1. The document discusses wound healing, defining it as the normal physiological process that results in the repair of injured tissue. 2. It describes the three phases of wound healing: inflammatory phase, proliferative phase, and remodeling phase. The inflammatory phase involves hemostasis and inflammation in the first 4-6 days. The proliferative phase involves re-epithelialization, angiogenesis, and matrix formation from days 4-14. The remodeling phase involves collagen remodeling from days 8 onwards. 3. It also discusses factors that affect wound healing such as oxygen, nutrition, infection, diabetes, radiation therapy, medications, and smoking. Syndromes associated with abnormal wound healing such as cutis laxa and Ehlers

1. ‫عامه‬ ‫صحت‬ ‫وزارت‬
‫تخصص‬ ‫اکمال‬ ‫ریاست‬
‫بلخی‬ ‫رابعه‬ ‫کمپلکس‬ ‫شفاخانه‬ ‫ریاست‬
‫عمومی‬ ‫جراحی‬ ‫دیپارتمنت‬
Wound Healing
‫جروحات‬ ‫التیام‬
‫نظر‬ ‫تحت‬:‫استاد‬‫هللا‬ ‫دکتورنجیب‬ ‫رنخوروال‬(‫نجیب‬)
‫عمومی‬ ‫پروفیسورجراحی‬
‫کننده‬ ‫ترتیب‬:‫ترینی‬ ‫سباوون‬ ‫داکترحمیدالرحمن‬‫اول‬ ‫سال‬
‫سال‬:27/1/1396

3. ‫تعریف‬:
‫به‬ ‫منتج‬ ‫که‬ ‫بوده‬ ‫نسجی‬ ‫نارمل‬ ‫تمادی‬ ‫رفتن‬ ‫ازبین‬ ‫جرحه‬
‫انواع‬
‫شود‬ ‫می‬ ‫ومالیکولی‬ ‫حجروی‬ ‫تشوشات‬.

5. Wound Healing
 Three basic types of healing
◦ Primary
◦ Delayed Primary
◦ Secondary

6. Primary healing
 Wound surfaces opposed
 Healing without complications
 Minimal new tissue

7. Delayed Primary
 Left open initially
 Edges approximated 4-6 days later

8. Secondary
 Surfaces not approximated
 Defect filled by granulation
 Covered with epithelium
 Less functional

9. Secondary Wound Healing

10. Secondary Wound Healing

11. Phases of Wound Healing
 Inflammatory Phase
 Proliferative Phase
 Remodeling Phase

13. Inflammatory Phase
 Hemostasis and Inflammation
 Days 4 - 6
 Exposed collagen activates clotting
cascade and inflammatory phase
 Fibrin clot = scaffolding and
concentrate cytokines and growth
factors

14. Inflammatory: PMN
 Are the first inflammatory cells
 Reached maximum 24-48 hr.
 Source for cytokine
 Cytokine stimulate neutrophils

15. Inflammatory: Macrophages
 Monocytes
◦ attracted to area by complement
◦ Activated by:
 fibrin
 foreign body material
 exposure to hypoxic and acidotic
environment
 Reached maximum after 24 hours
 Remain for weeks

16. Inflammatory Phase

17. Proliferative Phase
 Epithelization, Angiogenesis and
Matrix Formation
◦ Begins when wound is covered by
epithelium
 Day 4 through 14
 Production of collagen

18. Inflammatory Phase

19. Epithelialization
 Basal epithelial cells at the wound
margin flatten (mobilize) and migrate
into the open wound
 Basal cells at margin multiply
(mitosis) in horizontal direction
 Basal cells behind margin undergo
vertical growth (differentiation)

21. Proliferative: Fibroblast
 Work wound repair
 Produce Granulation Tissue:
◦ Main signals are PDGF and EGF
◦ Collagen type III
◦ Glycosaminoglycans
◦ Fibronectin
◦ Elastin fibers

22. Proliferative Phase

23. Wound Contraction
 Actual contraction with pulling of
edges toward center making wounds
smaller
 Myofibroblast: contractile properties
 Surrounding skin stretched, thinned
 Original dermal thickness maintained

24. Maturation Phase
 Day 8 through
years
 Type III replaced
by type I
 Wound may
increase in
strength for up to
2 years after
injury

25. Maturation Phase

27. Normal healing in specific
tissue:
Bone
 The phases are as skin
 Periosteal and endosteal proliferation
lead to callus
 In the remodelling phase cortical and
medullary cavity are restored.
 If fructure ends are fixed (primary
healing)
 If gap exist secandary healing

28. Normal healing in specific
tissue:
Bone
 The phases are as skin
 Periosteal and endosteal proliferation
lead to callus
 In the remodelling phase cortical and
medullary cavity are restored.
 If fructure ends are fixed (primary
healing)
 If gap exist secandary healing

29. Nerve
 Distal to the wound wallerian
degeneration.
 Proximal of the nerve suffer
regeneration
 1-2 mm per day

30. Tendon
vascular blood flow and synovial
diffusion.
Tendon lacks tensile strenght for 3-6
weeks.
Active mobilisation prevent from
adhesion.
Tendon protect by splint .

