About wounds

1. Wounds and wound process.
Treatment of clean wounds. Purulent
wounds. Infected and purulent
wounds.
DocentDocent of the Surgery chairof the Surgery chair
of the Dentistry departmentof the Dentistry department
Ryziuk M. D.Ryziuk M. D.
Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University

2. PLANE
OF LECTURE
Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University
1.1. DETERMINATION AND CLINICDETERMINATION AND CLINIC
2.2. HISTORY OF TREATMENT OF WOUNDSHISTORY OF TREATMENT OF WOUNDS..
3.3. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
4.4. PATHOGENESIS OF THE WOUNDSPATHOGENESIS OF THE WOUNDS
5.5. TREATMENT OF WOUNDSTREATMENT OF WOUNDS

3. ACTUALITY OF THEMEACTUALITY OF THEME

4. Physiology of Wound Healing
Blood leaksBlood leaksWounWoun
dd
occursoccurs
WounWoun
dd
occursoccurs
STOPSTOP
EpithelialEpithelial
cellscells
ScabScab
causescauses
obstructionobstruction
ScabScab
causescauses
obstructionobstruction
Thickening and returnThickening and return
to normal stateto normal state

5. DETERMINATION AND CLINICDETERMINATION AND CLINIC
WOUND (WOUND ( Vulnea)Vulnea) is the damage of integrity of skinis the damage of integrity of skin
or mucus membrane,deep tissues and the inneror mucus membrane,deep tissues and the inner
organs.organs.
Symptoms of woundSymptoms of wound (local):(local):
• bleeding;bleeding;
• hiatus;hiatus;
• pain.pain.

6. HISTORY OF TREATMENT OF WOUNDSHISTORY OF TREATMENT OF WOUNDS
HipokratHipokrat
M.I. PirogovM.I. Pirogov Ambruas PareAmbruas Pare

7. History of Wounds
• Herbal balms and ointments
• Initially, wounds were left open
• Oldest suture 1100BC
• Primary and secondary closure 2000 yrs
ago
• Middle ages: pus thought necessary
• Recent wound closure less that 200 yrs old

8. HISTORY OF TREATMENT OF WOUNDSHISTORY OF TREATMENT OF WOUNDS

9. Classification of wounds
І.І. According to the characterAccording to the character
 Різані рани (Різані рани (vulnus incisium)vulnus incisium);;
 Рубані раниРубані рани (vulnus caesum)(vulnus caesum);;
 Колоті раниКолоті рани (vulnus punctum)(vulnus punctum);;
 Забійні раниЗабійні рани (vulnus contusum)(vulnus contusum);;
 Рвані раниРвані рани (vulnus laceratum)(vulnus laceratum);;
 РозчавленіРозчавлені (vulnus conquassatum)(vulnus conquassatum);;
 Укушені раниУкушені рани (vulnus morsum)(vulnus morsum);;
 Отруєні раниОтруєні рани (vulnus venenatum)(vulnus venenatum);;
 ВогнепальніВогнепальні (vulnus(vulnus sclopetarium)sclopetarium);;
 Зсаднені раніЗсаднені рані ((vulnus excoriatum)vulnus excoriatum);;
 Царапині раниЦарапині рани (vulnus scarificatum)(vulnus scarificatum);;
 Змішані раниЗмішані рани (vulnus mixtum)(vulnus mixtum)..

10. In according to the damage of tissues the wounds areIn according to the damage of tissues the wounds are
distinguished:distinguished:
Cut wound – incisumCut wound – incisum
CLASSIFICATIONCLASSIFICATION OF THE WOUNDSOF THE WOUNDS

12. Incision

13. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
- Stab wound – punctum- Stab wound – punctum
- Sabre or slash wound – caecum- Sabre or slash wound – caecum

14. Puncture Wounds

16. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
- Lacerated wound – laceratumLacerated wound – laceratum
- Contused wound – contusumContused wound – contusum

17. Laceration

18. Degloving injury

20. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
- Scalped wound- Scalped wound

21. Avulsion

22. Avulsion

23. Avulsion (complete/amputation)

25. Avulsion Treatment
• Control bleeding
• Clean and dress
• Seek physician evaluation
• Watch for infection
• If complete avulsion (amputation), take avulsed
tissue to physician for reattachment!

