Wounds, Tissue Repair & Scar PDF

‫‪Wounds, tissue repair & scar:‬‬ ‫‪Wound healing is a mechanism whereby the body attempts to‬‬ ‫‪restore the integrity of the injured part.‬‬ ‫‪Several factors may influence the healing process.‬‬ ‫اﻟﺟروح وإﺻﻼح اﻷﻧﺳﺟﺔ واﻟﻧدﺑﺎت‪:‬‬...

‫‪Wounds, tissue repair & scar:‬‬ ‫‪Wound healing is a mechanism whereby the body attempts to‬‬ ‫‪restore the integrity of the injured part.‬‬ ‫‪Several factors may influence the healing process.‬‬ ‫اﻟﺟروح وإﺻﻼح اﻷﻧﺳﺟﺔ واﻟﻧدﺑﺎت‪:‬‬ ‫اﻟﺗﺋﺎم اﻟﺟروح ھو آﻟﯾﺔ ﯾﺣﺎول اﻟﺟﺳم ﻣن ﺧﻼﻟﮭﺎ اﺳﺗﻌﺎدة ﺳﻼﻣﺔ اﻟﺟزء اﻟﻣﺻﺎب‪.‬‬ ‫ھﻧﺎك ﻋدة ﻋواﻣل ﻗد ﺗؤﺛر ﻋﻠﻰ ﻋﻣﻠﯾﺔ اﻟﺷﻔﺎء‪.‬‬ ‫اﻟﻌواﻣل اﻟﻣؤﺛرة ﻋﻠﻰ ﺷﻔﺎء اﻟﺟروح‬ ‫ ﻣوﻗﻊ اﻟﺟرح‬ ‫ اﻟﮭﯾﺎﻛل اﻟﻣﻌﻧﯾﺔ‬ ‫ آﻟﯾﺔ اﻹﺻﺎﺑﺔ‬ ‫اﻟﺷﻖ‬ ‫اﻟﺳﺣﻖ‬ ‫ﺳﺣﻖ اﻟﻘذف‬ ‫ اﻟﺗﻠوث )اﻷﺟﺳﺎم اﻟﻐرﯾﺑﺔ‪/‬اﻟﺑﻛﺗﯾرﯾﺎ(‬ ‫ ﻓﻘدان اﻷﻧﺳﺟﺔ‬ ‫ اﻟﻌواﻣل اﻟﻣﺣﻠﯾﺔ اﻷﺧرى‬ ‫ﻗﺻور اﻷوﻋﯾﺔ اﻟدﻣوﯾﺔ )اﻟﺷرﯾﺎﻧﻲ أو اﻟورﯾدي(‬ ‫اﻹﺷﻌﺎع اﻟﺳﺎﺑﻖ‬ ‫ﺿﻐط‬ ‫ اﻟﻌواﻣل اﻟﻧظﺎﻣﯾﺔ‬ ‫ﺳوء اﻟﺗﻐذﯾﺔ أو ﻧﻘص اﻟﻔﯾﺗﺎﻣﯾﻧﺎت واﻟﻣﻌﺎدن‬ ‫اﻟﻣرض )ﻣﺛل داء اﻟﺳﻛري(‬ ‫اﻷدوﯾﺔ )ﻣﺛل اﻟﻣﻧﺷطﺎت(‬ ‫ﻧﻘص اﻟﻣﻧﺎﻋﺔ ]ﻋﻠﻰ ﺳﺑﯾل اﻟﻣﺛﺎل‪.‬اﻟﻌﻼج اﻟﻛﯾﻣﯾﺎﺋﻲ‪ ،‬ﻣﺗﻼزﻣﺔ ﻧﻘص اﻟﻣﻧﺎﻋﺔ اﻟﻣﻛﺗﺳب )اﻹﯾدز([‬ ‫ﺗدﺧﯾن‬ ‫ﻓﻲ اﻻﻧﻔﺟﺎرات‪ ،‬ﻗد ﯾﺗﻛون اﻟﺗﻠوث ﻣن أﻧﺳﺟﺔ ﻣﺛل‪.‬ﻋظم ﻣن ﻓرد آﺧر‪.