Types of wounds and the basic principles of wound healing · 2020. 3. 20. · Types of wounds...

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Types of wounds and the basic principles of wound healing

Transcript of Types of wounds and the basic principles of wound healing · 2020. 3. 20. · Types of wounds...

Page 1: Types of wounds and the basic principles of wound healing · 2020. 3. 20. · Types of wounds (accidental wounds) Incised, slashed wounds (vulnus scissum at caesum) Puncture wounds

Types of wounds and the

basic principles of wound

healing

Page 2: Types of wounds and the basic principles of wound healing · 2020. 3. 20. · Types of wounds (accidental wounds) Incised, slashed wounds (vulnus scissum at caesum) Puncture wounds

Types of wounds

Wound: loss of continuity of skin or mucous membrane(road traffic accidents, at home or at work)

Surgical wounds

Accidental wounds

Open, Closed

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Types of wounds (accidental

wounds)

Incised, slashed wounds (vulnus scissum at caesum)

Puncture wounds (v. punctum)

Contused wounds (v. contusum)

Lacerated wounds (v. lacerum)

Gunshot wounds

Bites (v. morsum)

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Incised wounds

Caused by sharp cutting edges

(knife, glass or metal)

Linear in appearance – all surgical wounds

Gap formation

Much bleeding

Less painful

No infection

Underlying structures should be examined

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Puncture wounds

Caused by pointed instruments (nails, knives, thorns of plants, flying fragments of explosion)

Damage of deep structures

Severe haemorrhage

No severe tissue damage

Apt for infection

Jeopardy of anaerobic infection

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Gunshot wounds

Caused by weapons gunshot splintersPerforating wounds: entry wound, wound

track, exit wound Entry wound is smaller Blind wound: no wound exit bullet or

splinters get stuck Life threatening injuries Major bleeding Apt for infectionLow velocity bullet – less damageSplinter of bomb – more tissue damage

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Bites

Caused by animals, humans, insects

Liable to infect

Considerable tissue damage (horses, cows, bears, etc.)

Apt for anaerobic infection

Typical human bite injury teeth cause to metacarpaphalangeal joint suppurative arthritis

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Types of wounds

(classification according to cleanless –

bacterial contamination)

Clean wounds (operation or strile conditions, normal skin bacteria are detectable)

Clean-contaminated wounds (the contamination of clean wounds is endogenous or comes from the enverioment)

Contaminated wounds (severe contamination by purulent area or leakage GI tract)

Dirty wound (due to nonviable tissues, crhronic wounds)

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Types of wounds (depending on

the time since the trauma)

Acute wounds

- fresh wounds: treatment within 8 h

- old wounds:> 8 h after trauma

Chronic wounds

(they do not heal within 4 weeks after the wound menegament or within 8 weeks)

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Wound management

Anamnesis (When did it occur?, Contamination? Tetanus vaccination? Associated diseases?..)

Diagnostic procedure

- accompayning injury

- examination of circulatory, sensitivity and motor functions

- bone fractures?

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Treatment of wounds

Anaesthesia: field, regional block

Torniquet: bloodless operation

Pneumatic torniquet

300 mmHg thigh

200 mmHg arm

Not more than 45 minutes

Cleansing: degreasing agent water, detergent, iodine,

Wound: physiologic salt, H2O2

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Surgical treatment

Exploration, toilet, repair

Surgical toilet: to remove all foreign material and devitalized tissue

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Surgical treatment

Irregular, devitalized skin edges should be removed by knife

Subcutan tissue and muscle removed by scissors

Smaller bone fragment could be removed

Deep tissues should be approximated by absorbable suture material

Do not excise wounds on the face

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Surgical treatment

Fascia and subcutaneous layer: interrupted stiteches

Skin: accurate approximation of the skin edges. Tension and ischaemia of the skin edges are to be avoided.- interrupted stitch, Donati vertical mattress suture, Allgöwer, continous intrcutenous, steri-strips,.

