The document discusses wound healing and fibrosis. It describes that wound healing occurs in three phases: inflammation, proliferation, and maturation. It also discusses primary and secondary wound healing. Primary healing involves wounds with opposed edges that heal with a thin scar, while secondary healing involves wounds with tissue loss that heal with more scarring and contracture. The document also discusses factors that influence wound healing and complications that can arise. It provides details on cutaneous wound healing and fracture healing processes. Finally, it discusses fibrosis, describing that it is excessive collagen deposition in tissue during repair. It notes the role of macrophages and TGF-beta in promoting fibrosis.
2. Cutaneous Wound Healing
Divided into three phases:
1. Inflammation
2. Proliferation &
3. Maturation
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3. Cutaneous Wound Healing
Inflammation: Platelet adhesion and
aggregation and the formation of a clot in the
surface of the wound, leading to inflammation
Proliferative phase there is formation of
granulation tissue, proliferation and migration
of connective tissue cells, and re-
epithelialization of the wound surface
Maturation involves ECM deposition, tissue
remodeling, and wound contraction
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4. Healing by primary union or
by FIRST INTENTION
• Death of a limited number of epithelial and
connective tissue cells
• Minimal disruption of epithelial basement
membrane continuity
• Formation of a relatively thin scar
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5. Healing by primary union or
by FIRST INTENTION
• Wounds with opposed edges
• Clean / sterile wounds
• Example:
– Surgical incision
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7. Healing by secondary union or
by SECOND INTENTION
• Large defects cause extensive loss of cells and
tissue
• More intense inflammatory reactions
• Formation of abundant granulation tissue
• Extensive collagen deposition
• Formation of a big scars
• Contractures
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8. Healing by secondary union or
by SECOND INTENTION
• Wounds with unopposed margins
• Gaps in tissue due to substantial loss
• Infection / foreign bodies
• Examples:
– Crush injury
– Infected wounds
– Burns
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14. However, the basic mechanisms of healing by
primary (first intention) and secondary
(second intention) union are similar
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15. The most distinct feature that
differentiates Primay & Seconday
wound healing is…
Wound contracture
That is seen in healing by second intention
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19. Blood clot
• Wounding causes the rapid activation of coagulation
pathways
• Formation of a blood clot on the wound surface
• Clot contains entapped red cells, the clot contains
fibrin, fibronectin, and complement components
• The clot serves to stop bleeding and also as a scaffold
for migrating cells, which are attracted by growth
factors, cytokines and chemokines released into the
area
• Dehydration occurs at the external surface of the clot,
forming a scab that covers the wound
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20. Neutrophils
• Within 24 hours, neutrophils appear at the margins
of the incision
• They release proteolytic enzymes that clean out
debris and invading bacteria
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21. Formation of Granulation Tissue
The hallmark of tissue repair: Formation of
granulation tissue
Granulation tissue consists of: proliferating
Fibroblasts and vascular endothelial cells which
occurs in the first 24 to 72 hours of the repair
process
The term derives from its pink, soft, granular
appearance on the surface of wounds
Characteristic histologic feature : Angiogenesis and
the proliferation of fibroblasts
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22. Formation of Granulation Tissue
• These new vessels are leaky, allowing the passage of
plasma proteins and fluid into the extravascular
space
• Granulation tissue progressively invades the incision
space
• By 5 to 7 days, granulation tissue fills the wound area
and neovascularization is maximal
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27. Accumulation of collagen – 2nd week
• Reduced number of leucocytes, edema
• Regression of vascular channels
• Accumulation of collagen
• Progressive blanching
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28. Progressive accumulation of collagen
“SCARRING”
• Cellular connective tissue
• No inflammatory cells
• Complete epithelialization of the surface
• Absence of adnexal structures
• Progressive increase in tensile strength of
wound
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29. Healing by secondary union or
by SECOND INTENTION
• Large tissue loss
• More intense inflammatory reaction
• More granulation tissue
• More fibrosis / collagen – substantial scar
• Wound contracture
• Thin epidermis
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33. Wound strength
How log it will take for the wound to attain
maximal strength?
When sutures may be removed?
• At the end of 1st week – 10% of strength of
unwounded skin
• By 3rd month – 70-80% of strength of
unwounded skin
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35. Complications of
cutaneous wound healing
May arise from abnormalities in basic
components of repair process:
1. Deficient scar formation
2. Excessive of repair components
3. Contractures
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36. Complications of
cutaneous wound healing
1. Deficient scar formation
Inadequate formation of granulation tissue or
assembly of scar may result in:
• Dehiscence
• Ulceration
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49. Fracture
• A fracture is a discontinuity of bone usually
due to trauma
• It's often associated with soft tissue injury
(e.g. hemorrhage, necrosis, tearing of muscle,
tendon, ligaments, nerves and vessels)
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50. Healing of Fracture
• There are three • 6 stages:
processes involved – the hematoma stage
in the healing of – inflammatory stage
fractures: – formation of
– Inflammatory
or granulation tissue
– reparative and – soft callus
– remodelling phases – 'hard' callus, and
– remodelling
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52. This picture shows a sagittal section of a fractured humerous. It is clear this is
recent fracture because there is a large haemtoma and no evidence of
primary callus fomation
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54. Granulation Tissue:
From 2 - 12 days. Presence of mesenchymal cells,
fibroblasts, new capillaries
Soft Callus:
One week to several months. Callus grows and bridges the
fracture site; cartilage and trabelcular bone laid down.