‬‬ ‫‪Normal wound healing‬‬ ‫اﻟﺗﺋﺎم اﻟﺟروح ﺑﺷﻛل طﺑﯾﻌﻲ‬ ‫‪There are 3 phases‬‬ ‫_ھﻧﺎك ‪ 3‬ﻣراﺣل‬ ‫‪1. Inflammatory phase‬‬ ‫‪2. Proliferative phase‬‬ ‫‪.1‬اﻟﻣرﺣﻠﺔ اﻻﻟﺗﮭﺎﺑﯾﺔ‬ ‫‪.2‬اﻟﻣرﺣﻠﺔ اﻟﺗﻛﺎﺛرﯾﺔ‬ ‫‪3. Remodeling phase‬‬ ‫‪.3‬ﻣرﺣﻠﺔ إﻋﺎدة اﻟﺑﻧﺎء‬ ‫‪1‬‬ The inflammatory phase begins immediately after wounding &lasts 2-3 days.Bleeding is followed by vasoconstriction & thrombus formation to limit blood loss. Platelets & the local injured tissue release the vasoactive substances (histamine, serotonin& prostaglandins). Inflammatory cells (macrophages) remove devitalized tissue & micro-organism. ‫ وﯾﺗﺑﻊ اﻟﻧزﯾف ﺗﺿﯾﻖ اﻷوﻋﯾﺔ وﺗﻛوﯾن اﻟﺧﺛرة ﻟﻠﺣد ﻣن‬.‫ أﯾﺎم‬3-2 ‫ﺗﺑدأ اﻟﻣرﺣﻠﺔ اﻻﻟﺗﮭﺎﺑﯾﺔ ﻣﺑﺎﺷرة ﺑﻌد اﻹﺻﺎﺑﺔ وﺗﺳﺗﻣر‬ ‫ ﺗﻘوم اﻟﺻﻔﺎﺋﺢ اﻟدﻣوﯾﺔ واﻷﻧﺳﺟﺔ اﻟﻣﺻﺎﺑﺔ اﻟﻣﺣﻠﯾﺔ ﺑﺈﻓراز اﻟﻣواد اﻟﻔﻌﺎﻟﺔ ﻓﻲ اﻷوﻋﯾﺔ اﻟدﻣوﯾﺔ )اﻟﮭﯾﺳﺗﺎﻣﯾن‬.‫ﻓﻘدان اﻟدم‬.‫ ﺗﻘوم اﻟﺧﻼﯾﺎ اﻻﻟﺗﮭﺎﺑﯾﺔ )اﻟﺑﻼﻋم( ﺑﺈزاﻟﺔ اﻷﻧﺳﺟﺔ اﻟﻣﯾﺗﺔ واﻟﻛﺎﺋﻧﺎت اﻟﺣﯾﺔ اﻟدﻗﯾﻘﺔ‬.(‫واﻟﺳﯾروﺗوﻧﯾن واﻟﺑروﺳﺗﺎﺟﻼﻧدﯾن‬ The proliferative phase lasts from the third day to the third week consisting mainly of fibroblast activity with the production of collagen fibers, the growth of new blood vessels as capillary loops. The wound tissue formed in the early part of this phase is called (granulation tissue). In the later part of this phase , there is an increase in the tensile strength of the wound due to increased collagen. ‫ﺗﺳﺗﻣر اﻟﻣرﺣﻠﺔ اﻟﺗﻛﺎﺛرﯾﺔ ﻣن اﻟﯾوم اﻟﺛﺎﻟث إﻟﻰ اﻷﺳﺑوع اﻟﺛﺎﻟث وﺗﺗﻛون ﺑﺷﻛل أﺳﺎﺳﻲ ﻣن ﻧﺷﺎط اﻟﺧﻼﯾﺎ اﻟﻠﯾﻔﯾﺔ ﻣﻊ إﻧﺗﺎج‬ ‫ وﯾﺳﻣﻰ ﻧﺳﯾﺞ اﻟﺟرح اﻟذي ﯾﺗﻛون ﻓﻲ اﻟﺟزء اﻷول‬.