WOUND CLASSIFICATION AND ITS MANAGEMENT

Presented by: Dr. Dhiren B. Bhoi E. Mail:-drdhirenvet@gmail.com

DEFINITION
A wound is a break in the continuity of soft tissues A wound is defined as a separation or discontinuity of the skin, mucous membrane or tissue caused by physical, chemical or biological insult

CLASSIFICATION
Open wound
There is discontinuity in the skin and other covering tissues to a varying depth

Classification
Incised wound
Caused by sharp cutting instruments. Minimum loss to tissue tends to gap (the extent of gaping depends upon elasticity and tension). Edges are regular. Bleeds freely and painful. Heals by primary intension healing.

Lacerated wound Caused by tearing of tissues, Wounds have irregular jagged borders Loss of tissue is limited to skin and s/c tissue.

eg: barbed wire. Penetrated wound Cause by sharp pointed objects like nails Have relatively small opening. May be very deep. Infection/ foreign particles might have been carried deep in to wound opening is inadequate for drainage. eg: punctured wound on foot due to gathered nail.

 Perforating wound Have two opening one of entrance and other of exit. Punctured wound
Deep wounds communicating with cavities like adbominal, throrax,joints etc. eg: stab wounds

Gunshot wound Abrasions wound

Avulsion Bite wound Virulent wound

Caused by bacteria or virus. leading to formation of pustules or vesicles. eg: FMD, anthrax, TB organisms

Ulcerating wound Granulating wound Septic wound Aseptic wound

Closed wound/ internal wound

In closed or internal wound only deeper tissues, barring the skin or mucous membrane are damaged.

Classification
1. Contusion or Bruises Produced by blunt objects
Results in damage to subcutaneous tissue without breaking the continuity of the skin surface. Classified into 1st, 2nd and 3rd damages according to the extent or severity of the injury. .

 Mild degree of contusion characterized by rapture of capillaries in skin giving rise to a reddish blue or purplish condition of the skin (Echymosis). First degree: There is rapture of capillaries of the skin and subcutaneous tissue to form echymosis. Second degree: Larger vessels are raptured leading to the formation of haemetoma. Third degree: Tissues are considerdly damaged and gangrene may set in. the internal organs which may also be impaired and there might be evidence of impending shock.

2. Haematoma:
Collection of blood beneath the skin Caused by injury to a superficial vein. Frequently seen s/c or submucosally. Common sites of haematoma in various species

Cow: mammary vein(fall) vaginal mucous membrane (copulation) Bull: haematoma involving penis (copulation) Horse: spur vein / external thoracic vein Dog: ear flap, vaginal mucous membrane (copulation)

Symptoms
Local
General Remote

Local Symptoms
Hemorrhage
Pain Gaping of the edges of wound Phenomena of repair

General Symptoms
Febrile disturbances

Remote Symptoms
Observed away from the wound
Abscess formation in a dependent lymph node Paralysis or a loss of function in a dependent portion Neuritis extending along the course of the nerve involved in the wound.

Management of wounds
Contusions: are treated with cold and astringent applications to minimize extravasation.
Haematomas: when small get absorbed ,other wise they may have to be opened and treated. Open wound: surgical or aseptic wound/ contaminated and septic wound/ accidental traumatic wounds.

Surgical or aseptic wounds

A surgical wound made with all aseptic precautions in a non infected tissue is an aseptic wound. Surgeon should avoid drying of the tissue, excessive trauma and haemorrhage lower the wound infection. Prophylaxis against tetanus Drainage should be provided if haemotoma or seroma formation is expected.

 Suture should be supported up to healing time 8 -14 days Systemic use of specific antibiotics as a therapeutic or prophylactic measure. Local application of Fly repellents hot summer months. The patient and the affected injured part should be kept at rest

Contaminated and septic wounds

A fresh wound gets contaminated when it is more than 4 -5 hours old. Management is mainly directed towards overcoming factors like.
Type and number of invading micro organisms Type and location of the wound Poor blood flow at the wound site Effective ness of the treatment Presence of foreign material

Dead tissue at the wound site.

General principle
Control of haemorrhage: Bleeding is controlled and
ligating large vessels if any
Wound and its periphery should be thoroughly cleaned with warm normal saline, water, soap or 2% H2O2 5% dettol, 0.5% potassium permanganate
Clipping and shaving of large area around wound

Cleaning of wound/ irrigation of wound

The wound and surrounding areas are irrigated with mild, non irritant, antiseptic lotions: 1:1000 Per chloride of mercury lotion. 1:500 acriflavin lotion 1:40 Eusol lotion (Eupad is 1:40 bleaching powder + boric acid) 5 10 % hyper tonic salines. If wound is fresh suturing may be attempted Infected and deep penetrating wounds are not sutured Wounds that are not sutured should be irrigated daily or on alternate days Wounds of feet: warm antisepic foot baths may be given with 10% formalin

Wound debridement
Debridement for removal of devitalized or necrosed tissue is either done by excising the unhealthy tissue or by use of topical mendicaments

2.5% sodium chloride solution.

