Basic skills
Classification and
management of acute
wounds
Senthil Kumar
David John Leaper
Abstract
Acute wounds are aetiologically and pathophysiologically diverse,
features that impact on their natural history and guide management.
Wound healing is a dynamic process and requires appropriate shifts in
perspective in the clinical management of the wound, and is reflected
in the terminology and classification systems which address different
domains of the wound. Wound management begins with assessment
and classification and may continue well after the wound has clinically
healed. Before a wound can be closed, it may need to be prepared by
toilet and debridement and protected against infection by appropriate
prophylactic measures. Judgement and surgical skill are necessary to
decide whether a wound is best allowed to heal by first, second or third
intention. Wounds may be directly closed by approximation of edges or
by transfer of tissues.
Keywords acute wounds; general surgery; wound classification; wound
closure; wound management
Wounds have diverse causes with varied anatomical associa-
tions that influence their morphology, natural history and man-
agement. Wound healing is a dynamic process and the clinical
perspective changes depending on the phase of healing.
Management of a wound consists of several interrelated steps
influenced by a number of factors that extend beyond the imme-
diate confines of the wound and the operating theatre. The gen-
eral principles are outlined in Table 1, but wounds often require
additional, individual treatment.
Wound classification systems (Table 2)
Aims: wound classification systems provide frameworks that:
aid diagnosis and stratification
ensure uniformity of documentation
offer prognostic information
guide management.
Senthil Kumar FRCSC(Ed) is a Clinical Research Fellow in Surgery at
University Hospital of North Tees, Stockton-on-Tees, UK. Conflicts of
interest: none declared.
David John Leaper FRCS FRCS(Ed) is Emeritus Professor of Surgery at
Newcastle upon Tyne University, Newcastle, UK, and Visiting Professor
of Surgery, Wound Healing Research Unit, Department of Surgery,
Cardiff University, Cardiff, UK. Conflicts of interest: none declared.
SURGERY 26:2
Principal steps in the management of an acute
wound
Steps Core issues and activities
Assessment Accurate history: magnitude of trauma,
contamination
Diagnosis and stratification
Associated injuries: neurovascular,
musculoskeletal, visceral
Need for referral/multidisciplinary
approach/triage
Preparation Prophylaxis: antibiotic, tetanus
Analgesia/anaesthesia
Exploration, toilet and debridement
Haemostasis
Definitive treatment Closure: when, how, where, which first?
Drainage
Referral/multidisciplinary approach?
After-care Dressings
Removal of sutures/splints
Surveillance for complications
Physiotherapy and rehabilitation
Table 1
Design: the diversity of wounds and the potential for continual
change makes it difficult to design a single, all-encompassing
classification system that incorporates all attributes of a wound
at all times. Hence, the descriptors used in classifications often
focus on one or a few of the aspects of the wound relevant to
the clinical context. The different systems of classification are
complementary, thus a comprehensive description of a given
wound requires the use of descriptors from more than one
system.
Types
Aetiological and morphological: the mode and pattern of injury
are the focus. Acute wounds usually follow trauma or inflam-
mation and usually heal within six weeks. Chronic wounds (in
addition to failing to heal after six weeks) have characteristic
pathological associations that inhibit or delay healing. The USA
National Research Council classification (Table 3) segregates
wounds according to the degree of contamination, which has
implications for management and predicts infection risk.
Wound complexity provides a wider perspective of the clinical
context of the wound and incorporates useful clinical informa-
tion with implications for management.
A simple wound involves skin and subcutaneous tissue,
without significant tissue loss and without any associated
complications.
A complex wound is associated with significant tissue loss
or devitalization; communicates with viscera (e.g. fistula), body
cavities (e.g. laparostomy), joints or prosthesis; or has associated
injuries or paths leading to vital structures. A complicated wound
has suffered a secondary complication such as an infection, isch-
aemia (flap necrosis), haematoma or compartment syndrome.
43 2007 Elsevier Ltd. All rights reserved.
 Basic skills

