1. In the Name of Allah, the Most
Beneficent, the Most Merciful
And whosoever fears Allah and
keeps his duty to Him, He will
make a way for him to get out
(from every difficulty). (2) And
He will provide him from
(sources) he never could
imagine. And whosoever puts
his trust in Allah, then He will
suffice him. Verily, Allah will
accomplish his purpose. Indeed
Allah has set a measure for all
things. (3)
Surat Aţ-Ţalāq
Wounds, Wound Healing And Complications ELHAWARY
3. Wound Healing And Suture Materials
WOUND – WOUND HEALING
Wounds, Wound Healing And Complications ELHAWARY
4. Definition
• Type of injury in which skin is torn, cut or
punctured (an open wound), or where blunt
force trauma causes a contusion (a closed
wound)
• In pathology: it specifically refers to a sharp
injury which damages the dermis of the skin
Wounds, Wound Healing And Complications ELHAWARY
6. Classifications of wounds
wound
According to the
According to
exposure to the
level of risk of
outer
sepsis
environement
Wounds, Wound Healing And Complications ELHAWARY
7. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
8. Classification according to object causing wound
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
9. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
10. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
11. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
12. Classification according to object causing wound
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
13. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma http://woundbegone.blogdrive.com/
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
14. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury http://en.wikipedia.org/wiki/File:Knee_puncture.JPG
Wounds, Wound Healing And Complications ELHAWARY
15. Classification according to object causing wound
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush http://journal.nzma.org.nz/journal/120-1267/2867/
injury
Wounds, Wound Healing And Complications ELHAWARY
16. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush injury http://www.podiatrytoday.com/article/6303
Wounds, Wound Healing And Complications ELHAWARY
17. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
18. Classification according to the exposure to the outer environment
Incision http://en.wikipedia.org/wiki/File:Bruises.jpg
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury
Wounds, Wound Healing And Complications ELHAWARY
19. Classification according to the exposure to the outer environment
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
http://www.buzzle.com/articles/hematoma-treatment.html
injury
Wounds, Wound Healing And Complications ELHAWARY
20. Classification according to object causing wound
Incision
Laceration
Abrasion
Open
Puncture
Penetration
wound Gunshot
Contusion
Closed Hematoma
Crush
injury http://www.smrteam.com/na1_crushinjury.htm
Wounds, Wound Healing And Complications ELHAWARY
22. Classification According to level of risk of sepsis
Clean wound
Clean
contaminated
wounds
wound
Contaminated
wounds
Dirty wounds
Wounds, Wound Healing And Complications ELHAWARY
23. Classification According to level of risk of sepsis
Clean wound
Clean
contaminated
wounds
wound
Contaminated
wounds
Dirty wounds
Wounds, Wound Healing And Complications ELHAWARY
24. Classification According to level of risk of sepsis
• No viscus entered
Clean wound • No septic area
• No break in aseptic technique
Clean • Such wounds should never become
contaminated infected; infection rates less than 3%
wounds
wound
Contaminated
wounds
Dirty wounds
Wounds, Wound Healing And Complications ELHAWARY
25. Classification According to level of risk of sepsis
Clean wound
Clean
contaminated
wounds
wound
Contaminated
wounds
Dirty wounds
Wounds, Wound Healing And Complications ELHAWARY
26. Classification According to level of risk of sepsis
Clean wound
Clean • Operation enters a non-infected area but
contaminated may encounter bacteria
wounds
• Careful control of the area should result
wound
in minimal spillage of organisms
Contaminated • Examples of this include surgery on the
wounds
upper gastrointestinal tract, biliary tree or
respiratory tract
• Infection rates for this type of surgery
Dirty wounds
should be less than 10%
