MANAGEMENT OF WOUNDS

By Dr Gargadi,S.I

Plastic and Reconstructive surgeon(FWACS)

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OUTLINE

• INTRODUCTION
• DEFINITION
• AETIOLOGY
• CLASSIFICATION
• PATHOLOGY/WOUND HEALING
• EFFECTS OF WOUNDS
• PRESENTATION
• INVESTIGATIONS
• TREATMENT OF WOUNDS
• CURRENT CONCEPT
• TAKE HOME MESSAGE
• REFERENCE.

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INTRODUCTION

CAIN SLAYING ABEL

ALL SET FOR TRAUMA

OLDEN DAY WOUND CARE

HISTORICAL PERSPECTIVE

• WOUND IS THE COMMONEST CONDITION IN MEDICAL PRACTICE.
• AS MAN INTERACTS WITH HIS ENVIRONMENT,ENGAGES IN CONFLICTS,DISCOVERS GUN POWDER,GETS INDUSTRIALIZED
• WOUNDS HAVE BECOMED INEVITABLE BUT CONTROLLABLE REALITY.
• TRAUMA FROM RTA IS THE MAJOR CAUSE OF DEATH IN YOUNG ADULTS IN NIGERIA.
• MID 1500AD AMBROISE PARE DISSCOVER THAT LESS AGGRESSIVE METHODS ARE BETTER
• JOSEPH LISTER WORKED ON ASEPTIC TECHNIQUE.
• ALEX CARREL WORKED ON TRANSPLANTATION.

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DEFINITION

• WOUND IS THE LOSS OF NORMAL TISSUE INTEGRITY(ANATOMY+PHYSIOLOGY)

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AETIOLOGY

• M.N.E.M.O.N.I.C –T.I.M.C.A.N
• TRAUMA –COMMONLY MECHANICAL AND THERMAL.
• INFLAMMATORY CONDITIONS- E.G BOIL,TUBERCULOUS ULCER.
• IMMUNOLOGICAL CONDITIONS-E.G PYODERMA GANGRENOSUM,STEVEN JOHNSON’S SYNDROME.
• METABOLIC CONDITIONS- E.G GAUCHER’S DISEASE.
• CONGENITAL/GENETIC –E.G HBSS ULCER,CLEFT LIP AND PALATE.
• ARTERIAL(VASCULAR)- E.G VENOUS ULCER
• NEOPLASM-E.G BASAL CELL CARCINOMA,SQUAMOUS CELL

CARCINOMA.

N.B:STRICTLY SPEEKING IN SURGERY WOUNDS RESULT FROM PHYSICAL AGENTS.

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INCISIONAL WOUND

PUNCTURED WOUND TO THE KNEE

LACERATION LEFT LEG

LACERATION MADE BY MACHETE

AVULSION OF SKIN OF INDEX FINGER

AVULSION INJURY

DOUGH LAMINATING MACHINE

BOMB BLAST INJURY

CLASSIFICATION�

• BASED ON MECHANISM OF WOUNDING

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• CONTUSION- WOUNDS CAUSED BY BLUNT OBJECTS,INJURY IS TO SUBJACENT TISSUE,SKIN IS USUALLY INTACT.
• INCISIONS- WOUNDS CAUSED BY SHARP OBJECTS INCLUDING THE SURGEON’S SCALPEL.EDGE OF THE WOUND IS STRAIGHT AND THERE IS MINIMAL TISSUE DAMAGE.WOUND CAN BE CLOSED PRIMARILY.
• LACERATION- WOUNDS MADE BY IRREGULAR SHARP OBJECTS OR BLUNT OBJECTS,TISSUE DAMAGE IS MODERATE, WOUND CAN BE DEBRIDED AND CLOSED.

CLASSIFICATION

• BASED ON MECHANISM OF WOUNDING
• PUNCTURED WOUNDS- WOUNDS CAUSED BY SHARP OBJECTS E.G NAILS.THERE IS MINIMAL TISSUE DAMAGE BUT THERE IS RISK OF MICROBIAL INNOCULATION PARTICULARLY ANAEROBIC TYPE E.G CLOSTRIDIUM TETANI.WOUND IS LAYED OPEN,DEBRIDED,ALLOW TO HEAL BY SECONDARY INTENSION.
• PENETRATING WOUNDS- WOUNDS CAUSED BY PROJECTILE OBJECTS(VELOCITY PROPELLED):

.WHEN IT BREACHES THE: DURA,PLATYSMA,PLEURA,PERITONIUM,AND DEEP FASCIA ARE REGARDED AS PENETRATING HEAD, NECK,CHEST,ABDOMINAL, AND LIMB INJURY RESPECTIVELY.

