Stages of Wounde Healing Factors affecting wound Healing Wound classification Dressings

1. WOUNDS, ITS MANAGEMENT & WOUND
HEALING
DR SMRUTI GHETLA
PROFESSOR AND HOD,
DEPARTMENT OF GENERAL SURGERY,
R N COOPER HOSPITAL, MUMBAI
DR AMITESHWAR SINGH
DEPARTMENT OF GENERAL SURGERY,
SETH GSMC AND KEM HOSPITAL, MUMBAI

2. NORMAL WOUND HEALING
 Three or four phases
 Hemostatic/Inflammatory phase - 2-3 days
 Proliferative phase - 3rd day to the 3rd week
 Remodelling phase (maturing phase) - 7 days

3. PHASES OF WOUND HEALING

4. THE INFLAMMATORY PHASE
 Bleeding > Vasoconstriction > thrombus formation
 Platelets
ADP
Platelet aggregation
 Platelets and local injured tissue
Vasoactive Amines histamine, serotonin and prostaglandins
Increased Vascular Permeability
Release cytokines
- (PDGF), platelet
factor IV and
(TGFβ)
Attract PMNs
and
Macrophages

5. Inflammatory Phase (Day 3)

6. THE PROLIFERATIVE PHASE
 3rd day to 3 weeks
 Mainly fibroblast activity
 Production of collagen and ground substance
(glycosaminoglycans and proteoglycans)
 Neoangiogenesis
 Re-epithelialisation of the wound surface
 Fibroblasts require vitamin C
 The wound tissue formed is called Granulation tissue

8. THE REMODELLING PHASE
 2 weeks to 2 years
 Maturation of collagen
 Replacing immature type III with more mature
type I collagen in the Ratio of 4:1
 Realignment occurs along the lines of tension
 Decreased vascularity
 Wound Contraction (Role of Myofibroblasts)

10. Hemostasis
Inflammation
Connective Tissue
Regeneration
Contracture
Stop Bleeding
Chemotaxis
Epithelial Migration
Proliferation
Maturation
Contraction
Scarring
Remodelling of scar
Inflammatory (Reactive)
Proliferative
(Regenerative)
Maturational
(Remodelling)

11. CLASSIFICATION OF WOUND CLOSURE AND
HEALING
 Primary intention:
 Normal healing
 Opposed edges
 Minimal scar
 Secondary intention
 Wound left open
 Granulation tissue, contraction and epithelialisation
 Increased inflammation and proliferation
 Poor scar
 Tertiary intention (Delayed Primary)
 Wound kept open
 Edges later opposed.

12. PRIMARY INTENTION

13. SECONDARY INTENTION

14. TERTIARY INTENTION

15. WOUNDS
 Healing of wounds is a mechanism whereby the body attempts
to restore the integrity of the injured part.
 Classification is based on
 Causative factors
 Appearance
 Age

16.  Closed wounds – Contusions, abrasions, hematomas, friction burns, crush
injuries.
 Open wounds – stab, incised wounds, puncture wounds, bites, lacerations,
traction and avulsion injuries.
 Tidy wound – Incised, clean wounds (vessels and nerves injured)
No tissue loss
 Untidy wound – crushed, avulsed, contaminated wounds with tissue loss
 Acute wounds – surgical incision, stab wounds and CLWs
 Chronic wounds – ulcers and pressure sores,

17. CONTUSION

18. ABRASION

19. FRICTION BURNS

20. LACERATION

21. DEGLOVING INJURIES

22. STAB WOUND

23. MANAGEMENT
 Aim is to convert an untidy wound into a tidy wound
Tidy wound Primary suturing (<6 hours)
No infection
Untidy wound if possible excise and primary suturing
Infected, lacerated, crushed wounds excision of wound and delayed primary
closure
Fasciotomy
Large clean wounds Skin grafting and flaps.

25. FACTORS AFFECTING WOUND HEALING
 Local
Site
Blood supply
(arterial/venous)
Infection
Foreign body
Hematoma
Pressure
Structure involved
 Focal
Location
Movement of the limb
Contamination
Loss of tissue
 General
Age
Co morbid conditions
Diabetes,
Jaundice
Malignancies
AIDS
Malnutrition – deficiency of
vitamins and minerals
Smoking
Medications – steroids,
chemotherapeutic drugs

26. DRESSINGS AND WOUND CARE
 Characteristics of an ideal dressing:
 Creates a moist environment
 Removes excess exudate
 Prevents desiccation
 Allows for gaseous exchange
 Impermeable to microorganisms
 Thermally insulating
 Prevents particulate contamination
 Non toxic to beneficial host cells
 Non traumatic
 Easy to use
 Cost effective

27. TYPES OF DRESSING
 Non adherent fabric:
 Fine mesh gauze supplemented with occlusive
and/or antibacterial abilities eg. Bactigras and
paraffin qauze
 Absorptive dressings:
 Gauze – wide mesh gauze eg. Gamgee dressings
 Foams – Polyurethane sheets
 Occlusive dressings
 Creams, Ointments and solutions

28. OCCLUSIVE DRESSINGS
 Non biologic dressings
 Films – Polyurethane
sheets – Opsite
 Hydrocolloids – gelatin,
pectin, cellulose –
duoderm, tegasorb
 Alginates – seaweed
derivative cellulose like Ca
alginate – Algiderm
 Hydrogels – Polyethelene
oxide (80% water) –
Tegacel
 Biologic dressings
 Homograft – cadaver skin
 Allograft – own skin
 Xenograft – pig’s Skin
 Amnion – Human Placenta
 Skin substitutes –
 Acellular cadaveric dermis
 Neonatal deriverd
fibroblasts on collagen
matrix

29.  Antibacterial Creams
 Iodine containing – Betadine
 Silver Nitrate
 Silver Sulfadizine
 Antibacterial ointments
 Neomycin
 Neosporin
 Enzymatic
 Collagenase
 Papain
CERAMS AND OINTMENTS

30.  Open therapies
 Hyperbaric Oxygen
 Negative pressure assisted wound closure
 Future
 Tissue engineering – scaffolds ( growth factors, genetherapy,
stem therapy)

31. Dressing options for non infected clean wounds