26. Care of the avulsed tissue
• Wrap tissue in clean
cloth
• Put wrapped tissue in
plastic bag
• Put plastic bag in a
bag of ice

27. Crushed wound – conqvassatumCrushed wound – conqvassatum
CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS

28. Crush injury

29. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
-Excoriation wound – excoriatumExcoriation wound – excoriatum
- Scratch wound – scarificatum- Scratch wound – scarificatum

30. Abrasion

31. Scrapes

32. -Bite wound – morsumBite wound – morsum
- Poisoned wound – venenatum- Poisoned wound – venenatum
CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS

33. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
Gunshot wound – sclopetariumGunshot wound – sclopetarium

34. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
In according to depth of the wounds they areIn according to depth of the wounds they are
distinguished:distinguished:
- superficial wounds;superficial wounds;
- deep wounds.deep wounds.
In relation to cavities of body the woundsIn relation to cavities of body the wounds areare
distinguished:distinguished:
- unpenetrable;- unpenetrable;
- penetrable.- penetrable.
In according toIn according to reason the woundsreason the wounds areare distinguish:distinguish:
- operative wounds;operative wounds;
- accidental wounds.accidental wounds.

35. In relation to the bodily cavities:In relation to the bodily cavities:
Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University
penetrativepenetrativedo not penetrativedo not penetrative

36. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
According to the level ofAccording to the level of
infection :infection :
- clean (aseptic) wounds;clean (aseptic) wounds;
- conditionally clean wounds;conditionally clean wounds;
- muddy (contaminated)muddy (contaminated)
wounds;wounds;
- infected wounds;infected wounds;
- purulent wounds.purulent wounds.

37. Classification of wounds
Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University
Depending on the cause:
surgical, or asepticsurgical, or aseptic accidental, or casualaccidental, or casual

38. CLASSIFICATION OF THE WOUNDSCLASSIFICATION OF THE WOUNDS
According to the origin wounds are distinguished:According to the origin wounds are distinguished:
-- fresh woundsfresh wounds ((from 1 till 24 hourfrom 1 till 24 hour););
- later woundslater wounds ((after 24 hour)after 24 hour)
According to the method of healing of the woundsAccording to the method of healing of the wounds
they arethey are::
-- primary tensionprimary tension (per primum)(per primum);;
- secondary tensionsecondary tension (per secundam);(per secundam);
- reparation under the crust.reparation under the crust.

39. Superficial Wounds
• Involve epidermis
only
• No breach of basement
membrane
• No bleeding
• Can be painful
• Ex- sunburn, “rug
burn”

40. Arterial Wounds
• Inadequate arterial
flow
– Tissue lacks nutrients
and oxygen to maintain
• Causes: peripheral
vascular disease,
diabetes, embolism
• Often located on tips
of toes and fingers

41. Venous Wounds
• Inadequate venous
drainage
• Causes: vein valve
disfunction, post vein
removal, DVT, vein
dilation
• Often located LE,
above ankle
• Weepy wound

42. Pressure Wounds
• Aka- “bedsore”
• Excessive or
unrelieved pressure
• Often over bony
prominences
• Impaired mobility

43. Neuropathic Wounds
• Wound develops in area
with impaired sensation
• Commonly on foot
• Often patients with
diabetes, s/p chemothepy,
neurodegenerative diseases,
nerve compression
• Often lead to amputation

44. Acute Surgical Wounds
• Often sutured or
stapled and heals
quickly
• Left open due to
swelling
• Infection, poor
nutrition can lead to
chronic wound

45. Atypical Wounds
• Dermal disease
– dermatitis, pemphigus, autoimmune, fungal
infection
• Trauma
• Malignancy
• Necrotizing fasciitis

46. PATHOGENESIS OF THE WOUNDSPATHOGENESIS OF THE WOUNDS
WOUND PROCESSWOUND PROCESS –– it is a large complex of theit is a large complex of the
biological reactions which develops as a result of thebiological reactions which develops as a result of the
damage of the tissues and will be finishing of its healingdamage of the tissues and will be finishing of its healing
as a rule.as a rule.
The first phaseThe first phase –– INFLAMMATIONINFLAMMATION ((ALTERATIONALTERATION,,
HYDRATIONHYDRATION,, CLEARNINGCLEARNING)) –– 1-5 DAY1-5 DAY
The second phaseThe second phase–– PROLIFFERATIONPROLIFFERATION ((DEHYDRATIONDEHYDRATION,,
REGENERATIONREGENERATION,, GRANULATIONGRANULATION)) –– 6-14 DAY6-14 DAY
The third phaseThe third phase –– FORMATION AND REORGANIZATIONFORMATION AND REORGANIZATION
OF THE SCAR –OF THE SCAR –15 DAY – 6 MONTH15 DAY – 6 MONTH