Wounds, Wound Healing And Complications ELHAWARY
27. Classification According to level of risk of sepsis
Clean wound
Clean
contaminated
wounds
wound
Contaminated
wounds
Dirty wounds
Wounds, Wound Healing And Complications ELHAWARY
28. Classification According to level of risk of sepsis
Clean wound
• Gross spillage of organisms, where there
Clean
is infection already present but without
contaminated
wounds pus formation
wound • There is a major break in aseptic
Contaminated
technique
wounds • There is an open wound that has been
exposed for less than 4 h (e.g. following
major trauma)
Dirty wounds • In this type of wound, sepsis frequently
exceeds 30%
Wounds, Wound Healing And Complications ELHAWARY
29. Classification According to level of risk of sepsis
Clean wound
Clean
contaminated
wounds
wound
Contaminated
wounds
Dirty wounds
Wounds, Wound Healing And Complications ELHAWARY
30. Classification According to level of risk of sepsis
Clean wound
Clean
contaminated
wounds
wound
Contaminated
wounds
• This is an operation through an infected
Dirty wounds area (e.g. perforated viscus, abscess or
traumatic wound) that has been
exposed for over 4 h
Wounds, Wound Healing And Complications ELHAWARY
31. Wound Healing And Suturing
WOUND HEALING
Wounds, Wound Healing And Complications ELHAWARY
32. Definition
• The process by which the body is trying to achieve
anatomical integrity of the injured part and to restore
full function
Wounds, Wound Healing And Complications ELHAWARY
33. Definition
• The process by which the body is trying to achieve
anatomical integrity of the injured part and to restore
full function
Wounds, Wound Healing And Complications ELHAWARY
34. Definition
• The process by which the body is trying to achieve
anatomical integrity of the injured part and to restore
full function
• As a secondary consideration, this should be combined
with an attempt to produce as perfect a cosmetic result
as possible
Wounds, Wound Healing And Complications ELHAWARY
36. Classification of wound healing
• Primary Intention
• Occurs when:
– The edges are clean and held
together with ligatures
– There is little gap to bridge Healing
• Healing properties (When
uncomplicated)
– Occurs quickly
– Rapid ingrowth of wound healing
cells (macrophages, fibroblasts, etc.)
– Restoration of the gap by a small
amount of scar tissue.
• soundly united within 2 weeks
• Dense scar tissue is laid down
within 1 month
Wounds, Wound Healing And Complications ELHAWARY
37. Classification of wound healing
• Primary Intention
• Occurs when:
– The edges are clean and held
together with ligatures
– There is little gap to bridge Healing
• Healing properties (When
uncomplicated)
– Occurs quickly
– Rapid ingrowth of wound healing
cells (macrophages, fibroblasts, etc.)
– Restoration of the gap by a small
amount of scar tissue.
• soundly united within 2 weeks
• Dense scar tissue is laid down
within 1 month
Wounds, Wound Healing And Complications ELHAWARY
38. Classification of wound healing
• Secondary Intention
• Occurs when:
– The edges are separated
– The gap can not be directly bridged
– Extensive epithelial loss
– Severe contamination
– Significant subepithelial tissue damage
• Healing properties
– Occurs slowly
– Granulation; healing from the bottom
towards the surface
– Restoration of the gap by a small
amount of scar tissue.
• Scaring
• Wound contracture
Wounds, Wound Healing And Complications ELHAWARY
39. Classification of wound healing
• Secondary Intention
• Occurs when:
– The edges are separated
– The gap can not be directly bridged
– Extensive epithelial loss
– Severe contamination
– Significant subepithelial tissue damage
• Healing properties
– Occurs slowly
– Granulation; healing from the bottom
towards the surface
– Restoration of the gap by a small
amount of scar tissue.
• Scaring
• Wound contracture
Wounds, Wound Healing And Complications ELHAWARY
40. Classification of wound healing
• Secondary Intention
• Occurs when:
– The edges are separated
– The gap can not be directly bridged
– Extensive epithelial loss
– Severe contamination
– Significant subepithelial tissue damage
• Healing properties
– Occurs slowly
– Granulation; healing from the bottom
towards the surface
– Restoration of the gap by a small
amount of scar tissue.