Magnesium sulphate and glycerin paste.

Control of infection

After irrigation and debridement wound may cover with

Moist antiseptic pad / antiseptic powder / ointment. Antiseptic powders, boric acid, eupad BIPP Ointments: Boric ointment, penicillin ointment, streptomycin, chloromycin ointment, terramycin ointment. Application of very strong antiseptics should be avoided as it will destroy granulation tissue.

Providing drainage
If there is exudation and discharge the wound should not be sutured.
Deep wounds fenestrated tube is advisable for drainage Deep wounds with narrow external opening may be enlarged for efficient drainage.

Counter opening may be made in a dependent part seton may be passed through it.

Immobilization of wounded area

If proper immobilization is not provided healing is delayed, formation of excessive granulation tissue (Exubeenrt granulation / pround flush) Application of caustics copper sulphate, potassium
permanganate

Accidental traumatic wounds

Check hemorrhage Avoid development of shock Prophylaxis against tetanus Cleaning, excision, debridement Systemic antibiotic treatment

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DETAILS OF WOUND HEALING

 A wound is defined as a separation or discontinuity of the skin, mucous membrane or tissue caused by physical, chemical or biological insult.
Wound healing is restoration of the tissue continuity

 Wound healing, is the foundation of surgery and complex process.

Always associated with process of inflammation. Inflammation is a local reaction of living tissues to an injury of microcirculaion and its associated tissues.

Wound Healing
First intension Second intension Mixed intension Third intension Healing under scab

Healing by First intension

Occurs in incised or surgical wounds, with minimal tissue damage and bleeding Repair begins in 12 hours by proliferation angioblast and fibroblast Healing is complited in about 14 days Scar formed is very little

 Wound should be clean and fresh Free form infection and bleeding Free from foreign bodies Edges should have good blood supply

Edges should have proper alignment and apposition

Healing by Sesond intension

By replacement of tissue
Wounds having extensive loss of tissue and edges widely separated Granulating tissue consist of budding capillaries and fibroblast, grows from edges and bottom to fill up gap

 Granulating tissue is velvety in appearance, soft, moist and pink in colour

Granulation tissue is called so due to granular appearance presented by budding capillaries Healing takes 14-21 days, in large wound with excessive loss of tissue it may take 42 days

Healing by Mixed intension

Wound healing is partly by first intension and partly by second intension
Happens when sutured wound has partially disrupted

Healing by Third intension

(Healing by secondary suture)
Granulating tissue are united by sutures for quicker healing

Healing under scab

In superficial wounds like abrasions
Exudate present in the wound dries and froms scab Granulation takes place under this scab

When granulation is complete the scab automatically separates and is cast off

Phases of wound healing

[A] Inflammatory phase: Immediate response to injury is acute inflammation Vasoconstriction of small vessels in the area Response last for 5-10 minutes and followed by active vasodilation

 Vasodilatation causes accumulation of exudate in the area

Dilatation is due to release of histamine, serotonin and bradykinin This causes swelling of vascular endothelial cells, creating gap between these cells

 Exudate provides fibrinogen and other clotting elements, which form fribin clots These clots plugs the damaged lymphatics, preventing further damage from injured area Inflammatory reaction is thus localized to a specific area surrounding the injury Redness, swelling and heat are seen during inflammatory reaction in the area

[B] Fibroblastic or Collagen phase: Begins at about 5th day Fibroblast are actively engaged in production of connective tissue matrix Fibrinogen in exudate is converted to fibrin by enzymes from blood and tissue cells

 Fibrin is laid down in the wound and provides a good frame work for repair besides haemostasis Collagen is synthesized by the fibroblasts
Few collagen fibers are present at the beginning but by 15th day wound gets good tensile strength Sutures are therefore removed about 2 weeks of surgery

[C] Maturation phase: It starts after collagen bed is laid Collagen fibers become thicker, denser and number of fibroblast decreases Pale scar is formed, full maturation of scar may take months or year

[D] Contraction phase: It involves movement of existing tissue at the wound edges resulting decrease in size of open wound Absence of attachment of the skin to the underlying structures allow maximal contraction Contraction has been reported to be a cell mediated phenomenon

Contractions near joints may result in the formation of tight band of scar tissue

Factors affecting wound healing

LOCAL FACTORS: Surgical technique Tissue vascularity Mechanical stress Movement Extent of wound surface Haemorrhages Foreign bodies Oedema and Dehydration Local irradiation Suture material and techniques Wound infection

 SYSTEMIC FACTORS: Age Obesity Malnutrition Vitamin deficiancy Anaemia and hypoxia Systemic disease Temperature

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