This topic comes under the General Principles of Surgery for MBBS Students. The student should know the various types of wounds, their assessment and dressing methods.

1. Prof. U. Murali.
Types of Wounds
& Management

2. LEARNING OBJECTIVES
• Define wound & list the types of wounds.
• Classify wounds and outline their salient features.
• Describe the management of wounds with respect to wound
debridement & wound closure.
• Outline the wound assessment & preparation methods.
• Discuss about - Crush syndrome & De-gloving injury.
• Mention the mode of tetanus prophylaxis against immunized
& non-immunized patents.

3. Types Of Wounds
Prof. U.Murali.

4. DEFINITION – WOUND
• A wound is a break in the
integrity of the skin (or) tissues
often, which may be associated
with disruption of the structure
and function.
• Wound is simply a disruption of
any tissues — soft tissue (or)
bone (or) internal organs.

5. CLASSIFICATION – BASED ON
• 1. Involvement of tissues
• 2. Neatness of wound – Rank & Wakefield
• 3. Type of wound
• 4. Thickness of the wound
• 5. Time elapsed
• 6. Type of Surgical wounds – Berard

6. 1. TISSUES INVOLVED
• Simple wounds
– Only skin / tissue is involved
• Combined/Complex wounds
– Involving mixed tissues
(vessels/nerves/tendons/bones)

7. 2. NEATNESS OF WOUND – RANK & WAKEFIELD
• Tidy wounds
– Surgical incisions & Sharp objects
– Clean / no tissue loss
– Primary suturing
• Untidy wounds
– Crushing, Tearing, Avulsion &
Devitalised injury
– # of bone + / - Infection – common
– Suturing after excision & cleaning

8. 3. TYPE OF WOUND
• Open wounds
• Closed wounds
• Complex wounds

9. 3 – A OPEN WOUND
• Abrasion
– It is superficial and is due to shearing of
skin where the surface is rubbed off.
• Incised
– It is a clean-cut wound with linear edge.
• Lacerated
– It has ragged edges with devitalisation of
some part of tissues.
• Penetrating / Punctured
– It is usually due to a pointed object where
depth > than the width.

10. 3 – B CLOSED WOUND
• Bruising / Contusion
– It is due to blow (or) blunt force to the skin
and tissues underneath with skin
discoloration and without breaking of skin.
• Haematoma
– It is a localized collection of blood after
blunt trauma.
• Closed Blunt Injury
-- It may be due to fall or blunt injury wherein
no obvious external injury is seen but
deeper injury can occur. Like in blunt
abdominal injury causing bowel / liver /
spleen / renal injuries.

11. 3 – C COMPLEX WOUND
• Traction / Avulsion Injury
– where the tissues are displaced from their
normal anatomical position and alignment. It
can occur in single plane like in subcutaneous
tissue (or) in multiple planes.
• Crush Injury
– It is due to major wounds, war wounds, natural
disaster like earthquake injuries, tourniquet
injury.
• Gunshot Injury
– These injuries may be superficial or deep.
• Injuries – Bones, joints, VAN & deep
organs

12. 4. THICKNESS OF WOUND
• Superficial wound
– Involving only epidermis & dermal papillae.
• Partial thickness
– skin loss up to deep dermis with only deepest part of
the dermis, hair follicle shafts and sweat glands are
left behind.
• Full thickness
– loss of entire skin and subcutaneous tissue causing
spacing out of the skin edges.
• Deep wound
– one extending deeper, across deep fascia into
muscles (or) deeper structures.
• Complicated wound
– are one associated with injury to vessels or nerves.
• Penetrating wound
– is one which penetrates into either natural cavities or
organs.

13. 5. TIME ELAPSED
• Acute wounds
– Are those that progress through the
normal healing phases and typically
show signs of healing in less than 4
weeks.
– Up to 8 hours of trauma.
• Chronic wounds
– Are those that do not follow the
normal healing process and show no
signs of healing in 4 weeks.
– After 8 hours of trauma.

