Wound Management.Dr Imran Javed.

Associate Professor Surgery.Fiji National University.

It is a circumscribed injury which is caused by an external force and it can involve any tissue or organ.

surgical, traumatic It can be mild, severe, or even lethal.

Simple wound Compound wound

Acute Chronic

Definition

Wound Shape

Incised Wound

Abrasions

Punctured Wound

Lacerated Wounds.

Crushed wounds

Bite Wounds.

Gunshot Wounds.

Burn Wounds.

Acid Burn Wounds.

Frost Bite.

Radiation Wounds

Clean woundClean-contaminated wound

Contaminated woundHeavily contaminated wound

Classification of the wounds

Skin Histology

Wound Healing

Healing By Tertiary Intention

Factors affecting wound healing

Local Ischemia Infection Foreign body Edema, elevated

tissue pressure

Systemic Age and gender Sex hormones Stress Ischemia Diseases Obesity Medication Alcoholism and

smoking Immuno-compromised

conditions Nutrition

The wound healing

Hemostasis-inflammation

Granulation-proliferation

Remodeling.

Stages of wound healing

The main steps of the wound healing

1. Hemostasis-inflammation vasoconstriction fibrin clot formation

Pro-inflammatory cytokines and growth factors releasing

vasodilatation infiltration PMNs, macrophages

cytokines releasing → angiogenesis → fibroblast activation → B- and T-cells activation → keratinocytes activation → wound contraction

2. Granulation-proliferation

fibroblast migration collagen deposition angiogenesis granulation tissue formation epithelisation contraction 3. Remodeling regression of many capillaries physical contraction myo-

fibroblasts collagen degeneration and

synthetisation new epithelium tensile strength – max. 80%

Wound Closure.

Assessment of Wound. Wound Irrigation. Local Anesthesia. Debridement. Methods of Closure. Dressings and Splints. Anti-septics & antibiotics. Removal of Sutures.

Management of Laceration

requires information in the following areas: force of injury, type of force (e.g. penetrating, hot oil burn) extent and depth of injury amount of blood loss level of contamination of the wound time from injury to presentation for treatment involvement of deeper structures damaged (e.g.

nerves, tendons) Direct communication from the outside to a fracture

of the bone (a compound fracture).

Assessment of the degree of damage

All wounds should be cleaned. Irrigation rids the wound of contaminants, debris and bacteria and is considered the most important means of reducing the incidence of wound infection.

Cleaning with Anti-septic solutions like betadine is standard method.

Local Anesthesia may be topical or infiltrated. Debridement: Once the wound is adequately

anaesthetized and irrigated, devitalized wound edges should be debrided using sharp scissors and/or a scalpel blade. Irrigate the wound again after debridement to remove tissue debris.

Wound Irrigation & Anesthesia

is also known as healing by primary intention. Wounds that heal by primary closure have a small, clean defect that minimizes the risk of infection and requires new blood vessels and keratinocytes to migrate only a small distance. Surgical incisions, paper cuts, and small cutaneous wounds usually heal by primary closure.

Primary wound closure

also known as healing by secondary intention, describes the healing of a wound in which the wound edges cannot be approximated. Secondary closure requires a granulation tissue matrix to be built to fill the wound defect. This type of closure requires more time and energy than primary wound closure, and creates more scar tissue.

Secondary wound closure

also known as healing by tertiary intention. Delayed primary closure is a combination of healing by primary and secondary intention, and is usually instigated by the wound care specialist to reduce the risk of infection. In delayed primary closure, the wound is first cleaned and observed for a few days to ensure no infection is apparent before it is surgically closed. Examples of wounds that are closed in this way include traumatic injuries such as dog bites or lacerations involving foreign bodies.

Delayed primary closure

Types of Sutures. natural and synthetic synthetic materials less reaction less inflammatory reaction absorbable and non-

absorbable Non-absorbable sutures

offer longer mechanical support

monofilament and multifilament

monofilaments have less drag

Infection is avoided

Absorbable suture materials lose tensile strength before complete

absorption gut last 4-5 days in terms of tensile

strength chromic form, gut can last up to 3

weeks Vicryl and Dexon maintain tensile strength for 7-14 days complete absorption takes several

months Maxon and PDS long-term absorbable sutures lasting several weeks requiring several months for complete

absorption Non-absorbable sutures silk has the lowest strength nylon has the highest Polypropylene.

Running, or continuous stitch

made with one continuous length of suture material

close tissue layers which require close approximation

speed of execution, and accommodation of edema during the wound healing process

greater potential for mal-approximation of wound edges with the running stitch than with the interrupted stitch

Interrupted Sutures. needle at a 90° angle to the

skin within 1-2 mm of the wound edge and in the superficial layer

exit through the opposite side equidistant to the wound edge and directly opposite the initial insertion

stitch is tied separately used in skin or underlying

tissue layers more exact approximation of

wound edges can be achieved with this technique than with the running stitch

Mattress suture

a double stitch that is made parallel (horizontal mattress) or perpendicular (vertical mattress) to the wound edge

advantage of this technique is

strength of closure each stitch penetrates

each side of the wound twice

inserted deep into the tissue

Purse string Suture.

continuous stitch paralleling the edges of a circular wound

wound edges are inverted when tied

used to close circular wounds, such as hernia or an appendiceal stump

Smead-Jones/Far-and-Near

a double loop technique alternating far and near stitches

greater mechanical strength than continuous or simple interrupted sutures

used for approximating fascial edges, especially for patients at risk for fascial disruption or infection

Continuous Locking, or Blanket Stitch

a self-locking running stitch used primarily for approximating skin edges

good approximation edges is paramount to proper wound closure technique

deep sutures serve to eliminate the dead space and relieve tension from the wound surface

deep sutures also ensure proper alignment of the wound edges and contribute to their final eversion

wound closure may require sharp undermining of the tissues to minimize tension on the wound

achieve hemostasis eversion of all skin edges avoids unnecessary

depression of the resultant scar

Features of Good Closure

Dressings function to protect the wound, absorb excess exudate and improve comfort.

Most lacerations to the facial area and scalp do not need to be dressed.

Most commonly, a non-adherent contact layer is placed, followed by a gauze layer and then an adhesive outer layer.

Wounds adjacent to joints may require splinting of the joint to prevent excessive tension on the wound.

Dressings should be kept clean and dry. Most dressings should be removed in 2 days and the wound reviewed

Dressings and Splints

Antibiotics are not indicated for simple lacerations.

Wounds which are contaminated require careful cleaning and debridement.

Antibiotics are often given for human and animal bites.

Amoxycillin/clavulanic acid for 5 days is a reasonable choice if antibiotics are to be prescribed.

Tetanus prophylaxis.

Antibiotics

face: 3-4 days scalp: 5 days trunk: 7 days arm or leg: 7-10 days foot: 10-14 days

Suture removal

Keloid & Hypertrophic Scars.

Immediate and delayed complications may occur with wound closure

formation of hematoma wound infection. reduced by prophylactic antibiotics Late complications scar formation excess tension lack of eversion of the edges hypertrophic scarring and keloid formation. stitch marks wound necrosis

Wound Complications.