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The Skin

Definition An injury created when skin is breached, which may occur traumatically or surgically, and initiates a chain of events that should end with wound healing

Types of Wounds
Abrasions- superficial wounds in which the epidermis is scraped off Avulsion- an injury that tears a whole piece of skin and tissue loose or leaves it hanging as flap Incisions- wounds produced by a sharp edge, eg a knife or razor Lacerations- irregular tear-like wounds caused by some blunt trauma

Puncture wounds- wounds produced by pointed objects, resulting deep damage through the skin Penetration wounds- caused by an object (eg a knife) entering and coming out from the skin Gunshot wounds- caused by a bullet/similar projectile driving into and through the body

Abrasion Avulsion

Hand abrasion



Puncture wounds

Closed wounds I. Contusions (bruises) II. Haematomas III. Crush injury

Definition A mechanism whereby the body attempts to restore the integrity of the injured part

Healing process is divided into 3 stages: I. Inflammatory phase II. Proliferative phase III. Remodeling (maturing) phase

Inflammatory phase
Begins immediately after wounding and lasts 2-3days Bleeding is followed by vasoconstriction and thrombus formation to limit the blood loss Platelets then release cytokines eg PDGF, platelet factor IV, and TGF , which in turn attract inflammatory cells (PMN lymphocytes and macrophages) into the wound bedchemotaxis

Platelets and local injured tissues release So what are the vasoactive amines eg histamine, serotonin and cardinal features of acute inflammation? prostaglandins, which increase vascular permeability and aid in infiltration of inflammatory cells- acute inflammation Macrophages remove debris, dead cells and bacteria by the process of phagocytosis

Proliferative phase
Last 2-4weeks (from 3rd day to 3rd week) Consist mainly of fibroblast activity with production of collagen and ground substance (glycosaminoglycans, proteoglycans), angiogenesis and re-epithelisation of wound surface Fibroblasts require vitamin C to produce collagen

Wound tissue formed in the early part is called granulation tissue, later, there is a increase in tensile strength of the wound due to increased collagen (type III, deposit in random fashion)

Remodeling phase
Maturation of collagen (type I replacing type III in a ratio 4:1) Realignment of collagen fibres along lines of tension, decreased wound vascularity and wound contraction due to fibroblast and myofibroblast activity

By primary intention By secondary intention

Healing by primary intention

Occur when fresh wound edges are opposed, by any means, within hours of injury Eg. Healing of a clean, uninfected surgical incision approximated by surgical sutures Because of minimal surrounding tissue trauma, it causes the least inflammation, normal healing and leaves minimal scar Delayed primary intention is used for contaminated, dirty wounds and when tissue viability is questionable

The wound is debrided, dressed and reinspected 24-48 hours later. Further debridement may be required before the wound is adequately clean for closure

Healing by secondary intention

Occur in the wound that is left open and allowed to heal by granulation, contraction and epithelialisation, eg in large wounds, abscess formation and ulceration Increased inflammation and proliferation, leaving poor scar For small wounds, this may leave an excellent cosmetic result; for larger wounds, this will result in deposition of scar tissue, contracture and deformity, particularly if it lies over a joint surface

Secondary healing differs from primary healing in: I. A larger clot/scab rich in fibrin and fibronectin II. Inflammation is more intense III. Mush larger amounts of granulation tissue are formed IV. Involve wound contraction

Wound strength
The recovery of tensile strength results from collagen synthesis exceeding degradation during 1st 2 months, and from structural modifications of collagen (crosslinking and increased fibre size) when synthesis declines at later times Wound strength reaches 70-80% of normal by 3 months but usually does not substantially improve beyond that


1. Sites of wound 2. Structures involved 3. Mechanism of wounding -Incision -Crush -Crush avulsion 4. Contamination 5. Loss of tissues

6. Other local factors -vascular insufficiency ( arterial/venous) -Previous radiation - pressure 7. Systemic factors -Malnutrition/vitamin & minerals deficiency -Disease ( DM ) -Medication ( Steroids ) -Immune deficiencies ( chemotherapy, AIDS) -Smoking


In clinical practice many wounds are slow to heal and difficult to manage. The recently introduced technique of topical negative pressure therapy (TNP) has been developed to try to overcome some of these difficulties.