‫أﻟﯾﺎف اﻟﻛوﻻﺟﯾن وﻧﻣو أوﻋﯾﺔ دﻣوﯾﺔ ﺟدﯾدة ﻋﻠﻰ ﺷﻛل ﺣﻠﻘﺎت ﺷﻌرﯾﺔ‬.‫ ﺗزداد ﻗوة ﺷد اﻟﺟرح ﺑﺳﺑب زﯾﺎدة اﻟﻛوﻻﺟﯾن‬،‫ وﻓﻲ اﻟﺟزء اﻷﺧﯾر ﻣن ھذه اﻟﻣرﺣﻠﺔ‬.(‫ﻣن ھذه اﻟﻣرﺣﻠﺔ )اﻟﻧﺳﯾﺞ اﻟﺣﺑﯾﺑﻲ‬ 2 ‫‪The remodeling phase achieved by a realignment of‬‬ ‫‪collagen fibers along the line of tension, decreased‬‬ ‫‪vascularity & wound contraction.‬‬ ‫‪Abnormal healing‬‬ ‫‪Delay healing may result in loss or poor tissue function or‬‬ ‫‪poor cosmetic outcome. The aim of treatment is to achieve‬‬ ‫‪healing by primary intention & so to reduce the‬‬ ‫‪inflammatory &proliferative responses.‬‬ ‫ﻣرﺣﻠﺔ إﻋﺎدة اﻟﺗﺷﻛﯾل اﻟﺗﻲ ﯾﺗم ﺗﺣﻘﯾﻘﮭﺎ ﻣن ﺧﻼل إﻋﺎدة ﺗﻧظﯾم أﻟﯾﺎف اﻟﻛوﻻﺟﯾن ﻋﻠﻰ طول ﺧط اﻟﺗوﺗر‪ ،‬واﻧﺧﻔﺎض اﻷوﻋﯾﺔ‬ ‫اﻟدﻣوﯾﺔ وﺗﻘﻠص اﻟﺟرح‪.‬‬ ‫ﺷﻔﺎء ﻏﯾر طﺑﯾﻌﻲ‬ ‫ﻗد ﯾؤدي ﺗﺄﺧﯾر اﻟﺷﻔﺎء إﻟﻰ ﻓﻘدان اﻷﻧﺳﺟﺔ أو ﺿﻌف وظﺎﺋﻔﮭﺎ أو ﻧﺗﺎﺋﺞ ﺗﺟﻣﯾﻠﯾﺔ ﺳﯾﺋﺔ‪.‬اﻟﮭدف ﻣن اﻟﻌﻼج ھو ﺗﺣﻘﯾﻖ اﻟﺷﻔﺎء‬ ‫ﻣن ﺧﻼل اﻟﻧﯾﺔ اﻷﺳﺎﺳﯾﺔ وﺑﺎﻟﺗﺎﻟﻲ ﺗﻘﻠﯾل اﻻﺳﺗﺟﺎﺑﺎت اﻻﻟﺗﮭﺎﺑﯾﺔ واﻟﺗﻛﺎﺛرﯾﺔ‪.‬‬ ‫ﺗﺻﻧﯾف إﻏﻼق اﻟﺟروح واﻟﺷﻔﺎء‬ ‫ ﺣﺳب اﻟﻧﯾﺔ اﻷوﻟﯾﺔ‬ ‫ﺣواف اﻟﺟرح ﻣﺗﻌﺎرﺿﺔ‪.‬اﻟﺷﻔﺎء اﻟطﺑﯾﻌﻲ‪.‬اﻟﺣد اﻷدﻧﻰ ﻣن اﻟﻧدﺑﺔ‬ ‫ ﺑﺎﻟﻧﯾﺔ اﻟﺛﺎﻧوﯾﺔ‬ ‫ﺗرك اﻟﺟرح ﻣﻔﺗوﺣﺎ‪.‬ﯾﺗم اﻟﺷﻔﺎء ﻋن طرﯾﻖ اﻟﺗﺣﺑﯾب واﻻﻧﻛﻣﺎش واﻟﺗﺷﻛل اﻟظﮭﺎري‬ ‫زﯾﺎدة اﻻﻟﺗﮭﺎب واﻟﺗﻛﺎﺛر‬ ‫ﻧدﺑﺔ ﻓﻘﯾرة‬ ‫ﺿﺎ اﻟﻧﯾﺔ اﻷﺳﺎﺳﯾﺔ اﻟﻣﺗﺄﺧرة(‬ ‫ ﺣﺳب اﻟﻧﯾﺔ اﻟﺛﺎﻟﺛﺔ )وﺗﺳﻣﻰ أﯾ ً‬ ‫اﻟﺟرح ﺗرك ﻣﻔﺗوﺣﺎ ﻓﻲ اﻟﺑداﯾﺔ‬ ‫ﻋﺎرض إﯾدج ﻻﺣﻘًﺎ ﻋﻧدﻣﺎ ﻛﺎﻧت ظروف اﻟﺷﻔﺎء ﻣواﺗﯾﺔ‬ ‫‪3‬‬  ‫‪Healing by primary intention:‬‬ ‫‪Because of minimal surrounding