I prepare this slide for my final presentation at surgery department for clerkship- I, AMBO university, school of medicine, 2015

1. SEMINAR PRESENTATION ON
WOUND: CLASSIFICATION,HEALING
AND PRINCIPLES OF MANAGEMENT
BY
DEBELA URGESSA
C –I
AMBO UNIVERSITY
COLLEGE OF MEDICINE AND HEALTH
SCIENCE DEPARTMENT OF MEDICINE
1

2. OUTLINE
Objectives
Definition
Classification
Wound healing
Management principles
Complications
Referances
2

3. OBJECTIVE
At the end of this session students are expected to :
•Define wound
•Classify wound
•Explain steps of wound healing
•Explain general management of wound
•Identify the complications of wound healing
3

4. WOUND
4

5. DEFINITION
Wound is defined as a break in the normal continuity of a tissue.
 It is caused by a transfer of any form of energy into the body
which can be either to an externally visible structure like the skin or
deeper structures like muscles, tendons or internal organs
5

6. Parts of the wound
Wound edge Wound
corner
Surface of
the wound
Base of the wound
Cross section of a simple wound
Skin surface
Subcutaneus tissue
Superficial fascia
Muscle layer
Base of the wound
Wound edge
Surface of
the wound
Wound
cavity
6

7. CLASSIFICATION OF WOUNDS
7

8. 1. Based on the origin
I. Mechanical:
1. Abraded wound
2. Punctured wound 5. Bite wound
3. Incised wound 6. Shot wound
4. Crush wound
II. Chemical:
1. Acid
2. Base
III. Wounds caused by radiation
IV. Wounds caused by thermal forces:
1. Burning
2. Freezing
V. Special
8

9. Mechanical wounds
1) Abraded wound
•Superficial part of the epidermal layer
•Good wound healing
9

10. Mechanical wounds
2) Punctured wound
Sharp-pointed object
Seems negligible
BUT
Anaerobic infection
Injury of big vessels and nerves
10

11. Mechanical wounds
3) Incised wound
Sharp object
Best healing
11

12. Mechanical wounds
5) Crush wound
Blunt force
Pressure injury
Bleeding
12

13. Mechanical wound
6) Shot wound
Close - burn injury
Foreign materials
13

14. Mechanical wounds
7) Bite wound
Crushed tissue
Infection
Bone fracture
14

15. Chemical:
1. Acid
2. Base
15

16. Wounds caused by radiation
Symptoms and severity depend on:
Amount of radiation
Length of exposure
Body part that was exposed
Symptoms may occur immediately, after a few days,
or even as long as months.
16

17. Wounds caused by thermal forces
1.) Burning
1st
degree – superficial injury (epidermis)
2nd
degree –partial or deep partial thickness (epidermis+superficial or
deep dermis)
3rd
degree – full thickness (epidermis + entire dermis)
4th
degree – (skin + subcutaneous tissue + muscle and bone)
17

18. Wounds caused by thermal forces
2.) Freezing
mild, moderate, severe (redness, bullas, necrosis)
18

19. Special wounds
Exotic, poisonous animals
Toxins, venom - toxicologist
Skin necrosis
19

20. 2. According to the bacterial contamination
1. clean Wound:
Operative incisional wounds that follow nonpenetrating (blunt) trauma.
2. Clean-Contaminated Wound:
uninfected wounds in which no inflammation is encountered but the respiratory,
gastrointestinal, genital, and/or urinary tract have been entered.
3. Contaminated Wound:
open, traumatic wounds or surgical wounds involving a major break in sterile
technique that show evidence of inflammation.
4. Infected Wound:
old, traumatic wounds containing dead tissue and wounds with evidence of a
clinical infection (e.g., purulent drainage).
20

21. Superficial
Partial thickness
Full thickness
Deep wound
3. Depending on the depth of injury
+ bone, opened cavities, organs…etc.
21

22. WOUND HEALING
22

23. Wound healing
• It is a mechanism whereby the body attempts to restore the
integrity of the injured part.
The disruption in the integrity of tissues, whether surgical
or traumatic, stimulates a series of events that attempts to
restore the injured tissue to a normal state.
23