Synopsis of wound classification systems for acute wounds

Aetiological Morphological Contamination Complexity

Surgical Abrasion Clean Simple

Penetrating trauma Incision Implant Complex
Stab Superficial Non-implant Open fracture
Projectile injury Deep Clean-contaminated Laparostomy
Bite/envenomation Laceration Contaminated Complicated
Blunt trauma Superficial Dirty-infected Wound infection
Avulsion/traction Deep Gas gangrene
Crush injury Degloving injury Flap necrosis
Burns Ulceration
Thermal Superficial
Electrical Deep
Irradiation
Frost-bite

Table 2

Grading and scoring systems exist for specific conditions (e.g.
pressure ulcers, diabetic ulcers), but are beyond the scope of
this review. Two systems that are relevant to the acute surgical
wound when comparing outcomes in audit and for risk predic-
tion are discussed below.
The ASEPSIS scoring system assigns empirical scores to dif-
ferent dimensions of the wound (additional treatment, serous dis-
charge, erythema, purulent discharge, separation of deep tissues,
isolation of bacteria, duration of hospital stay). The wound is seri-
ally assessed and scored over five days. The individual scores are
summated to give a single numerical value which is used to grade
the wound. A summated score of >20 defines an infection.
The National Nosocomial Infection Surveillance system score
was adopted by the Centers for Disease Control and Prevention
(Atlanta, USA). The score assigns one point each for:
a non-clean (clean-contaminated, contaminated and dirty)
wound
American Society of Anesthesiology physical status of 3 or more
an operative time more than the seventy-fifth centile for similar
procedures.
The higher the score, the greater the risk of infection. This score
is a risk stratification score used primarily to adjust for case-mix
and allow for comparing groups of patients across institutions.
However, it underlines the fact that, in addition to contamination,

USA National Research Council system of wound classification

Wound classification Criteria Examples

Clean An incised wound through uninflamed tissue created at elective surgery and Non-implant
closed primarily. Only a closed system of drainage employed Mastectomy
Oropharyngeal, tracheobronchial, gastrointestinal, biliopancreatic, genitourinary Herniorrhaphy
tracts are not entered Implant
No breach in aseptic technique Hip replacement
Hernioplasty
Clean-contaminated Wound (that is otherwise clean) created at emergency surgery Cholecystectomy
Reoperation via clean incision within 7 days Elective lung resection
Elective controlled entry into visceral tracts with minimum spillage of contents
Minor break in aseptic technique
Contaminated Wounds left open; fresh accidental wounds; penetrating trauma < 4 hours old Stab wound
Operations with gross spillage of gastrointestinal contents; major breaks in Non-perforated appendicitis
sterile technique
Dirty Presence of pus Laparotomy wound for
Preoperative perforation of oropharyngeal, tracheobronchial, gastrointestinal, sigmoid diverticular
biliopancreatic, genitourinary tracts perforation
Penetrating trauma > 4 hours old

