wound healing

1. WOUND AND
WOUND HEALING
Presented by: Dr Mubashir
Moderator : Professor Musharraf Hussain

2. DEFINITION
A wound is a break in the integrity of the
skin or tissues often associated with
disruption of structure and function.

3. Classification of wound

4. Rank-wakefield classification
Tidy wounds
• They are wounds like
surgical incisions and
wounds caused by sharp
objects.
• Usually primary suturing is
done.
• Healing is by primary
intention

5. Untidy wounds
• Resulting from crushing,
tearing, avulsion,
vascular injury or burns.
• Contain devitalised
tissue.
• Fracture of underlying
bone may be present.
• Healing is by secondary
intention.

6. Other classifications
A) Severity
Simple wounds
• Only skin is
involved.
Complex wounds
• Vessels, nerves,
tendons or bones are
involved

7. b) Integrity of skin
Open wounds
• Incised wound,
lacerated wound,
crush injuries,
penetrating
wounds.
Closed wounds
• Contusion,
abrasion,
haematoma.

8. Acute wounds
• That usually heal in
the anticipated time
frame.
• Duration: immediately
to few weeks.
• Examples: trauma or
surgical procedure.
c) Duration of wound healing

9. Chronic wounds
• Fail to heal in the anticipated
time frame and often recur.
• Duration: 4 weeks to 3
months.
• Causes : poor circulation,
extended pressure on tissues,
or even poor nutrition.
• Examples -pressure ulcers,
venous leg ulcers, diabetic
ulcer etc

10. Superficial wounds
• Only epidermis is
affected
• Does not bleed.
• Examples include:
abrasions and blisters
D) Wound depth

11. Partial thickness wounds
• Epidermis and part of
dermis is affected.
• Does bleed.
• several days to several
weeks to heal.

12. Full thickness wounds
• Epidermis and dermis is
affected.
• Underlying fatty tissues,
muscles, bones and
tendons may also be
damaged.
• May take several months
to heal

13. Crush wounds
• Cause- great or extreme
amount of force applied
over a long period of time.
• Often accompanied by de-
gloving injuries and
compartment syndrome.

14. E) Degree of contamination
Clean wound:
• No break in aseptic
technique.
• No sign of infection or
inflammation.
• Respiratory, GI, GU tracts
are NOT entered.
• Excisions, hernia repair.
• Infective rate is less than
2%.

15. Clean contaminated wound
• Respiratory, GI, or GU
tracts entered under
controlled conditions.
• No major break in
aseptic technique.
• No spillage.
• Appendectomy, bowel,
biliary and pancreatic
surgeries.
• Infective rate is less
than 10%.

16. Contaminated wound
• Major break in aseptic
technique.
• Acute non purulent
inflammation encountered.
• Spillage from GIT.
• Penetrating abdominal
wound, Open fresh
accidental wounds.
• Infective rate is about 20%.

17. Dirty infected wound
• Purulence or existing
infection present.
• Contain devitalised
tissue.
• Abscess, faecal
peritonitis.
• Infective rate is about
40%.

19. Wound healing
It is the body’s natural process of restoring normal
function and structure after an injury.
Healing is a complex series of events that begins at the
moment of injury and can continue for months to years.

20. Types of Wound healing
Primary intention.
• Wound edges opposed.
• Normal healing.
• Minimal scar

21. Secondary intention.
• Wound left open
• Heals by granulation, contraction & epithelialisation.
• Increased inflammation and proliferation.
• Poor scar.
Tertiary intention (also called delayed primary intention).
• Wound initially left open.
• Edges later opposed when healing conditions
favourable.

