BY

PROF/ GOUDA ELLABBAN

 Wounds may be defined as

disruption of the normal
continuity of bodily structure
due to trauma, which may be
penetrating or nonpenetrating

 Incised wound:
caused by sharp instruments, if
there is associated tearing of
tissue it is called lacerated wound
Abrasion:
result from friction damage to the
body surface and it characterized
by superficial bruising and loss of

 Crush injury:
These are due to severe pressure, even
though skin may not be breached there
can massive tissue destruction also
there is massive edema which may
prevent wound closure
Degloving injury:
Result from sharing forces that cause
parallel tissue plane to move against
each other, e.g.: when a hand is caught
between roller or in moving machinery.
Large areas of apparently intact skin
may be deprived of their blood supply
by rapture of feeding vessels.

 Gunshot wounds:
May be low or high velocity. Bullets
fired from high velocity cause
massive tissue destruction.
Burn:
These are caused by heat,
electricity, irradiation and
chemicals.

 Classification:
Surgical procedure can be classified according to
the likelihood of contamination and wound
infection into:
1- Clean procedure :
Those in which wound contamination is not
expected and should not occur. e.g. incision for
a clean elective procedure when there is no
infective focus is encountered and no viscus is
entered ( hernia repair, thyroidectomy). Wound
infection rate is less than 1%
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2- Clean contaminated procedure:

There is no focus of infection is encountered
but significant risk is still present may be
because of the opening of viscus such as
colon. Infection rate is > 5%.
3- Contaminated:
When there is obvious spillage
or obvious
c
inflammatory disease, e.g. a gangrenous
appendix. Infection rate 15-20%.
4- Dirty wounds:
When there is a frank pus or gross soiling. E.g.
perforated large bowel or drainage of
subphrenic abscess. Infection rate is up to
40%.
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 The principle causes of wound infection

are the penicillin-resistant staph.aureus,
together with strept. Faecalis,
pseudomonas, coliform bacteria and other
bowel bacteria including bacteriodes.
With continuous use antibiotics, more
resistant strains of organisms are
appearing, such as methicillin-resistant
staph.aureus (MRSA) and the vancomycinresistant enterococcus (VRE).

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Risk factors of wounds

infection
Preoperative factors:
Local factors: pre-existing infection. e.g.
a perforated appendix or infected
compound fracture.
General factors: nasal carrier of
staphylococci or having skin infection,
malnourishment and immunosuppression
(Children elderly HIV patients
cancer patients diabetics).
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Operative factors:
1- Failure of adequate sterilization of instruments, surgeons
hands or dressings.
2- Nasal or skin carriers of staphylococci among the nursing and
surgical staff.
3- Site of wound:
common when alimentary, biliary or urinary tract is opened
allowing bacterial contamination to occur.
Wounds placed on poorly vascularized tissue, such as in
amputation because necrotic tissue is a good medium for
bacterial growth and a good supply is necessary to provide
access for the inflammatory cells.
Postoperative factors:
1- cross-infection from elsewhere on the patients body or from
other infected cases in the ward during dressing change or
wound inspection.
2- new infection due to contamination of the wound from the
nose or hands of the surgical or nursing staff.

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Clinical features
It usually become evident 3-4 days after operation.
1st sign is cellulitis around the margin of the wound, or
swelling of the wound with discharge from between
the sutures.
Fluctuation can be elicited when there is an abscess
or liquefying hematoma.
Crepitus may be present if gas-forming organisms are
involved.
The patient may have pyrexia and increase wound
tenderness
General effect of infection (malaise, anorexia,
vomiting)
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Managements
Established infection is treated by drainage,
antibiotics are given if there is spreading
cellulitis.
A wound swab or specimen is sent routinely for
bacteriological culture and sensitivity
determination.
The state of immunity against tetanus is
assessed and appropriate action taken.
Area of redness is mapped out so that its
extent can be monitored.
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Prevention
Careful patient preparation
Isolation of infected cases.
Elimination of carriers with colds or
septic lesions among the medical
and nursing staff.
Prophylactic use of antibiotic in high
risk patients
Meticulous attention to good
operating theatre and dressing
techniques
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 It is the disruption of the

continuity of an epithelial
surface .
It follows traumatic removal or
death and desquamatation by
disease of the whole or part of
an epithelium.
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Features of an ulcer
1- Edge:
It is the junction between healthy and diseased
tissue
Types:
A- slopping edge:
Reddish-purple an consist of new healthy
epithelium growing over the base of the ulcer.
Example: traumatic, venous ulcer, healing
ulcer

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B- punched-out edge:
The edge drops down at right
angle to the skin surface
It indicates a localized area of skin
loss surrounded by healthy tissue
Example: deep trophic ulcer,
ischemic, and syphilitic ulcer.

