wound classification management

1. Wound & Wound Healing

2. Definition of a wound :
ANY break in the integrity of the skin or
tissues which may be associated with
disruption of structure or function
 Etiology: - Trauma
- Radiation
- Infection
- Iatrogenic Etc

3. CLASSIFICATION OF WOUNDS

4. RANK & WAKEFIELD CLASSIFICATION
 Tidy Wounds
 Surgical incisions,
 wounds by sharp objects,
 keloid,
 Untidy Wounds
 Avulsion
 Crush injury
 Devitalised injury

5. BASED ON TYPE OF WOUND
 Bruising & contusion
 Haematoma
 Clean Incised Wound
 Lacerated Wound
 Abrasion
 Crush injury
 Penetrating wounds

6. CLASSIFICATION OF SURGICAL
WOUNDS
 Clean Wound
 Clean Contaminated Wound
 Contaminated Wound
 Dirty Infected Wound

7. CLEAN WOUND
 Clean wound is a nontraumatic, uninfected
operative wound in which neither the
respiratory, alimentary or genitourinary tracts
nor the oropharyngeal cavities are entered.
 Clean wounds are elective, primarily closed,
and undrained wounds.
 Infection rate is <2%

8. CLEAN CONTAMINATED WOUND
 Gastrointestinal, respiratory or genitor-
urinary tracts entered without significant
spillage or wounds which are mechanically
drained.
 Eg: appendicectomy, gallbladder, biliary,
pancreatic surgeries
 Infection rate <10%

9. CONTAMINATED WOUND
 Operative wound contaminated
 Fresh traumatic wound from clean source
 Gross spillage from the gastrointestinal tract
 When infected urine or bile is present
 Incision encountering acute non-purulent
inflammation.
 Eg: penetrating abdominal injury, enterotomy
 INFECTION RATE – 15 – 30%

10. DIRTY WOUND
 Traumatic wound from dirty source
 Fecal contamination
 Foreign body, Retained devitalized tissue
 Operative wound w/ acute bacterial
inflammation or perforated viscus
 Presence of pus
Eg: abscess drainage, pyocoele
INFECTION RATE : 40 – 70 %

11. WOUND HEALING

12. WHAT IS WOUND HEALING???
 Wound Healing Is the Physiologic
Response to Tissue Trauma
 It is related to tissue reconstitution which is
the process by which the body replenishes
cells that are being lost

13. TYPES OF WOUND HEALING
WOUNDHEALING
PRIMARY
SECONDARY
TERTIARY

14. PRIMARY HEALING
 Occurs in clean incised
wound
 More epithelial
regeneration than
fibrosis.
 Wound heals rapidly
 Scar will be linear,
smooth & supple.

15. SECONDARY HEALING
 Occurs in wounds
with extensive soft
tissue loss
 Heals slowly with
fibrosis
 Wide
hypertrophied and
contracted scar

16. TERTIARY / DELAYED PRIMARY
 Intial wound
debridement and
control of local
infection
 Wound closed with
sutures or covered
with skin graft

17. PHASES OF WOUND HEALING
Wound Heals In 3 Phases That Partially
Overlap:
 Inflammatory Phase
 Fibroplasia Phase
 Remodelling Phase

18. INFLAMMATORY PHASE

19. INFLAMMATORY PHASE
 (aka. lag phase or substrate phase) 0-48 hrs
INFLAMMATORY
PHASE
VASCULAR
RESPONSE
CELLULAR
RESPONSE

20. VASCULAR RESPONSE
PRIMARY PHASE –
Haemostasis
• Vasoconstriction
• Platelet Aggregation
And Degranulation
• Fibrinous Clot
• Fibrinolysis

21. VASCULAR RESPONSE
SECONDARY PHASE
 Venular Vasodilatation - 10 X Increase In
Blood Flow
 Increased Vascular Permeability - Aids In
Flow Of Chemical And Cellular Mediators
(PDGF) In Inflammation To Site Of Injury
 Lymphatic Obstruction Leads To Tissue
Edema

22. CELLULAR RESPONSE
Increased Vascular Permeability During
Inflammatory Phase Facilitates Margination,
Extravasation And Migration Of Cellular Mediators
(Pmn’s And Macrophages)
PMN’S
 Function Short Lived (0-48 Hours)
 Attacks Bacteria, Then Leaves
 Not Essential For Wound Healing Process

23. Macrophages
 Monocyte–derived
 Central Cell During Inflammatory Phase Of
Wound Repair
 Activated By Lymphokines, Immune Complexes
 Release Angiogenesis Factor
 Phagocytosis Of Wound Debris
 Essential For Wound Healing
CELLULAR RESPONSE

24. Factors Affecting Inflammatory Phase:
 Pus
Contains Both Proteolytic And Collagenolytic
Enzymes; Prolongs Inflammatory Phase And
Retards Epithelialization
 Necrotic Tissue, Foreign Body, Haematoma -
Prolongation Of Inflammatory Phase
 Steroids - Inhibit Macrophage Function

25. PROLIFERATIVE PHASE

26. PROLIFERATIVE PHASE
(Aka. Fibroplasia Phase) Day 2 To ~ 6 Weeks
CLINICAL SIGNS:
 Disappearance Of Inflammatory Signs,
 Reduction Of Swelling,
 Reduction Of Wound Size (Contraction),
 Itching

