This is a preliminary clinical understanding of wounds where I have collected the pictures from my hospital, books and internet source. I tried to explain basics in a short way.

1. PRELIMINARY CLINICAL UNDERSTANDING
OF WOUNDS
MODERATOR:
Dr. PUJAN BAJRACHARYA
LECTURER (GENERAL SURGERY)
DMCRI
PRESENTER:
Dr. NITESH ADHIKARI
1st
Year Resident (General Surgery) DMCRI

2. OBJECTIVES:
• To know about types of wound and its classification
• To understand about normal wound healing
• To know adverse affects of wound healing.
• To understand the principle of wound management.

3. CONTENTS
• Introduction
• Types of wound
• Classification of wound
• Phase of wound healing
• Factors affecting wound healing
• Wound Examination
• Wound Management
• Complications
• Chronic Wound

4. Definition
• Wound is defined as disruption in tissue integrity, leading to division of blood vessels
and direct exposure of extracellular matrix to platelets.
(Schwartz’s eleventh edition)
• It can affect skin, muscle, tendons, internal organs or any parts.

5. Types of Wounds
1. Incised wound :
• clean, sharp-edged wound
• caused by sharp objects as of knife, razor or scalpel

6. Types of Wounds
2. Lacerated wound:
• tearing or crushing of skin and underlying tissues with irregular, ragged edges
• caused by RTA, machinery accidents

7. Types of Wounds
3. Abrasion:
• friction or scarping that removes the epidermis and sometimes part of dermis.
• Often occurs when the skin rubs against a rough surface.

8. Types of Wounds
4. Contused wound:
• crushing and bruising of the skin and underlying tissue without a break in the skin
surface
• Caused by falls, blunt force trauma, blow by blunt objects etc

9. Types of Wounds
5. Punctured wound:
• small, deep wound caused by a sharp, pointed objects
• depth is more than the width (e.g. puncture by nails, stab wound)

10. Types of Wounds
6. Gunshot:
• caused from the fire-arms
• can penetrating (entry only) or perforating (entry and exit wounds)

11. Classification by Duration
1. Acute wounds: heals within
days to weeks
2. Chronic wounds: healing
prolonged, within weeks to
months.

12. Classification by Contamination
1. Clean wound: surgical wound made under aseptic condition where no evidence of
infection or inflammation.

13. Classification by Contamination
2. Clean-contaminated: Controlled opening of a normally colonized body cavities

14. Classification by Contamination
3. Contaminated: A fresh wound or surgical cut where germs are likely present because
of the dirt or spillage from inside the body but there is no established infection.

15. Classification by Contamination
4. Dirty/infected: A wound that already has pus, old infection, or a hole in an organ
leaking contents before or during surgery

16. Classification by Cause
1. Surgical wounds

17. Classification by Cause
2. Traumatic wounds
3. Diabetic ulcers

18. Classification by Cause
4. Pressure sores
5. Burns
(Scald Burn)

19. Phases of Wound Healing
• Hemostasis
• Inflammation
• Proliferation
• Remodeling

20. Hemostasis Phase
• Begins immediately (minutes to hours) and is followed by:
• Vasoconstriction
• Platelet aggregation
• Clot formation.

21. Inflammatory Phase
• 0-3 days. Neutrophils clean debris. Macrophages release cytokines for healing.

22. Proliferative Phase
• Duration (3-21) days.
• Fibroblasts proliferation
• Collagen deposition.
• Angiogenesis.
• Granulation tissue formation
and epithelialization.

23. Maturation and Remodeling Phase
• Duration (weeks to months).
• Collagen type III replaced by type I by MMPs
• Scar strength increases.

25. Types of Healing
• 1. Primary intention: Clean wounds with edges approximated; minimal scarring.
• 2. Secondary intention: Wounds left open to heal by granulation; larger scars
• 3. Tertiary intention (delayed primary closure): Initially open wounds closed after
infection control; intermediate outcomes

27. Local Factors (Delays Healing)
• Infection
• Ischemia
• Foreign body
• Tension
• Edema
• Radiation.

28. Systemic Factors
• Diabetes
• Malnutrition
• Smoking
• Age
• Immunosuppression
• Anemia.

29. Nutrition in Healing
• High Protein Diet
• Vitamin C,
• Zinc and Iron are essential.
• We must address deficiencies

30. Wound Examination
• INSPECTION:
• Site and Location: Anatomical Position(e.g. Anterior aspect of left leg)
• Size and Shape: (Length X Width) in cm, (linear, oval, globuler)
• Depth: From the surface of the skin to the deepest part.
• Edge: Sloping (healing), Punched-out(Syphilis), Undermined(Tubercular Ulcer),
everted (Malignant), Rolled(Basal Cell)
• Base: Granulation tissue (healthy red/ unhealthy pale), slough, necrosis
• Exudate: Serous, Sanguineous, Sero-Sanguineous, Purulent
• Odor: Foul Smelling/Absent
• Surrounding skin. Erythematous, Induration, Maceration, Pigmentation

31. PALPATION (with gloves)
• Temperature: Increased(Inflammation), Decreased(Ischemia)
• Tenderness: Present/Absent
• Induration: Extent beyond wound edges.
• Crepitus/Fluctuation: Presence of gas or pus
• Edge and Base: Confirm findings of inspection
• Bleeding on touch: Healthy granulation tissue bleeds easily

32. TIME Framework in wound assessment and management
• Tissue : To have a clean wound bed with healthy granulation tissue
• Inflammation/infection: Control infection and reduce excessive inflammation
• Moisture balance: Not too dry, Not too moist
• Edge of wound: Encourage healthy edge progression.