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C- Undermined edge:
The disease causing this type spread in
and destroy the subcutaneous tissue
faster than it destroys the overlying
skin
The overhanging skin is usually reddishblue, febrile and unhealthy
Example: chronic infection
( tuberculosis-carbuncle)

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D- Rolled edge:
It is necrotic at its center but
grows quite quickly at its
periphery so that it rises above
the surface of the skin.
Example: basal cell carcinoma

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E- everted edge:
Caused by a fast growing infiltrating
cellular disease. The growing portion
at the edge of ulcer goes up and
spills over the normal skin to
produce an everted edge
Example: sequamous cell carcinoma,
ulcerated adenocarcinom

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2- The base:

It consist of 3 types of tissue:

1-granulation tissue:
1st stage of healing process.
2-dead tissue:
It is also called slough
3-malignant tissue:
It is maybe slightly vascular or necrotic but
never develop granulation tissue

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3- Discharge:
May be serous, purulent,
offensive, copious or so slight
which dries into scab
It should be cultured to
determine the nature of
infective organisms.

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Deferential diagnosis of leg

ulcers
Venous ulcer complicating venous insufficiency.
Ischemic ulcer due to impaired arterial blood supply.
Neuropathic ulcer; particularly common in diabetics
where they are often compounded by ischemia due to
diabetics micro-angiopathy.
Malignant ulcer; a squamous carcinoma, often arising
on a pre-existing chronic ulcer, or an ulcerated
malignant melanoma.
Ulcer complicating systemic disease, e.g.: acholuric
jaundice, ulcerative colitis and rheumatoid arthritis.
Arteriovenous fistula-associated ulcer.
Repetitive self-inflected injury.
Gummatous ulcer of syphilis.
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 Ulceration due to venous hypertension is due to

deep veins incompetence although
incompetence of superficial vein may be present.
Usually seen in patients 40-60 years old but
severe disease can cause ulceration in young
adult and it can appears in children with
congenital venous malformation.
Women affected more than men.
Usually the patient has a history of deep venous
thrombosis, childbirth or immobilization in bed
for any reason.
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 The patient usually suffered from

aching pain, discomfort and
tenderness of the skin,
pigmentation and eczema for
months before an ulcer appears.
At 1st it is painful then it settles
down and become chronic. It is
rarely very painful.

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Site:
Usually it occurs around the medial malleoli not in the foot
because in this area the subcutaneous tissue is less well
supported than in foot.
The surrounding tissue shows signs of chronic venous
hypertension (indurations, pigmentation, warmth, redness,
and tenderness)
Edge:
It can be of any shape and size.
The edge is sloping and pale purple-blue in color.
Base:
The base is usually covered with pink granulation tissue but
in chronic ulcer there maybe fibrous tissue more than
granulation tissue.
It is shallow and flat, and fixed to the deep tissue
Discharge:
The discharge is serropurulent with a trace of blood
sometimes.
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Investigation:
Full blood count, blood glucose
determination.
Duplex ultrasound to defined
nature and distribution of disease
Ascending venography

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Treatment:

Medical:
If patient have co-morbidity, but it doesnt
increase healing.
Dressing.
Compression therapy:
- elastic, multiple or graduated.
- After healing, compression stocking to reduce
chance of recurrence.
Surgery:
- split-skin grafting to spread up ulcer healing.
- Correction of superficial venous reflux by
short and long saphenous surgery.
- Ligating medial calf perforating vein either
endoscopicaly or by open surgery.
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 It is caused by an inadequate blood supply.

