1. Keloid scars is made up of –
a) Dense collagen b) Loose fibrous tissue
c Granulamatous tissue d) Loose areolar tissue
What is true about keloids – (JIPMER 95)
a)It appears immediately after surgery
b)It appears a few days after surgery
c)It is limited in its distribution (grows beyond the limits of the original wound)
d) it is common in old people
Keloid is best treated by – (UPSC 95)
a)Intrakeloidal injection of triamcinolone
b)Wide excision and grafting
c)Wide excision and suturing
d)Deep X-ray therapy
The following statement about keloid is true- A) They do not extend in normal
skin (extreme overgrowth of scar tissue that grows beyond the limits of the original
wound)
b)Local recurrence is common after excision
c) They often undergo malignant change
d) They are more common in whites than in blacks
The best cure rate in keloids is achieved by –
a)Superficial X – ray therapy (UPSC 2001)
b)Intralesional injection of triamcinolone
c)Shaving
d)Excision and radiotherapy
Combination is always better.
Surgery:-Excision alone of keloids is subject to a high recurrence rate, ranging from
45 to 100%. There are fewer recurrences when surgical excision is combined with
other modalities such as intralesional corticosteroid injection, topical application of
silicone sheets, or the use of radiation or pressure
Radiation:-Poor results with 10 to 100% recurrence when used alone. It is more
effective when combined with surgical excision. Given the risks of
hyperpigmentation, pruritus, erythema, paresthesias, pain, and possible secondary
malignancies, radiation should be reserved for adults with scars resistant to other
modalities.
Combination therapies:- Intralesional corticosteroid injections decrease fibroblast
proliferation, collagen and glycosaminoglycan synthesis, the inflammatory process,

2. and TGF levels. When used alone, however, there is a variable rate of response
and recurrence, therefore steroids are recommended as first-line treatment for keloids
and second-line treatment for HTSs if topical therapies have failed. Intralesional
injections are more effective on younger scars. They may soften, flatten, and give
symptomatic relief to keloids, but they cannot make the lesions disappear nor can
they narrow wide HTSs. Success is enhanced when used in combination with surgical
excision. Serial injections every 2 to 3 weeks are required.
Sabiston:- Intralesional injection of steroids into a keloid scar can inactivate and
shrink the scar; such therapy is not indicated for hypertrophic scars.
Scars that are perpendicular to the underlying muscle fibers tend to be flatter and
narrower, with less collagen formation than when they are parallel to the underlying
muscle fibers. The position of an elective scar can be chosen in such a way to make a
narrower and less obvious scar in the distant future. As muscle fibers contract, the
wound edges become reapproximated if they are perpendicular to the underlying
muscle. If, however, the scar is parallel to the underlying muscle, contraction of that
muscle tends to cause gaping of the wound edges and leads to more tension and scar
formation.
_____________________________________________________________________
_____________________________________________________________________
__________________________________
Wounds
Primary closure of incised wounds must be done in –
a) 2 hrs b) 4 hrs
c) 6 hrs d) 12 hrs
e) 16 hrs
(Because of the fear of bacterial invasion, primary wound closure beyond 6 to 8 hours
after injury was historically proscribed. However, several scientific studies have since
shown that when blood supply to a wound is adequate and bacterial invasion is
absent, wounds can be safely closed at any time after proper débridement and
irrigation)
The tensile strength of wound reaches that of normal tissue by – (PGI 88)
) 6 weeks
c) 4 months
b) 2 months
d) 6 months
NEVER
In the healing of a clean wound the maximum immediate strength of the wound is
reached by –
a) 2 – 3 days b) 4 – 7 days
10 – 12 days d) 13 – 18 days

