WOUNDS: CAUSES, FACTORS INFLUENCING WOUND HEALING, STAGES OF

WOUND HEALING, TYPES OF WOUND HEALING, ABNORMAL WOUND

HEALING AND MANAGEMENT OF ACUTELY CONTAMINATED WOUNDS

CAUSAL CONDITIONS
• Laceration: cut or torn tissue
• Abrasion: superficial skin layer is removed, variable depth
• Contusion: injury caused by forceful blow to the skin and soft tissue; entire outer layer of
skin intact yet injured
• Avulsion: tissue/limb forcefully separated from surrounding tissue, either partially or fully;
“de-gloving”
• Puncture wounds: cutaneous opening relatively small as compared with depth (e.g. needle),
includes bite wounds
• Crush injuries: caused by compression
• Thermal and chemical wounds

PRINCIPLES OF WOUND HEALING

• Wounds result from a disruption of the normal anatomical relationships of tissue as a result
of injury

FACTORS INFLUENCING WOUND HEALING

 Local (reversible/controllable)
• Mechanical (local trauma, tension)
• Blood supply (ischemia/circulation)
• Nutrition (protein, vitamin C, O2)
• Temperature
• Technique and suture materials
• Retained foreign body
• Infection
• Hematoma/seroma (Increases infection rate)
• Venous HTN
• Peripheral vascular disease
• PVD
  General (often irreversible)
• Chronic illness (e.g. DM, cancer, CVD)
• Immunosuppression (steroids, chemo, radiation)
• Tissue irradiation
 Age
 Nutrition
 Smoking
 collagen vascular disease

STAGES OF WOUND HEALING

• Growth factors released by tissues play an important role in initiating and completing
wound healing
• Scar is mature once it has completed the final stage, usually after 1 yr

PROCESSES INVOLVED IN WOUND HEALING

Hemostasis Phase

Hemostasis is the process of the wound being closed by clotting. Hemostasis starts when
blood leaks out of the body. The first step of hemostasis is when blood vessels constrict to
restrict the blood flow. Next, platelets stick together in order to seal the break in the wall of
the blood vessel. Finally, coagulation occurs and reinforces the platelet plug with threads of
fibrin which are like a molecular binding agent. The hemostasis stage of wound healing
happens very quickly.

Inflammatory Phase

Inflammation is the second stage of wound healing and begins right after the injury when the
injured blood vessels leak transudate (made of water, salt, and protein) causing localized
swelling. Inflammation both controls bleeding and prevents infection. The fluid engorgement
allows healing and repair cells to move to the site of the wound. During the inflammatory
phase, damaged cells, pathogens, and bacteria are removed from the wound area. These white
blood cells, growth factors, nutrients and enzymes create the swelling, heat, pain and redness
commonly seen during this stage of wound healing. Inflammation is a natural part of the
wound healing process and only problematic if prolonged or excessive.

Proliferative Phase

The proliferative phase of wound healing is when the wound is rebuilt with new tissue made
up of collagen and extracellular matrix. In the proliferative phase, the wound contracts as
new tissues are built. In addition, a new network of blood vessels must be constructed so that
the granulation tissue can be healthy and receive sufficient oxygen and nutrients.
Myofibroblasts cause the wound to contract by gripping the wound edges and pulling them
together using a mechanism similar to that of smooth muscle cells. In healthy stages of
wound healing, granulation tissue is pink or red and uneven in texture. Moreover, healthy
granulation tissue does not bleed easily. Dark granulation tissue can be a sign of infection,
ischemia, or poor perfusion. In the final phase of the proliferative stage of wound healing,
epithelial cells resurface the injury. It is important to remember that epithelialization
happens faster when wounds are kept moist and hydrated. Generally, when occlusive or
semi-occlusive dressings are applied within 48 hours after injury, they will maintain correct
tissue humidity to optimize epithelialization.

Maturation Phase

Also called the remodeling stage of wound healing, the maturation phase is when collagen is
remodeled from type III to type I and the wound fully closes. The cells that had been
used to repair the wound but which are no longer needed are removed by apoptosis, or
programmed cell death. When collagen is laid down during the proliferative phase, it is
disorganized and the wound is thick. During the maturation phase, collagen is aligned
along tension lines and water is reabsorbed so the collagen fibers can lie closer together
and cross-link. Cross-linking of collagen reduces scar thickness and also makes the skin
area of the wound stronger. Generally, remodeling begins about 21 days after an injury and
can continue for a year or more. Even with cross-linking, healed wound areas continue to be
weaker than uninjured skin, generally only having 80% of the tensile strength of unwounded
skin.

The stages of wound healing are a complex and fragile process. Failure to progress in the
stages of wound healing can lead to chronic wounds or ulcers. Factors that lead up to chronic
wounds are venous disease, infection, diabetes and metabolic deficiencies of the elderly.
Careful wound care can speed up the stages of wound healing by keeping wounds moist,
clean and protected from reinjury and infection.
TYPES OF WOUND HEALING

1. Healing by Primary Intention

• Definition: Wound closure by direct approximation of edges within hours of wound creation
(i.e. with sutures, staples, skin graft, etc.)
2. Healing by Secondary Intention
• Definition: wound left open to heal spontaneously (epithelialization 1 mm/d from wound
margins in concentric pattern), contraction (myofibroblasts) and granulation – maintained in
inflammatory phase until wound closed; requires dressing changes;has inferior cosmetic
result.
• Indication: when 1° closure not possible or indicated
3.Healing by tertiary Intention
• definition: Intentionally interrupt healing process (e.g. with packing), then wound can be
closed at 4-10 d post-injury after granulation tissue has formed and there is <105
bacteria/gram of tissue
• Indication: contaminated (high bacterial count), long time lapse since initial injury, severe
crushcomponent with significant tissue devitalization, closure of fasciotomy wounds
• prolongation of inflammatory phase decreases bacterial count and lessens chance of
infection after closure.