Common in elderly with symptoms of
coronary or cerebral vascular disease but can
occur in the young.
It is very painful and they can cause rest
pain.
It can be of any size.
There is no signs of heeling and often they
get deeper and larger slowly.
The pulse maybe absent.
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causes:
1- Large-artery obliteration :
Atherosclerosis, embolism.
2- small-artery obliteration:
Raynauds disease, Scleroderma,
Buergers disease, embolism,
diabetes, radiation, trauma,
electrical burn
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 Site:
- usually it found at the tip of toes and over the pressure
area.
- Surrounding tissue are cold, pale, atrophic because also
they are ischemic . If it is warm. It suggest that the ulcer
is due to local factor.
Edge:
- The edge is punched-out and if heeling does begin the
edge becomes slopping.
Base:
- It may contain grey-yellow sloughing tissue and is often
infected.
- Often it is deep penetrating down to bone and underlying
joints.
Discharge:
- It doesnt bled but discharge a thin serous exudates which
is sometimes purulent.

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Investigation:
Angiography to reveal the filling of
leg vessels.
Duplex.
X-ray shows gas in the tissue
indicates anaerobic infection, an
may shows bony destruction if
osteomylitis occur.

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Angiogram showing
irregularity of
outline with stenosis
in left superficial

Treatment:
1- necrotic tissue; debridement
abscess; incision, drainage
gangrene; amputation
2- Dry dressing.
3- antibiotic should be administered
if there is associated infection.
4- surgical arterial bypass or
angioplasty.
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Clinical
features
Gender
Age

Ischemic ulcer

Venous ulcer

Men > women

Women > men

Usually presents > 60 years

Typically develops 40-60 years

Risk factors Smoking, diabetes,

hyperlipidemia and
hypertension

Previous DVT, thrombophilia,

varicose vein

Symptoms Severe pain unless there is

diabetic neuropathy

Pain but not severe, relieved

by elevation

Site

Pressure area (heel,

metatarsal head and base)

Medial and lateral malleoli

Edge

Regular, punched out

Irregular, with neo-epithelium

Base

Deep, green (sloughy) or black Pink and granulating

(necrotic) with no granulation
tissue, may involve tendon,
bone and joint

Surroundin Shows signs of ischemia (cold, Varicose eczema, indurations,

g skin
pale, atrophic.) WWW.SMSO.NET pigmentation, redness.

 Caused by local ischemia due to lack of

sensation in the tissue.
They are deep penetrating ulcer. Similar to
ischemic ulcer occur in pressure area but
the surrounding tissue are healthy and have
a good circulation.
The foot is well nourished, healthy and often
has hair.
Good dorsalis pedis and posterior tibial
pulses.
It is warm, deep penetrating ulcer.
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Diagnostic feature:
1- They are painless.
2- The surrounding tissue are
unable to appreciate pain.
3- The surrounding tissue is
healthy and have a normal
blood supply.
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Causes:
1- Peripheral nerve injury:
Diabetes, nerve injury, leprosy.
2- Spinal cord lesions:
Spina bifida, tabes dorsalis,
syringomyelia.

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 DM can be associated with true

ischemic ulcer due to large vessels
atherosclerosis, also it can be
associated with neuropathic ulcer
due to peripheral neuritis.
Neuropathic ulcer
Ischemic ulcer
Painless
Painful
Normal arterial pulse Reduced arterial pulse
Loss of sensation
Variable sensory
finding
Warm foot
Cold foot
Planter ulceration
Toe ulceration
No intermittent
claudication
Intermittent
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claudication

Investigations:
1- blood glucose level.
2- CBC; leukocytosis.
3- swab for culture and sensitivity.
4- biopsy.
5- nerve conduction test to confirm
diagnosis of neuropathy.
6- arteriogram.
7- LFT, PT, PTT to prepare for surgery.

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Treatment:
1- control of diabetes.
2- incision and removal of dead tissue.
3- dry dressing.
4- antibiotic if infected.
5- skin graft.
6- follow-up and education.
7- if failed; amputation

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1- squamous ulcer carcinoma (Marjolins

ulcer):
Arise in a long standing benign ulcer or scar.
The commonest ulcer to become malignant is a
longstanding venous ulcer.
The scar that is most often associated with
malignant change is the scar of an old burn.
It has the same characteristics of ordinary
squamous carcinoma but the edge is not always
raised and everted.
This type is not so invasive, slower growing and
slightly less malignant

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2- Malignant melanoma:
Because the tumor cells multiply,
so the overlying epithelium
become anoxic and either
ulcerates spontaneously or break
after minor injury.

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