Dressing: should be removed on the second postoperative day, regular changing

Sutures are usually removed after 4-6 days (5-14 days)

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Surgical treatment

Early complications of wound closure

- haematoma

- seroma

- wound infections

usually Staphylococcus aureus

culture

treatment: removal of sutures, saline or H2O2 bathing, drainage

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Surgical treatment

Dressing should be checked regularly

Drains

Timing

Primary closure within 12 hours

Delayed closure within 24 hours (clean)

> 24 hours toilet, exploration (left open)

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Surgical treatment

Primary wound management is contraindicated:

- infectious signs

- severe contamination

- an incompletely removed foreign body

- bite, shot or deep incised wounds

Cleansing, covering, primary delayed suturing (3-8 days)

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Surgical treatment

Early complications of wound closure

- haematoma

- seroma

- wound infections

usually Staphylococcus aureus

culture

treatment: removal of sutures, saline or H2O2 bathing, drainage

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Phases of wound healing

Inflammatory phase

Vascular response

Vasoconstriction response to bleeding

Activation coagulation cascade

Platelet adhesion, aggregation clot formation

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Inflammatory phase

Vasodilation, increased permeability

Histamin, serotonin liberation

Kinin – kallikrein activation

Classic sign of inflammation erythemia, warmth vasodilaton oedema increase in cells and plasmapain tension due to oedema

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Inflammatory phase

Cellular response

Leukocytes (few hours)

Macrophages (1-2 days)

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Proliferative phase (5 days to 3rd

week)

Epithelial repair

Collagen synthesis (fibroblast transformation)

Wound contraction

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Maturation or remodelling phase

(within 3 months)

Wound flatter, softer, lighting colour

Collagen thicker, denser

Blood vessels constrict, disappear

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Primary healing

Simple surgically closed wound

No soft tissue lost

No infection and contamination

No foreign body

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Secondary healing

Not closed surgically

More granulation tissue

Wound contraction

Epithelialization

Scar wider, weaker

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Tertiary healing

Combination of the first two

Open wound

Delayed suture (4 to 5 days)

Classic example:„ruptured appendix”

Page 47: Types of wounds and the basic principles of wound healing · 2020. 3. 20. · Types of wounds (accidental wounds) Incised, slashed wounds (vulnus scissum at caesum) Puncture wounds

Factors affecting the wound healing

process

Nutrition Vitamin C (cofactor of collagen synthesis) Vitamin A (role in epithelialization) Zink Oxygen – blood supply tissue necrosis

infection Contamination – infection Nature of wound Chronic disease

diabetescancerimmundeficiency

Adrenal corticosteroids

Page 48: Types of wounds and the basic principles of wound healing · 2020. 3. 20. · Types of wounds (accidental wounds) Incised, slashed wounds (vulnus scissum at caesum) Puncture wounds

Scars

Factors influencing scar formation • Individual genetic make up • Race • Anatomical site • Wound tension • Age • Placement of incision • Surgical technique

To minimise the degree of postoperative scarring: • Incisions should run along Langer's lines • The finest suture possible should be used • Tension should be avoided • Sutures should be removed as soon as possible • Traumatic wounds should be clean and edges excised • Exposure to sunlight should be avoided in the early postoperative

period

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Problematic scars

Contractures Result if scars shorten Particularly seen in badly aligned scars not

corresponding to Langer's lines Can reduce joint mobility May require a z-plasty or skin graft

Depressed scars Result if skin becomes attached to deep tissue Can be treated by release of normal skin from

margins of scar Scar is then de-epithelialised and skin edges

closed over the top

Page 50: Types of wounds and the basic principles of wound healing · 2020. 3. 20. · Types of wounds (accidental wounds) Incised, slashed wounds (vulnus scissum at caesum) Puncture wounds

Terminology related to abnormal

wound healing

Hypertrophic scars – wound healing excessive (epithelium raised, wide, radder) All scars become red and thickened during the normal healing process After several months maturation results in flattening of the wound In some scars collagen formation is excessive Results in elevated and red scar If confined to wound = hypertrophic scar

Page 51: Types of wounds and the basic principles of wound healing · 2020. 3. 20. · Types of wounds (accidental wounds) Incised, slashed wounds (vulnus scissum at caesum) Puncture wounds

Terminology related to abnormal

wound healing

Keloid (tumor like moliferation of well vascularized connective tissue) If extends beyond wound into normal tissue = keloid scar

Seen particularly in patients of Afro-Caribbean origin Particularly affects scars on the presternal and deltoid areas Treatment is often difficult Treatment options include: Intra-lesional steroid injections (e.g. triamcinolone) Compression dressings with elasticated compression garments Silastic gel therapy Excision and radiotherapy Laser therapy

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