tissue trauma, it causes the‬‬ ‫‪least inflammation & leaves the best scar. Delayed primary‬‬ ‫‪intention healing occurs when the wound edges are not‬‬ ‫‪opposed immediately, which may be necessary in‬‬ ‫‪contaminated or untidy wounds. Healing by 2ndary‬‬ ‫‪intention occurs in the wound that is left open& allowed to‬‬ ‫‪heal by granulation, contraction & epithelialization.‬‬ ‫اﻟﺷﻔﺎء ﺑﺎﻟﻧﯾﺔ اﻷﺳﺎﺳﯾﺔ‪:‬‬ ‫ﺑﺳﺑب اﻟﺣد اﻷدﻧﻰ ﻣن ﺻدﻣﺔ اﻷﻧﺳﺟﺔ اﻟﻣﺣﯾطﺔ‪ ،‬ﻓﺈﻧﮫ ﯾﺳﺑب أﻗل اﻟﺗﮭﺎب وﯾﺗرك أﻓﺿل ﻧدﺑﺔ‪.‬ﯾﺣدث ﺗﺄﺧر ﺷﻔﺎء اﻟﻧﯾﺔ اﻷوﻟﯾﺔ‬ ‫ﻋﻧدﻣﺎ ﻻ ﺗﺗﻌﺎرض ﺣواف اﻟﺟرح ﻋﻠﻰ اﻟﻔور‪ ،‬وھو ﻣﺎ ﻗد ﯾﻛون ﺿرورﯾًﺎ ﻓﻲ اﻟﺟروح اﻟﻣﻠوﺛﺔ أو ﻏﯾر اﻟﻣرﺗﺑﺔ‪.‬ﯾﺣدث‬ ‫اﻟﺷﻔﺎء ﺑﺎﻟﻘﺻد اﻟﺛﺎﻧﻲ ﻓﻲ اﻟﺟرح اﻟذي ﯾُﺗرك ﻣﻔﺗو ًﺣﺎ وﯾُﺳﻣﺢ ﻟﮫ ﺑﺎﻟﺷﻔﺎء ﻋن طرﯾﻖ اﻟﺗﺣﺑﯾب واﻻﻧﻛﻣﺎش واﻟﺗﺷﻛل اﻟظﮭﺎري‪.‬‬ ‫‪Types of wounds ---Tidy VS Untidy‬‬ ‫‪The aim is to convert untidy to tidy by removing all‬‬ ‫‪contaminated & devitalized tissue‬‬ ‫أﻧواع اﻟﺟروح ‪ ---‬ﻣرﺗب ﻣﻘﺎﺑل ﻏﯾر ﻣرﺗب‬ ‫اﻟﮭدف ھو ﺗﺣوﯾل ﻏﯾر ﻣرﺗب إﻟﻰ ﻣرﺗب ﻋن طرﯾﻖ إزاﻟﺔ ﺟﻣﯾﻊ اﻷﻧﺳﺟﺔ اﻟﻣﻠوﺛﺔ واﻟﺿﻌﯾﻔﺔ‬ ‫ﻣرﺗﺑﺔ ﻣﻘﺎﺑل اﻟﺟروح ﻏﯾر ﻣرﺗﺑﺔ‬ ‫ﻣرﺗب‬ ‫ﻏﯾر ﻣرﺗب‬ ‫ﻣﺣﻔور‬ ‫ﻣطﺣوﻧﺔ أو ﻣﻧﺗﻔﺧﺔ‬ ‫ﯾﻧظف‬ ‫ﻣﻠوﺛﺔ‬ ‫أﻧﺳﺟﺔ ﺻﺣﯾﺔ‬ ‫اﻷﻧﺳﺟﺔ اﻟﻣﻔﻌﻣﺔ ﺑﺎﻟﺣﯾوﯾﺔ‬ ‫ﻧﺎدرا ﻓﻘدان اﻷﻧﺳﺟﺔ‬ ‫ﻓﻲ ﻛﺛﯾر ﻣن اﻷﺣﯾﺎن ﻓﻘدان اﻷﻧﺳﺟﺔ‬ ‫‪4‬‬ Primary repair of all structures (e,g bones , tendons, vessels,& nerves)may be possible in a tidy wounds, but a contaminated wound with dead tissues