Table 3

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 Basic skills

operative factors and comorbid conditions are important factors
in wound outcomes.
Management
Preparation
A wound represents a violation of natural defence barriers and
encourages invasion by micro-organisms. Many factors related to
the host, the wound and the micro-organism interact soon after
the wound is created and influence the occurrence of wound
infection. Chief factors in otherwise immunocompetent individu-
als are the size and virulence of the inoculum, the presence of
foreign body, and tissue hypoxia. One or more of these factors
can be manipulated in most clinical settings and form the basis
of infection prevention. Antibiotics (see below) have a role in
reducing wound infections, but they do not replace the need for
aseptic technique, atraumatic handling of tissue and good peri-
operative wound care.
Antibiotic prophylaxis is needed for clean-contaminated and
contaminated wounds. The use of antibiotics in dirty wounds
must be prolonged and is essentially therapeutic.
The role of antibiotic prophylaxis in clean wounds is contro-
versial and subject to a wide variation in practice. The situations
described below may warrant antibiotic prophylaxis in clean
wounds.
When the risk of infection is high
Observed rates of infection for a particular procedure in a
given clinical environment is >4% (arbitrary cut-off point).
National Nosocomial Infection Surveillance score of >1.
Presence of other high-risk factors (e.g. immunosuppression,
poorly controlled diabetes, morbid obesity, remote infection, re-
operation, prior local irradiation, severe malnutrition, extremes
of age).
When the consequences of an infection are potentially
disastrous
Involves an implant (vascular graft, joint prosthesis).
Involves incised bone leading to a cavity (sternotomy,
craniotomy).
Presence of a prosthetic heart valve.
The choice of antibiotic varies depending on the site of trauma
or surgery, which determines the type of organisms encoun-
tered. In general, an agent with a broad spectrum (e.g. second-
generation cephalosporin) is recommended, and metronidazole is
added if anaerobic cover is necessary. In wounds with significant
contamination, prophylaxis against gas gangrene must be insti-
tuted (e.g. benzyl penicillin 1.2 g (i.v.) 46 hourly for 48 hours).
Adjuncts to antibiotic prophylaxis: there are two adjuncts to
antibiotic prophylaxis that may further reduce the incidence of
wound infections.
Perioperative oxygen supplementation oxygen tension in
the wound plays a vital role in local defence mechanisms. Peri-
operative oxygen supplementation reduces wound infection rates
after colorectal surgery.
Maintenence of perioperative normothermia has immuno
logical and haemorrheological advantages that augment the
capacity of the wound to fight infection; it also improves the
oxygen tension of the wound. Perioperative systemic warming
and local warming reduce wound infection rates after colorectal
surgery, as well as breast, hernia and varicose vein surgery.
Tetanus prophylaxis (Table 4): a decision regarding tetanus
prophylaxis must be made in every patient with an injury. Teta-
nus is rare in clean wounds, but is more likely in wounds:
contaminated with soil or manure
with extensive devitalized tissue (especially muscle)
in the lower limbs, axilla
caused by bites
that are punctured deeply.
Wound exploration, wound toilet and debridement: acute
post-traumatic wounds are often contaminated when they pr-
esent. They must be prepared by a combination of exploration,
wound toilet and debridement before a definitive treatment
plan can be formulated.
Wound exploration with the exception of minor superficial
wounds, most post-traumatic wounds must be explored to assess
the anatomical extent of injury and to detect associated injur
ies to underlying neurovascular structures, tendons, joints and

Guidelines for tetanus prophylaxis

Immunization status Type of wound

Low risk High risk

Last of 3-dose course or a reinforcing dose
given < 10 years ago
Last of 3-dose course or reinforcing dose
given > 10 years ago
Not immunized/status unknown
Further immunization is not needed
A single reinforcing dose of
adsorbed vaccine (0.5 ml i.m./deep
subcutaneous)
Full course of adsorbed vaccine
None if moderate risk
Give a dose of tetanus immunoglobulin (250 IU in
1 ml i.m.) if particularly high risk
A single reinforcing dose of adsorbed tetanus vaccine
+
Human tetanus immunoglobulin in a different site
Full course of adsorbed vaccine
+
Human tetanus immunoglobulin in a different site

Table 4

SURGERY 26:2 45 2007 Elsevier Ltd. All rights reserved.