47. PHASE OF INFLAMMATIONPHASE OF INFLAMMATION
- duration 1-4 days- duration 1-4 days
(depending on a trauma);(depending on a trauma);
- destroying of tissues;- destroying of tissues;
- spasm of vessels;- spasm of vessels;
- swelling;- swelling;
- hypoxia and acidosis;- hypoxia and acidosis;
- infection;- infection;
- cleaning from dead tissues- cleaning from dead tissues
(enzymes).(enzymes).

48. PHASE OF REGENERATIONPHASE OF REGENERATION
- lasts from 3-4 dayslasts from 3-4 days
tilltill ................
- decrease of the swelling;decrease of the swelling;
- decrease of thedecrease of the
inflammation;inflammation;
- normalization of рН;normalization of рН;
- decrease of the secretedecrease of the secrete
from the wound;from the wound;
- wound process fills bywound process fills by
granulative tissue.granulative tissue.

49. GRANULATTIVE TISSUEGRANULATTIVE TISSUE
GRANULATIONGRANULATION - this is the- this is the
special kind of connective tissue,special kind of connective tissue,
which forms only during heal of thewhich forms only during heal of the
wound by second tension and has 6wound by second tension and has 6
layers:layers:
1.1. Superficial leukocytic-necroticSuperficial leukocytic-necrotic
layers.layers.
2. Layer of the band vessels.2. Layer of the band vessels.
3. Layer of the vertical vessels.3. Layer of the vertical vessels.
4. Mature layer of fibroblasts.4. Mature layer of fibroblasts.
5. Layer of5. Layer of horizontalhorizontal fibroblasts.fibroblasts.
6. Fibrous layer.6. Fibrous layer.

50. PHASE OF FORMATION ANDPHASE OF FORMATION AND
REORGANIZATION OF THE STICHREORGANIZATION OF THE STICH
- begins in 2-4 weeks andbegins in 2-4 weeks and
goes on till 6 mons;goes on till 6 mons;
- active forms of theactive forms of the
collagen and elasticcollagen and elastic
fibers;fibers;
- take place the process oftake place the process of
the epithelization.the epithelization.

51. PHASE OF FORMATION ANDPHASE OF FORMATION AND
REORGANIZATION OF THE STITCHREORGANIZATION OF THE STITCH

52. PHASE OF FORMATION ANDPHASE OF FORMATION AND
REORGANIZATION OF THE STITCHREORGANIZATION OF THE STITCH

53. TYPES OF REPARATIONTYPES OF REPARATION
REPARATIONREPARATION
BY PRIMARYBY PRIMARY
TENSIONTENSION

54. TYPES OF REPARATIONTYPES OF REPARATION
REPARATIONREPARATION
BYBY
SECONDARYSECONDARY
TENSIONTENSION

55. TYPES OF REPARATIONTYPES OF REPARATION
REPARATIONREPARATION
UNDER THEUNDER THE
CRUSTCRUST

56. Acute Wound Healing

57. Hemostasis/Coagulation
• Goals:
– Control bleeding
• Clotting cascade
– Begins immediately upon injury
– Activate platelets

58. Hemostasis/Coagulation
Cellular component
• The Platelet
– Activates to form
fibrin clot
– Stems blood flow
– Release cytokines
• PDGF
• TGF-ß
• EGF

59. Hemostasis/Coagulation
Cytokines
• Platelet derived growth factor
(PDGF)
– Directs collagen
expression
– Released with platelet
activation
– Neutrophil, macrophage
chemotaxis
• TGF-ß
– Directs collagen
expression

60. Inflammatory Phase
• 0-3 days
• Begins with clotting cascade and platelets
• Characterized by:
– Rubor (redness)
– Turgor (swelling)
– Calor (heat
– Dolar (pain)

61. Inflammatory Phase
• Goals:
– Destroy pathogens
• White blood cells
– Clean wound site
• Breakdown cellular and extracellular debris
– Signal cells of repair
• Cytokines, growth factors,