requires debridement on one or several occasions before definitive repair can be carried out. This is true in injuries caused by explosions, bullets. ‫ ﻟﻛن‬،‫ﻗد ﯾﻛون اﻹﺻﻼح اﻷوﻟﻲ ﻟﺟﻣﯾﻊ اﻟﮭﯾﺎﻛل )ﻣﺛل اﻟﻌظﺎم واﻷوﺗﺎر واﻷوﻋﯾﺔ واﻷﻋﺻﺎب( ﻣﻣﻛﻧًﺎ ﻓﻲ اﻟﺟروح اﻟﻧظﯾﻔﺔ‬ ‫ وھذا ﯾﻧطﺑﻖ ﻋﻠﻰ‬.‫اﻟﺟرح اﻟﻣﻠوث ﺑﺄﻧﺳﺟﺔ ﻣﯾﺗﺔ ﯾﺗطﻠب اﻟﺗﻧﺿﯾر ﻣرة واﺣدة أو ﻋدة ﻣﻧﺎﺳﺑﺎت ﻗﺑل إﺟراء اﻹﺻﻼح اﻟﻧﮭﺎﺋﻲ‬.‫اﻹﺻﺎﺑﺎت اﻟﻧﺎﺟﻣﺔ ﻋن اﻻﻧﻔﺟﺎرات واﻟرﺻﺎص‬ Managing of acute wound. 1. Examine the whole pt. 2. Examine the wound itself. 3. Bleeding wound should elevated & a pressure pad applied. 4. After assessment, thorough debridement is essential. 5. Devitalized tissue must be excised until bleeding occurs with the obvious exception of nerves. 6. Skin closure should always carried without tension..‫إدارة اﻟﺟروح اﻟﺣﺎدة‬.‫ اﻓﺣص اﻟﻧﻘطﺔ ﺑﺄﻛﻣﻠﮭﺎ‬.1.‫ ﻓﺣص اﻟﺟرح ﻧﻔﺳﮫ‬.2.‫ ﯾﺟب رﻓﻊ اﻟﺟرح اﻟﻧﺎزف ووﺿﻊ وﺳﺎدة ﺿﻐط ﻋﻠﯾﮫ‬.3.‫أﻣرا ﺿرورﯾًﺎ‬ ً ‫ ﯾﻌد اﻟﺗﻧﺿﯾر اﻟﺷﺎﻣل‬،‫ ﺑﻌد اﻟﺗﻘﯾﯾم‬.4.‫ ﯾﺟب اﺳﺗﺋﺻﺎل اﻷﻧﺳﺟﺔ اﻟﻣﯾﺗﺔ ﺣﺗﻰ ﯾﺣدث اﻟﻧزﯾف ﺑﺎﺳﺗﺛﻧﺎء اﻷﻋﺻﺎب اﻟواﺿﺣﺔ‬.5.‫ ﯾﺟب أن ﯾﺗم إﻏﻼق اﻟﺟﻠد داﺋ ًﻣﺎ دون ﺗوﺗر‬.6 Chronic wounds: 5 ‫‪Chronic wounds:‬‬ ‫‪1. Leg ulcer: An ulcer defined as a break in the epithelial‬‬ ‫‪continuity. It is a long standing wound (ulcer) of the leg‬‬ ‫اﻟﺟروح اﻟﻣزﻣﻧﺔ‪:‬‬ ‫‪.1‬ﻗرﺣﺔ اﻟﺳﺎق‪ :‬ﻗرﺣﺔ ﺗﻌرف ﺑﺄﻧﮭﺎ اﻧﻘطﺎع ﻓﻲ اﻻﺳﺗﻣرارﯾﺔ اﻟظﮭﺎرﯾﺔ‪.