WOUND HEALING

WOUND HEALING
1. Primary union
Healing by first intention

2. Secondary union
Healing by second intention

3. Delayed Primary union

Healing by tertiary intention

HEALING BY 1ST INTENTION

CHARECTERISTICS:
Simplest and fastest type of wound closure clean and uninfected Superficial wounds Deep wounds with well approximated edges Epithelial regeneration predominates over fibrosis Lower risk of infection, minimal tissue loss and minimal scarring

EXAMPLE:
Surgical wound with well approximated edges

SEQUENCE OF EVENTS IN PRIMARY INTENTION: 1. Initial hemorrhage 2. Acute inflammatory response 3. Epithelial changes 4. Organisation 5. Suture tracks

TIME LINE: With in 24 hours:

Clot forms Neutrophils come in Epithelium begins to regenerate

With in 3 to 7 days:
Macrophages come in Granulation tissue is formed New blood vessels Fibroblasts Collagen begins to bridge incision Epithelium increases in thickness

Weeks later:
Granulation tissue gone Collagen is remodeled Epidermis full, mature (but without dermal appendages!) Eventually, scar forms

How do wounds heal by primary intention?

Hematoma (day 1) Initially wound is filled with coagulated blood and cell detritus and influx of neutrophils Inflammation and early granulation tissue(days 2-3) Macrophages stimulate the ingrowth of fibroblasts and angioblasts, which start forming collagen. Epidermal cells forms a bridge that seals off the defect Fully developed granulation tissue(days 4-6) Neo-vascularization reaches its peak, so entire area looks swollen and red. Also newly formed capillaries and granulation tissue contains fibroblasts that form ECM

Blanching (week 2) Deposits of collagen compress and replace the blood vessels, thus reduce the blood flow through the healing wound. Scar formation Macrophages become less prominent. Granulation tissue is replaced by fibrous scar. By the end of 3rd month tissue has approx 80% of its original strength.

Remodeling of the scar This takes several months and tissue acquire more tensile strength.

6 hours

24 hours

2 days

1 week

HEALING BY 2ND INTENTION

CHARACTERISTICS:
Occurs in larger wounds that have gaps between wound margins There is extensive loss of cells and tissues The wound is not approximated by surgical sutures but is left open and at times infected Contents are sloughs and blood clot Fibrosis predominates over epithelial regeneration Healing is slower, with more inflammation and granulation tissue formation and more scarring

EXAMPLES:
Infarction Large burns and ulcers Extraction sockets

The sequence of events in second intention: 1. Initial hemorrhage 2. Inflammatory phase 3. Epithelial changes 4. Granulation tissue formation 5. Wound contraction 6. Presence of infection

Differences from healing by 1st intention

1. More inflammation 2. More granulation tissue 3. Wound contraction

FACTORS DELAYING WOUND HEALING

1. Infection is the most common cause of delay in healing, by prolonging the inflammatory response and by increasing local tissue injury. 2. Poor nutrition and specially Vitamin C deficiency inhibits collagen synthesis and retards healing. 3. Glucocorticoids have a known anti-inflammatory effect and their administration results in poor wound strength due to diminished fibrosis. 4. Mechanical variables such as local pressure or torsion may cause wounds to pull apart or dehisce.

5) Poor perfusion secondary to arteriosclerosis, diabetes, or obstructive venous drainage also impairs healing.
6) Foreign bodies like glass fragments, steel fragments, or bone may disturb healing.

Aberrations of cell growth: May be due to a genetic predisposition (Keloid formation). This condition is more common in African American patients.

HEALING BY DELAYED PRIMARY CLOSURE (THIRD INTENTION)

This healing process takes place when approximation of wound edges is delyed by 3-5 days or more after injury or surgery

The condition contribute to a decision for a dalyed closure are:

1. Removal of an inflamed organ 2. Heavy contamination of wound

WOUND STRENGTH
Initially
depends on suturing

Week 1 ( removal of sutures)

10 % of normal.

Month 3
70-80 % of normal.

Recovery of tensile strength is by:

collagen synthesis >> degradation Cross linking of collagen fibers Increased collagen fiber size

DIFFERENCE BETWEEN HEALING OF SKIN WOUND BY:

1st intention
1. Two edges are approximated together 2. Minimal tissue loss 3. No sepsis 4. Minimal amount of granulation tissue, so the scar is very thin 5. Little contraction of the scar

2nd intention
1. Wide gap 2. Marked tissue loss and necrosis 3. Sepsis might by present 4. Large amount of g.t so the scar is large and wide. 5. Much contraction of the scar reaching 5-10 % of the original one

SOME TERMS
WOUND CONTRACTION:
Reduction in size of wound healing by secondary intention is called wound contraction (myofibroblasts in granulation tissue)

CONTRACTURE:
Are deformities of extremities caused by irregular scars formed over the joints.

DEHISCENCE (split apart)

Opening of a healing or partially healed wound with separation of its edges. (mechanical)

KELOID:
Hyperplastic scars with irregular deposits of excessive collagen in dermis.

PROUD FLESH:
Excessive granulation tissue preventing wound closure or proper epithilialization was historically called proud flesh.