62. Inflammatory Phase
Cellular Component
• Neutrophils
– Migrate into wound within 24
hours
• Initially largest proportion of
WBCs
– Remain 6 hours to 4 days
– Called to wound by presence of
fibrinogen, fibrin degradation
products
– Move into wound from
vasculature by diapedesis

63. Inflammatory Phase
Cellular Component
• Macrophages
– Most active in late
inflammatory phase
– Main regulatory cell of
inflammation
– Remain through
proliferative and
remodeling phases

64. Inflammatory Phase
Cellular Component
• Macrophages
– Phagocytize bacteria and exogenous debris
– Secrete collagenases to remove damaged
extracellular matrix
– Release nitric oxide to kill bacteria
– Release fibronectin to recruit fibroblasts
– Can stimulate angiogenesis

65. Inflammatory Phase
Molecular Component
• Compliment
– Immunology course
– Bacterial destruction
• Opsization
• Bacterial lysis
– Chemotactic factors
• Phagocytic cells, neutrophils, macrophages

66. Inflammatory Phase
Molecular Component
Macrophage Derived
• PDGF
• TNF-α
Proinflammatory
Induce MMPs
• IL-1
– Proinflammatory
– Stimulates NO
synthesis
– Amplifies
inflammatory response
– IL-6
• Proinflammatory
– G-CSF
• proinflammatory
– CM-CSF
• ECM degradation

67. Proliferative Phase
• Overlaps inflammatory
phase
• Begins 3-5 days post
injury
• Length of phase dictated
by wound size (~3 weeks
for closed surgical
wounds)
• Includes angiogenesis, re-
epithelialization,
fibroplasia

68. Proliferative Phase
Angiogenesis
• Neovascularization
• Granulation tissue
– Buds of new capillaries
• Does not occur if
ECM absent
• Stimulated by FGF,
VEGF, TGF-ß, EGF,
wound angiogenesis
factor

69. Proliferative Phase
Matrix Formation
• Aka- fibroplasia
• Begins 48-72 hours post injury
• Fibroblasts secrete collagen (type III) and
ground substance
• Maximally secretes for 5-7 days
• Forms scaffold for endothelial migration
• Binds cytokines, growth factors

70. Wound Extracellular Matrix
• Composed of collagen
and ground substance
• Produced by
fibroblasts
• Provide structure for
cells and tissues
• Bind growth factors,
helps create gradient

71. Ground Substance
• Amorphous viscous gel produced by fibroblasts
• Comprised of glycosaminoglycans (GAGs) and
proteoglycans
• Occupies space between cells and fibers
• Allows medium for diffusion of nutrients and
wastes

72. Ground Substance
• Major GAGs- hyularonic acid, chondroitin
sulfate
• Composition varies by age and location
– Decreased water with age
– GAGs increased in wounds, weight bearing
surfaces

73. Collagen and Wounds
• Normal surgical wound has 15% tensile strength of non-
injured tissue after 3 weeks.
• Increases to 70-80% in two years
• Wound recurrence: gravity, swelling, poor closure

74. Proliferative Phase
Re-epithelialization
• Resurfaces wound
• Restores integrity of epithelium
• Keratinocytes migrate into and proliferate
over wound bed
– Inhibited by scabs
• REQUIRES basement membrane

75. Proliferative Phase
Re-epithelialization
• Begins within 24 hours of injury
• Closed surgical wounds complete in 48-72
hours
• New skin tensile strength ~15% of original
skin
• After remodelling tensile strength only 70-
80%

76. Remodeling Phase
• Begins during proliferative phase
• Continues 1-2 years post injury
• Scar tissue/ECM remodeled
• Increases tensile strength of scar
– Type III collagen replaced by type I

77. TREATMENT OF WOUNDSTREATMENT OF WOUNDS

78. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
PRIMARY SURGICAL TREATMENT OF THEPRIMARY SURGICAL TREATMENT OF THE
WOUNDWOUND is the first surgical operation, providedis the first surgical operation, provided
in aseptic conditions, with anesthesia, whichin aseptic conditions, with anesthesia, which
contains the following stages.contains the following stages.
THE MAIN STAGES:THE MAIN STAGES:
1.1. Disinfection of the operative field.Disinfection of the operative field.
2.2. Anesthesia.Anesthesia.
3.3. Cutting of the wound.Cutting of the wound.
4.4. Revision of the wound channel.Revision of the wound channel.
5.5. Removing of the margins, walls and bottom of theRemoving of the margins, walls and bottom of the
wound.wound.
6.6. Hemostasis.Hemostasis.
7.7. Rehabilitation of injured organs and structures.Rehabilitation of injured organs and structures.
8.8. Applying of stitches on the wound with leaving ofApplying of stitches on the wound with leaving of
drainages (according to indications)drainages (according to indications)

79. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
Full and partial treatment of theFull and partial treatment of the
wound.wound.
Primary and secondary treatment ofPrimary and secondary treatment of
the wound.the wound.
Early, delayed and later treatment ofEarly, delayed and later treatment of
the wound.the wound.

80. Wound Preparation
• Removal of hair
– Not eyebrow
• Scrubbing the wound
• Irrigation with saline
– Avoid peroxide,
betadine, tissue toxic
detergents

81. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
Cutting of the wound and removing ofCutting of the wound and removing of
margins, walls and bottom of the woundmargins, walls and bottom of the wound..

82. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
CUTTING OF APONEVROSISCUTTING OF APONEVROSIS

83. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
REMOVING OF THE NECROTIC TISSUESREMOVING OF THE NECROTIC TISSUES

84. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
REVISION OF ZONE OF SPEADING OF WOUNDREVISION OF ZONE OF SPEADING OF WOUND
CHANNEL AND CHARACTER OF INJURYCHANNEL AND CHARACTER OF INJURY

85. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
WASHING OF THE WOUNDWASHING OF THE WOUND

86. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
DRAINAGES OF THE WOUNDDRAINAGES OF THE WOUND

87. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
PASSIVE DRAINAGE OF THE WOUNDPASSIVE DRAINAGE OF THE WOUND

88. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
ACTIVE DRAINAGE OF THE WOUNDACTIVE DRAINAGE OF THE WOUND
REDONS SET OFREDONS SET OF
DRAINAGINGDRAINAGING

89. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
WASHING DRAINAGES OF THE WOUNDWASHING DRAINAGES OF THE WOUND

90. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
SEWING OF THE WOUNDSEWING OF THE WOUND

91. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
ACCORDING TO THE TIME OF APPLYING OF THE STITCHES:ACCORDING TO THE TIME OF APPLYING OF THE STITCHES:
1.1. Primarily.Primarily.
2.2. Primarily delayed.Primarily delayed.
3.3. Early secondary.Early secondary.
4.4. late secondarylate secondary..

92. Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University

93. PRIMARY SURGICAL TREATMENT OFPRIMARY SURGICAL TREATMENT OF
THE WOUNDTHE WOUND
SEWING OF THE WOUNDSEWING OF THE WOUND

94. SURGICAL TREATMENT OF THESURGICAL TREATMENT OF THE
PURULENT WOUNDPURULENT WOUND

95. Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University

96. Ideal Wound Closure
• Allow for meticulous wound closure
• Easily and readily applied
• Painless
• low risk to provider
• Inexpensive
• Minimal scarring
• Low infection rate

97. Sutures
• Non-absorbable sutures
– Tinsel strength 60 days
– Non-reactive
– Outermost closure

98. Sutures
• Absorbable sutures
– Synthetic > natural
– Synthetic increases
wound tinsel strength
– Deeper layers
– Avoid in highly
contaminated wounds
– Avoid in adipose tissue
– Synthetic &
monofilament > natural
& braided

99. Staples
• More rapidly placed
• Less foreign body
reaction
• Scalp, trunk,
extremities
• Do not allow for
meticulous closure

100. Adhesive Tapes
• Less reactive than
staples
• Use of tissue adhesive
adjunct (benzoin)
• Poor outcome in areas
of tension
• Seldom used for
primary closure
• Use after suture
removal

101. Tissue Adhesives
• Dermabond, Ethicon
• Topical use only
• Outcome equal to 5-0
and 6-0 facial repairs
• Less pain and time
• Slough off in 7-10 days
• Act as own dressing
• No antibiotic ointment

102. Post-procedural Care
• Dressing for 24-48 hours
• Topical antibiotics
• Start cleansing in 24 hours
• Suture/staple removal
– Face 3-5 days
– Non-tension areas 7-10 days
– Tension areas 10-14 days