Negative-pressure wound therapy (NPWT) is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of first and second degree burns. The therapy involves the controlled application of subatmospheric pressure to the local wound environment,using a sealed wound dressing connected to a vacuum pump. The use of this technique in wound management increased dramatically over the 1990s and 2000s and a large number of studies have been published examining NPWT. NPWT appears to be useful for diabetic ulcers but further research is required for other wound types.

Topical negative pressure (TNP) therapy has emerged as a high-technology, microprocessor-controlled physical wound-healing modality. Complex effects at the wound-dressing interface following application of a controlled vacuum force have been documented. These include changes on a microscopic, molecular level and on a macroscopic, tissue level: interstitial fluid flow and exudate management, oedema reduction, effects on wound perfusion, protease profiles, growth factor and cytokine expression and cellular activity, all leading to enhanced granulation tissue formation and improved wound-healing parameters. Primary indications for clinical use have been documented and include traumatic wounds, open abdominal wounds, infected sternotomy wounds, wound bed preparation, complex diabetic wounds and skin-graft fixation. Whilst this therapy now forms an essential part of the wound healing armamentarium, extensive clinical trials are recommended to confirm efficacy and delineate its optimum use.

Application of a vacuum pump using a foam dressing to a wound

Pump used to create negative pressure

Acute wound 1. Cleansing 2. Exploration & diagnosis 3. Debridement 4. Repair of structures 5.Replacement of lost tissue when indicated 6. skin cover if indicated 7. Skin closure without tension 8. All of above with careful tissues handling & meticulous technique

Mx of Different Type of WOUNDs

General principles of Mx of wound

Admission or observation in hospital Monitoring of temperature, pulse and respiration Systemic antibiotics depending upon the contamination of wound Injection tetanus toxoid for prophylaxis against tetanus Treatment of the wound in the form of cleaning, dressing or suturing

Cleaning & bandage

Arrest the bleeding

Splint, if there is fracture


IV line, transport



ADMITTING THE PATIENT Immediate first aid: A, B, C 1) Check the airway. Be prepared to pass an endotracheal tube, or to perform a tracheostomy. 2) Check the breathing. Place a chest tube or a wide-bore needle in patients with an evident tension pneumothorax. Cover and seal a sucking chest wound. 3) Arrest haemorrhage (circulation). 4) Place an intravenous cannula, take blood for blood grouping and possible cross-matching and start intravenous crystalloids. 5) Start treatment of shocked patients immediately. 6) Give benzyl penicillin 5 million units intravenously (see Chapter 6). 7) Give human anti-tetanus immunoglobulin (HAI) 500 IU intramuscularly, and start a course of tetanus toxoid.

Then, take the history and other relevant information are recorded on the admission chart. And its very important to note the weapon cause the injury and also the time has elapsed since injury Next, Assess the patient. The aim of the initial examination is to know whether the patient is shocked and requires resuscitation, and to assess the extent of wounds

Signs of shock are a rapid and possibly weak pulse, reduced blood pressure, pallor, sweating and cold skin. Severely shocked patients may complain of thirst, and maybe excessively agitated, nauseated, confused and anxious, or quiet and apathetic. The respiratory rate is increased. Signs of shock may be misinterpreted as being secondary to head injury and shock can thus be missed in patients who have sustained a head injury.

Always record the blood pressure, pulse and respiratory rate and whether the patient is shocked. Start treatment immediately for those who are in hypovolaemic shock; blood volume must be replaced. Continue monitoring such patients by observing urine flow, by means of an in-dwelling Foley catheter. Low blood pressure with no other signs of shock points to an injury to the spinal cord. Signs of respiratory distress raise the possibility of an unstable segment of the chest wall or a haemo-pneumothorax.

