2. DEFINITION
• A wound is a break in the continuity of soft
tissues
• defined as a separation or discontinuity of
the skin, mucous membrane or tissue caused
by physical, chemical or biological insult
3. Wound healing
• Wound healing is a mechanism whereby the
body attempts to restore the integrity of the
injured part.
4. Site of the wound
Structures involved
Mechanism of wounding
Incision
Crush
Crush avulsion
Contamination (foreign bodies/bacreria
Factors influencing healing of a
wound
5. Continue-----
Other local factorsVascular insufficiency
(arterial or venous)
Loss of tissue
• Previous radiation
• Pressure
• Systemic factors
• Malnutrition or vitamin and mineral
deficiencies
9. • Primary intention
Wound edges opposed
Normal healing
Minimal scar
• Secondary intention
– Wound left open
10. Heals by granulation, contraction and
epithelialisation
Increased inflammation and proliferation
Poor scar
• Tertiary intention (also called delayed
primary intention)
Wound initially left open
Edges later opposed when healing conditions
favourable
11.
12.
13.
14.
15. Managing the acute wound
• Cleansing
• Exploration and diagnosis
• Debridement
• Repair of structures
• Replacement of lost tissues where indicated
16. • Skin cover if required
• Skin closure without tension
• All of the above with careful tissue
handling and meticulous technique
18. Leg ulcer
• Venous disease leading to local venous
hypertension (e.g.
• varicose veins)
• Arterial disease, either large vessel
(atherosclerosis) or small
• vessel (diabetes)
• Arteritis associated with autoimmune
disease (rheumatoid
19. • Trauma – could be self-inflicted
• Chronic infection – tuberculosis/syphilis
• Neoplastic – squamous or basal cell
carcinoma, sarcoma
25. Remote Symptoms
• Observed away from the wound
• Abscess formation in a dependent lymph node
• Paralysis or a loss of function in a dependent portion
• Neuritis extending along the course of the nerve involved
in the wound.
26. Management of wounds
• Contusions: are treated with cold and astringent
applications to minimize extravasation.
• Haematomas: when small get absorbed ,other wise they
may have to be opened and treated.
• Open wound: surgical or aseptic wound/ contaminated
and septic wound/ accidental traumatic wounds.
27. Surgical or aseptic wounds
• A surgical wound made with all aseptic precautions
in a non infected tissue is an aseptic wound.
• Surgeon should avoid drying of the tissue, excessive
trauma and haemorrhage – lower the wound
infection.
• Prophylaxis against tetanus
• Drainage should be provided if haemotoma or
seroma formation is expected.
28. • Suture should be supported up to healing time 8 -14
days
• Systemic use of specific antibiotics as a therapeutic
or prophylactic measure.
• Local application of Fly repellents – hot summer
months.
• The patient and the affected injured part should be
kept at rest
29. Contaminated and septic wounds
• A fresh wound gets contaminated when it is more
than 4 -5 hours old.
• Management is mainly directed towards overcoming
factors like.
– Type and number of invading micro organisms
– Type and location of the wound
– Poor blood flow at the wound site
– Effective ness of the treatment
– Presence of foreign material
• Dead tissue at the wound site.
30. General principle
• Control of haemorrhage: Bleeding is controlled and
ligating large vessels if any
➢ Wound and its periphery should be thoroughly cleaned with warm
normal saline, water, soap or 2% H2O2 5% dettol, 0.5% potassium
permanganate
➢ Clipping and shaving of large area around wound
31. Cleaning of wound/ irrigation of wound
• The wound and surrounding areas are irrigated with mild, non irritant,
antiseptic lotions:
1:1000 Per chloride of mercury lotion.
1:500 acriflavin lotion
1:40 Eusol lotion (Eupad is 1:40 bleaching powder + boric acid)
5 – 10 % hyper tonic salines.
• If wound is fresh suturing may be attempted
• Infected and deep penetrating wounds are not sutured
• Wounds that are not sutured should be irrigated daily or on alternate
days
• Wounds of feet: warm antisepic foot baths may be given with 10%
formalin
32. Wound debridement
• Debridement for removal of devitalized or necrosed
tissue is either done by excising the unhealthy tissue or
by use of topical mendicaments
➢ 2.5% sodium chloride solution.
➢ Magnesium sulphate and glycerin paste.
33. Control of infection
• After irrigation and debridement wound
may cover with
➢ Moist antiseptic pad / antiseptic powder / ointment.
➢ Antiseptic powders, boric acid, eupad BIPP
➢ Ointments: Boric ointment, penicillin ointment,
streptomycin, chloromycin ointment, terramycin ointment.
➢ Application of very strong antiseptics should be avoided as
it will destroy granulation tissue.
34. Providing drainage
• If there is exudation and discharge the wound should not
be sutured.