3. 21 days is ans
The tensile strength of the wound starts and increases after – (MAHE 05)
a)Immediate suture of the wound
b)3 to 4 days
c)7-10 days
d 6 months
see figure
When is the maximum collagen content of wound
tissue – (PGI 81, ROHTAK 87)
a)Between 3rd to 5th day
b)Between 6th to 17th day
C) Between 17th to 21st day d) None of the above
In a sutured surgical wound, the process of epithelialization is completed within –
(UPSC 07)
a) 24 hours b) 48 hours
c) 72 hours d) 96 hours
Ref schwartz Epithelialization:- While tissue integrity and strength are being re-
established, the external barrier must also be restored. This process is characterized
primarily by proliferation and migration of epithelial cells adjacent to the wound The
process begins within 1 day of injury and is seen as thickening of the epidermis at the
wound edge.Re-epithelialization is complete in less than 48 hours in the case of
approximated incised wounds, but may take substantially longer in the case of larger
wounds, in which there is a significant epidermal/dermal defect.
Sabiston : – Finally, adequate dressing of the closed wound isolates it from the
outside environment. Providing an appropriate dressing for 48 to 72 hours can
decrease wound contamination. However, dressings after this period increase the
subsequent bacterial count on adjacent skin by altering the microenvironment
underneath the dressing.
Following are required for wound healing except – a) Zinc
b) Copper c) Vitamin C d) Calcium
Copper is also a component of ferroprotein, a transport protein involved in the
basolateral transfer of iron during absorption from the enterocyte. As such, copper
plays a role in iron metabolism, melanin synthesis, energy production,
neurotransmitter synthesis, and CNS function; the synthesis and cross-linking of
elastin and collagen :- Harrison
Copper Deficiency:- Anemia, growth retardation, defective keratinization and
pigmentation of hair, hypothermia, degenerative changes in aortic elastin, osteopenia,
mental deterioration.
Patient has lacerated untidy wound of the leg and attended the casualty after 2 ‘hours.
His wound (AIIMS 84)should be –

4. a) Sutured immediately b) Debrided and sutured immediately c) debrided and
sutured secondarily d) Cleaned and dressed
Wound healing is worst at –
(ALL INDIA 93) a) Sternum b) Anterior neck
c) Eyelid d) Lips
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 reapproximated with stainless steel staples or nonabsorbable monofilament
sutures. Care must be taken to remove these from the wound before epithelialization
of the skin tracts where sutures or staples penetrate the dermal layer. Failure to
remove the sutures or staples by 7 to 10 days after repair will result in a cosmetically
inferior wound
(Anatomic areas where tension is excessive are avoided if possible. The shoulders,
back, and anterior chest are high tension and mobile areas where wide scarring
is difficult to avoid. Patients are also questioned as to propensity for development of
hypertrophic scars or keloid formation. Ears, anterior chest, and shoulders are areas
prone to these problematic scars)
Sabiston :-Wound strength increases rapidly within 1 to 6 weeks and then appears to
plateau up to 1 year after the injury .When compared with unwounded skin, tensile
strength is only 30% in the scar. An increase in breaking strength occurs after
approximately 21 days, mostly as a result of cross-linking.The rate of collagen
synthesis declines after 4 weeks and eventually balances the rate of collagen
destruction by collagenase (MMP-1). At this point the wound enters a phase of
collagen maturation.
Taylor:-The tensile strength of the young scar is only about 10% that of normal skin.
Scar strength increases to about 30–50% of normal skin by 4 weeks and to 80% after
several months.
Robbins:-We now turn to the questions of how long it takes for a skin wound to
achieve its maximal strength, and which substances contribute to this strength. When
sutures are removed, usually at the end of the first week, wound strength is
approximately 10% of the strength of unwounded skin, but it increases rapidly over
the next 4 weeks. This rate of increase then slows at approximately the third month
after the original incision and then reaches a plateau at about 70 to 80% of the tensile
strength of unwounded skin, which may persist for life.
Schwartz:-Wound strength and mechanical integrity in the fresh wound are
determined by both the quantity and quality of the newly deposited collagen. The
deposition of matrix at the wound site follows a characteristic pattern: Fibronectin and
collagen type III constitute the early matrix scaffolding, glycosaminoglycans and
proteoglycans represent the next significant matrix components, and collagen type I is
the final matrix. By several weeks postinjury the amount of collagen in the wound
reaches a plateau, but the tensile strength continues to increase for several more
months.20 Fibril formation and fibril cross-linking result in decreased collagen
solubility, increased strength, and increased resistance to enzymatic degradation of the

5. collagen matrix. Scar remodeling continues for many (6 to 12) months postinjury,
gradually resulting in a mature, avascular, and acellular scar. The mechanical strength
of the scar never achieves that of the uninjured tissue.
Factors That Inhibit Wound Healing
Infection
Ischemia
Circulation
Respiration
Local tension
Diabetes mellitus
Ionizing radiation