Assessment of the wound It is wise to take down dressings to look at wounds before the patient goes to the operating theatre. Dressings on traumatically amputated limbs or very large wounds may be left in place as the extent of injury and the necessity for operation are evident. All wounds must be assessed; the doctor must observe their site and size and consider what deeper structures may be involved

Radiological assessment X-ray films are taken in two planes and can provide a great deal of information. Chest and abdominal X-rays are best taken with the patient upright. The absence of X-rays should not prevent sound surgical treatment of war wounds. Look for: 1) The position of metallic bodies: but remember that X-rays can be misleading and difficult to interpret unless it is known exactly in which planes the films were taken. 2) The presence of fragments of a bullet which has broken up: this indicates that there will be extensive tissue damage. 3) The type and exact position of a fracture: this will indicate the best method of fracture immobilization. 4) The extent of bone destruction: this may help decisions about the need and level of amputation. 5) The presence and amount of air and blood in the pleural cavity: this will help the decision as to whether to place chest tubes and on which side to place them. 6) Intramuscular or intrafascial gas


For distal limb wounds, a pneumatic tourniquet is invaluable in the initial surgery. Application before removal of field dressings minimizes blood loss and produces a bloodless field which facilitates wound excision Surgical objective is the removal of all dead and severely contaminated tissue and all loose foreign material which would serve as a culture medium for bacterial growth. An important consequence of wound surgery is that it allows decompression of adjacent healthy tissues. Failure to remove dead and contaminated tissue causes most post-operative wound infection.

An incision in the line of the limb allows decompression of muscles. The commonest mistake is to make incisions too short. Swelling is an inevitable consequence of injury and can be sufficient to compromise the local circulation and lead to further tissue death; extension incisions prevent this. With through-and-through wounds the skin incisions and muscle dissection are based on both the entry and the exit and may meet. The entry site of some wounds may, however, not need surgery.

Subcutaneous fat: Fat has a poor blood supply and contributes nothing to healing. Dirty, contaminated fat should be generously excised, especially around the buttocks and posterior aspect of the thighs Muscle, tendon and fascia: All heavily blood-stained and contaminated fascia, either on the surface or between muscles, should be excised. Incisions of muscle fascia may be required to see the extent of damage. Individual muscles and tendons are bluntly dissected and their damaged part excised back to healthy tissue. Viable muscle is recognized by its colour, bleeding, texture and contractility. Dead muscle fails to bleed, fails to contract when pinched, is darker than normal and feels different in consistency; it often disintegrates when held with forceps. Bone: When the wound includes a fracture, that part of the bone must be displayed. Unattached bone fragments must be removed: if left in situ they act as a nidus for chronic wound infection and will not serve as a bone graft. Exposed medullary bone must be curetted back to firm marrow. Exposed cortical bone can be left in situ if not stripped of its periosteum by the injury

Major nerves and vessels: repaired vessels should not be left exposed but need covering by viable muscle and may require a muscle flap. Nerves exposed after wound excision can be left without soft tissue cover until delayed closure

Foreign material: Within the wound there may be pieces of metal, plastic, clothing, extraneous bone fragments, mud, earth and other debris. All that is loose must be removed. Foreign material and loose bone fragments can be felt in the wound depths. As part of the excision, remove all mud, earth and clothing which are embedded in tissue, as they are potent sources of infection if left behind. Mine injuries often contain mud and earth which have been projected into the tissues and are particularly troublesome if not completely removed. Small embedded metallic fragments, however, are not only difficult to find but their removal is unnecessary and hazardous. If they come away with tissue which requires excision this is good, but an exploration should not be made for them. Prolonged surgery to locate bullets and fragments that have come to rest in undamaged tissue is unnecessary and dangerous; they should be removed later if symptoms subsequently occur.

All wounds are left open and covered with a dressing with the exception of wounds of the face, scalp, neck, buccal mucosa, dura, peritoneum, pleura and synovium of joints, which are closed primarily. A large quantity of dry, bulky, loosely applied, fluffed up gauze is placed on the wound. Gauze moistened with normal saline can be used over tendons, joints and exposed bone. Cavities are not packed. The function of this dressing is to absorb blood and serum which exudes from the raw surface of the wound. Vaseline gauze, with or without antibiotics or antiseptics, and special non-adherent dressings should not be used.

Post-operative orders are essential and include antibiotic protocols, intravenous fluid regimes, nursing positions, and instructions about physiotherapy. Patients with head or chest wounds should be nursed sitting up. Legs and amputation stumps are best elevated on pillows or Braun frames and passive mobilization of joints should be started early. Arms may be placed in slings or elevated using a sling and a drip stand.