• Deep wounds – fenestrated tube is advisable for drainage
• Deep wounds with narrow external opening – may be
enlarged for efficient drainage.
• Counter opening may be made in a dependent part seton
may be passed through it.
35. Immobilization of wounded area
• If proper immobilization is not provided healing is
delayed, formation of excessive granulation tissue
(Exubeenrt granulation / pround flush)
• Application of caustics – copper sulphate, potassium
permanganate
36. Accidental traumatic wounds
➢ Check hemorrhage
➢ Avoid development of shock
➢ Prophylaxis against tetanus
➢ Cleaning, excision, debridement
➢ Systemic antibiotic treatment
39. • A wound is defined as a separation or
discontinuity of the skin, mucous membrane
or tissue caused by physical, chemical or
biological insult.
• Wound healing is restoration of the tissue
continuity
40. • Wound healing, is the foundation of
surgery and complex process.
• Always associated with process of
inflammation.
• Inflammation is a local reaction of living
tissues to an injury of microcirculaion
and its associated tissues.
41. Wound Healing
• First intension
• Second intension
• Mixed intension
• Third intension
• Healing under scab
42. Healing by First intension
• Occurs in incised or surgical wounds, with
minimal tissue damage and bleeding
• Repair begins in 12 hours by proliferation
angioblast and fibroblast
• Healing is complited in about 14 days
• Scar formed is very little
43. • Wound should be clean and fresh
• Free form infection and bleeding
• Free from foreign bodies
• Edges should have good blood supply
• Edges should have proper alignment and
apposition
44. Healing by Sesond intension
• By replacement of tissue
• Wounds having extensive loss of tissue and
edges widely separated
• Granulating tissue consist of budding
capillaries and fibroblast, grows from edges
and bottom to fill up gap
45. • Granulating tissue is velvety in
appearance, soft, moist and pink in colour
• Granulation tissue is called so due to
granular appearance presented by budding
capillaries
• Healing takes 14-21 days, in large wound
with excessive loss of tissue it may take 42
days
46. Healing by Mixed intension
• Wound healing is partly by first intension
and partly by second intension
• Happens when sutured wound has partially
disrupted
47. Healing by Third intension
(Healing by secondary suture)
• Granulating tissue are united by sutures for
quicker healing
48. Healing under scab
• In superficial wounds like abrasions
• Exudate present in the wound dries and froms scab
• Granulation takes place under this scab
• When granulation is complete the scab
automatically separates and is cast off
49. Phases of wound healing
[A] Inflammatory phase: -
• Immediate response to injury is acute
inflammation
• Vasoconstriction of small vessels in the area
• Response last for 5-10 minutes and followed by
active vasodilation
50. • Vasodilatation causes accumulation of
exudate in the area
• Dilatation is due to release of histamine,
serotonin and bradykinin
• This causes swelling of vascular
endothelial cells, creating gap between
these cells
51. • Exudate provides fibrinogen and other clotting
elements, which form fribin clots
• These clots plugs the damaged lymphatics,
preventing further damage from injured area
• Inflammatory reaction is thus localized to a
specific area surrounding the injury
• Redness, swelling and heat are seen during
inflammatory reaction in the area
52. [B] Fibroblastic or Collagen phase: -
• Begins at about 5th day
• Fibroblast are actively engaged in
production of connective tissue matrix
• Fibrinogen in exudate is converted to fibrin
by enzymes from blood and tissue cells
53. • Fibrin is laid down in the wound and provides a
good frame work for repair besides haemostasis
• Collagen is synthesized by the fibroblasts
• Few collagen fibers are present at the beginning
but by 15th day wound gets good tensile strength
• Sutures are therefore removed about 2 weeks of
surgery
54. [C] Maturation phase: -
• It starts after collagen bed is laid
• Collagen fibers become thicker, denser
and number of fibroblast decreases
• Pale scar is formed, full maturation of
scar may take months or year
55. [D] Contraction phase: -
• It involves movement of existing tissue at the wound
edges resulting decrease in size of open wound
• Absence of attachment of the skin to the underlying
structures allow maximal contraction
• Contraction has been reported to be a cell mediated
phenomenon
• Contractions near joints may result in the formation of
tight band of scar tissue
56. Factors affecting wound healing
• LOCAL FACTORS: -
– Surgical technique
– Tissue vascularity
– Mechanical stress
– Movement
– Extent of wound surface
– Haemorrhages
– Foreign bodies
– Oedema and Dehydration
– Local irradiation
– Suture material and techniques
– Wound infection
57. • SYSTEMIC FACTORS: -
– Age
– Obesity
– Malnutrition
– Vitamin deficiancy
– Anaemia and hypoxia
– Systemic disease
– Temperature