14. 6. TYPE OF SURGICAL WOUND - BERARD
• Class 1 - Clean wound
– It is a non-traumatic, uninfected operative
wound. Elective & primarily closed.
– E.g.: Excision / Thyroid & Hernia surgeries
– Infection rate is < 2%
• Class 2 - Clean contaminated wound
– Gastrointestinal, respiratory or genito-urinary
tracts entered without significant spillage or
wounds which are mechanically drained.
– E.g.: appendicectomy, gallbladder, biliary,
pancreatic surgeries
– Infection rate is < 10%

15. 6. TYPE OF SURGICAL WOUND
• Class 3 - Contaminated wound
– Acute abdominal conditions.
– Spillage from hollow organs.
– Break in sterile technique.
– Chronic open wounds.
– Infection rate is 15 - 30%
• Class 4 - Dirty Infected wound
– Abscess drainage.
– Pyocele.
– Faecal peritonitis.
– Empyema gallbladder.
– Infection rate is 40 - 70%

17. Wound Management
Prof. U.Murali.

18. WOUND MANAGEMENT
• Wound Assessment
• Proper Management

19. WOUND ASSESSMENT
• Detailed history
– Mode of injury – Timing
– Severity of pain / bleeding
– Look out for other organ
injury
• Examination
– Follow ATLS principles
– Site, size, type and extent
– Swelling, deformities &
viability
– Contamination – level –
Any FB
– Functions – Motor &
Sensory

22. WOUND PREPARATION
• Antibiotic prophylaxis
– It is needed for clean–contaminated,
contaminated and dirty wounds. It may also be
used in clean wounds when there is a high risk of
infection.
• Tetanic prophylaxis
– Should be given based on the type of wound &
immunization status.
• Analgesia / Anesthesia
– Ensure that the patient has adequate analgesia or
a local anesthetic block.
• Wound irrigation
– Is washing the wound thoroughly using warm normal
saline. It allows better visualization of the wound.

24. WOUND DEBRIDEMENT
• Debridement & Irrigation
– Debridement is essential to remove any devitalized
tissue and foreign material from the wound. Non -
viable tissue must be excised until healthy bleeding
occurs at the wound edges.
– Irrigation can also be performed with a soft brush or
sponge to clear particulate matter prior to preoperative
application of skin antiseptic preparation.
• Exploration
– Wounds should be explored to determine the extent of
injury, including any damage to underlying
neurovascular structures, tendons, joints & bones.
• Repair Structures
– Careful tissue handling & meticulous technique are
important throughout. Repair of all damaged structures
may be attempted once the wounds are clean. Repair of
nerves and vessels should be performed.

25. WOUND CLOSURE
• Skin Closure
– Skin closure should always be without tension. Direct
closure is not always possible and other
reconstruction methods should be considered.
• Reconstruction
– The reconstructive ladder and its variants have been
used as a framework to consider the simplest means
to achieve wound closure for the desired goal – Skin
Graft / Flap.
• Optimal Dressings
– Much care should be given to the wound by dressing
after the wound closure. Dressing is done daily (or)
twice daily (or) once in 2-3 days depending on the
type of wound and type of dressing used.

26. WOUND CLOSURE – METHODS – 1
• Primary suturing – Suturing within
6 hrs. Done in clean incised
wounds.
• Delayed primary suturing –
Suturing within 48 hrs to 10 days.
Done in lacerated wounds.
• Secondary suturing – Suturing in
10 – 14 days (or) later. Done in
infected wounds.

27. WOUND CLOSURE – METHODS – 2
• Skin Graft
– It is transfer of skin
from one area to the
required defective
area.
• Flap
– It is transfer of donor
tissue with its blood
supply to the
recipient area.

28. WOUND CLOSURE – METHODS – 3
• Negative Pressure Wound Therapy [NPWT]
– It is a useful adjunct to definitive wound
closure.
– Negative pressure helps draw the wound
edges together, remove exudate, reduce
oedema and promote granulation tissue
formation.
• Vacuum Assisted Closure [VAC]
– It is by creation of negative pressure (25-200
mmHg), continuous (or) intermittent over the
wound surface.
– It reduces fluid in the interstitial space, reduces
edema, increases the cell proliferation
& promotes formation of healthy GT.