103. Choosing Your Suture
• 6-0
– Face
• 5-0
– Chin
– Low tension/detail
• 4-0
– Large laceration
– Moderate tension
• 3-0
– Significant tension

104. The Interrupted Stitch

105. The Interrupted Stitch
• Instrumentation
– Hemostat
– Scissors
– Forceps with teeth
– Plain forceps
– Control syringe
– Tub for saline
– Gauze
– Sterile towels
– Syringe and splash shield

106. Anesthesia of the Laceration
• Lidocaine with/out epi, marcaine
• TAC
• Local vs regional
• Mechanisms to reduce pain

107. The Interrupted Stitch
• Finger tip grip
• Palm grip
• Grip needle one-third of way from thread

108. The Interrupted Stitch
• Curl needle into dermis of 1st
side

109. The Interrupted Stitch
• Curl needle into dermis of 1st
side
• Curl needle trough parallel opposite subcutaneous side

110. The Interrupted Stitch
• Curl needle into dermis of 1st
side
• Curl needle trough parallel
opposite subcutaneous side
• Tie square knot with at least
two braids

111. The Interrupted Stitch
• Curl needle into dermis of 1st
side
• Curl needle trough parallel
opposite subcutaneous side
• Tie square knot with at least
two braids
• Repeat three to four throws

112. Points to Remember
• Specific points affecting wound
healing
• Evaluation of laceration and
neurovascular assessment
• Types of sutures
• Staples
• Adhesive tapes
• Tissue adhesives

113. Points to Remember
• Advantages vs disadvantages
• Post procedure care
• Choosing your suture
• Instruments
• Be able to perform interrupted
suture for lab final

114. Suture Patterns
Interrupted
– simple
– horizontal mattress
– vertical mattress
Running (continuous)
– simple
– subcuticular

115. Simple Interrupted

116. Simple Interrupted

117. Horizontal Mattress

118. Vertical Mattress

119. Simple Continuous

120. Simple Subcuticular

121. Corner/flap

122. PRINCIPELS OF THE LOCALPRINCIPELS OF THE LOCAL
TREATMENT OF THE WOUNDTREATMENT OF THE WOUND
1.1. During the first phase of the wound process:During the first phase of the wound process:
- immobilization of the wound;- immobilization of the wound;
- use of the proteolytic ferments;- use of the proteolytic ferments;
- use of antisepsis- use of antisepsis
solutions.solutions.
2.2. During the second phase of the wound processDuring the second phase of the wound process ::
- treatment bandaging;- treatment bandaging;
- stimulation of the grows of granulative tissues;- stimulation of the grows of granulative tissues;
- the bandages are conducted rarely.- the bandages are conducted rarely.

123. USE OF PROTEOLYTIC FERMENTSUSE OF PROTEOLYTIC FERMENTS
FOR THE TREATMENT OF THEFOR THE TREATMENT OF THE
WOUNDWOUND
BeforeBefore
treatmenttreatment
One week afterOne week after
beginning of thebeginning of the
treatmenttreatment

124. PRINCIPELS OF THE GENERALPRINCIPELS OF THE GENERAL
TREATMENT OF THE WOUNDTREATMENT OF THE WOUND
1.1. Antibacterial therapy.Antibacterial therapy.
2.2. Desintoxication therapy.Desintoxication therapy.
3.3. Immune correcting therapy.Immune correcting therapy.
4.4. Correction of the haemostasis.Correction of the haemostasis.
5.5. Analgetics.Analgetics.

125. Moist Wound Healing
• DRY IS DEAD!
• Moist environment allows:
– Cell function
– Diffusion of chemical factors
– Migration of cells
– Autolytic debridement

126. Moist Wound Healing
Dressings
• Gauze is bad
• Absorb or give
moisture
• Antimicrobial
• Conform to wound
• Limit dressing
changes

127. Chronic Wounds
• Wound “fails to proceed through an orderly
and timely process to produce anatomic and
functional integrity, or proceeded through
the repair process without establishing a
sustained anatomic and functional result”
• No definitive amount of time to be
considered chronic

128. Chronic Wounds
• Wound gets “stuck” in one phase of healing
• Causes can be intrinsic, extrinsic or iatrogenic

129. Chronic Wounds
Intrinsic causes
• Age
• Chronic disease
• Perfusion/oxygenation
• Immunosuppression
• Neurologic impairments