23. Phases of Wound healing
• Inflammatory phase
• Proliferative phase
• Maturation and remodelling phase

24. Injury
Platelets release
growth factors
and cytokines
Neutrophils and macrophages
engulf bacteria; release
growth factor, cytokines and
proteases
Neutrophils and
macrophages
are attracted
into the wound
Inflammatory
phase
(Begins
immediately
and lasts for
2-3 days)
Fibroblasts , epithelial
cells & endothelial cells
are attracted into the
wound

25. Epithelial cells, fibroblasts and
endothelial cells produce
growth factors
Synthesis of ECM , collagen
and new capillaries
Proliferative &
repair phase:
Lasts from 3rd day
to 3rd week

26. Fibroblasts orchestrate the
remodelling of scar by
producing ECM, MMPs &
TIMPs & maturation of
collagen.
Mature contracted
scar
Remodelling
phase
Lasts from 3
weeks to 2
years

28. Factors affecting wound healing
Local factors include,
• Site of wound
• Structures involved
• Mechanism of wounding
• Contamination
• Loss of tissue
• Other local factors like vascular insufficiency,
radiation & Pressure.

29. Systemic factors include,
• Malnutrition or vitamin and mineral deficiencies
• Diseases(e.g. diabeties mellitus)
• Medications (e.g. steroids)
• Immune deficiencies(e.g. chemotherapy, AIDS)
• Smoking

30. Complications of wound healing
• Hypertrophic scar
• Keloids

31. Hypertrophic scar
• Appears as a raised scar
tissue.
• Doesn’t extend beyond
the boundary of scar
tissue.
• Can regress with time.
• Anywhere in body.
• Growth usually limited
to 6 months.
• Equal in both sexes.

32. Keloid
• Often appears as a shiny
round protuberance.
• Extends beyond the
margins of original
wound.
• Doesn’t regress with time.
• Site: ears, shoulders
anterior chest wall.
• Continues to grow
without time limit.
• Genetic predisposition
present.
• More common in females

33. Wound management
1. Wound is inspected and classified as per the type
of wounds.
2. In vital area, then
• airway should be maintained.
• bleeding should be controlled.
• Intravenous fluids are started.
• Oxygen, if required, may be given.
• Deeper communicating injuries and fractures etc.
should be looked for.
3. If it is an incised wound then primary suturing is
done after thorough cleaning.

34. 4. Lacerated wound excision of devitalised tissue and
primary suturing is done.
5. In Crushed wound devitalised tissue is excised,
oedema is allowed to subside then delayed primary
suturing is done.
6. In deep devitalised wound, wound is Debrided &
allowed to granulate completely.
Then secondary suturing is done in small wound &
split skin graft is used in large wound.

35. 7. In a wound with tension, fasciotomy is done so as
to prevent the development of compartment
syndrome.
8. Vascular or nerve injuries are dealt with
accordingly.
9. Internal injuries has to be dealt with accordingly.
Fractured bone is also identified and properly dealt with.
10. If needed Antibiotics, IV fluid, blood transfusion, TT
(0.5 ml IM) or anti tetanus globulin (ATG) given.

36. Principles of wound suturing
• Primary suturing should not be done if there is
oedema/infection/devitalised tissues/haematoma.
• Always associated injuries vessels/nerves or tendons
should be looked for before closure of the wound.
• Wound should be widened to have proper evaluation of
the deeper structures – proper exploration.
• Proper cleaning, asepsis, wound excision/debridement.

37. • Any foreign body in the wound should be removed.
• Proper aseptic precautions should be undertaken.
• Antibiotics/analgesics are needed.
• Sutured wound should be inspected in 48 hours.
• Suture removal.

38. • Wound toileting
Washing the wound thoroughly using normal saline.
• Wound excision
Excision of devitalised tissues once or serially.
• Radical wound excision
Excising entire devitalised tissues leaving tissues
with visible bleeding from all layers

39. Wound debridement :
• Liberal excision of all devitalized tissue at regular
intervals (of 48-72 hours) until healthy, bleeding,
vascular tidy wound is created.
Primary suturing :
• Suturing the wound immediately within 6 hours.
• Done in clean incised wounds.

40. Delayed primary suturing
• Suturing the wound in 48 hours to 10 days.
• Done in lacerated wounds.
• This time is allowed for the oedema to subside.
Secondary suturing
• Suturing the wound in 10-14 days or later.
• Done in infected wounds &
• After the control of infection, once healthy
granulation tissue appears.

41. Thank you