All penetrating wounds: all patients receive penicillin intravenously and human antitetanus immunoglobulin intramuscularly, and start a course of tetanus toxoid. An intravenous cannula is placed for administration of penicillin, except for patients with such minor wounds that they would not be admitted to hospital. Five million units of benzyl penicillin are given intravenously on admission and repeated 6-hourly for 24 hours. This is followed by oral penicillin V 500 mg 6-hourly until the fifth day. In particularly severe limb wounds, the intravenous penicillin may be continued for 48 hours. Erythromycin, chloramphenicol or a cephalosporin is substituted in case of penicillin allergy. All patients receive 500 IU of human anti-tetanus immunoglobulin (HAI) intramuscularly and begin a course of tetanus toxoid. Penicillin is used because the dangerous organisms Streptococcus pyogenes, Clostridium welchii, and Clostridium tetani are always sensitive to it.


The ideal time for wound closure is between four and six days after primary surgery. Post-traumatic swelling has diminished and the early processes of wound healing are under way. Wounds left longer than this are indurated and inelastic, making apposition of tissues difficult

Good signs are: The wound is clean and red with bleeding which indicates early granulation tissue formation. The exudate in the deeper dressings has dried and the dressing itself is hard, a little like plaster of Paris. The gauze dressing on the raw wound is adherent and resistant to being gently peeled off. Bad signs are: a fever; a wet dressing that floats off, leaving a shiny, moist appearance with little bleeding; frank pus; skin erythema and dead muscle.

Direct suture and skin grafting are the most frequently employed methods of restoring integrity of skin cover. The decision to revert to healing by second intention should be a deliberate one. Very rarely are reconstructive procedures required

Direct suture
Wounds in which there has been little skin loss can usually be brought together without undue tension. The wound should be manipulated as little as possible and ideally no fresh planes should be opened. Undermining the skin may help to free the skin edges for apposition but has the disadvantage of causing further bleeding. If a haematoma results, closure may fail. Leaving a drain in place may help reduce the problem of haematoma. A balance has to be found between undermining the skin edges, with the risk of a haematoma, and the need to close the wound with minimal tension. It is advisable to limit the undermining of skin to a 2-cm wound margin on limbs and a 3-cm margin on central wounds



A scar is an inevitable consequence of wound repair. The final phase of wound repair is the process of remodeling and scar maturation. The fibroblasts, capillaries, glycosaminoglycans, and glycosaminoglycans, immature collagen of granulation tissue and the newly healed wound are replaced by relatively acellular, acellular, avascular scar tissue, composed of mature collagen with scattered fibroblasts. Manifested by a change in appearance of the scar from a red, raised, firm, contracting, sometimes itchy area to a pale, flat, softer, static, symptomless plaque of mature scar.

Factors that affect a scar maturation:


Wound : clean incised edges, no tissue loss. Age : scars in older people mature quickly compared to a young person. Site : thin-skinned areas, e.g. face, eyelids, genitalia, thinpalms, vermilion. Time :wound that healed rapidly by first intention, not infected, no scar dehiscence. Direction : aligned with skin wrinkles, junction, or relaxed skin tension line. Tension : scars that have minimal tension across them.

Types of scars:

Normal scars :form after 2-3 weeks, initially appearing pink or 2red and raised, and then flattened to a linear white line. Adverse scars : Wrong direction Poor alignment of features Stretched scar Contracted scar Pigment alteration Contour deformity Tattooing Stitch marks Hypertrophic scar Keloid scar


Wrong direction : Incisions that pass along ideal lines are more likely to have acceptable scars E.g. Line which pass along skin wrinkles or along relaxed skin tension lines, at junctions between anatomical areas, such as the nose and the cheek or the cheek and the ear, or the junction between a hairy and hairless area. A scar which crosses these lines will have a greater tendency to stretch or become hypertrophic or appear more conspicuous. Poor alignment of features : Where a scar crosses the junction between distinct anatomical features, such as the vermilion of the lip, it is essential that these features are accurately realigned. Such misalignments result in conspicuous adverse scars.