6. Advanced age
Malnutrition
Vitamin deficiencies:- Vitamin C Vitamin A
Mineral deficiencies:-Zinc Iron
Exogenous drugs:-Doxorubicin (Adriamycin) Glucocorticosteroids
suture marks are to be avoided, skin sutures should be removed by - a) hours b) 1
week
2 weeks d) 3 weeks
Epidermal skin sutures function for fine alignment of skin edges. Interrupted sutures
are less constrictive than running sutures. The needle enters and exits the skin at 90
degrees in order to evert the skin edges. These skin sutures are removed as soon as
adequate intrinsic bonding strength is sufficient. Skin sutures left in place too long
result in an unsightly track pattern. On the other hand, sutures removed prematurely
risk wound dehiscence. Nonabsorbable sutures on the face are typically removed
after 5 days. Sutures in the hand, foot, or across areas that are acted on by
motion are left for 14 days or longer .Alternatively, by employing the running
intradermal suturing technique, the time constraints of suture removal may be
disregarded, and these sutures may be left in place for a longer time without risking a
track pattern scar. Finally, epidermal approximation can be achieved without suture
using a medical-grade cyanoacrylate adhesive such as Dermabond. Such adhesives
are applied across the coapted skin edges only and contribute no tensile strength. Tape
closure strips such as Steri-Strips can be applied at the completion of wound closure
to help splint the coapted skin edges.
Guidelines for Day of Suture Removal by Area
BODY REGION REMOVAL (DAYS)
Scalp 6-8
Ear 10-14
Eyelid 3-4
Eyebrow 3-5
Nose 3-5
Lip 3-4
Face (other) 3-4
Chest, abdomen 8-10
Back 12-14
Extremities 12-14
Hand 10-14

7. BODY REGION REMOVAL (DAYS)
Foot, sole 12-14
A patient with grossly contaminated wound presents 12 hours after an accident. His
wound should be managed by – (UPSC 96)
a)Thorough cleaning and primary repair
b)Thorough cleaning with debridement of all dead and devitalised tissue without
primary closure
c)Primary closure over a drain
d)Covering the defect with split skin graft after cleaning
Management of an open wound seen 12 hrs. after
the injury – (AIIMS 87)
a)Suturing
b)Debridement and suture
c)Secondary suturing
d)Heal by granulation
Delayed wound healing is seen in all except-(AP 96)
a) Malignancy b) Hypertension
c) Diabetes d) Infection
All of the following favour postoperative wound dehiscence except – (Karnat 05)
a)Malignancy
b)Vitamin B complex deficiency
c)Hypoproteinaemia
d)Jaundice
Fibroblast in healing wound derived from –
a) Local mesenchyme b) Epithelium (PGI 98)
c) Endothelial d) Vascular fibrosis
(Sabiston) Fibroplasia:- Fibroblasts are specialized cells that differentiate from resting
mesenchymal cells in connective tissue; they do not arrive in the wound cleft by
diapedesis from circulating cells. After injury, the normally quiescent and sparse
fibroblasts are chemoattracted to the inflammatory site, where they divide and
produce the components of the ECM.The primary function of fibroblasts is to
synthesize collagen, which they begin to produce during the cellular phase of
inflammation. The time required for undifferentiated mesenchymal cells to
differentiate into highly specialized fibroblasts accounts for the delay between injury
and the appearance of collagen in a healing wound. This period, generally 3 to 5 days,
depending on the type of tissue injured, is called the lag phase of wound healing.The
rate of collagen synthesis declines after 4 weeks and eventually balances the rate of
collagen destruction by collagenase (MMP-1). At this point the wound enters a phase
of collagen maturation. The maturation phase continues for months or even years.
Glycoprotein and mucopolysaccharide levels decrease during the maturation phase,
and new capillaries regress and disappear. These changes alter the appearance of the
wound and increase its strength.