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CLASSIFICATION

• BASED ON MECHANISM OF WOUNDING
• ABRASION- WOUNDS MADE BY SUPERFICIAL FRICTIONAL INJURIES CAUSING LOSS OF EPIDERMIS AND PART OF DERMIS.THE SURFACE MAY BE INGRAINED WITH DIRT WHICH REQUIRE COPIOUS IRRIGATION WITH SALINE; SOMETIMES BRUSH MAY BE REQUIRED.
• BRUISING – SKIN IS INTACT BUT DAMAGE IS BELOW THE SKIN
• AVULSION- WOUNDS MADE BY SHEARING FORCE THAT PEELS THE SKIN AND UNDERLYING TISSUE,OFTEN AVULSED TISSUE IS CRUSHED DISTALLY.WOUND REQUIRES RECONSTRUCTION
• DEGLOVING WOUNDS:CAUSED BY SHEARING &TRACTIONAL FORCE E.G WHEN HANDS OR LIMBS TRAPPED IN A MOVING MACHINERY SUCH AS ROLLERS.
• EXPLOSIVE WOUNDS- WOUNDS CAUSED BY GUNSHOTS OR BLAST FROM BOMBS.THERE IS ENORMOUS TISSUE DAMAGE FROM TRANSFER OF KINETIC ENERGY,SHEARING FORCE AND IRRADIATION.DAMAGE CONTROL IS REQUIRED.

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CLASSIFICATION

• BASED ON DEGREE OF CONTAMINATION/RANK AND WAKEFIELD
• TIDY WOUNDS- CLEAN WOUNDS MADE BY KNIFE,GLASS .WOUND IS CLOSED PRIMARILY.
• UNTIDY WOUNDS- CONTAMINATED RAGGED WOUNDS ; REQUIRE DELAYED PRIMARY CLOSURE.
• INDETERMINATE WOUND- SEVERE CRUSH OR BURNS THAT IS NOT POSSIBLE TO ACERTAIN EXTEND OF INJURY.WOUND REQUIRE REGULAR CARE AND SUBSEQUENT RESURFACING.

THE SAN ANTONIO UNION OF TEXAS WOUND CLASSIFICATION SYSTEM

GUSTILLO CLASSIFICATION OF TIBIAL FRACTURE

PATHOLOGY

• LOCAL EFFECT OF WOUNDS
• INFLAMMATORY/DEMOLISION/LAG PHASE –OCCURS 0-3DAYS,TRANSIENT VASOCONSTRICTION(NEUROHUMORAL),VASODILATATION(SEROTONIN,HISTAMIN,BRADYKINN,PROSTAGLANDINS),CHEMOTAXIS AND PHAGOCYTOSIS ,EPITHELIAZATION,FORMATION OF GRANULATION TISSUE BEGINS.CHARACTERIZED BY SWELLING ,PAIN,REDNESS,HEAT AND LOSS OF FUNCTION

L0CAL EFFECTS OF WOUND

• PROLIFERATIVE(ENGLISH TERMINOLOGY)/FIBROPLASIA(AMERICAN TERMINOLOGY)
• RECRUITMENT OF MACROPHAGES-PDGF,TGF-b LEADING TO NEOVASCULIRIZATION AND ATTRACTION OF FIBROBLAST
• RECRUITMENT OF FIBROBLAST – BASIC FGF,TGF-b
• FIBROBLAST LAY COLLAGEN INTO GROUND SUBSTANCE(HYALURONIC ACID,CHONDROITIN SULPHATE,LAMININ,AND GLUCOSAMINOGLYCANS)
• HYDROXYPROLINE -------HYDROXYLASE-----🡪COLLAGEN

VIT.C,ZN,METHIONINE

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• HYDROXYLYSINE
• GRANULATION TISSUE IS FORMED COMPRISING OF TYPE III COLLAGEN,GROUND SUBSTANCE AND NEW BLOOD VESSELS.