 Basic skills

bones. This is particularly important in penetrating (especially
projectile) injuries because significant damage to deeper struc-
tures may be masked by an apparently small surface wound.
The second purpose of exploration is to locate and remove for-
eign bodies. If glass, gravel or metallic foreign bodies are suspected,
radiological expertise with surface markers in place before and
after exploration may be useful. However, many organic foreign
bodies (e.g. wooden splinters) and many synthetic materials (e.g.
plastic) may be missed on a radiograph. Even if no foreign body
is suspected, exploration may be necessary for better access for
debridement of potentially devitalized tissue and for haemostasis.
Wound toilet is the cleansing of the wound with water, saline
or antiseptics (e.g. chlorhexidine, cetrimide, povidone iodine).
Several litres of warmed isotonic fluid may be needed for large
wounds. A soft brush or sponge may be used to gently scrub the
wound to clear particulate matter. Wound toilet should be per-
formed at the first available opportunity because bacterial counts
increase with time.
Debridement is the removal of foreign matter, necrotic and
devitalized tissue from the wound. Debridement aims to achieve
a clean, raw area that is well perfused and has a low bacterial
count. Surgical and mechanical debridement are commonly used
in acute wounds, whereas autolytic, enzymatic and biologi-
cal methods are more relevant in wounds presenting late or in
chronic wounds (Table 5).
Surgical debridement is the most rapid method and, in post-
traumatic wounds, involves excising subcutaneous tissue and
muscle until bleeding from the cut edges is satisfactory. Free-lying
bone denuded of periosteum must be removed. The skin must not
be undermined because the blood supply may be compromised.
Wound closure
Types of healing: the three types of clinical wound healing depend
on the timing and method by which wound closure is achieved.
Primary closure (healing by primary or first intention) refers
to a wound which, when mechanically closed by approximation
of wound edges, heals without complications at the first instance.
Advantages of primary closure are good cosmetic effect and
shorter time to clinical healing. Primary closure is the preferred
method of closure for clean wounds with minimal tissue loss.
Primary closure should ideally be performed within 68 hours
of trauma. However, wounds in vascular areas (e.g. face, scalp)
may be closed up to 24 hours after trauma.
Secondary closure (healing by secondary or second inten-
tion) occurs when a wound which is left open heals largely by
formation of granulation tissue and contraction. Wounds that are
candidates for secondary closure include those with significant
tissue loss precluding tension-free approximation of edges, de
vitalized edges, ulcerations, and abscess cavities. There is evi-
dence that the wound contraction that occurs with secondary
healing gives a better cosmetic result than early skin grafting in
certain situations (e.g. healing of fasciotomy wounds).
Tertiary closure (healing by tertiary or third intention) is
the delayed closure of a wound after a variable period of time for
which it has been left open. In general, tertiary closure is applied
to wounds that are grossly contaminated or present late, but do
not have significant tissue loss. Wounds that need to be consid-
ered for delayed primary closure include those contaminated by
soil, manure or faeces, caused by animal bites or projectiles. Such
wounds need a thorough wound toilet, exploration and debride-
ment, after which they are observed for 37 days before closure.
The term secondary suture is usually applied when a wound is
left open for >10 days, allowing the formation of clean granula-
tion tissue before mechanical closure can be undertaken.
Modes of closure: there are two types
Direct closure is the closure of wound by approximation of the
wound edges. Wound closure includes ensuring a clean wound
with satisfactory vascularity and haemostasis, and apposition
without tension, inversion or dead space.
Tension in the wound may be reduced by the use of subcu-
taneous sutures or undermining of the wound edges. Eversion

Debridement

Type Description

Surgical Excision of devitalized tissue and particulate matter using sharp instruments. Useful in the following wound types: post-
traumatic, infected or necrotic postoperative, chronic.
Mechanical Forced irrigation of saline from a 50 ml syringe through an 18-G catheter applies about 15 pounds per square inch of pressure
to remove loose necrotic tissue.
An alternative is the wet-to-dry dressing method, in which a moist gauze dressing is allowed to dry on the wound. Removal
without wetting results in removal of fibrin and slough. This method as often insufficient, can be painful and may damage
underlying epithelium.
Topical negative pressure (vacuum-assisted closure) removes exudate and necrotic tissue, and is used in a variety of wounds
to reduce the size of the defect (e.g. laparostomies, wounds after pilonidal sinus excision).
Autolytic An occlusive dressing applied to the wound allows wound proteases to liquefy the necrotic tissues, which may be washed
away at dressing changes.
Enzymatic Collagenase liquefies collagen and elastin (but not fibrin); papain with urea degrades fibrin and collagen. Enzymatic debriding
agents should be applied only on non-viable areas of the wound. They are expensive and have a limited role in selected
chronic wounds.
Biological Medical-grade larvae of Lucilia sericata are necrophagous and are useful in selected chronic wounds.

