1- Wound I (Fall 2024).pdf

Wound I Professor/ Khaled Maher Lecturer of General surgery Faculty of Medicine, Delta University Wound definition: It is a break in the integrity of the skin or tissues often, which may be associated with disruption of the structure & function. Classification of wounds: I. Rank & Wakefie...

Wound I Professor/ Khaled Maher Lecturer of General surgery Faculty of Medicine, Delta University Wound definition: It is a break in the integrity of the skin or tissues often, which may be associated with disruption of the structure & function. Classification of wounds: I. Rank & Wakefield classification: 1- Tidy wounds: They are wounds like surgical incisions & wounds caused by sharp objects. It is incised, clean, healthy wound without any tissue loss. Usually, primary suturing is done. Healing is by primary intention. 2- Untidy wounds: 1) Crushing. 2) Tearing. 3) Avulsion. 4) Devitalized injury. 5) Vascular injury. 6) Multiple irregular wounds. 7) Burns. Healing by secondary intention. Secondary suturing, skin graft or flap may be needed. II. Classification based on the type of the wound: 1) Clean incised wound: It is a tidy, simple, clean cut wound with linear cut edges; usually due to a sharp object. It is treated by primary suturing. 2) Lacerated wound: It has irregular edges. Adequate wound excision, warm saline wash & suturing of the wound layer-by-layer is required. 3) Bruise or contusion: It is due to blow or blunt force to the skin & tissues underneath. There is skin discoloration without breaking of the skin. It is more on the skin over the bones; lax area like face, scrotum, eyes; vascular areas; children, old aged, fair skin people. 4) Hematoma: It is a localized collection of blood after blunt trauma or after surgery. Types: subcutaneous/ intramuscular/subfascial/intra-articular. Large hematoma needs drainage under regional anesthesia. Small hematoma usually gets absorbed. 5) Abrasion: It is superficial injury (scratch/graze/pressure) & is due to shearing of the skin where the surface is rubbed off.  6) Puncture wounds & bites: It is usually a stab wound with a pointed object; here depth of the wound is more than the width. 7) Penetrating wounds: They are similar like puncture wounds; due to stab. Abdomen & chest are common sites. 8) Traction & avulsion injuries: These are complex injuries with tissues getting displaced from its normal anatomical position & alignment. 9) Crush injury: It is due to major wounds, war wounds, natural disaster, tourniquet injury. It leads to compartment syndrome, muscle ischemia, loss of tissues, gangrene, sepsis, loss of contractility & will not bleed on cutting. 10) Gunshot injuries: These injuries may be superficial or deep. Usually entry wound & exit wound will be present. It causes explosive & destructive injuries along with burn injuries in the deeper planes & organs. 11) Closed blunt injury: It may be due to fall; blunt injury wherein no obvious external injury may be seen but deeper injury occurs. III. Classification based on thickness of the wound: 1) Superficial wound involving only epidermis & dermal papillae. 2) Partial thickness wound with skin loss up to part of deep dermis. 3) Full thickness wound with loss of entire skin & subcutaneous tissue. 4) Deep wounds are the one extending across deep fascia into deeper structures. IV. Classification based on involvement of structures: 1) Simple wounds are one involving only one organ or tissue. 2) Combined/complex wounds are one involving mixed tissues. V. Classification based on the time elapsed: 1) Acute wounds: in less than 4 weeks 2) Chronic wounds: in more than 4 weeks. VI. Classification of surgical wounds: 1) Clean wound: 1. Herniorrhaphy. 2. Excisions. 3. Surgeries of the brain, joints, heart, transplant. 4. Infective rate is less than 2%. 2) Clean contaminated wound: 1. Appendicectomy. 2. Bowel surgeries. 3. Gallbladder, biliary & pancreatic surgeries. 4. Infective rate is 10%.  3) Contaminated wound: 1. Acute abdominal conditions. 2. Open fresh accidental wounds. 3. Infective rate is 15–30%. 4) Dirty infected wound: 1. Abscess drainage. 2. Fecal peritonitis. 3. Infective rate is 40–70%. Crush syndrome: It is due to crushing of muscles causing extravasation of blood & release of myohaemoglobin into the circulation leading to acute tubular necrosis & acute renal failure. Causes: 1. Earthquakes. 2. Mining & industrial accidents. 3. Air crash. 4. Tourniquet. 5. Train accidents. Complications: 1. Renal failure. 2. Toxemia. 3. Septicemia. 4. Disability with extensive tissue loss. 5. Gas gangrene. Treatment: 1. Fasciotomy. 2. Mannitol is given to improve the urine output by improving the renal function. 3. Alkalization of urine is done by giving sodium citrate or sodium bicarbonate. 4. Hemodialysis. 5. Catheterization. 6. Oxygen therapy. 7. Antibiotics. 8. Blood transfusion. 9. Correction of severe hyperkalemia.