MATURATION PHASE

• PEAK PHASE OF FIBROPLASIA DECLINES
• NUMBER OF FIBROBLAST IN RELATION TO COLLAGEN FALLS.
• SCAR THINS OUT AND FLATTENS
• BLOOD VESSELS NEWLY FORMED DEVELOP ENDARTERITIS OBLITERANS AND GRADUALLY DISAPPEAR.
• COLLAGEN FIBRES ARE CROSS-LINKED AND ARRANGED IN THE DIRECTION OF MECHANICAL STRESS.MYOFIBROBLAST CONTRACTS TO REDUCE WOUND SIZE(GABBIANI1979)
• WOUND TENSILE STRENGTH RISES UPTO 70-80% OF PRE-WOUND STRENGTH.

CHRONIC PHASE

• REPEATED TRAUMA,EXISTENCE OF HAEMATOLOGICAL DISEASES,ARTERIAL DISEASE,VENOUS INSUFFICIENCY,INFECTION,DIABETES,MALIGNANCY,LEAD TO DEFICIENCY IN NUTRIENTS,ACCUMULATION OF TOXIC METABOLITES.
• THIS LEADS TO TISSUE HYPOXIA,CELL DEATH,NECHROSIS WHICH SLOUGH OFF TO BEGIN A VICIOUS CYCLE.
• HALL-MARK OF THIS STAGE IS SCARRING.

STAGES OF WOUND HEALING OVERLAP

STAGES OF WOUND HEALING

SYSTEMIC EFFECTS OF WOUNDS

• PAIN,BLOOD OR FLUID LOSS FROM WOUNDS INITIATES METABOLIC AND CHEMICAL CHANGES IN THE BODY.
• EBB PHASE – CORRESPONDS TO PERIOD OF TRAUMATIC SHOCK; THERE IS DEPRESSION OF ENZYMATIC ACTIVITY AND OXYGEN CONSUMPTION.
• FLOW PHASE(3-8DAYS) :-
• CATABOLIC PHASE- CATECHOLAMINES,CORTISOL,TNF-a IL1 CAUSE PROTEOLYSIS AND LYPOLYSIS ASSOCIATED WITH HYPERGLYCAEMIA,INCREASED NITROGEN EXCRESION AND WEIGHT LOSS.
• ANABOLIC PHASE(LASTING FOR WEEKS) - PROTEIN AND FAT STORES ARE RESTORED RESULTING IN WEIGHT GAIN(THE RECOVERY)

STEMIC EFFECTS OF WOUNDS

• SHOCK – HYPOVOLAEMIC,SEPTIC.
• CARDIORESPIRATORY ABNORMALITIES – CARDIAC DEPRESSION,DVT,ATELECTASIS,ARDS.
• G.I.T ABNORMALITIES – PARALYTIC ILEUS,ACUTE GASTRIC DILATATION,CURLINGS ULCERS AND LIVER DAMAGE.
• GENITOURINARY ABNORMALITIES – UTI,CALCULI,FROM PROLONGED CATHETERIZATION.
• M.S.S –DEFORMITIES ,DISUSE ATROPHY,JOINT STIFFNESS.
• C.N.S ABNORMALITIES – DEPRESSION, PSYCHOSIS AND FEELING OF MISERABLE EXISTANCE.

DIAGNOSIS/EVALUATION

• HISTORY – CAUSE,DURATION,SITE,SYMPTOMS OF PAIN ,SWELLING ,FEVER,JAUNDICE,FUNCTION.CARE RECEIVED,PMHX, FMHX ,DRUG/ALLERGY.
• EXAMINATION –CHARACTERISE WOUND AND EXTEND AND SYSTEMIC EFFECTS .
• INVESTIGATIONS – WOUND SWAB FOR M.C.S,WOUND TISSUE CULTURE,WOUND EDGE BIOPSY ,XRAYS,DOPPLER USS OF PERIPHERAL VESSELS,ISCHAEMIC INDEX ;BRACHIAL ANKLE INDEX : CRITICAL LEVEL IS 0.45,U&E+CR,FBC.

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TREATMENT OF WOUNDS

• REQUIRES A MULTIDISCIPLINARY APPROACH INVOLVING, THE PLASTIC SURGEON,NURSES,NUTRITIONIST,INTERNIST,PHYSIOTHERAPIST,PSYCHOTHERAPIST,AND SOCIAL WORKER.
• THE INITIAL MANAGEMENT OF WOUND BY FIRST INTERVENTIONIST HAS PROFOUND EFFECT ON THE OUT COME.

