WOUND HEALING AND COMPLICATIONS

1. WOUND HEALING AND
ITS COMPLIACTIONS
Presented by: Dr. Sourav Panda
DNB JR 1
Max Superspecial

2. Wound Healing
• Defined as response of the host tissue to
injury to restore the mechanical integrity and
to restore the barrier to fluid lossand
infection and to re establish normal blood and
lymphatic flow patterns is known as wound
healing.

3. Phases of wound healing
• Haemostasis
• Inflammatory phase (3 to 5 days)
• Proliferative phase (starts from D3, lasts for
2-4 weeks)
• Remodelling phase.(starts after 2-4weeks,
lasts for years)

4. Haemostasis
• Response of the host tissue to stop hemorrhage and
restore normal blood flow.
Injury to blood vessels
Local Vasoconstriction
Formation of primary platelet plug
Coagulation cascade

5. Inflammation
• Starts soon after the injury and lasts for 3 –
5 days.
• Predominant cells:
Initially Neutrophil, Later Monocytes
(Macrophages).
Release of chemicals as a result of platelet
activation
Bradykinin, C3a C5a, Histamines and
leukotrienes.
Neutrophils help in wound decontamination
Macrophages aid in wound debridement.

6. Proliferation
• Starts around day3, lasts for 2-4 weeks.
• Predominant cells: Fibroblasts.
• Angiogenesis, Collagen deposition, Re-
epithilialisation.
• Multiple growth factors: PDGF, VEGF, EGF, TGF-b
• Formation of granulation tissue and production
of ECM.
• Myofibroblasts: Wound contraction.

7. Remodelling
• Starts by 2-3 weeks and lasts for 1 to 2 years.
• Further Crosslinking of collagen
• Conversion of collagen type 3 to type1 (4:1)
• Regression of capillaries.
• Increase in wound strength

8. Local factors affecting wound
healing
• Oxygenation
• Infection/ Prolonged Inflammation
• Foreign body
• Hydration of the wound
• Wound Characteristics

9. Systemic factors affecting
wound healing
• Age and Gender
• Systemic Diseases
• Diabetes
• Obesity
• Nutrition
• Alcohol and Smoking
• Drugs: Glucocorticoids, Adriamycin.

10. Complications of wound healing
Keloid
• Grow beyond the borders of the
original wound margin.
• Rarely regress with time
• Common in darkly pigmented skins
(Africans/ Asians)
• Genetic susceptibility
(multigenetic disposition)
• Defective apoptosis and increased
TGF-b
• Not preventable
Proliferative scars characterized by excessive net collagen deposition.
Hypertrophic scar
• Raised scars within the
margin of the original
wound.
• Regresses spontaneously
with time.
• Increased tension in the
wound acts as a stimulus
for activation of
fibroblasts and increased
collagen deposition.
• Preventable
 Tension relief
 Hydration and occlusion of
wounds

11. Treatment of Keloids
• First line: Silicones sheets with pressure
therapy + intralesional triamcinolone.
• Intralesional 5FU, Bleomycin and Verapamil can
be used as 2nd line medical treatment
• Refractory cases after 12 months: Surgical
excision (High recurrence rate of 50 to 100%)
• Immediate post operative brachytherapy with
iridium-192 reduces recurrence rates.
• Internal cryotherapy: reduction in scar volume
without recurrence
• Imiquimod (TLR-7 agonist)

12. Classification of surgical
wounds
Type1: Clean wound
• Uninfected
• No brak in sterile technique
• No inflammation is encountered
• Respi/ GI/Genital/ uninfected urinary tract is not entered
• Primary closure.

13. Clean Contaminated wound
• Respi/ GI/ Genital/ Urinary tract is entered
under controlled conditions and without unusual
contamination.
• Specifically surgeries of Billiary tract,
appendix, oropharynx, vagina are included in
this category.
• No evidence of infection.

14. Contaminated
• Open traumatic wounds<4h
• Surgeries with major breaks in sterile
technique
• Gross spillage from the GI tract
• Incision with acute non purulent inflammation

15. Dirty/ Infected
• Old open traumatic wounds>4h
• Surgeries for perforated viscera
• The organism causing post op infection were
present in the surgical field before the
procedure.

16. Risk of SSI in surgical wounds
Type w/o
Abx prophylaxis with abx prophylaxis
• Clean
2%
1%
• Clean contaminated 10%
3%
• Contaminated 20%
6%
• Dirty

17. SSI
• Signs of infection at the site of surgery that
occurs
Within 30 days of surgery
or
 Within 1 year of surgery with an implant in situ.
• Types of SSI
Superficial Incisional
Deep incisional
Organ or body space

18. Southampton Wound Grading system
• Grade 0: Normal Healing
• Grade 1: Mild brusing/ Erythema.
• Grade 2: Erythema + Other signs of
inflammation.
• Grade 3: Clear/ Serosanguinous discharge
• Grade 4: Pus discharge
• Grade 5: Deep wound infection with anatomical
separation or hematoma requiring aspiration

19. Asepsis Wound score
Criterion points
A Additional Treatment
 Antibiotics for wound infection
 Drainage of pus under LA
 Debridement of wound under GA
10
5
10
S Serous discharge 0-5
E Erythema 0-5
P Pus discharge 0-10
S Separation of deep tissues 0-10
I Isolation of bacteria from the wound 10
S Stay in hospital >14days 5

20. Interpretaion
• 0 to 10 Satisfactory Healing
• 11 to 20 Disturbance of healing
• 21 to 30 Minor wound infection
• 31 to 40 Moderate wound infection
• >40 Severe wound infection