• Scaring
• Wound contracture
Wounds, Wound Healing And Complications ELHAWARY
42. Differences between primary and secondary healing
Feature Primary healing Secondary healing
Cleanness Clean Unclean
Infection Generally uninfected May be infected
Margins Surgically clean Irregular
Healing Scanty granulation tissue Granulation tissue fill the gap
Healing period Short long
Healing direction Direct healing From the bottom to the edge
Outcome Neat linear scar Contracted irregular wound
Wounds, Wound Healing And Complications ELHAWARY
43. Normal sequence of wound healing
Wounds, Wound Healing And Complications ELHAWARY
44. Normal sequence of wound healing
Wounds, Wound Healing And Complications ELHAWARY
45. Normal sequence of wound healing
Phases of wound healing
Hemostasis
Days Weeks Months
Wounds, Wound Healing And Complications ELHAWARY
46. Normal sequence of wound healing
Phases of wound healing
Inflammation
Hemostasis
Days Weeks Months
Wounds, Wound Healing And Complications ELHAWARY
47. Normal sequence of wound healing
Phases of wound healing
Proliferation
Inflammation
Hemostasis
Days Weeks Months
Wounds, Wound Healing And Complications ELHAWARY
48. Normal sequence of wound healing
Phases of wound healing
Maturation & Remodeling
Proliferation
Inflammation
Hemostasis
Days Weeks Months
Wounds, Wound Healing And Complications ELHAWARY
50. Normal sequence of wound healing
• Inflammatory phase
• Proliferative Phase
• Remodeling Phase
Wounds, Wound Healing And Complications ELHAWARY
51. Normal sequence of wound healing
Starts 1st day lasts from 3-5 days
• Proliferative Phase • 1st vasoconstriction
• 2nd blood clot formation
• Remodeling Phase
• 3rd platelets aggregation
• 4th platelets degranulation
• 5th vasodilatation
• 6th chemotaxis
• Leucocytes
• Neutrophils
• Macrophages
Wounds, Wound Healing And Complications ELHAWARY
52. Normal sequence of wound healing
• Inflammatory phase Starts 3rd day lasts for 3rd week
• 1st Angiogenesis
• 2nd fibroblasts migration
• Remodeling Phase
• 3rd formation of granulation tissue
• 4th reepithelialization
Wounds, Wound Healing And Complications ELHAWARY
53. Normal sequence of wound healing
• Inflammatory phase Starts from weeks to years
• Proliferative Phase • The fibroblasts start to disappear
• Collagen type III is gradually replaced
by stronger type I collagen
• The tensile strength of the scar tissue
gradually increase
Wounds, Wound Healing And Complications ELHAWARY
64. Factors affecting healing
Wound
sepsis
Blood
supply
Local
factors Wound • Tension across a healing a healing wound
tension
• Separate wound edges
Foreign • Impairs blood supply
bodies
• Complicate wound healing
Previous
Factors irradiation
Poor
technique
Nutritional
deficiencies
Systemic Systemic
factors diseases
Therapeutic
agents
Age
Wounds, Wound Healing And Complications ELHAWARY
65. Factors affecting healing
Wound
sepsis
Blood
supply
Local
factors Wound • Tension across a healing a healing wound
tension
• Separate wound edges
Foreign • Impairs blood supply
bodies
• Complicate wound healing
Previous • Bridging a gap can be achieved by plastic surgery
Factors irradiation techniques rather than suturing under tension
Poor
technique
Nutritional
deficiencies
Systemic Systemic
factors diseases
Therapeutic
agents
Age
Wounds, Wound Healing And Complications ELHAWARY
66. Factors affecting healing
Wound
sepsis
Blood
supply
Local
factors Wound • Tension across a healing a healing wound
tension
• Separate wound edges
Foreign • Impairs blood supply
bodies
• Complicate wound healing
Previous • Bridging a gap can be achieved by plastic surgery
Factors irradiation techniques rather than suturing under tension
Poor • Incision along lines of collagen bundles (Langer’s
technique lines)
Nutritional • Skin creases
deficiencies • Transverse at the joints
Systemic Systemic • Longitudinal on long parts (limbs)
factors diseases
Therapeutic
agents
Age
Wounds, Wound Healing And Complications ELHAWARY
78. Factors affecting healing
Wound
sepsis
Blood
supply
Local
factors Wound
tension
Foreign
bodies
Previous
Factors irradiation
Poor • Vitamins: A & C
technique
• vit. A: Involved in epithelialisation and
Nutritional collagen production
deficiencies • vit. C: Production and modification of collagen
Systemic Systemic
factors diseases
Therapeutic
agents
Age
Wounds, Wound Healing And Complications ELHAWARY
79. Factors affecting healing
Wound
sepsis
Blood
supply
Local
factors Wound
tension
Foreign
bodies
Previous
Factors irradiation
Poor • Vitamins: A & C
technique
• Minerals: Zinc
Nutritional • Acts as an enzyme cofactor
deficiencies • Has a role in cell proliferation
Systemic Systemic • It accelerates wound healing in experimental
factors diseases models
Therapeutic
agents
Age
Wounds, Wound Healing And Complications ELHAWARY
80. Factors affecting healing
Wound
sepsis
Blood
supply
Local
factors Wound
tension
Foreign
bodies
Previous
Factors irradiation
Poor • Vitamins: A & C
technique
• Minerals: Zinc
Nutritional • Protein: The main building block in wound healing
deficiencies • A malnourished, hypoproteinaemic patient
Systemic Systemic has impaired inflammatory and immune
factors diseases responses, vital for normal wound healing
Therapeutic and prevention of wound infection.