Table 5

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 Basic skills
can be achieved by using vertical or horizontal mattress sutures.
Dead space in clean wounds may be obliterated by deep subcu-
taneous sutures. However, overzealous closure tends to leave a
large volume of suture material in the depths and increases the
risk of infection. Sutures, staples, skin tapes and cyanoacrylate
glue are commonly used in direct closure of wounds.
Subcuticular sutures produce a better cosmetic result than
percutaneous sutures and are suitable in most postoperative
wounds. In post-traumatic wounds, interrupted percutaneous
sutures are preferred because they accommodate wound oedema
and allow efflux of wound fluid. The smallest-diameter suture
necessary to provide wound strength should be chosen. In the
face, a 5/0 or 6/0 suture is usually used; 3/0 or 4/0 sutures will
suffice in most other areas. Synthetic monofilament sutures are
the least reactive and are preferred to silk and catgut. Sutures
should be removed in:
48 hours in the eyelid
4 days in the face
710 days in the trunk
1012 days in the upper limb
1014 days in the lower limb.
Staples are inert, may be used in most straight lacerations and
are particularly useful if quick closure of skin is necessary. They
should be avoided in the hands, face and if imaging (CT, MRI) of
the area is planned.
Skin tapes do not leave scars and are suitable for superficial
wounds under no tension and for additional support for the
wound after suture removal. Another useful application is in avul-
sions with doubtful skin viability; for example, a pretibial injury
that leaves a distal triangulated flap, where suturing is contraindi-
cated but the flap needs to be replaced back on its bed.
Transplanted closure is the term used if non-native tissue
(e.g. skin grafts, skin flaps) is employed to achieve closure. Skin
grafting can provide wound cover in large raw areas that cannot
be closed by direct closure, for example:
wounds following avulsion injuries (especially injuries that
cause a distal flap in the leg)
SURGERY 26:2
raw areas resulting after wound excision for full-thickness
burns.
Split-skin grafts have a superior take rate, but poorer cosmetic ef-
fect when compared to full-thickness grafts. Skin should not be
grafted over bare bone, tendon, cartilage, major vessels or an irra-
diated area. Local or distant flaps are preferred to skin grafting if:
the wound bed is not very vascular
bare tendons or nerves are exposed
the wound is over a bony prominence
radiotherapy or repeat surgery is contemplated
better cosmetic effect is required.
Wound drainage: blood and wound fluid collecting within or
under a wound may give rise to:
pressure effects (vascular compromise, airway compromise,
pressure on nerves, compartment syndromes)
infectious complications (infected seroma, infected haematoma,
abscess)
unsightly swellings that may or may not be symptomatic.
Wound drainage is usually employed if the risk of a fluid collec-
tion is estimated to be high or unacceptable because of anatom
ical factors (which lead to pressure effects) or if the volume of
collection is anticipated to be high.
A closed system of drainage should be employed because it is
aseptic. Open systems such as wicks and corrugated drains cov-
ered with gauze swabs are not ideal for clean wounds (though
they may have advantages in selected contaminated wounds).
Drains may fail because of blocked or exposed holes, kinking, or
due to thick effluent or coagulum. Suction may make the drains
more efficient, but is contraindicated if the drain is close to major
vessels or bowel.
There are no evidence-based guidelines for the duration of
drainage because it depends on the site and complexity of the
wound, and the purpose it was employed for. The volume and
quality of the effluent should inform decision making. Leaving
the drain for too long may act as a foreign body, irritating the raw
area and be a potential nidus for infection.
47 2007 Elsevier Ltd. All rights reserved.