29. WOUND MANAGEMENT - INITIAL
• Wound Inspection
• Follow ATLS principles
• Bleeding – present – to be controlled
• To facilitate exam – Anesthesia – L /R /G
• Antibiotics, Fluid & electrolyte balance &
TT injection
• Deeper communicating injuries – looked
for
• Wound assessment & preparation
• Vascular (or) nerve injuries – dealt
accordingly

30. WOUND MANAGEMENT - PROPER
• Incised
– Primary Suturing
• Lacerated
– Excision & Primary Suturing
• Crushed
– Debridement, excision
– Delayed Primary Suturing
• Deep devitalized
– Debridement
– Secondary Suturing / Grafting

31. CRUSH SYNDROME
• It is due to crushing of
muscles causing
extravasation of blood &
release of myoglobin into
the circulation leading to
ATN & ARF.

32. CRUSH SYNDROME
Causes
• Earthquakes
• Mining & Industrial
accidents
• Battlefield incidents
• Air crash
• Tourniquet
Pathogenesis
• Tension ↑ muscle
compt.
• ↓
• ↑ ischaemic damage
• ↓
• Urine – discoloured
& Scanty
• ↓
• Uraemia [restless,
apathy]
Effects
• Renal failure
• Toxaemia
• Septicaemia
• Disability with tissue
loss
• Gas gangrene

33. C S – TREATMENT
• Volume load – saline 1-1.5 l – ideal
• Mannitol – to improve urine output
• Alkalinization of urine
• Relieve Tension – parallel deep incisions.
• Hemodialysis – last stage
Other measures:
• Catheterization.
• Oxygen therapy.
• Antibiotics.
• Blood transfusion.
• Correction of severe hyperkalaemia.

34. DEGLOVING INJURY
• It occurs due to shearing force
between tissue planes as traction
– avulsion injury.
• It occurs between sub. cut. tissue
& deep fascia (or) between
muscle & bone.
• It can be localized (or)
circumferential.

35. DEGLOVING INJURY
• It can be in one plane (or)
multiple planes.
• It is commonly observed in
machinery injuries (or)
major road traffic accidents.
It is much more extensive
than of on initial
presentation.

36. DEGLOVING INJURY
• It needs examination under
GA, wound excision /
radical excision, flap
coverage, micro-flap
surgeries, skin grafting, with
proper asepsis and blood
transfusion as there is
significant blood loss in
these injuries.

37. TO SUMMARIZE
• Classification of wounds with their salient features.
• Types of surgical wounds.
• Wound assessment & preparation methods.
• Various types of wound debridement & closure methods.
• Crush syndrome & Degloving injury.
• Post-exposure treatment of tetanus prone wounds.

38. REFERENCES

39. QUESTION TIME
• Define wound & list the types of wounds.
• Classify wounds. Explain any one with their salient features.
• Enumerate the types of wound debridement methods.
• How do you prepare a wound & assess it?
• Outline the causes of crush syndrome and its effects.
• Explain the principles of wound management.

40. WHICH IS A CLEAN SURGERY AMONG THE
FOLLOWING?
• A. Hernia surgery.
• B. Gastric surgery.
• C. Cholecystectomy.
• D. Rectal surgery.

41. ALL THE FOLLOWING ARE PRINCIPLES OF
NEGATIVE PRESSURE WOUND THERAPY [NPWT]
EXCEPT –
• A. Stabilization of wound environment.
• B. Clearance of infection.
• C. Drawing the edges together.
• D. Decreased oedema.

42. FOLLOWING ACTIVE IMMUNIZATION WITH TETANUS
TOXOID, WHEN SHOULD A TETANUS TOXOID
BOOSTER BE GIVEN? –
• A. Every year.
• B. Every 2 years.
• C. Every 5 years.
• D. Every 10 years.

43. WHICH ONE OF THE FOLLOWING STATEMENTS IS
FALSE? –
• A. In case of severe uncontrollable bleeding, a soft clamp must be applied
immediately across the vessel in the wound.
• B. Wounds should be classified as tidy & untidy before deciding upon
intervention.
• C. Repair of all damaged structures can be attempted under certain situations.
• D. A large hematoma should be actively treated.

44. DEGLOVING INJURY IS –
• A. Separation of skin only.
• B. Separation of skin + subcutaneous tissue.
• C. Separation of tendon exposing the bone.
• D. Separation of facia exposing tendons.

45. Thank you