Treatment of clean wd / wd become clean from
contaminated wound
- Skin closure d/on type of wound
( 1 ) when skin can oppose together eg .in incise &
lacerated wound ( less tissue loss )
- Primary closure – for clean wound.
- delayed primary closure – for contaminated wound.
30. - secondary closure – clean wound become
contaminated
- after primary closure & remove the suture and then
wait for clean wound and then reapplication of
suture
( 2 ) when skin cannot oppose together (tissue loss very
much) crush wound
a. Close the wound by – skin graft ( to fasten the wd
healing ) ( or )
b. Left the wound open and healing from base of
wound ( wd complication increased )