27. KEY-ELEMENTS:
 Net Collagen Synthesis,
 Increase In Wound Tensile Strength,
 Scar Formation
PROLIFERATIVE PHASE

28. PROLIFERATIVE PHASE
EPITHELIALISATION
WOUND CONTRACTION
C COLLAGEN DEPOSITION

29. EPITHELIALIZATION
 Is A Requirement For Orderly Progression
Into The Proliferative Phase. It Starts In The
Inflammatory Phase.
 It Requires De-differentiation, Mitosis,
Migration And Then Re-differentiation By
Basal Cells Of Epidermis
PROLIFERATIVE PHASE

30. WOUND CONTRACTION
 “wounds heal from side to side but contract
from end to end”
 Thought to be mediated by myofibroblast -
can produce collagen but also contains
smooth muscle filaments.
 Highest rate of contraction from days 10-21
PROLIFERATIVE PHASE

31. Wound Contraction
 Begins approximately 4-5 days after
wounding.
 Represents centripetal movement of the
wound edge towards the center of the
wound.
 Maximal contraction occurs for 12-15
days, although it will continue longer if
wound remains open.

32. Wound Contraction
 The wound edges move toward each other at an
average rate of 0.6 to .75 mm/day
 Wound contraction depends on laxity of tissues,
so a buttocks wound will contract faster than a
wound on the scalp or pretibial area.
 Wound shape also a factor, square is faster than
circular.

33. Wound Contraction
 Contraction of a wound across a joint can cause
contracture.
 Can be limited by skin grafts, full better than split
thickness.
 The earlier the graft the less contraction.
 Splints temporarily slow contraction.

34. COLLAGEN DEPOSITION
 Prior to collagen deposition fibroblasts deposit
“ground substance” composed mainly of
glycosaminoglycans.
 Function of ground substance is to create
scaffold onto which collagen can be deposited,
aggregated, and oriented in appropriate fashion
PROLIFERATIVE PHASE

35.  Starting at day 3 or 4 collagen is deposited,
net collagen deposition is positive until day
21.
 It reaches a maximum at 60 days post-
injury (80% of tensile strength of normal
skin)
PROLIFERATIVE PHASE

36. MATURATION &
REMODELLING

37. MATURATION AND RE-
MODELLING PHASE
 3 Weeks To 1-2 Years
 Type III Collagen Is Replaced By Type I Collagen,
Creation Of More Stable Bonds Between Fibers -
Decreases The Amount Of Collagen Required To
Maintain Wound Integrity
 Duration Of Phase Dependent Upon Patient Age
(Decreased Age - Increased Duration), Racial
Differences, Type Of Wound, Body Location And
Duration Of Inflammatory Phase

42. Incised wound
 Caused by sharp cutting instruments.
 Minimum loss to tissue tends to gap (the
extent of gaping depends upon elasticity
and tension).
 Edges are regular.
 Bleeds freely and painful.
 Heals by primary intension healing.

44. Lacerated wound
 Caused by tearing of
tissues,
 Wounds have irregular
jagged borders
 Loss of tissue is limited
to skin and s/c tissue.

46. DEGLOVING/AVULSION
INJURY
 Occurs when skin &
subcutaneous tissue
are stripped from
underlying fascia
leaving
neurovascular
structures, tendons,
bone exposed.

47. What is the type of wound according to Rank & Wakefield classification?

48. FACTORS AFFECTING
WOUND HEALING

49. FACTORS
WOUND
HEALING
LOCAL
SYSTEMIC

50. LOCAL FACTORS
 Infection & haematoma
 Presence of necrotic tissues and foreign
body
 Poor blood supply
 Venous or lymph stasis
 Tissue tension
 Large defect or poor apposition

51. LOCAL FACTORS
 H/O IRRADIATION
 Underlying diseases lie malignancy /
osteomyelitis
 Tissue hypoxia

52. GENERAL/SYSTEMIC FACTORS
 Age
 Obesity, smoking
 Malnutrition
 Vitamin deficiency
 Anaemia, uremia, jaundice
 Diabetes
 Steroids & cytotoxic drugs

53. MANAGING ACUTE WOUND
 HAEMOSTASIS
 CLEANSING
 EXPLORATION AND DIAGNOSIS
 DEBRIDEMENT
 REPAIR OF STRUCTURES
 REPLACEMENT OF LOST TISSUES

54.  SKIN COVER IF REQUIRED
 SKIN CLOSURE WITHOUT TENSION
 ALL THE ABOVE WITH CAREFUL
TISSUE HANDLING

55. WHEN DOES A WOUND BECOME
CHRONIC?
 In healthy individuals with no underlying factors
an acute wound should heal within three weeks
with remodeling occurring over the next year or
so.
 If a wound does not follow the normal trajectory
it may become stuck in one of the stages and the
wound becomes chronic.


56.  Chronic wounds are thus defined as wounds,
which have “failed to proceed through an
orderly and timely process to produce anatomic
and functional integrity, without establishing a
sustained anatomic and functional result.