Surgery - Principle of Wound Healing and Management

PRINCIPLE OF WOUND HEALING AND MANAGEMENTSUPERVISOR:

ASSOC. PROF DR. JUNAINI KASIAN

Outline of Presentation

Wan Muhammad Muizzuddin Shah Bin Zulkiffli Definition of Wound Classification of Wound Types of Wound Definition of Wound Healing Phases of Wound Healing Classification of Wound Healing

Cont.

Abd Hayyul Ihsan Bin Abd Suhaimi Factors Influencing Wound Healing Problems In Wound Healing Chronic Wound

Mohd Arif Bin Mohd Noor Principle Management Of Wound

DEFINITION OF WOUND

Wound

1) Trauma to any of the tissues of the body, especially that caused by physical means and with interruption of continuity

2) A surgical incision

Stedman’s Medical Dictionary

CLASSIFICATION OF WOUND

Classification Of Wound

Bailey & Love’s Short Practice of Surgery

Tidy wound Untidy wound

Incised Crushed or avulsed

Clean Contaminated

Healthy tissues Devitalised tissues

Seldom tissue loss Often tissue loss

Classification Of Surgical Wound

Clean wounds Clean contaminated Contaminated Dirty

Guideline For Prevention Of Surgical Site Infection, 1999

TYPES OF WOUND

Types Of Wound

According to mode of damage Incised wounds Abrasions Crush injuries Degloving injury Gunshot wounds Burns

Principles & Practice of Surgery

Incised Wound

Caused by a sharp instrument Common causes are knives and glass Lacerated wound : associated with tissue

tearing

Abrasion

Damage to the body surface resulting from friction

Characterized by superficial bruising and loss of varying thickness of skin and underlying tissue

Dirt and foreign bodies are frequently embedded in the tissues

Crush Injuries

Due to severe pressure Massive tissue destruction although the

skin is not breached Often accompanied by degloving and

compartment syndrome

Compartment syndrome

Muscle ischemia

Bleeding, exudate, swelling

Introduction of excess fluid

Increase intracompartme

ntal pressure

Decreased tissue perfusion

Degloving Injury

Result from shearing forces that causes parallel tissue planes to move against each other

I.e a hand caught in rollers or moving machinery

Large areas of apparently intact skin may be deprived of blood supply because rupture of feeding vessels

Gunshot wound

Low velocity (shotguns) or high velocity (military rifles) cause massive tissue destructions after skin penetration.

Burns

Other causes besides heat: Chemical Radiation Electrical

Others

Bites Puncture wounds or avulsions Small animal bites children Human bites ear, tips of nose and

lower lip injuries Bites wounds highly virulent

Puncture wounds Sharp objects i.e needle stick

injuries


DEFINITION OF WOUND HEALING

Wound Healing

Restoration of integrity to injured tissues by replacement of dead tissue with viable tissue

Dorland’s Medical Dictionary

PHASES OF WOUND HEALING

Phases of Wound Healing

Lag phase (2-3 days) Inflammatory response

Incremental/Proliferative phase (3 months) Fibroblast migration Capillary ingrowth (granulation tissue) Collagen synthesis with rapid gain in tensile strength Wound contraction

Plateau/Maturation phase (6 months) Organization of scar Slow final gain in tensile strength (80% or original strength)

Principles & Practice of Surgery

Cont.

Lag Phase

Characterized by inflammatory response Capillary permeability increases

protein rich exudate accumulates Collagen synthesized inflammatory

cells migrate into the area dead tissue removed by macrophages capillaries at the wound edges begin to proliferate

Incremental/Proliferative Phase Progressive collagen synthesis by

fibroblast increase in tensile strength Increased collagen turnover in areas

remote from the wound systemic stimulus for fibroblastic activity

Collagen synthesis increase in 3 weeks gain in tensile strength accelerates

Old collagen undergoes lysis new collagen laid down

Plateau/Maturation phase

Gain in tensile strength levels off Excess collagen removed during process

number of fibroblasts and inflammatory cells declines

Orientation of collagen fibres in the direction of local mechanical forces increase tensile strength for 6 months

Skin & fascia recover only 80% of their original strength

Cont.

At time of suture removal edges of newly healed wound directly apposed and flat

Up to 3 months scar become progressively raised, red, thickened

Remain static for 3 more months slowly improving becomes narrow, flat, pale

Changes vary with age, race, direction of scar, degree of dermal damage Children: longer to resolve Elder: tend to mature and fade very quickly

CLASSIFICATION OF WOUND HEALING

Classification of Wound Healing Primary Intention Secondary Intention Tertiary Intention


Primary Intention

Most surgical wounds Wound edges opposed directly next to one

another and little tissue loss Normal healing Minimal scarring occurs Wound closure sutures, staples, or adhesive

Secondary Intention

Wound left open heals by granulation, contraction and epithelialisation

Results in a broader & poorer scar Wound may pack with gauze or use drainage

system Wound care must be performed daily to encourage

wound debris Removal to allow for granulation tissue formation

Tertiary Intention

Also called delayed primary intention Wound initially left open edges opposed later

when healing conditions favourable For wound in which primary intention was

preferred but not possible due to contamination. Delay in primary closure to allow clear infection,

wound contracture and create granulation base.

References

Garden, O. J. (2007), Principles & Practice of Surgery, 5th Edition, Churchill Livingstone Elvesier

Williams, N. S. (2008), Bailey & Love’s Short Practice of Surgery, 25th Edition, Hodder Arnold

Guideline For Prevention Of Surgical Site Infection, Centre For Disease Control and Prevention, 1999

Mercandetti, M. (2008), Wound Healing, Wound & Repair, Medscape, http://emedicine.medscape.com/article/1298129-overview#showall

Stedman’s Medical Dictionary Dorland’s Medical Dictionary

NATURAL HEALING IN SPECIFIC TISSUES

Natural Healing in Specific Tissues

Bone Nerve Tendon


Bone

Phase as above but periosteal & endosteal proliferation callus formation (immature bone consists of osteoid)

Remodelling phase corticol structure & medullary cavity restored

Fracture ends accurately opposed, rigidly fixed minimal callus formation, primary healing

Gap exists secondary healing delayed union, non-union, or malunion

Nerve

Distal to the wound Wallerian degeneration Proximal nerve suffer traumatic degeneration Regenerating nerve fibres attracted to their

receptors by neurotropism -- > mediated by growth factors, hormones and other

Characterized by profuse growth of new nerve fibres sprout from the cut proximal end

Overgrowth + poor approximations = neuroma formation

Tendon

Follows normal pattern of wound healing Two main mechanisms nutrients, cells, new

vessels reached severd tendon: Intrinsic: vincular blood flow & synovial diffusion Extrinsic: formation of fibrous adhesions between

tendon & tendon sheath Random nature of the initial collagen produced

lacks tensile strength for 1st 3-6 weeks Active mobilization prevents adhesion limiting

range of movements Tendon must be protected by splintage in order to

avoid rupture of the repair

Surgery - Principle of Wound Healing and Management

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