130. Chronic Wounds
Extrinsic causes
• Medication
• Nutrition
• Irration/chemotherapy
• Psychophysiologic stress
• Wound bioburden

131. Chronic Wounds
Iatrogeneic causes
• Local ischemia
• Poor wound care
• Trauma
• Wound extent
• Wound duration

132. Ischemic arterial ulcers
• Poor blood supply
• Painful, usually distal
• Shallow wound,
• smooth margins, pale
• S/Sx of PVD: intermittent claudication, rest
pain, color changes, ↓ pulses, ABI < 1, dry
skin, pallor, hair loss
• Tx: revascularization, wound care

133. Venous stasis ulcers
• Incompetence of the deep vein
perforators
• capillary leakage-
polymerization of fibrin impairs
oxygenation
• Painless, shallow ulcer with
irregular margins, possible skin
pigmentation (hemoglobin
extravasation and breakdown)
• Tx: compression therapy (rigid
or flexible)

134. Diabetic ulcers
• 10-15% of DM pts develop ulcers
• Causes: ischemia, neuropathy
(unrecognized injury,Charcot foot)
• Poor healing
• Tx: Tight blood glc control, abx, wide
debridement of necrotic/
infected tissue, relief of
pressure via orthotics/casts,
potentially: topical PDGF and
GM-CSF, skin grafts

135. Decubitus/pressure ulcers
• Localized tissue necrosis from compression
over a bony prominence, ↓ nutrients/O2
• ↑ by friction, moisture
• 3-9% acute care, 2.4-23% in long-term care
facilities
• Tx: debridement of all necrotic tissue,
relief of pressure, wound care (moist
environ), surgical flap repair, nutrition
• 4 stages:
– I. Non blanchable erythema, intact skin
– II. Partial thickness skin loss of
epidermis/dermis
– III. Full thickness skin loss, above
fascia
– IV. Full thickness, involves muscle or
bone

136. Excess Dermal Scarring
• Occur after trauma, may burn or be pruritic
• Xs of collagen/glycoprotein deposition
• Hypertropic scars
– Usu develop within 4 wks of trauma
– Collagen bundles are wavy pattern
– Stay within the original wound, elevated < 4mm
– Occur across areas of tension/flexing
– Often regress
– Tx: excision + corticosteroids
• Keloids
– 15x more common in pts with darker skin
pigmentation
– Develop 3mos-years after trauma
– Collagen fibers are larger, random/ not bundled
– Expand beyond wound edges, can become large
– Rarely regress
– Excision alone (45-100% recurrence). Corticosteroids
then Excision + corticosteroid injections, topical
silicone, external compression, xrt, IFN-γ, 5-FU,
bleomycin

137. Dressings
• Mimics epithelial barrier, protection of site
• Compression provides hemostasis, decreases
edema
• Occlusion controls hydration and allows for
oxygenation/gaseous diffusion
• Occlusion stimulates collagen synth and epith cell
migration
• Primary- directly on wound
• Secondary- placed on a primary dressing

138. Skin Grafts
• Split/partial thickness graft = epidermis + partial dermis
– Require less vascular supply
• Full thickness = entire epidermis and dermis
– Greater mechanical strength, increased resistance
to wound contraction, improved cosmesis
• Autograft – transplant from another site
• Allograft – transplant from a living nonidentical donor or cadaver
– Subject to rejection, may contain pathogens
• Xenograft – from another species
– Subject to rejection, may contain pathogens
• Preparation of wound bed – debridement of necrotic/fibrinous
tissue, control of edema, minimizing exudate, revascularization of
wound bed, ↓ bacterial load

139. Hydrocolloid : Indication
• For low to moderate exuding wounds
• For clean, granulating, superficial
wounds
• With safe surrounding skin

140. Hydrocolloids : Advantage
• Require changing only every 3 -
7 days
• Provide effective occlusion and
barrier (prevent the spread of
Infection
• Cost effective
• More effective than traditional
dressings
1 week1 week

141. 21days
Diabetic ulcer for
5 month
Hydroc
olloid
loids
Hydrocolloid

142. Absorption baseAbsorption base
dressingdressing
AlginateAlginate
HydrofibreHydrofibre
Moist woundMoist wound healinghealingMoist woundMoist wound healinghealing