8. Degloving injury is – (KERALA 2K)
a) Surgeon made wound b) Lacerated wound
c) Blunt injury d) Avulsion injury
e)Abrasive wound
Avulsion injuries are open injuries where there has been a severe degree of tissue
damage. Such injuries occur when hands or limbs are trapped in moving machinery,
such as in rollers, producing a degloving injury. Degloving is caused by shearing
forces that separate tissue planes, rupturing their vascular interconnections and
causing tissue ischaemia. This most frequently occurs between the subcutaneous fat
and deep fascia. Degloving injuries can be open or closed. Degloving can be localised
or circumferential. It can occur only in the single, subcutaneous plane, but where
present in multiple planes, such as between muscles and fascia and between muscles
and bone, is an indication of a severe high-energy injury with a limited potential for
primary healing. Similar injuries occur as a result of runover road traffic accident
injuries where friction from rubber tyres will avulse skin and subcutaneous tissue
from the underlying deep fascia (Fig. 3.11). The history should raise the examiner’s
suspicion and it is often possible to pinch the skin and lift it upwards revealing its
detachment from the normal anchorage. The danger of degloving or avulsion injuries
is that there is devascularisation of tissue and skin necrosis may become slowly
apparent in the following few days. Even tissue that initially demonstrates venous
bleeding may subsequently undergo necrosis if the circulation is insufficient.
Treatment of such injuries is to identify the area of devitalised skin and to remove the
skin, defat it and reapply it as a full-thickness skin graft. Avulsion injuries of hands or
feet may require immediate flap cover using a one-stage microvascular tissue transfer
of skin and/or muscle.
In treatment of hand injuries, the greatest priority is – (A1 96)
a)Repair of tendons
b)Restoration of skin cover
c)Repair of nerves
d) Repair of blood vessels
During the surgical procedure – (AIIMS 83)
a)Tendons should be repaired before nerves
b)Nerves should be repaired before tendons
c)Tendons should not be repaired at the same time
d)None is true
In hand injuries first to be repaired is – (A195)
a) Bone b) Tendon
c) Muscle d) Nerve
In the case of injuries, treatment is directed at the specific structures damaged:
skeletal, tendon, nerve, vessel, and integument. In emergency situations, the goals of
treatment are to maintain or restore distal circulation, obtain a healed wound, preserve
motion, and retain distal sensation. Stable skeletal architecture is established in the
primary phase of care because skeletal stability is essential for effective motion
and function of the extremity. This also results in reestablishing skeletal length,
straightening deformities, and correction of compression or kinking of nerves

9. and vessels. Arteries are also repaired in the acute phase of treatment to maintain
distal tissue viability. Additionally, extrinsic compression on arteries must be released
emergently such as in compartment pressure problems. In clean-cut injuries, tendons
can be repaired primarily. In situations in which there is a chance that tendon
adhesions may form, such as when there are associated fractures, it is nonetheless
better to repair tendons primarily with preservation of their length and if necessary at
a later date to perform tenolysis. However, when there are open and contaminated
wounds or a severe crushing injury, it is best to delay repair of both tendon and
nerve injuries
Prevention of wound infection done by –
a)Pre-op shaving (PGI 05)
b)Pre-op antibiotic therapy
c)Monofilament sutures
d)Wound apposition
SSIs are the most common nosocomial infection in our population and constitute 38%
of all infections in surgical patients. By definition, they can occur anytime from 0 to
30 days after the operation or up to 1 year after a procedure that has involved the
implantation of a foreign material (mesh, vascular graft, prosthetic joint, and so on).
Incisional infections are the most common; they account for 60% to 80% of all SSIs
and have a better prognosis than organ/space-related SSIs do, with the latter
accounting for 93% of SSI-related mortalities.
Preoperative shaving has been shown to increase the incidence of SSI after clean
procedures as well. This practice increases the infection rate about 100% as compared
with removing the hair by clippers at the time of the procedure or not removing it at
all, probably secondary to bacterial growth in microscopic cuts. Therefore, the
patient is not shaved before an operation. Extensive removal of hair is not
needed, and any hair removal that is done is performed by electric clippers with
disposable heads at the time of the procedure and in a manner that does not
traumatize the skin
1.Basic principles include size of the OR, air management (filtered flow, positive
pressure toward the outside, and air cycles per hour), equipment handling
(disinfection and cleansing), and traffic rules. All OR personnel wear clean scrubs,
caps, and masks, and traffic in and out of the OR is minimized.
2.The CDC recommends the use of chlorhexidine showers, and it is reasonable to
implement such a policy, particularly in patients who have been in the hospital for a
few days and in those in whom an SSI will cause significant morbidity (cardiac,
vascular, and prosthetic procedures). Skin preparation of the surgical site is done with
a germicidal antiseptic such as tincture of iodine, povidone-iodine, or chlorhexidine.
An alternative preparation is the use of antimicrobial incise drapes applied to the
entire operative area. Traditionally, the surgical team has scrubbed their hands and
forearms for at least 5 minutes the first time in the day and for 3 minutes every
consecutive time.
3.As many as 90% of an operative team puncture their gloves during a prolonged
operation. The risk increases with time, as does the risk for contamination of the