PRINCIPLES OF WOUND CARE

1. FIRST AID/BASIC LIFE SUPPORT- RESCUE, SAFE TRANSPORTATION OF PATIENT AND BASIC RESUSCITATIVE MEASURES.
2. ADVANCED LIFE SUPPORT – ABC OF RESUSCITATION HOSPITAL BASED AND DETAILED ASSESSEMENT.
3. WOUND DEBRIDEMENT/REGULAR WOUND DRESSING
4. ANTI-TETANUS,ANTI-RABIES VACCINES
5. PROPHYLACTIC OR THERAPEUTIC ANTIBIOTICS
6. ANALGESICS
7. REST AND ELEVATION
8. CONSIDER THE RECONSTRUCTION LADDER
9. TREAT PRIMARY PATHOLOGY
10. PHYSIOTHERAPY AND REHABILITATION
11. FOLLOW-UP

LADDER OF RECONSTRUCTION

READY TO WALK HOME

FREE RADIAL FOREARM FLAP

CURRENT CONCEPTS

• SKIN SUBSTITUTES – UNILAMINAR MEMBRANES E.G HYDROGELS ,HYDROCOLLOIDS DRESSINGS OR VAPOUR PERMEABLE MEMBRANES.AND BILAMINAR SKIN SUBSTITUTES E.G LEVINE SYNTHETIC BILAMINAR SKIN SUBSTITUTE;MADE OF INNER NYLON FIBRIC AND OUTER LAYER OF POLYTETRA-FLUROETHYLENE(PTFE)
• MESHED INHENCED SKIN GRAFT
• CULTURED KERATINOCYTES OF PATIENTS
• V.A.C
• ROLE OF PHENYTOIN AND HONEY: has been found to improve wound healing.

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CURRENT CONCEPTS�

ROLE OF 3 ISOFORMS OF TGF-b:1 &2 promotes wound healing while 3 slows healing.

ROLE OF MAST CELLS:increase densities of mast cells is associated with excess scarring.

ROLE OF INTERGRINS:alpha3-b1 &alpha6-b4 help cells to stick to the surfaces to bring an end to wound healing.

ROLE OF METALLOPROTEINASES(MMP):mmp-1(collagenase),mmp-2(gelatinase A),mmp-9(gelatinase B) are found in chronic wounds.

ROLE OF ULTRASOUND:uss of1-3MHZ applied for 2-3 minutes for 2-3 weeks increases collagen deposition by fibroblasts.

ROLE OF LASER:low levels of laser improves wound healing.

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REHABILITATION

• EARLY PHYSIOTHERAPY AND SPLINTAGE WHERE APPLICABLE.
• SCAR REVISION/RECONSTRUCTION
• PROSTHESIS/FUNCTION AIDING APPLIANCES

TAKE HOME MESSAGE

• THE SURGEON SHOULD INCREASE IN KNOWLEDGE OF THE MECHANISMS OF TRAUMA,THE RESPONSE OF THE BODY TO INJURY,PROCESS OF WOUND HEALING AND COMPLICATIONS THAT MAY ARISE SO AS TO PROVIDE APPROPRIATE PROMPT THERAPY AND SHOULD BE ABLE TO GUIDE THOSE CONCERN WITH SAFETY MEASURES AND INDUSTRIAL DESIGN.

PHILOSOPHY

• “A WISE PHYSICIAN SKILLED OUR WOUNDS TO HEAL MORE THAN ARMIES FOR THE COMMON WEAL” HOMER(GREATEST GREEK EPIC POET)

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• “THERE IS ONLY ONE GOOD,KNOWLEDGE,AND ONE EVIL,IGNORANCE” SOCRATES 470-399B.C

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• WHO WE ARE DETERMINES HOW WE SEE OTHERS.

ASSOP WATER FALL RIYOM L.G.C

RIYOM ROCK FORMATION

FAMILY OF THE LAND OWNER OF THE FAMOUS RIYOM ROCK FORMATION

SWEET HOME JOS-ANGELES

NATURE IS A CHARM

REFERENCES

• PRINCIPLES AND PRACTICE OF SURGERY,INCLUDING PATHOLOGY IN THE TROPICS : BADOE CHAP.5 3TH EDITION
• SELECTED READINGS IN PLASTIC SURGERY : VOL.9 NO.3
• PLASTIC SURGERY: GRAB AND SMITH
• BASIC PATHOLOGY: ROBINS CHAP.1-3 1992:3-60
• ROYAL COLLEGE OF PATHOLOGIST CONFERENCE

1971.

• REPAIR METHODS:O.M .OLUWATOSIN 2009.

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THANK YOU FOR LISTENING!