143. Alginate : Indication
• For moderate to heavily exudating
wounds
• Help to debride (in addition with
mechanical debridement)

144. Alginate : Indication
•For moderate to heavily exudating wounds
• Help to debride (in addition with mechanical
debridement

146. Hydrofibre : AquacelHydrofibre : Aquacel
• CMC fiber : gel formation
• Same indications than
alginate
• Non haemostatic

147. • For light to medium
exuding wounds
• Granulating and
epithelializating
wounds
Foam dressing : Indication

148. For
Cavity Wounds

149. Cavity Wounds
(Healthy Granulation )

150. Silver DressingSilver Dressing
•SilverceSilvercell (Alginate+sliver)(Alginate+sliver)
•AquacelAquacel((Ag(hydrofibre+silvAg(hydrofibre+silver)er)
•ActicoatActicoat (Nanocrystalline(Nanocrystalline
silver-based dressing)silver-based dressing)

151. Promogran™
• Growth factors
protection
• Binding and
inactivating
proteases in
excess
Promogran
Protease
Growth Factors
inactive
Post traumatic chronic ulcer

152. SKIN COVER:
The best dressing is the
patients skin whether the
wound be closed directly,
or by skin graft or skin flap.
Early cover means early
healing and potential
avoidance of infection and
bad scarring

153. PLASTIK REPLACEMENT OF SKINPLASTIK REPLACEMENT OF SKIN

154. EASY CLOSURE WITHOUT
TENSION:
Be aware of closing wounds under
tension, the wound edges may
slough, the wound may dehisce, and
there is the potential for a bad scar
(either hypertrophic, keloidal or
stretched). Sometimes a flap or a
graft may be required to reduce the
tension in a wound.

155. Wound classification
• Aetiology is therefore important in your
understanding of how a wound arose and what
structures may also be damaged or require
attention
• Although there are many causes of wounds, in
practise, as part of your assessment prior to
definite management, you will need to categorise a
wound into “tidy” or “untidy”

156. Practical Classification of
Wounds:
• TIDY • UNTIDY

157. Tidy wounds:
• Clean incision
• Uncontaminated
• Less than 6 hours old
• Low energy trauma

158. Tidy wounds:
• Can be repaired immediately after adequate
wound exploration , cleansing and
haemostasis
• Are associated with a low incidence of
wound infection post repair

159. Untidy wounds:
• Ragged edge,crush or burn
• Contaminated
• More than 12 hours old
• High energy trauma

160. Untidy wounds:
• Need to be converted into tidy wounds
• May require repeated debridements until
tissue viability is ensured
• Never close an untidy wound unless it has
been made tidy
• If in doubt, it is safer to leave the wound
unrepared (but not undebrided!) and
reinspected at 48 hour intervals

161. Evacuate haematoma and
obtain haemostasis

162. ANTIBIOTIC and
ANTITETANUS
COVER

163. NECROTIC TISSUE
REMOVED

164. DRAINS
and
DEAD -SPACE
OBLITERATION
Dead space will fill up with blood or serous fluid which is an
ideal culture medium. Obliterate this dead space by drainage,
suture or by healthy tissue.

165. Closure of Tidy Wounds:
• Tidy wounds should be closed primarily
• All damaged structures should be repaired
• Sutures are to oppose NOT necrose
• Use monofilament materials

166. Closure of Untidy Wounds
• Only close primarily if can be converted to
a tidy wound
• Doubtful tissue must be meticulously but
ruthlessly excised
• Copious Levage “Dilution is the solution to
pollution”
• If in doubt, don’t close
• 48 hourly “second looks”

167. THE COMPLICATIONS AFTER LOCALTHE COMPLICATIONS AFTER LOCAL
TREATMENT OF THE WOUNDTREATMENT OF THE WOUND
1.1. Development of theDevelopment of the
inflammatory infiltrate.inflammatory infiltrate.
2.2. Haematoma.Haematoma.
3.3. Pusing.Pusing.
4.4. Marginal necrosis.Marginal necrosis.
5.5. Kelloid and hypertrophicalKelloid and hypertrophical
ruptures.ruptures.
6.6. Destroy the innervationsDestroy the innervations
and lymphodranages ofand lymphodranages of
the wound.the wound.

168. Practice Time!
•

169. Thank you for attention !Thank you for attention !
Ivano-Frankivsk National Medical UniversityIvano-Frankivsk National Medical University