ABNORMAL HEALING

Hypertrophic Scar
• Scar remains roughly within boundaries of original scar
• red, raised, widened, frequently pruritic
• common sites: back, shoulder, sternum
• treatment: scar massage, pressure garments, silicone gel sheeting, corticosteroid injection,
surgical excision if other options fail (however, may still recur)
Keloid Scar
• scar grows outside boundaries of original scar
• red, raised, widened, frequently pruritic
•caused by 1. genetic factors, 2. endocrine factors and/or 3. excess tension on wound or
delayed
closure (as in burn wounds)
• common sites: back, shoulder, sternum, angle of mandible
• Treatment: multimodal therapy, including pressure garments, silicone gel sheeting,
corticosteroid Injection, surgical excision with post-surgical management if other options fail
(however, may still recur), fractional carbon dioxide ablative laser, radiation
Chronic Wound
• fails to achieve primary wound healing within 4-6 wk
• common chronic wounds include diabetic, pressure and venous stasis ulcers
• treatment: may heal with meticulous wound care; may also require surgical intervention

Definitions

• Contamination: the presence of non-replicating microorganisms within a wound

• Colonization: the presence of replicating microorganisms within a wound
• Infection: greater than 10^5 microorganisms in a wound without intact epithelium, a wound
may also be infected with small amounts of a very virulent organism (e.g. GBS)

Management of Acute Contaminated Wound (<24 h)

• Cleanse and irrigate open wound with physiologic solution (NS or RL) using sufficient
pressure
• Evaluate for injury to underlying structures (vessels, nerve, tendon and bone)
• Control active bleeding
• Debridement: removal of foreign material, devitalized tissue, old blood
ƒ Surgical debridement: blade and irrigation if indicated
• Systemic antibiotics are commonly indicated for obvious infection. Risk factors include
wound older than 8 h, severely contaminated, human/animal bites, immunocompromised,
involvement of deeper structures (e.g. joints, fractures)
• Anti-tetanus
 AMPUTATIONS

Definition

Amputation is defined as surgical removal or loss of body part such as arms or limbs in
part or full.

Causes of Amputations

There are several conditions that can lead to amputation.

 Severe infection with extensive tissue damage

 Gangrene
 Trauma resulting from accident or injury, such as crush or blast wound
 Congenital/ Paediatric limb deficiency undergoing conversion amputation
 Congenital deformities of digits or limbs
 Congenital extra digits or limbs
 Necrosis or Necrotizing Fasciitis
 Cellulitis
 Peripheral Arterial Disease
 Frostbite
 Malignant/ cancerous tumor in bone or muscle of the limb e.g. Osteosarcoma
 Conditions that affect blood flow for example Diabetes
Surgery for Amputation

Anesthesia is the first step to any surgery. During amputation, choice of anesthesia
depends on the type of amputation, described above on levels of amputation. Two option
of anesthesia for amputation are general anesthesia or epidural anesthesia.

While performing amputation, special care is to be taken to make sure the procedure
does not hamper the functioning of remaining limb. It is vital to condition, shorten &
smoothen the remaining bone, so there is a healthy stump that in future can take the load
of a prosthetic limb and reduce complication risk.

Muscle is sutured to the bone at the distal residual bone so maximal strength of the
remaining limb can be retained. This procedure is known as myodesis.

Distal stabilization of the muscles is always recommended, allowing for effective muscle
contraction and reduced atrophy. This in turn allows for a greater functional use of the
stump and maintains soft tissue coverage of the remnant bone. As the procedure for
amputation is completed, the wound us sealed by performing myoplasty: suture to
opposite muscle in the residual limb to to each other and to the periosteum or to the
distal end of the cut bone for weight bearing purposes; and is covered with a bandage. A
drainage tube might be placed to drain all excess fluid. Hence, every possible measure is
taken to reduce risk of infection.

Ideal Stump

1. Skin flaps: skin should be mobile, sensation intact, no scars

2. Muscles are divided 3 to 5 cm distal to the level of bone resection
3. Nerves are gently pulled and cut cleanly, so that they retract well proximal to the
bone level to reduce the complication of neuroma

Stump care

 For hygiene and skin care see handout on amputations

 A hip flexion contracture may develop because of elevation to reduce swelling
 Stump bandaging is done to ‘cone’ the stump, thereby preventing oedema, which
occurs because there is no muscle pump and the stump hangs
 Swelling must be prevented to allow proper attachment of the prosthesis, and the
prevention of pressure sores
 The stump sock is put on first, then the prosthesis
 The prosthesis must be cleaned and maintained (children who are still growing, grow
out of their prostheses)
Complications of Amputation

 Edema & Swelling

 Wounds Infection
 Stump pain
 Pain (phantom limb)
 Muscle weakness
 Muscle Tightness & contractures
 Joint Instability
 Autonomic dysfunction