Baghdad University Surg Depart
SurgeryHameed Ali Al-Timmemi MSc, PhD
Wound Management
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Referances Fossum,T W., Hedlund, C., Johnso,A., Schul, K., Seim, H., Willard, M., Bahr, A., Carroll, G. and Knap, K. (2007). Small Animal Surgery, 3rd Ed., St. Louis, Missouri
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Surgical Anatomy Skin composed of Epidermis: outermost layer, avascular Dermis: lies deep to the epidermis, Associated adnexa: (hypodermis)
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Terminal arteries and veins branch from direct cutaneous vessels and Form Subdermal (deep) plexus Cutaneous (middle) plexus Subpapillary (superficial) plexus
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Wound: Disruption of normal tissue integrity. Wound Healing Wound healing is a biologic process that restores tissue continuity after injury. It is a combination of Physical Chemical, and Cellular events that restore wounded tissue or replace it with collagen.
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Wound Classification: A: According to the etiology Abrasion wound Laceration wound Avulsion (degloving injuries) wound Puncture wound Crush wound Burn wound
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
B: According to the skin involvement Open wounds: When the whole thickness of skin is opened (Laceration and skinloss) Closed wound: Skin is contact (not opened) and contusion.
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
Surgery
Dr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
C: According to the condition (Clinically) of the wound Clean wound Clean-contaminated wounds Contaminated wounds Dirty and infected wounds
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
Surgery
Dr H, Al-Timmemmi
Vasoconstriction is mediated by catecholamines, serotonin, bradykinin, and histamine.Platelet aggregation and blood coagulation form a clot that ensures hemostasis and provides a scaffold for cell migrationPlatelets also release potent chemoattractants and growth factors (epidermal, platelet-derived, transforming growth factors: a and b) that are necessary in later stages of wound healingFibrin and plasma transudates fill wounds and plug lymphatics, localizing inflammation and “gluing” wound edges together.
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Macrophages secrete Collagenases, removing necrotic tissue, bacteria, and foreign material. Gowth factors andchemotactic d. (i.e., PDGF, TGF-a, b, FGF, and IL-1) can initiate, maintain, and coordinate formation of granulation tissue. Chemotactic factors (i.e., complement, collagen fragments, bacterial endotoxins, and inflammatory cell products)
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Recruit mesenchymal cells, stimulate angiogenesis, and modulate matrix production in wounds. Platelets release growth factors important for fibroblastic activity. Lymphocytes appear later in the debridement phase
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Surgery
Dr H, Al-Timmemmi
3. Repair phase: Usually begins 3 to 5 days after injury Macrophages stimulate deoxyribonucleic acid (DNA) and fibroblast proliferation. Cytokines, in concert with extracellular matrix molecules, stimulate fibroblasts in the surrounding tissue to proliferate. A tissue oxygen content of approximately 20 mm Hg and slight acidity also stimulate fibroblast proliferation and collagen synthesis.
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Fibroblasts originate from undifferentiated mesenchymal cells in surrounding connective tissue and migrate to wounds along fibrin strands in the fibrin clot. The amount of collagen reaches a maximum within 2 to 3 weeks after injury. Capillaries invade wounds behind migrating fibroblasts by the process of angiogenesis which relying on interaction of extracellular matrix with cytokines that stimulate migration and proliferation of endothelial cells.
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Epithelial cells in the layers behind these altered cells migrate over them until they contact the wound surface. The migrating cells move under scabs and produce collagenase, which dissolves the base of the scab so it can be shed. Wound contraction reduces the size of wounds subsequent to fibroblasts, reorganizing collagen in granulation tissue and myofibroblast contraction at the wound edge Wound contraction involves a complex interaction of cells, extracellular matrix, and cytokines. Wound contraction stops when wound edges meet, when tension is excessive
Baghdad University Surg Depart
Surgery
Dr H, Al-Timmemmi
4. Maturation phase Wound maturation begins once collagen has been adequately deposited in wounds (17 to 20 days after injury) and may continue for years. The cellularity of granulation tissue is reduced as cells die. There is also a reduction in collagen content of the extracellular matrix
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Nonfunctionally oriented collagen fibers are degraded by proteolytic enzymes (matrix metalloproteinases) secreted by macrophages, epithelial cells, endothelial cells, and fibroblasts within the extracellular matrix. As the number of capillaries in fibrous tissue declines, the scar becomes paler. Scars also become less cellular, flatten, and soften during maturation. Collagen synthesis and lysis occur at the same rate in maturing scars.
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Type of wound healing Healing by first intention Healing by 2nd intention Healing by 3rd intention Healing by mixed intention Healing under scab:
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Treatment of Wounds Clean wounds Contaminated wound Treatment of infected wound
Baghdad University Surg Depart
Surgery
Dr H, Al-Timmemmi
Wound Closure 1. Primary wound closure: Wounds may be closed immediately (within 1 to 3 days after injury). 2. Delayed primary wound closure: when they are free of infection but before granulation tissue has appeared 3. Secondary closure: after the formation of granulation tissue 4. Secondary intention: allowed to contract and epithelialize
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Factors that affect the decision to close wounds include the following: Howlong time that has elapsed since injury. wounds older than 6 to 8 hours are initially treated with bandages Degree of contamination Amount of tissue damage Completeness of debridement Status of the wound's blood supply
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
6. The animal's health 7. Extent of tension or dead space 8. Location of the wound
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Factor effect wound healing: A. Local factors that Influence healing 1. Oxygenation 2. Infections: 3. Foreign body 4. Venous sufficiency B. Systemic factors that influence healing Age Sex Hormones Diabetes
Baghdad University Surg Depart
Surgery
Dr H, Al-Timmemmi
4. Stress 5. Medications 6. Obesity 7. Nutrition
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
Complication of wound: Bleeding Syncope Shock Traumatic neuralgia Damage to nerve Traumatic emphysema Traumatic fever.
Baghdad University Surg Depart
SurgeryDr H, Al-Timmemmi
8. Cellulitis. 9. Erysipelas 10. Septicemia & pyemia. 11. Venous thrombosis and embolism 12. Gas gangrene