Wounds and Tissue Repair

Wounds and Tissue Repair

Notes from Bailey and Love

Wound healing is the mechanism by which the body attempts to restore the integrity of the
injured part. Several factors influence healing of a wound such as:
a. Site of the wound
b. Structures involved
c. Mechanism of wounding
1) Incision
2) Crush
3) Crush avulsion
d. Contamination (foreign bodies/bacteria)1
e. Loss of tissue
f. Other local factors
1) Vascular insufficiency (arterial or venous)
2) Previous radiation
3) Pressure
g. Systemic factors
1) Malnutrition or vitamin and mineral deficiencies
2) Disease (e.g. diabetes mellitus)
3) Medications (e.g. steroids)
4) Immune deficiencies (e.g. chemotherapy, acquired immunodeficiency syndrome (AIDS))
5) Smoking

Normal Wound Healing Phases are:

a. Haemostatic phase (occasionally described)

b. Inflammatory phase
Begins after wounding, lasts 2-3 days.
Classically described as: rubor, tumor, calor and dolor. [for more details, read up on acute
inflammation from pathology]
c. Proliferative phase lasts from day 3 to 3rd week. There is increased fibroblast activity, growth
of new blood vessels and re-epithelialisation.
During early phase, wound tissue formed is called granulation tissue. Later tensile strength
increases due to increased type III collagen.
d. Remodeling phase (maturing phase) maturation of collagen (type I replaces III till 4:1 is
achieved), realignment of collagen fibers, decreased wound vascularity and wound contraction.

1
In explosions, the contamination may consist of tissue such as bone from another individual.

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Classification of Wound Closure and Healing

Healing by Primary intention

i. Wound edges opposed
ii. Normal healing
iii. Minimal scar
Healing by Secondary intention
i. Wound left open
ii. Heals by granulation, contraction and epithelialization
iii. Increased inflammation and proliferation
iv. Poor scar
Healing by Tertiary intention (also called delayed primary intention)
i. Wound initially left open
ii. Edges later opposed when healing conditions favourable
iii. Less satisfactory scar than after primary intention

Types of Wounds

Wounds can be classified as tidy and untidy. The features which discriminate them are given above.

Primary repair of all structures is possible on tidy wound but untidy wound requires
debridement before definitive repair (second look surgery).
Surgeons aim is to convert untidy to tidy by removing all contaminated and devitalized tissue.
Multiple debridements are often required for crush injuries in RTAs or natural disasters such as
earthquakes. The external wound may appear smaller than wider extent of deep damage.

Managing the Acute Wound

Examine whole patient per ATLS protocol; then examine wound to consider site and possible
extent of damage.
Tetanus cover should be noted

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Bleeding wound should be elevated and pressure pad must be applied.for examination,
adequate anaesthesia must be given.
Cleansing
Exploration and diagnosis
Debridement to the limit of blood staining
Repair of structures
Replacement of lost tissues where indicated
Skin cover if required
Skin closure without tension
All of the above with careful tissue handling and meticulous technique

Compartment Syndromes

Typically in closed lower limb injuries; characterized by:

a. Severe pain
b. Pain on passive movement of affected compartment muscles
c. Distal sensory disturbance
d. Absence of pulses distally
Compartment pressure: if constantly greater than 30mm Hg or if above signs are present
fasciotomy indicated.
In crush injuries that present several days after the event, late fasciotomy can be dangerous as
dead muscle produces myoglobin which when suddenly released in blood causes
myoglobinuria. This leads to:
a. Glomerular blockage
b. Renal failure
So in late treatment of lower limb injuries it is safer to amputate after demarcation of viable and
non-viable tissue.

Necrotizing Soft Tissue Infections

Rare but fatal

Most common polymicrobial infections with:
a. Gram +ve aerobes (Staphylococcus aureaus, S. pyogenes)
b. Gram ve anaerobes (E. coli, Pseudomonoas, Clostridium, Bacteroides)
c. -hemolytic streptococcus
Usual history of trauma or surgery with wound contamination; sometimes patients immunity is
compromised. Sudden presentation, rapid progression.

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Two main types of necrotizing infections:

a. Clostridial (gas gangrene)
b. Non-clostridial (streptococcal gangrene and necrotizing fasciitis)
Necrotising fasciitis is due to S. pyogenes which is called Flesh Eating Bug.

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