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    Wound Healing

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    yayassssss
    The document discusses wound classification and the stages of wound healing. It describes the 4 stages of wound healing as hemostasis, inflammation, granulation tissue formation, and maturation. Wounds can be classified as acute or chronic, and also based on the mode of damage such as incised wounds, lacerations, abrasions, crush injuries, and burns. The stages of wound healing involve hemostasis, inflammation, formation of granulation tissue, and maturation of the wound. Sutures are used to approximate wound edges and provide initial strength but are later removed as strength returns.

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    Wound Healing

    Uploaded by

    yayassssss
    43 views4 pages
    The document discusses wound classification and the stages of wound healing. It describes the 4 stages of wound healing as hemostasis, inflammation, granulation tissue formation, and maturation. Wounds can be classified as acute or chronic, and also based on the mode of damage such as incised wounds, lacerations, abrasions, crush injuries, and burns. The stages of wound healing involve hemostasis, inflammation, formation of granulation tissue, and maturation of the wound. Sutures are used to approximate wound edges and provide initial strength but are later removed as strength returns.

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    The document discusses wound classification and the stages of wound healing. It describes the 4 stages of wound healing as hemostasis, inflammation, granulation tissue formation, and maturation. Wounds can be classified as acute or chronic, and also based on the mode of damage such as incised wounds, lacerations, abrasions, crush injuries, and burns. The stages of wound healing involve hemostasis, inflammation, formation of granulation tissue, and maturation of the wound. Sutures are used to approximate wound edges and provide initial strength but are later removed as strength returns.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    43 views4 pages

    Wound Healing

    Uploaded by

    yayassssss
    The document discusses wound classification and the stages of wound healing. It describes the 4 stages of wound healing as hemostasis, inflammation, granulation tissue formation, and maturation. Wounds can be classified as acute or chronic, and also based on the mode of damage such as incised wounds, lacerations, abrasions, crush injuries, and burns. The stages of wound healing involve hemostasis, inflammation, formation of granulation tissue, and maturation of the wound. Sutures are used to approximate wound edges and provide initial strength but are later removed as strength returns.

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    Wound Healing

    Wound : A breach in the normal tissue continuum.

    The term ‘wound’ is generally applied to more superficial forms of tissue damage whereas ‘injury’ is used for
    damage to deeper structures.

    Classification
    Acute
    Closed wounds
    Bruise/contusion
    Hematoma
    Open wounds
    Puncture wounds and bites
    Abrasions
    Laceration
    Burns
    Incision
    Complex
    Crush/avulsion
    Internal organs
    War wounds & gunshot injuries
    Tissue loss

    Chronic
    Ulcers
    Pressure sores

    Wounds may be classified according to the mode of damage:

     Incised wound - caused by a sharp instrument


     Laceration - a jagged, tearing wound.
     Abrasions - result from friction damage. Characterized by superficial bruising and loss of varying
    thickness of skin and underlying tissues.
     Crush injuries - due to severe pressure. Even though the skin is not breached there may be massive tissue
    destruction.
     Gunshot wounds - may be low velocity or high velocity.
     Burns - caused by heat, electricity, irradiation or chemicals.

    Note : Removal of skin sutures without wound disruption can be done after 4-5 days on the face and 10-14 days
    on the trunk and limb. This is because wounds of the head and neck heal quickly as compared to wounds of
    the leg and foot.

    4 stages of wound healing


    Stage I : Hemostasis (first 4 hours)
    Stage II : Inflammation (first 24-48 hours)
    Stage III : Granulation tissue formation (28 hours - 5 days)
    Stage IV : Maturation (5 days - months)

    Hemostasis
    Neurogenic reflex vasoconstriction + activation of coagulation  hemostatic plug
    Inflammation
    Vasodilatation (mediated by histamine & serotonin released by platelets and tissue mast cells) 
    slower blood flow +  permeability  WBC margination & diapedesis + exudates
    Granulation tissue formation
    Macrophages replacing neutrophils. Macrophage has 3 main functions:
    Phagocytes
    Stimulation of existing endothelial cells to proliferate, migrate and mature as new blood
    vessels (neovascularization)
    Stimulation of fibroblast proliferation
    Granulation tissue = fibroblast + new vessel formation
    Maturation
    This long process consists of a gradual strengthening, remodelling and realignment of collagen fibres
    along the lines of tension, together with a steady regression of vascular channels which formed in the
    early stages of healing but are unnecessary by this stage. This process results in an acellular,
    avascular, collagenous scar.

    Types of wound
    Clean - e.g. thyroid surgery
    Clean contaminated - appendicectomy
    Contaminated - abscess
    Dirty -

    Clean & clean contaminated can be closed by primary intention


    Clean contaminated, contaminated and dirty must be closed by tertiary intention

    Types of wound healing


    3 types:
    Healing by primary intention
    Clean surgical incisions generally heal in this way. There has usually been minimal tissue loss or
    damage with minimal bacterial contamination. The divided tissue edges are reapproximated (by
    sutures, clips, tape or glue) without tension.
    In clean, incised wound there is little separation of tissue and approximation of the edges by sutures
    effectively approximates the margins, thereby minimising the amount of cellular proliferation and
    migration necessary to bridge the defect.
    Healing by secondary intention
    This describes the way wounds with a more extensive defect between the edges undergo healing.
    There is an outgrowth of vascular granulation tissue from the raw wound edges.
    Secondary union may arise because of:
    Tissue loss or injury (surgical excision or trauma)
    Deliberately keeping the wound apart because there has been heavy wound contamination
    (e.g. trauma patients or following laparotomy for faecal peritonitis).
    Problems:
    Complicated wound care
    Larger tissue defect needs to be filled
    Wound contraction
    Slower healing process
    More scar tissue

    Healing by tertiary intention (Delayed primary healing)

    Wound strength
    Most wounds of skin, subcutaneous tissue, muscle, fascia or tendon never regain their pre-injury strength.
    70-80% of pre-injury strength in 3 months. Thereafter wound strength reaches a plateau below 100%.
    The development of wound strength is related to the type of collagen produced, the early granulation tissue
    type III collagen being weaker than the later (maturation stage) type I.

