01 WOUND
Outlines
Introduction
Classification of Wounds
Types of wound
Wound Healing
Introduction
Wound is a discontinuity or break in the surface epithelium.
A wound is simple when only skin is involved. It is complex when it involves
underlying nerves, vessels and tendons.
Connective
Tissue
CLASSIFICATION OF WOUNDS
Aim of classification: diagnosis and stratification, prognostic information,
guide management, uniformity of documentation
Wounds can be classified using the following criteria:
Time - acute, subacute, chronic
Aetiology – surgical, penetrating trauma, blunt trauma, burns, frost bite
Morphology – abrasion, incision, laceration, degloving, ulceration
Degree of contamination – aseptic, contaminated, septic
Complexity – simple, complex, complicated
For Surgical wounds: CDC, ASEPSIS, Southampton
CLASSIFICATION OF WOUNDS
CLASSIFICATION OF WOUNDS
CDC Classification of Surgical Wounds
Clean: Elective, not emergency, non-traumatic, primarily closed; no acute
inflammation; no break in technique; respiratory, gastrointestinal, biliary and
genitourinary tracts not entered.
Clean-contaminated: Urgent or emergency case that is otherwise clean;
elective opening of respiratory, gastrointestinal, biliary or genitourinary tract
with minimal spillage (e.g. appendectomy) not encountering infected urine or
bile; minor technique break.
CLASSIFICATION OF WOUNDS
CDC Classification of Surgical Wounds
Contaminated: Non-purulent inflammation; gross spillage from
gastrointestinal tract; entry into biliary or genitourinary tract in the presence of
infected bile or urine; major break in technique; penetrating trauma <4 hours
old; chronic open wounds to be graſted or covered.
Dirty: Purulent inflammation (e.g. abscess); preoperative perforation of
respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma
>4 hours old.
Types of wound
Basically there are 2 types of wound;
1. Open Wounds
• They are the wounds with exposed underlying tissue and open to the
outside environment, for example, penetrating wounds. Types of open
wounds include:
Lacerations
Punctures
Incisions
Avulsions
Abrasions
• They can be caused by falls, bites, burns, or accidents with sharp objects.
Types of wound
2. Closed Wounds
• Closed wounds occur without any exposure to the underlying damaged
tissue and organs and are generally caused through blunt trauma. Types of
closed wounds include:
Contusions
Blisters
Seroma
Hematoma
Crush injuries
• While closed wounds may not be exposed to the air, they can still become
infected and develop into an abscess.
Abrasion - In this wound, epidermis of the skin is scraped away exposing the
dermis.
- They are painful as dermal nerve endings are exposed.
- These wounds need cleaning, antibiotics and proper dressing.
Lacerated - Caused by blunt injury such as fall on a stone or RTA.
- Edges are jagged.
- The injury may involve only skin and subcutaneous tissue or
sometimes deeper structures also.
- Due to the blunt nature of the object, there is crushing of the tissue
which may result in haematoma, bruising or even necrosis of the
tissue.
- Treated by wound excision and primary suturing.
- Provided they are treated within six hours of injury.
Incised - Caused by sharp objects.
- This type of wound has a sharp edge.
- Less contaminated.
- Primary suturing is ideal for such wounds.
Contusion - Can be minor soft injury without break in the skin, or major such
as when being run over by a vechile.
- Generally, it produces discolouration of the skin due to collection
of blood underneath.
Hematoma - This refers to collection of blood usally following injury.
- It can occur spontaneously in patients who have bleeding
tendencles such as haemophilia.
- Depending upon the site, it can be subcutaneous, intramuscular
or even subperiosteal.
- A knee joint hematoma may need to be aspirated followed by
application of compression bandage. Small haematomas get
absorbed. If not, they can get infected.
Hematoma
Whenever we want to treat a patiet wth any type of wound the first thing is
measure the vitals; pulse,Bp, tempreature, aspiration and heart rate.
Wound Healing
PHYSIOLOGY OF WOUND HEALING
Wound healing is a complex process involving coordinated interactions
between diverse immunological and biological systems
Wound healing is a continuous process but can be di fferentiated into four time-
dependent phases for understanding:
Inflammation phase
Proliferation phase
Remodelling phase
Scar Formation Phase
PHYSIOLOGY OF WOUND HEALING
Inflammatory Phase
Injury results in the release of mediators of inflammation, mainly histamine
from platelets, mast cells and granulocytes.
This results in increased capillary permeability.
Later kinins and prostaglandins act and they play a chemotactic role for white
cells and fibroblasts.
In the first 48 hours, polymorphonuclear (PMN) leukocytes dominate.
They play the role of scavengers by removing the dead and necrotic tissue.
PHYSIOLOGY OF WOUND HEALING
Proliferative Phase
Between 3rd and 5th days, polymorphonuclear leukocytes diminsh in number
but monocytes increase.
By 5th or 6th day, fibroblasts appear, proliferate and eventually give rise to a
protocollagen.
protocollagen enhydroxylase
Protocollagen Collagen
Fibroplasia along with cappillarybudding gives rise to granulation tissue.
Epithelialization occurs mainly from the edges of the wound by a process of
cell migration and cell multiplication.
This is mainly brought about by marginal basal cells. Thus, within 48 hours,
the entire wound is re-epithelialized.
PHYSIOLOGY OF WOUND HEALING
Remodelling Phase
It is brought about by specialized fibroblasts.
Because of their contractile elements, they are called myofibroblasts.
It is the nature’s way of reducing the size of defect, therby helping the wound
healing.
Wound contraction readily occurs when there is loose skin as in back and
gluteal region.
Skin contraction is greatly reduced when it occurs over tibia (skin) or
malleolar surface.
PHYSIOLOGY OF WOUND HEALING
Scar Formation Phase
Fibroplasia and laying of collagen is increased.
Vascularity become less (devascularization).
Epithelialization continues.
Ingrowth of lymphatics and nerve fibers takes place.
Remodeling of collagen takes place with cicatrisation, resulting in a scar.
PHYSIOLOGY OF WOUND HEALING
Classification of Wound Healing
Primary intention
Wound edges apposed
Minimal scar
Secondary intention
Wound leſt open
Heals by granulation, contraction and epithelialization
More pronounced scar
Tertiary intention
Also called delayed primary intention
Wound initially leſt open
Edges apposed later when healing conditions are favourable
Difference between 1” & 2” union of wound
FEATURES PRIMARY SECONDARY
CLEANLINESS CLEAN NOT CLEAN
INFECTION NOT INFECTED INFECTED
MARGINS SURGICALLY CLEAN IRREGULAR
SUTURES USED NOT USED
HEALING SMALL GRANULATION LARGE GRANULATION
TISSUE TISSUE
OUTCOME LINEAR SCAR IRREGULAR WOUND
COMPLICATION NOT FREQUENT FREQUENT
PATHOLOGY OF WOUND HEALING
Chronic wound
Necrotizing soſt tissue infections
Compartment syndrome
Scars
Contractures
Genetic syndromes: Ehlers-Danlos, cutis laxa, homocystinuria, osteogenesis
imperfecta
Common factors Affecting the Wound Healing
Age : Old age.
Poor nutrition : lack of protein, vitamins and minerals
Chronic medical conditions : Diabetes (chronic Hyperglycemia) & immune
disorders
Medications : chemo drugs, corticosteroids or immunosuppressive drugs
Infection
psychological factor : stress, anxiety and depresssion
Wound Characteristics : Large, deep or complex wounds
THANK
YOU!!!
Done by : Meron Haftay
(MRT/R/012)