agents • Protein amino acids are essential for collagen
production which is itself a protein.
Age
Wounds, Wound Healing And Complications ELHAWARY
82. Factors affecting healing
Wound
sepsis
Blood
supply
Local
factors Wound
tension
Foreign
bodies
Previous
Factors irradiation
Poor
technique
Nutritional
deficiencies
Systemic Systemic • Several diseases are known to impair wound
factors diseases
healing via a number of mechanisms
Therapeutic • Important examples include diabetes, uraemia and
agents
jaundice
Age
Wounds, Wound Healing And Complications ELHAWARY
84. Factors affecting healing
Wound
sepsis
Blood
supply
Local
factors Wound
tension
Foreign
bodies
Previous
Factors irradiation
Poor
technique • Immunosuppressive drugs dampen the
Nutritional inflammatory and immune responses, hence
deficiencies impairing wound healing
Systemic
• Chemotherapeutic agents for malignancy
Systemic
factors diseases • Immunosuppressive and antiprostaglandin drugs
used for inflammatory conditions such as
Therapeutic
agents rheumatoid disease; corticosteroid therapy
N.B. Steroids have the additional effect of increasing
Age the fragility of small blood vessels
Wounds, Wound Healing And Complications ELHAWARY
89. Complications of wound healing
• Classification of wounds according to risk of
Infection sepsis
Dehiscence
complications Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
Wounds, Wound Healing And Complications ELHAWARY
90. Complications of wound healing
• Classification of wounds according to risk of
Infection sepsis
• Prevention of wound infection
• Environment
Dehiscence • Theatre personnel
• Patient preparation
• Operating technique
complications Incisional • Prophylactic antibiotics
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
Wounds, Wound Healing And Complications ELHAWARY
91. Complications of wound healing
• Classification of wounds according to risk of
Infection sepsis
• Prevention of wound infection
• Environment
Dehiscence • Theatre personnel
• Patient preparation
• Operating technique
complications Incisional • Prophylactic antibiotics
Hernia • Treatment
• Prophylactic antibiotics
• Empirical antibiotic
Hypertrophic
• Therapeutic /specific antibiotics
scaring • I&D
• Antiseptic packs
Keloid
scarring
Contractures
Wounds, Wound Healing And Complications ELHAWARY
92. Complications of wound healing
• Classification of wounds according to risk of
Infection sepsis
• Prevention of wound infection
• Environment
Dehiscence • Theatre personnel
• Patient preparation
• Operating technique
complications Incisional • Prophylactic antibiotics
Hernia • Treatment
• Prophylactic antibiotics
• Empirical antibiotic
Hypertrophic
• Therapeutic /specific antibiotics
scaring • I&D
• Antiseptic packs
Keloid
scarring
Contractures
Wounds, Wound Healing And Complications ELHAWARY
98. Complications of wound healing
• Definition: Breakdown of the deeper layers of a
Infection wound in which the skin layer remains intact with
protrusion of underlying structures through the deeper
defect
Dehiscence
complications Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures http://www.melbournegallbladder.com.au/patientinfosheets/info_incisional
_hernia/info-incisional-hernia-gen-1.htm
Wounds, Wound Healing And Complications ELHAWARY
101. Complications of wound healing
• Definition: Excess collagen scar tissue formation -
Infection almost an over healing of a wound
Dehiscence
complications Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
http://www.ehow.com/about_542243
Contractures 1_natural-herbs-hypertrophic-
scars.html
Wounds, Wound Healing And Complications ELHAWARY
102. Complications of wound healing
• Definition
Infection • Clinical features:
• It is non-progressive after 6 months
• Does not extend beyond the edges of the
Dehiscence wound.