24. The wound healing
steps:
 Inflammation
 Proliferation
 Remodelling
24

25. The main steps of the wound healing
1.Inflammatory phase
The inflammatory phase begins immediately after wounding
and lasts 2–3 days.
It is recognized at the skin level by the cardinal signs of inflammation—
which result from changes in the microcirculation.
Polymorphonuclear leukocytes (PMNs) are the dominant
inflammatory cells in the wound for the first 24 to 48 hours,
-Phagocytize foreign material
-Release cytokines
25

26. 2. proliferation
fibroblast migration
collagen deposition
angiogensis
granulation tissue formation
epithelialization
contraction
3. Remodelling
regression of many capillaries
physical contraction – myofibroblasts
collagen degeneration and synthesization
new epithelium
tensile strength
26

27. Types of wound healing
 Healing by Primary Intention:
All Layers are closed. The incision that heals by first intention does so in a
minimum amount of time, with no separation of the wound edges, and
with minimal scar formation.
27

28.  healing by secondary intention:
Deep layers are closed but superficial layers are left to heal from the
inside out. Healing by second is appropriate in cases of infection,
excessive trauma, tissue loss, or imprecise approximation of tissue.
28

29.  Healing by tertiary intention:
• Also referred to as delayed primary closure
• Wound initially left open
• is a useful option for managing wounds that are too heavily
contaminated for primary closure but has appearance of clean wound.
• the wound will be well vascularized after 4 to 5 days of open
observation so that the cutaneous edges can be approximated at that
time
29

30. Factors affecting wound healing
Local factors:
 Ischemia
 Infection
 Foreign body
30

31. Cont…………
Systemic factors:
 Age
 Stress
 Ischemia
 Diseases
 Medication
 Alcoholism and smoking
 Immunocompromised conditions
 Nutrition
31

32. PRINCIPLES OF WOUND MANAGEMENT
32

33. General principles of wound management
The primary goal of wound management is:
 To aid the natural body process
To produce optimal functional and cosmetic result.
Management of acute wounds begins with obtaining a
careful history of the events surrounding the injury.
The history is followed by a meticulous examination of
the wound. Examination should assess:
The depth and configuration of the wound,
The extent of nonviable tissue, and
The presence of foreign bodies and other contaminants.
33

34. Mx contin…….
Examination of the wound may require:
 Irrigation and
debridement of the edges of the wound, and is facilitated by
use of local anesthesia.
Antibiotic administration and tetanus prophylaxis may be
needed, and planning the type and timing of wound repair
should take place.
After completion of the history, examination, and
administration of tetanus prophylaxis, the wound should be
meticulously anesthetized.
Lidocaine (0.5 to 1%) or bupivacaine (0.25 to 0.5%) combined
with a 1:100,000 to 1:200,000 dilution of epinephrine provides
satisfactory anesthesia and hemostasis.
34

35. Mx contin…….
Epinephrine should not be used in wounds of the:
Fingers
 Toes
Ears
Nose or
penis due to the risk of tissue necrosis secondary to
terminal arteriole vasospasm in these structures
35

36. Mx contin…….
Injection of these anesthetics can result in significant
initial patient discomfort, and this can be minimized by:
Slow injection,
Infiltration of the subcutaneous tissues, and
Buffering the solution with sodium bicarbonate.
Care must be observed in calculating the maximum
dosages of lidocaine to avoid toxicity-related side effects.
36

37. Mx contin…….
Irrigation to visualize all areas of the wound and remove
foreign material is best accomplished with normal saline .
High-pressure wound irrigation is more effective in achieving
complete debridement of foreign material and nonviable
tissues.
Iodine, povidone-iodine, hydrogen peroxide, and organically
based antibacterial preparations have all been shown to impair
wound healing due to injury to wound neutrophils and
macrophages, and thus should not be used.
37

38. Mx contin…….
After the wound has been anesthetized, explored,
irrigated, and débrided, the area surrounding the wound
should be cleaned, inspected, and the surrounding hair
clipped.
The area surrounding the wound should be prepared with
povidone-iodine or similar solution and draped with
sterile towels.
38