31. Scar
 The immature scar becomes mature
a year or more.
 It is at the first pink ,hard , raised and
often itchy.
 The mature scar become paler ,
softer , flatten , most of change first 3
month.
 Mature scar during 1-2 year .
 Scar can be atrophic , hypertrophic
and keloid.

32. Wound Healing
 To treat the wound, you have to treat
the patient
 Optimize the patient
◦ Circulatory
◦ Pulmonary
◦ Nutrition
◦ Associated diseases or conditions

33. Wound Healing

35. ‫جروحات‬ ‫درالتیام‬ ‫موثر‬ ‫فکتورهای‬
Oxygen
◦ Fibroblasts are oxygen-sensitive
◦ PO2 < 40 mmHg collagen synthesis
cannot take place
◦ Decreased PO2: most common cause of
wound infection

36.  Hypoxia:
◦ Endothelium responds with vasodilation
◦ Capillary leak
◦ Fibrin deposition
◦ TNF-a induction and
apoptosis)Programmed cell death)

37.  Edema
◦ Increased tissue pressure
◦ Compromise perfusion
◦ Cell death and tissue ulceration

38.  Infection
◦ Decreased tissue PO2 and prolongs the
inflammatory phase
◦ Impaired angiogenesis and epithelialization
◦ Increased collagenase activity

39.  Nutrition
 Low protein levels prolonged inflammatory
phase
 impaired fibroplasia
 Of the essential amino
 Methionine is critical
 Hydration
 A well hydrated wound will epithelialize faster
than a dry one
 Occlusive wound dressings hasten epithelial
repair and control the proliferation of
granulation tissue

40.  Temperature
◦ Wound healing is accelerated at
environmental temperatures of 30°C
◦ Tensile strength decreases by 20% in a
cold (12°C) wound environment
 Denervation
◦ Denervation has no effect on either
wound contraction or epithelialization

41.  Diabetes Mellitus
◦ Larger arteries, rather than the arterioles,
are typically affected
 Sorbitol accumulation
 Increased dermal vascular permeability
and pericapillary albumin deposition
 Impaired oxygen and nutrient delivery
◦ Stiffened red blood cells and increased
blood viscosity
◦ impaired phagocytosis and bacterial killing
◦ neuropathy

42.  Radiation Therapy
 stasis and occlusion of small vessels
 fibrosis and necrosis of capillaries
 decrease in wound tensile strength
 direct, permanent, adverse effect on
fibroblast

43.  Medications
◦ Steroids
 Stabilize lysosomes and arrest of inflammation
response
 inhibit both macrophages and neutrophils
 interferes with fibrogenesis, angiogenesis, and
wound contraction
 Also direct effect on Fibroblasts
 vitamin A
 oral ingestion of 25,000 IU per day pre op
 Restores inflammatory response and
promotes epithelializaton.

44.  Nutritional Supplements
◦ Vitamin C ( Ascorbic Acid)
 is an essential cofactor in the
synthesis of collagen
 excessive concentrations of ascorbic
acid do not promote supernormal
healing
◦ Vitamin E
 large doses of vitamin E inhibit healing
 increase the breaking strength of
wounds

45.  Nutritional Supplements
 Glutamine
 Enhance actions of lymphocytes,
macrophages and neutrophils
 Glycine
 Inhibitory effect on leukocytes, might
reduce inflammation related tissue injury
 Zinc
 common constituent of dozens of enzymes
 Influences B and T cell activity
 epithelial and fibroblastic proliferation is
impaired in patients with low serum zinc
levels

46. Factors in Wound Healing
 Smoking
 Nicotine acts via the sympathetic system
 vasoconstriction and limit distal perfusion
 1 cigarette = vasoconstriction > 90 min
 Decrease proliferation of erythrocytes,
macrophages and fibroblasts
 Smoke contains high levels of carbon
monoxide
 decreased tissue oxygen delivery

47. Syndromes Associated with
Abnormal Wound Healing
 Cutis Laxa
◦ Think defective elastin fibers
◦ Congenital
 AD, recessive or X-linked recessive
◦ Acquired
 Drug, neoplasms or inflammatory skin conditions
 Ehlers-Danlos Syndrome
◦ Think defective collagen metabolism
◦ AD and recessive patters

48. Syndromes Associated with
Abnormal Wound Healing
 Ehlers-Danlos Syndrome
◦ Four major clinical features
 Skin hyper-extensibility
 Joint hyper-mobility
 Tissue fragility
 Poor wound healing

49. Thanks