This topic is under the General Principles of Surgery for MBBS Students. It also deals with Scars & Contractures. The student should know to differentiate between Hypertrophic Scar & Keloid..

1. Prof. U. Murali.
Chronic Wounds

2. Learning Objectives
•Introduction
•Leg ulcers / Pressure ulcers
• Scars - Hypertrophic scar / Keloid
• Contractures
• Sinus & Fistula

3. • Chronic wounds fail to progress through the
normal stages of wound healing in a timely
manner.
• They are often characterized by a prolonged
inflammatory phase and persistent
infections.
• The management of chronic wounds
therefore often involves debridement,
control of infection and inflammation and
appropriately selected dressings to correct
moisture imbalances.
• Chronic wounds can be categorized into –
• Vascular ulcers (venous or arterial)
• Diabetic ulcers &
• Pressure ulcers.
Introduction

4. Leg Ulcers
Prof. U.Murali.

5. • In developed countries, the most
common chronic wounds are leg
ulcers.
• Defn: An ulcer is a break in the
continuity of the covering
epithelium, either skin or mucous
membrane due to molecular
death.
• A prolonged inflammatory phase
leads to overgrowth of granulation
tissue and attempts to heal by
scarring leave a fibrotic margin.
Leg Ulcers

6. 6
Leg Ulcers

7. •CBP / Sr. Protein
•Study of discharge – C/S
• Edge biopsy
• X-ray of the part
• FNAC – Lymph node
• Chest X-ray / Mantoux
test
• Arterial / Venous Doppler
Leg Ulcers – Investigations

8. Leg Ulcers – Treatment
• Cause should be found & treated.
• Correction of anaemia,
deficiencies like protein &
vitamins.
• Control of pain & infection.
• Rest, immobilization, elevation &
avoidance of repeated trauma.
• Care of the ulcer by debridement,
ulcer cleaning & dressing.
• Once the ulcer granulates, defect
is Closed with secondary
suturing, skin graft (or) flaps.

9. Pressure Ulcers
Prof. U.Murali.

10. • Pressure sore is tissue necrosis and
ulceration due to prolonged pressure.
It is more prominent between bony
prominence and an external surface.
• They can appear & extend rapidly in
immobile patients and in those with
debilitating illness.
• It can also be called as –
• Trophic ulcer.
• Neuropathic / Neurogenic ulcer.
• Bed sore &
• Decubitus ulcers.
Pressure Sore / Ulcer / Injury

11. SITES FACTORS
Pressure Sore / Ulcer / Injury
• Pressure
• Sensory
Loss
• Anemia
• Malnutrition
• Moisture
• Def. blood
supply
• Injury

12. Pressure Sore / Ulcer / Injury

13. Clinical Features
• Occurs in 5% of in-
patients.
• Deep punched out
edges.
• Non-mobile ulcers
– bone as its base.
Type
Investigations
• Pus – C/S
• Blood tests
• Biopsy
• X-ray - part
Pressure Sore / Ulcer / Injury

14. • Postural changes:
- Change in position – once in 2 hours
- Lifting limb upwards – 10 s – once in10 mts
• Use of – waterbed/air bed/air-fluidized bed.
• Special pressure dispersion cushion / foams.
• Absorbent porous clothing.
• Regular use of talcum powder – skin dry.
• Urinary & faecal care.
• Good nutrition / Psychological counseling.
• Treating the cause – Anemia/Diabetes….
• Antibiotics & Regular dressings - VAC.
• Slough excision → skin grafting / flap cover
to be done.
P U - Treatment

15. Scar
Prof. U.Murali.

16. • A scar is an area of fibrous tissue that
replaces normal skin after an injury. Thus,
scarring is a natural part of the healing
process.
• The remodelling and maturation phase of
wound healing results in scar formation.
• Scars result from the biological process of
wound repair in the skin, as well as in
other organs, and tissues of the body.
• Exception of very minor lesions, every
wound (e.g., after accident, disease, or
surgery) results in some degree of
scarring.
Scar – Introduction

17. • Initially immature scar is formed during
remodeling phase; this scar is raised, itchy,
hard and pink in colour.
• A mature scar is paler, acellular, softer, flat,
without itching (diminishes).
• An atrophic scar takes the form of a sunken
recess in the skin. These are caused when
underlying structures are lost.
• A hypertrophic scar is excess scar but will not
extend beyond the margin of the scar of the
original wound.
• Keloid is persistent excessive growth of the
scar beyond its margin into the adjacent skin.
Scar – Types

18. Scar – Prevention

19. Scar – Treatment

20. • Hypertrophic scar is excessive
formation of abnormal scar tissue
which is raised, often vascular but
confined within the margin of the
original wound; usually its growth
stops in 6 months and often
regresses spontaneously.
• They are more common in areas of
increased tension, wounds crossing
tension lines, deep dermal burns &
wounds left to heal by secondary
intention (longer than 3 weeks).
Hypertrophic Scar / Keloid
• Keloid scars extend beyond the
boundaries of the original incision (or)
wound, do not spontaneously regress
and are difficult to treat.
• The etiology is unknown but genetic
predisposition is implicated. They often
occur because of relatively minor
trauma and mainly in those with darker
skin pigmentation.