33. Scoring Systems
• 1. ASEPSIS: It evaluates wound healing and infection in a post operative period typically
5-14 days Score
-Additional Treatment 0-10: Satisfactory Healing
-Serous Discharge 11-20:Disturbance of healing
-Erythema 21-30: Minor Wound Infection
-Purulent Exudate Infection 31-40: Moderate Wound
Infection
-Separation of deep tissues >40: Severe Wound Infection
-Isolation of bacteria
-Stay ( Prolonged Hospital Stay)

34. Scoring Systems
• 2. Southampton Wound Grading: It is used to grade surgical wound healing and
detect infection. It is graded as:
-Grade 0: Normal healing
-Grade 1: Normal healing with mild bruseing and erythema
-Grade 2: Notable Erythema plus other inflammation.
-Grade 4: Pus (Purulent Discharge)
- Grade 5: Deep or Severe wound infection , with tissue break
requiring aspiration. (abscess, wound dehiscence)

35. Wound Management Principles
• Hemostasis
• Debridement
• Dressing
• Closure
• Monitoring

36. Debridement Types
• Surgical
• Autolytic
• Enzymatic
• Mechanical
• Biological (maggots)

37. Basic Dressings
• Gauze: Covering clean and dry wounds, absorbs the exudate
• Paraffin gauze: Cotton gauze impregnanted with soft paraffin
– Burns ,Skin grafts, lacerations
• Film: Thin, transparent which allows oxygen and water vapor blocks bacteria and
fluids
• Foams. Highly absorbent absorbs exudates, maintains moist environment.

38. Advanced Dressings
• Hydrocolloid: Forms a gel when in contact with wound exudate
-Maintains moist environment, Impermeable to bacteria and water
• Hydrogel: Maintains moist environment-helps in epithelialization
-Softens necrotic tissue
• Alginate: Used for moderate to heavy exudate
-Venous Ulcer, Diabetic foot ulcer, Pressure Sores
• Silver-impregnated: consists of silver ions which disrupts bacterial cell membranes, DNA,
enzymes
-Infected or colonized wounds, High risk wounds, Burns
• Negative pressure wound therapy (NPWT). Eg: Drainage tube, Vacum Pump. Used
for Post Surgical Wounds, Open abdomen management, Traumatic wounds

39. How to choose a Dressing?
• Depends on wound type
• exudate level
• infection
• granulation tissue.

40. Tetanus Prophylaxis

41. Antibiotic Use
• Reserved for infected wounds. Empiric and culture-guided.
• Clean wounds: Not usually required. Only prophylactic in some cases(e.g. implants)
• Clean-Contaminated wounds: Prophylactic antibiotics recommended.
• Contaminated wounds: Therapeutic and Prophylactic antibiotics indicated.
• Dirty or Infected wounds: Therapeutic antibiotics essential.

42. Early Complications
• Bleeding
• Hematoma
• Seroma
• Infection
• Dehiscence.

43. Late Complications
• Chronic non-healing
• Hypertrophic scar
• Keloid
• Contractures
• Sinus/fistula formation.

44. Chronic Wound
• Wounds that takes weeks to months to heal, and which does not follow the normal
healing process.
• Often multifactorial causes.

45. Diabetic Foot Ulcers
• A diabetic foot ulcer is a chronic wound typically appears as an open sore on the feet
of an individuals with diabetes.
• Caused by:
• Neuropathy
• Ischemia
• Infection.
• Glycemic control is essential.

46. Pressure Ulcers
• Due to prolonged pressure over a bony prominence .
Prevention and repositioning important.
• Common sites:
– Ischium
– Greater trochanter
– Sacrum
– Heel
– Malleolus
– Occiput

47. Summary
• Thorough assessment
• individualized care and
• prevention of complications are key to wound healing.

48. Take home message
• Early and accurate assessment of a wound is critical for optimal healing
• Wound healing follows four phases: Hemostasis, Inflammation, Proliferation and
Remodeling
• Proper wound care includes cleaning, debridement, infection control and moisture
balance
• Timely intervention and multidisciplinary care can prevent complications like
infections and amputation
• Patient education and follow up are vital for compliance and monitoring progress.

49. References
• Bailey & Love’s Short Practice of Surgery
• WHO Guidelines
• Schwartz Principles of Surgery
• Research: Biomedical applications of starch by Daud Hussain
• SRB

50. Thank You

51. Open questions floor