    Sutures
    Carefully placed sutures will appose the side of the wound and encourage healing by first intention. In addition
    the sutures provide support to the wound, which regains 40-70% of its original strength immediately after
    operation. However, when skin sutures are removed (usually at 10 days) the wound weakens to only 10% of its
    pre-injury level.

    Disadvantage of sutures
    Provide a route for bacteria to penetrate through to the deeper tissue layers
    Can initiate foreign body reactions

    Special notes
    In wound healing, the skin and fascia never regain the original strength. They usually recover only 80% of
    their original tensile strength.

    Healing of specialized tissue


    Epithelium
    Heals by regeneration and not by scar formation.
    Nerve tissue
    Neural tissue in the CNS cannot regenerate and fibroblasts derived from glial or perivascular cells replace
    nervous tissue with collagen. In peripheral nerves, as long as the body of the nerve cell survives, axons from
    the proximal stump can regenerate.

    Intestine
    Damage confined to gut mucosa is repaired by reepithelialization without scarring whereas ulceration
    extending through to the submucosa and underlying muscle always leaves a permanent fibrous scar.

    PROBLEMS IN WOUND MANAGEMENT


    Postoperative wound infection
    Usually becomes evident 3-4 days after surgery.
    Initially there is superficial cellulitis around the wound margins or swelling of the wound with some serous
    discharge from between the sutures. Fluctuation is occasionally elicited when there is an abscess or liquifying
    hematoma, and crepitus may be present if gas-forming organisms are involved.
    In some cases of deep infection there are no local signs although the patient may have pyrexia and increased
    wound tenderness.
    Toxemia, bacteremia and septicemia can complicate serious wound infection.

    Wounds with skin loss


    The aim of wound care is to obtain skin cover and healing as soon as is safely possible, either by primary or by
    delayed primary closure. If skin has been lost it is often better to speed healing by importing skin to close the
    wound. (Unless the skin defect is small and at a functionally or aesthetically unimportant site, it may be
    allowed to heal by secondary intention).

    2 ways to replace skin:


     Skin graft - requires a vascular bed as it has no blood of its own.
     Flap - bring their own blood supply to the new site

    Skin grafts
    Can be divided into:
     Autograft - from self
     Allograft - from compatible donor
     Xenograft - from other species

    Autograft can be divided into


    Split skin graft (SSG) - Take only the epidermis and the papillary layer of the skin
    Full thickness (FTSG) - Take the epidermis, dermis and subcutaneous tissue (then scrap off the subcutaneous
    tissue.

    Split skin graft (SSG)


    Are cut with a special, guarded freehand knife or an electric dermatome.
    To cover very large areas the graft can be expanded by ‘meshing’. The thinner the graft, the more easily it will
    take on a bed of imperfect vascularity, but the poorer the quality of skin, the more it will shrink.
    The donor site heals by re-epithelialization from epithelial appendages in the dermis (the bases of hair
    follicles and sweat ducts) within 2-3 weeks, so that large sheets of skin can be taken.
    Used to cover wounds after acute trauma, granulating areas and burns, or when the defect is large.

    Full thickness skin graft (FTSG)


    Such grafts are strong, do not shrink and looks better than a SSG.
    Requires a well-vascularized bed to survive.
    There are rarely advisable after acute trauma but are commonly used in reconstructive surgery to close small
    defects where strength is needed (e.g. on the palm of the hand) or a good cosmetic result is important (e.g. on
    the lower eyelid).
    FTSG leaves a donor defect (which needs to be sutured or grafted as large as the one to be filled.

    Flap
    While grafts require a vascular bed to survive, flaps bring their own blood supply to the new site. They can
    therefore be thicker and stronger than grafts and can be applied to avascular areas such as exposed bone,
    tendon or joints.
    Used usually for reconstruction of surgical defects and for secondary reconstruction after trauma.
    Used in acute trauma only if closure is not possible by direct suture or skin grafting.
    The simplest flaps use local skin and fat and are often a good alternative to skin grafting for small defects such
    as those left after excision of facila tumours. If enough local tissue is not available, a flap may have to be
    brought from a distance and remain attached temporarily to its original blood supply until it has picked up a
    new one locally. This usually takes 2-3 weeks, after which the pedicle can be divided.

    Crushing and degloving injuries, gunshot wounds


    Wounds of this type should never be closed primarily, as tissue destruction is always much greater than appears
    at first. After thorough irrigation and removal of any obviously dead tissue and foreign material such wounds
    should be lightly packed and dressed. Dressings are removed 48 hours later under anaesthesia and further
    excision is carried out if necessary. The wound is closed by suture, skin grafting or flap cover once it is clear
    that all dead tissue has been removed.

    Needle
    The needle may be round-bodied or triangular on cross-section. The round-bodied needle is used when tissue
    resistance is low (e.g. for intestinal suture), while a triangular needle is preferred when sharp cutting edges are
    needed to facilitate passage through tough tissues such as skin and aponeurosis.

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