39. Mx contin…….
Having ensured hemostasis and adequate débridement of
nonviable tissues and removal of any remaining foreign
bodies, irregular, macerated, or beveled wound edges
should be débrided in order to provide a fresh edge for
reapproximation.
Initial sutures that realign the edges of these different
tissue types will speed and greatly enhance the aesthetic
outcome of the wound repair.
39

40. Mx contin…….
In general, the smallest suture required to hold the various
layers of the wound in approximation should be selected
in order to minimize suture-related inflammation.
In areas with significant superficial tissue loss, split-
thickness skin grafting may be required.
This will speed formation of an intact epithelial barrier to
fluid loss and infection.
40

41. Mx contin…….
After closing deep tissues and replacing significant tissue
deficits, skin edges should be reapproximated for:
 Cosmesis and
To aid in rapid wound healing.
Skin edges may be quickly re approximated with stainless
steel staples or non absorbable monofilament sutures.
41

42. Mx contin…….
Failure to remove the sutures or staples by 7 to 10 days
after repair will result in a cosmetically inferior wound.
When wound cosmesis is important, the above problems
may be avoided by placement of buried dermal sutures
using absorbable braided sutures.
42

43. Antibiotics
Antibiotics should be used only when there is an obvious
wound infection.
Most wounds are contaminated or colonized with
bacteria.
Signs of infection to look for include :
 Erythema,
Cellulitis,
Swelling, and
Purulent discharge.
43

44. Antibiotics can also be delivered topically as part of
irrigations or dressings, although their efficacy is
questionable.
Indiscriminate use of antibiotics should be avoided to
prevent emergence of multidrug-resistant bacteria.
44

45. DRESSING
The main purpose of wound dressings is to provide the ideal
environment for wound healing.
The dressing should facilitate the major changes taking place
during healing to produce an optimally healed wound.
Covering a wound with a dressing mimics the barrier role of
epithelium and prevents further damage.
In addition, application of compression provides hemostasis
and limits edema.
45

46. Desired Characteristics of Wound Dressings
Promote wound healing
Pain control
Odor control
Non allergenic and nonirritating
Permeability to gas
Safety
Non traumatic removal
Cost-effectiveness
46

47. Occlusion of a wound with dressing material helps:
Healing by controlling the level of hydration and oxygen
tension within the wound.
It also allows transfer of gases and water vapor from the
wound surface to the atmosphere.
Occlusion affects both the dermis and epidermis, and it
has been shown that exposed wounds are more inflamed
and develop more necrosis than covered wounds.
47

48.  As it may enhance bacterial growth, occlusion is
contraindicated in infected and highly exudative wounds.
Many types of dressings exist and are designed to achieve
certain clinically desired endpoints. These includes:
Absorbent Dressings
Non adherent dressings
Medicated Dressings
Occlusive and Semi occlusive Dressings,
48

49. Absorbent Dressings
49
Accumulation of wound fluid can lead to maceration and
bacterial overgrowth.
Ideally, the dressing should absorb without getting soaked
through, as this would permit bacteria from the outside to
enter the wound.
The dressing must be designed to match the exudative
properties of the wound and may include cotton, wool,
and sponge.

50. Non adherent Dressings
Non adherent dressings are impregnated with paraffin,
petroleum jelly, or water-soluble jelly for use as non
adherent coverage.
A secondary dressing must be placed on top to seal the
edges and prevent desiccation and infection.
50

51. Occlusive and Semi occlusive Dressings
Occlusive and semi occlusive dressings provide a
good environment for clean, minimally exudative
wounds.
These film dressings are waterproof and impervious
to microbes, but permeable to water vapor and
oxygen.
51

52. Absorbable Materials
Absorbable materials are mainly used within wounds as
hemostats and include collagen, gelatin, oxidized
cellulose, and oxidized regenerated cellulose.
Medicated Dressings
 Medicated dressings have long been used as a drug-delivery
system.
 Agents delivered in the dressings include benzoyl peroxide, zinc
oxide, neomycin, and bacitracin-zinc.
 These agents have been shown to increase epithelialization by
28%.
52