Stretched scar : Scars from excisional wounds on the trunk and limbs often stretch as it have greater skin tension. The width of scar depends on the tension across the wound at the time of wound closure. Prolonged wound support with buried non-absorbable or long-term nonlongabsorbable sutures can minimize scar stretching. Contracted scar : The process of wound contraction continues in the remodeling phase of scar maturation such that a scar will always be shorter than the incision from which it results. Where a linear scar crosses a flexor surface, this may result in a scar contracture. When scarring is extensive, scar contractures may be inevitable, for example, in burn scars. Linear scar contractures can be corrected by realignment of the scar. There are various techniques to do this, includind the Z-plasty and Zmultiple Y-V plasty. More extensive contractures will require release Y- plasty. and introduction of additional skin by means of grafts or flaps.


Pigment alteration : The new epidermis of a scar will often not have the same degree of pigmentation as surrounding unscarred areas. Most scars are hypopigmented, but hyperpigmentation can also hypopigmented, occur. The only ways to deal with this problem are cosmetic camouflage or tattooing. Contour deformity : When wound edges are not anatomically aligned in the vertical plane, or if a bevelled cut is not repaired accurately, there is a risk of contour irregularity in the healed scar. This can usually be avoided by accurate wound repair, excising bevelled edges if necessary to restore even vertical edges for repair.




Tattooing : In traumatic wounds, it is possible for particles of girt, dirt, or soot to become implanted in the wound as it heals which results in tattooed scars in which the particles of foreign material show through as blue or black discoloration of the scar. Adequate primary wound management can prevent this. Abrasions in which dirt is ingrained should be scrubbed with a stiff brush; more deeply tattooed wounds should be excised. Stitch marks : If skin sutures are left in place for more than 7 days then scars from the stitch marks will usually result. This problem can be avoided by using subcuticular sutures wherever possible, removing skin sutures after 7 days and, where prolonged wound support is needed, supplementing skin sutures with subcuticular sutures, allowing early removal of the skin sutures. Adverse scars due to prominent stitch marks can rarely be improved by scar revision.



Hypertrophic scars : In some circumstances, scars remain in the remodeling phase for longer than usual. These scars are more cellular and more vascular than mature scars; there is increased collagen production and collagen breakdown, but the balance is such that excess collagen is produced. Clinically, these scars are red, raised, itchy, and tender. It will eventually mature to become pale and flat, and it is this spontaneous resolution that distinguishes it from keloid scars. Hypertrophic scars typically occur in wounds whose healing was delayed, perhaps because of complications such as infection or dehiscence occurred. It is more common in children and where skin tension is high, such as at the tip of the shoulder or across relaxed skin tension lines. Massage of the scar with moisturizing cream or the application of pressure to the remodeling scar can accelerate the natural process of maturation.


Patients with hypertrophic burn scars are supplied with customcustommade Lycra pressure garments that promote acceleration of scar maturation. Revision of hypertrophic scars is appropriate if they cross skin tension lines or if a specific wound-healing complication occurred. woundIn the absence of these factors, scar revision should be avoided as it will usually be met with recurrence.



Keloid scars : In some situations there is an extreme overgrowth of scar tissue beyond the limits of the original wound and which shows no tendency to resolve. Ti is biologically identical to hypertrophic scars, which, in turn, are an extension of normal scar behaviour. behaviour. Keloid scars are more common in Afro-Caribbean and Oriental Afroracial groups. They often occur in wound that healed perfectly without complications. They are more common in some sites such as the central chest, the back and shoulders, and the ear lobes. Many keloid scars are untreateble, and surgical treatment as a untreateble, single modality will usually be met with recurrence.


Some keloid scars will improve with the application of pressure. Intralesional injections of steroids such as triamcinolone can be helpful. The best cure rates are achieved with a combination of surgery and postoperative interstitial radiotherapy.

Comparison of hypertrophic and keloid scars:

Features Genetic Race Sex Age Borders Natural history Site Aetiology Increased risk Hypertrophic scar Not familial Not race related Female = male Children Keloid scar May be familial Black > white Female > male 10 30 years

Remains within wound Outgrows wound area Subsides with time Flexor surfaces Related to tension Not affected by pregnancy/ puberty Rarely subsides Face, chest, shoulder, ear lobes Unknown Increased risk in pregnancy and puberty

Management :