10. surgical site if the glove is not changed at the moment of puncture. The use of double
gloving is becoming a popular practice to avoid contamination of the wound, as well
as exposure to blood by the surgical team. Double gloving is recommended for all
surgical procedures.Instruments that will be in contact with the surgical site are
sterilized in standard fashion, and protocols for flash sterilization or emergency
sterilization, or both, must be well established to ensure the sterility of instruments
and implants.
Local Wound Related:-Intraoperative measures include appropriate handling of tissue
and assurance of satisfactory final vascular supply, but with adequate control of
bleeding to prevent hematomas/seromas. Complete débridement of necrotic tissue
plus removal of unnecessary foreign bodies is recommended, as well as avoiding the
placement of foreign bodies in clean-contaminated, contaminated, or dirty cases.
Monofilament sutures have proved in experimental studies to be associated with
a lower rate of SSI. Sutures are foreign bodies that are used only when required.
Suture closure of dead space has not been shown to prevent SSI. Large potential
dead spaces can be treated with the use of closed-suction systems for short periods,
but these systems provide a route for bacteria to reach the wounds and may cause SSI.
Open drainage systems (e.g., Penrose) increase rather than decrease infections in
surgical wounds and are avoided unless used to drain wounds that are already
infected.
In heavily contaminated wounds or wounds in which all the foreign bodies or
devitalized tissue cannot be satisfactorily removed, delayed primary closure
minimizes the development of serious infection in most instances. With this
technique, the subcutaneous tissue and skin are left open and dressed loosely with
gauze after fascial closure. The number of phagocytic cells at the wound edges
progressively increases to a peak about 5 days after the injury. Capillary budding is
intense at this time, and closure can usually be accomplished successfully even with
heavy bacterial contamination because phagocytic cells can be delivered to the site in
large numbers. Experiments have shown that the number of organisms required to
initiate an infection in a surgical incision progressively increases as the interval of
healing increases, up to the fifth postoperative day.
Finally, adequate dressing of the closed wound isolates it from the outside
environment. Providing an appropriate dressing for 48 to 72 hours can decrease
wound contamination. However, dressings after this period increase the subsequent
bacterial count on adjacent skin by altering the microenvironment underneath the
dressing.
Elective cholecystectomy is – (APPG 06)
a) Clean contaminated b) Clean
Dirty d) Contaminated
Which one of the following surgical procedures is considered to have a clean-
contaminated wound ?
a),Elective open cholecystectomy for cholelithiasis
b)Hemiorrhaphy with mesh repair

11. c)Lumpectomy with axillary node dissection
d)Appendectomy with walled off abscess
The accepted range of infection rates has been 1% to 5% for clean, 3% to 11% for
clean-contaminated, 10% to 17% for contaminated, and greater than 27% for dirty
wounds.
Table 14-2 – Surgical Wound Classification According to Degree of
Contamination
WOUND
CLASS DEFINITION
Clean An uninfected operative wound in which no inflammation is
encountered and the respiratory, alimentary, genital, or infected
urinary tract is not entered. Wounds are closed primarily and, if
necessary, drained with closed drainage. Surgical wounds after blunt
trauma should be included in this category if they meet the criteria
Clean- An operative wound in which the respiratory, alimentary, genital,
contaminated or urinary tract is entered under controlled conditions and
without unusual contamination
Contaminated Open, fresh, accidental wounds. In addition, operations with major
breaks in sterile technique or gross spillage from the
gastrointestinal tract and incisions in which acute, nonpurulent
inflammation is encountered are included in this category
Dirty Old traumatic wounds with retained devitalized tissue and those that
involve existing clinical infection or perforated viscera. This
definition suggests that the organisms causing postoperative infection
were present in the operative field before the operation
Staphylococcus aureus remains the most common pathogen in SSIs, followed by
coagulase-negative staphylococci, enterococci, and Escherichia coli. However, for
clean-contaminated and contaminated procedures, E. coli and other
Enterobacteriaceae are the most common cause of SSI.
The Vitamin which has inhibitory effect on wound healing is – (MAHE 05)
a) Vitamin-A b) Vitamin-E
c) Vitamin-C d) Vitamin B-complex