53. Skin Replacements
All wounds require coverage in order to prevent
evaporative losses and infection and to provide an
environment that promotes healing.
Both acute and chronic wounds may demand use of
skin replacement, and several options are available.
Skin grafts have long been used to treat both acute
and chronic wounds.
53

54. MANAGING CHRONIC WOUNDS
A chronic ulcer, unresponsive to dressings and simple
treatments, should be biopsied to rule out neoplastic
change.
54

55. PRESSURE SORES
These can be defined as tissue necrosis with ulceration
due to pro-longed pressure. Less preferable terms are
bed sores, pressure ulcers and decubitus ulcers. They
should be regarded as preventable but occur in
approximately 5% of all hospitalised patients.
55

56. Staging of pressure sores
Stage 1 : Non-blanchable erythema without a breach
in the epidermis
Stage 2 : Partial-thickness skin loss involving the
epidermis and dermis
Stage 3 : Full-thickness skin loss extending into the
subcutaneous tissue but not through underlying fascia
Stage 4 : Full-thickness skin loss through fascia with
extensive tissue destruction, maybe involving muscle,
bone, tendon or joint.
56

57. Prevention is obviously the best treatment with good
skin care, special pressure dispersion cushions or
foams, the use of low air loss and air-fluidised beds
and urinary or faecal diversion in selected cases.
Pressure sore aware-ness is vital, and the bed-bound
patient should be turned at least every 2 hours.
Surgical management of pressure sores follows the
same principles involved in acute wound treatment.
57

58. Complications of wound healing
I. Early complications
Seroma
Hematoma
Wound disruptin
Superficial wound infection
Deep wound infection
Mixed wound infection
58

59. Early complications of wound healing
1. Seroma
 Filled with serous fluid, lymph or blood
 Fluctuation, swelling, rednessa nd tenderness.
TREATMENT:
 Sterile punture and compression
 Suction drain
59

60. 2. Hematoma
Bleeding, short drainage time, anticoagulant
Risk of infection
Swelling, fluctuation, pain, redness
TREATMENT
Sterile puncture
Surgical exploration
60

61. Early complications of wound healing
3.) Wound disruption
Surgical error
Increased intraabdominal pressure
Wound infection
TREATMENT:
U-shaped sutures
61

62. Early complications of wound healing
4. Superficial wound infection
1. Diffuse
Located below the skin
TREATMENT
Resting position
Antibiotic
Dermatological consultation
62

63. 2. Localized
Anywhere
TREATMENT
Surgical exploration
Drainage
X-ray examination
Eg. abscess
63

64. Early complications of wound healing
5.Deep wound infection
1. Diffuse
TREATMENT
Surgical exploration
Open therapy
H2O2 and antibiotics
e.g. anaerobic necrosis
64

65. 2. Localized
Inside the tissues or body cavities
TREATMENT
surgical exploration
drainage
65

66. Early complications of wound healing
6. Mixed wound infection
e.g. gangrene
necrotic tissues
anaerobic infection
a severe clinical picture
TREATMENT
aggresive surgical debridement
effective and specified (antibiotic) therapy
66

67. Complications of wound healing
II. Late complications
Hyperthrophic scar
Keloid formation
Necrosis
Inflammatory infiltration
Abscesses
Foreign body containing abscesses
67

68. Late complications
1. Hypertrophic scar
Develop in areas of thick chorium
Non-hyalinic collagen fibres and fibroblasts
Confine to the incision line
TREATMENT
Regress spontaneously
(1-2 yrs)
68

69. 2. Keloid scar
Mostly African and Asian population
Well-defined edge
Emerging, tough structure
Overproliferation of collagen fibers in the
subcutaneous tissue
Subjective complains
TREATMENT
Postoperative radiation
Corticosteroid + local anaesthetic injection
69

70. Referances
Bailey and loves, short practice of surgery, 26th
edition.
Schwartzs, principles of surgey, 8th
edition.
Surgery lecture note for health officers.
Sabiston, textbook of surgery, 18th
edition.
70

71. 71