There is no universal treatment for abnormal scars. Prevention of formation of poor or abnormal scar is the primary treatment to consider. Most unsatisfactory scars should be left alone for at least 1 year to allow scar maturation before a decision is made about treatment. Preventing formation of a poor/ abnormal scar: Attention to patient population: careful planning in those prone to hypertrophic/ keloids Orientate scar along relaxed skin tension lines Decrease wound tension ( direct closure of appropriately sized wounds only, otherwise use of skin grafts or flaps) Careful selection of suture material Minimize tissue hypoxia by correct laying/ tension of sutures Optimize handling of soft tissue Vertical incisions (bevelled incisions for hairy areas to minimize hair loss) (bevelled Postoperative hypoallergenic taping/ silicone gel/ sheets as preventive measures


Pressure : Compressive garments (e.g. Tubigrip, zinc oxide plaster, customTubigrip, custommade splinting) may be helpful for hypertrophic scars and contractures. The mechanism of action of pressure dressings is unknown, but may include localized hypoxia causing degradation of fibroblasts and collagen. Garments should be worn 24 hours a day and optimal results occur after 6-12 months and; patient compliance can be a 6problem. Adhesive micropore tape may be effective as a preventive measure; its action is thought to be partly through pressure and partly occlusive (by maintaining hydration).

Medical treatment :


Silicone gel sheets and cream: The sheets are of variable thickness and formed from crosslinked polymers. They are thought to work by occlusion, increasing hydration to the scar. Side effects are local irritation, skin breakdown, and poor compliance (they should be worn 24 hours a day for up to 1 year). They are effective and are widely used to manage hypertrophic and keloid scars.



Corticosteroids : Intralesional injections of corticosteroids (e.g. 40mg/mL 40mg/mL tramcinolone acetonide at intervalls of 4-6 weeks until the scar 4flattens or discomfort is controlled) can be used to treat hypertrophic and keloid scars. More successful if combined with surgical excision. Side effects include pain of injection, hypopigmentation, hypopigmentation, ulceration, and systemic response.


The use of radiation is controversial due to the potential for malignant transformation, and is not recommended in children or near radiosensitive area (e.g. breast, thyroid). It is most effective immediately after surgical excision and some studies have shown a prevention of keloid recurrence in about 75% of patients at 1 year follow-up. followThe dose used is usually 1500Gray,delivered in fractions within the first 10 days postoperatively. Using high-dose-rate iridium-192 brachytherapy after high-doseiridiumsurgical excision of keloid scars is effective in preventing the recurrence. Laser therapy : Useful because they are precise and haemostastic, causing haemostastic, minimal trauma to tissue. 3 types of laser can be used : pulse-dye, pulseneodymium:yttrium, neodymium:yttrium, and erbium:yttrium. erbium:yttrium. Combining laser treatment with corticosteroids reduces symptoms of previously resistant keloid scars.




Cryotherapy : Liquid nitrogen can be effective if applied to small hypertrophic scars, severe atrophic scars and some keloids. keloids. It is applied in 1-3 freeze cycles (from 10-30seconds) 110every 20-30days. Treatment is delayed to allow 20postoperative healing to take place. The mechanism of action is cell damage, resultant necrosis, and therefore decrease scar bulk. Adverse effect are pain and permanent hypopigmentation. hypopigmentation. Other therapies : There is little evidence for the topical use of creams (e.g. vit. E, allantoin-sulfomucopolysaccharide gel) in vit. allantoinscar management. Newer treatments (skin equivalents incorporating dermis constructs, ciclosporin, verapamil, imiquimod cream) are ciclosporin, verapamil, still in development.


Surgical treatment :



Scar revision : Revision should be considered only if the conditions for wound healing are more favourable than on the first occasion. Scars should be placed, if possible, along relaxed skin tension lines. A Z-plasty is one of the most versatile scar revision techniques Zbecause it aids reorientation of scars and breaks up the length of the scar, as well as increasing its total length. A Z-plasty lengthen a scar, so a linear scar contracture can also be Zimproved with this technique. If there is insufficient local tissue, release of the scar may necessitate importing tissue, in the form of skin grafts (partial/ full thickness), local, regional or evev free flaps. Large areas of scar can be managed with tissue expansion or serial excision. Surgical excision of keloid/ hypertrophic scars is most effective when keloid/ combined with radiation, corticosteroid injection or pressure therapy.

Z-plasty :

Y-V advancement flap to lengthen scar :

Thank you!