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55. Hard Callus:
One week to several months. When callus has sealed
the bone ends. Trabecular bone.
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57. Fracture healing rates are:
• Faster in the young than the old
• Slower in the lower limb than the upper limb
• Faster in spongy bone than compact bone
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58. Systemic Factors Affecting
Fracture Healing
• Age: Young patients heal rapidly and have a remarkable ability
to remodel and correct angulation deformities. These abilities
decrease once skeletal maturity is reached
• Nutrition: A substantial amount of energy is needed for
fracture healing to occur. An adequate metabolic stage with
sufficient carbohydrates and protein is necessary
• Systemic Diseases: Diseases like osteoporosis, diabetes, and
those causing an immunocompromised state will likely delay
healing. Illnesses like Marfan’s syndrome and Ehlers-Danlos
syndrome cause abnormal musculoskeletal healing
• Hormones: Thyroid hormone, growth hormone, calcitonin,
and others play significant roles in bone healing.
Corticosteroids impede healing through many mechanisms
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59. Local Variables Affecting
Fracture Healing
• Type of bone: Cancellous (spongy) bone fractures are usually more stable, involve greater
surface areas, and have a better blood supply than do cortical (compact) bone fractures.
Cancellous bone heals faster than cortical bone.
• Degree of Trauma: The more extensive the injury to bone and surrounding soft tissue, the
poorer the outcome. Mild contusions with local bone trauma will heal easily, whereas
severely comminuted injuries with extensive soft tissue damage heal poorly.
• Vascular Injury: Inadequate blood supply impairs healing. Especially vulnerable areas are the
femoral head, talus, and scaphoid bones.
• Degree of Immobilization: The fracture site must be immobilized for vascular ingrowth and
bone healing to occur. Repeated disruptions of repair tissue, especially to areas with marginal
blood supply or heavy soft tissue damage, will impair healing.
• Intraarticular Fractures: These fractures communicate with synovial fluid, which contains
collagenases that retard bone healing. Joint movement will cause the fracture fragments to
more, further impairing union. When intraarticular fractures are comminuted, the fragments
tend to float apart owing to loss of soft tissue support.
• Separation of Bone Ends: Normal apposition of fracture fragments is needed for union to
occur. Inadequate reduction, excessive traction, or interposition of soft tissue will prevent
healing.
• Infection: Infections cause necrosis and edema, take energy away from the healing process,
and may increase the mobility of the fracture site.
• Local Pathology: Any disease process that weakens the musculoskeletal tissue, like
osteoporosis or osteomalacia, may impair union.
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62. FIBROSIS
• The term fibrosis is used more broadly to
denote the excessive deposition of collagen
and other ECM components in a tissue
• The terms scar and fibrosis are used
interchangeably
63. FIBROSIS
“Classically activated macrophages”
Removal of microbes and dead tissues
Factors: IFN-γ and TNF
“Alternatively activated macrophages”
Little microbicidal activities
Greater role in tissue remodelling, angiogenesis
and scar formation
Factors: IL-4 and IL-13
64. FIBROSIS
“Alternatively activated macrophages”
produce TGF-β and other growth factors that are
involved in the repair process
TGF-β is an important fibrogenic agent
Produced by most of the cells in granulation
tissue
Causes fibroblast migration and proliferation,
Increased synthesis of collagen and fibronectin,
and decreased degradation of ECM due to
inhibition of metalloproteinases.
65. FIBROSIS - Osteopontin - OPN
Osteopontin : OPN
Plays an important role in fibrosis of the
heart, lung, liver, kidney
Blockage of OPN expression decreases the
formation of granulation tissue and scarring
66. FIBROSIS - Scarless healing
Secretion of non-fibrogenic forms of TGF-β
Lack of osteopontin
Absence of a TH2 response
Clinically useful antifibrotic agents:
Inhibitors of TGF-β binding
Angiogenesis Inhibitors
Toll-like receptors antagonists
IL-13 blockers
74. Figures. (A) Left lateral telecardiogram showing thick intense calcification of
the pericardium consistent with constrictive pericarditis. (B) Increased
respiratory variation of mitral E velocity on pulsed-wave Doppler
echocardiography of left ventricular inflow.