22. Mgt – Algorithm – Hypertrophic Scar

23. Mgt – Algorithm – Keloid

24. Contracture
Prof. U.Murali.

25. • Contracture is the result of a stiffness or
constriction of muscles, joints, tendons,
ligaments (or) skin that restricts normal
movements.
• Contracture develops when normally
elastic connective tissues become
replaced with inelastic fibrous tissues.
Contracture
• Contractures are either neurally (or) non-
neurally mediated -
• Neurally mediated – are due to spasticity and are a
common sequalae of UMN lesions.
• Non-neurally mediated – contractures are due to
structural adaptations of soft tissues [Occur in
response to prolonged immobilization of soft
tissues].

26. • Inactivity & Scarring –
from an injury / burn.
• Muscular dystrophy.
• Cerebral palsy.
• Polio.
• Rheumatoid arthritis.
• L E – plantar flexion, hip
flexion & knee flexion
contractures are
common.
• UE – elbow flexion &
supination / adduction &
internal rotation
contractures of shoulder.
• Muscles that cross
multiple joints – biceps,
hamstrings, TFL &
gastrocnemius are
predisposed to
contractures.
Sites Types
Contracture
Causes

27. • Scar contractures can cause severe
functional, psychological and aesthetic
problems.
• Contractures across joints may restrict the
range of movement, leading to deformity,
impairment and disability.
• Surgical contracture release and
reconstruction can be an effective
treatment option. Release of contracture
surgically and use of skin graft (or) "Z"
plasty (or) different flaps.
• Proper physiotherapy and rehabilitation is
essential.
Contracture

28. Sinus/Fistula
Prof. U.Murali.

29. • It is a blind track lined by
granulation tissue leading from an
epithelial surface into the
surrounding tissues.
• Sinus means "hollow" or "a bay"
(Latin).
Sinus / Fistula
• It is an abnormal communication
between the lumen of one viscus to
another or the body surface or between
the vessels.
• Fistula means "flute" or "a pipe or tube."

30. Sinus / Fistula

32. Sinus / Fistula

33. Sinus / Fistula

34. • Aetiology & treatment of Leg ulcers.
• Basic Investigations & treatment aspects of Leg ulcers.
• Sites & Factors causing Pressure ulcers.
• Staging of Pressure injury | C/F & Treatment of Bedsore.
• Scar – Types, Prevention & Treatment of scars.
• Difference between Hypertrophic scar & Keloid.
• Contracture – Causes, Sites & Types.
• Defn – Sinus / Fistula | Causes for its persistent occurrence.
To Summarize

35. References

36. • List 4 aetiological factors causing leg ulcers.
• Mention the staging methods of decubitus ulcer.
• Enumerate 3 sites & 3 factors causing pressure injuries.
• Write the management algorithm for keloid.
• Compare & Contrast hypertrophic scar from keloid.
• Outline the various preventive methods of scar formation.
• Write 5 causes for persistence of a sinus / fistula.
• Mention the various sites & types of contractures.
Question Time

37. The drug used for intralesional injection of
keloid treatment is –
◼ a) Prednisolone.
◼ b) Triamcinolone.
◼ c) Androgen.
◼ d) Hydrocortisone.
◼

38. A patient with an injury that has full-thickness loss
without exposure of underlying bone or muscle is
at which of the following pressure ulcer stages? –
◼ a) Stage – 4.
◼ b) Stage – 3.
◼ c) Stage – 2.
◼ d) Stage – 1.
◼

39. Which one of the following is true regarding leg
ulcers & their location? –
◼ a) Pressure ulcer – Tip of the toes.
◼ b) Arterial insufficiency – Medial side of leg.
◼ c) Venous insufficiency – Gaiter area.
◼ d) Diabetic ulcer – Above medial malleolus.
◼

40. A hirsute young male has a sinus just above the
natal cleft. Which is the most likely diagnosis? –
◼ a) Tubercular sinus.
◼ b) Hidradenitis suppurativa.
◼ c) Fistula-in-ano.
◼ d) Pilonidal sinus.
◼

41. Which one of the following sites is more prone
for contracture formation? –
◼ a) Hip flexion.
◼ b) Elbow pronation.
◼ c) External rotation of shoulder.
◼ d) Wrist flexion.
◼

46. THANK YOU