• It occurs most frequently around joints and
where Langer's lines of tension are crossed by
complications Incisional the incision
Hernia
Hypertrophic
scaring
Keloid
scarring
http://www.ehow.com/about_542243
Contractures 1_natural-herbs-hypertrophic-
scars.html
Wounds, Wound Healing And Complications ELHAWARY
103. Complications of wound healing
• Definition
Infection • Clinical features:
• Etiology: Poor skin suturing
• The edges of the skin are overlapping instead
Dehiscence of being accurately apposed
complications Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
http://www.ehow.com/about_542243
Contractures 1_natural-herbs-hypertrophic-
scars.html
Wounds, Wound Healing And Complications ELHAWARY
104. Complications of wound healing
• Definition
Infection • Clinical features
• Treatment:
• Difficult
Dehiscence • Further surgery should not be attempted for at
least 6 months
• Excision of the scar and re-suturing often has
complications Incisional disappointing results, resulting in the same over
Hernia healing
• Radiotherapy used to be used but has now
been abandoned
Hypertrophic
• Some improvement can be achieved with local
scaring injection of corticosteroids directly into the scar,
a process that might need repeating several
Keloid times
scarring
Contractures
http://www.ehow.com/about_542243
1_natural-herbs-hypertrophic-
scars.html
Wounds, Wound Healing And Complications ELHAWARY
107. Complications of wound healing
• Definition: Overhealing with excess collagen scar
Infection formation due to abnormality in collagen metabolism
Dehiscence
complications Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
Wounds, Wound Healing And Complications ELHAWARY
108. Complications of wound healing
• Definition
Infection • Clinical features:
• Excess scar tissue
• Extends out beyond the wound edges
Dehiscence • Continue to enlarge after 6 months
• Prevalence is higher in
• Patients with dark skin
complications Incisional • young patients
Hernia • Burn wounds
Hypertrophic
scaring
Keloid
scarring
Contractures
Wounds, Wound Healing And Complications ELHAWARY
109. Complications of wound healing
• Definition
Infection • Clinical features
• Treatment:
• Excision generally results in a larger recurrence
Dehiscence • Although excision followed by compression
bandaging can have slightly better results
• Corticosteroid injections give some
complications Incisional improvement
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures
Wounds, Wound Healing And Complications ELHAWARY
112. Complications of wound healing
• Wound Contractures can occur with any wounds
Infection • More commonly with delayed healing wounds
• Infection
• Burns
Dehiscence • Incision crosses Langer's lines
complications Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures http://www.patient.co.uk/health/
Dupuytren%27s-
Contracture.htm
Wounds, Wound Healing And Complications ELHAWARY
113. Complications of wound healing
• Wound Contractures can occur with any wounds
Infection • More commonly with delayed healing wounds
• Contracture of a scar across a joint can result in
marked limitation of movement
Dehiscence • It is therefore essential to avoid vertical incisions
across a joint if possible
complications Incisional
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures http://www.patient.co.uk/health/
Dupuytren%27s-
Contracture.htm
Wounds, Wound Healing And Complications ELHAWARY
114. Complications of wound healing
• Wound Contractures can occur with any wounds
Infection • More commonly with delayed healing wounds
• Contracture of a scar across a joint can result in
marked limitation of movement
Dehiscence • Surgical treatment include
• Skin grafting
• local flaps
complications Incisional • wound Z-plasty
Hernia
Hypertrophic
scaring
Keloid
scarring
Contractures http://www.patient.co.uk/health/
Dupuytren%27s-
Contracture.htm
Wounds, Wound Healing And Complications ELHAWARY