‬إﻧﮫ ﺟرح طوﯾل اﻷﻣد )ﻗرﺣﺔ( ﻓﻲ اﻟﺳﺎق‬ ‫اﻟﻣﺳﺑﺑﺎت اﻟﻣرﺿﯾﺔ ﻟﻘرﺣﺔ اﻟﺳﺎق‬ ‫ ﻣرض ورﯾدي ﯾؤدي إﻟﻰ ارﺗﻔﺎع ﺿﻐط اﻟدم اﻟورﯾدي اﻟﻣﺣﻠﻲ )ﻣﺛل اﻟدواﻟﻲ(‬ ‫ ﻣرض اﻟﺷراﯾﯾن‪ ،‬إﻣﺎ اﻷوﻋﯾﺔ اﻟﻛﺑﯾرة )ﺗﺻﻠب اﻟﺷراﯾﯾن( أو اﻷوﻋﯾﺔ اﻟﺻﻐﯾرة )ﻣرض اﻟﺳﻛري(‬ ‫ اﻟﺗﮭﺎب اﻟﺷراﯾﯾن اﻟﻣرﺗﺑط ﺑﺄﻣراض اﻟﻣﻧﺎﻋﺔ اﻟذاﺗﯾﺔ )اﻟﺗﮭﺎب اﻟﻣﻔﺎﺻل اﻟروﻣﺎﺗوﯾدي‪ ،‬اﻟذﺋﺑﺔ‪ ،‬إﻟﺦ‪(.‬‬ ‫ اﻟﺻدﻣﺔ ‪ -‬ﯾﻣﻛن أن ﺗﻛون ذاﺗﯾﺔ‬ ‫ اﻟﻌدوى اﻟﻣزﻣﻧﺔ ‪ -‬اﻟﺳل‪/‬اﻟزھري‬ ‫ اﻷورام ‪ -‬ﺳرطﺎن اﻟﺧﻼﯾﺎ اﻟﺣرﺷﻔﯾﺔ أو اﻟﻘﺎﻋدﯾﺔ‪ ،‬ﺳﺎرﻛوﻣﺎ‬ ‫‪6‬‬ ‫‪2. Pressure sores‬‬ ‫‪.2‬ﻗروح اﻟﺿﻐط‬ ‫ﺗﻛرار ﻗرح اﻟﺿﻐط ﺑﺎﻟﺗرﺗﯾب اﻟﺗﻧﺎزﻟﻲ‬ ‫ اﻹﯾﺷﯾوم‬ ‫ اﻟﻣدور اﻷﻛﺑر‬ ‫ اﻟﻌﺟز‬ ‫ ﻛﻌب‬ ‫ اﻟﻛﻌب )اﻟﺟﺎﻧﺑﻲ ﺛم اﻟوﺳطﻲ(‬ ‫ اﻟﻘﻔﺎ‬ ‫‪:‬‬ ‫‪7‬‬ Scars : Is the maturation phase (end phase) of wound healing. The external appearance of the scar becomes pale , white , soft, flattens& its itching diminishes. Most of these changes occur over the first 3 months, but scar continue to mature for 1-2 years. An atrophic scar is pale, flat &stretched in appearance. A hypertrophic scar is defined as excessive scar tissue that does not extend beyond the boundary of the original wound. It results from a prolonged inflammatory phase of wound healing & from unfavorable scar sites A keloid scar is defined as scar tissue that extends beyond the boundaries of the original wound. : ‫اﻟﻧدﺑﺎت‬.‫ھﻲ ﻣرﺣﻠﺔ اﻟﻧﺿﺞ )اﻟﻣرﺣﻠﺔ اﻟﻧﮭﺎﺋﯾﺔ( ﻣن اﻟﺗﺋﺎم اﻟﺟروح‬ ‫ ﺗﺣدث ﻣﻌظم ھذه اﻟﺗﻐﯾﯾرات ﺧﻼل‬.‫ وﺗﻘل اﻟﺣﻛﺔ‬،‫ ﻣﺳطﺣﺎ‬،‫ ﻧﺎﻋﻣﺎ‬،‫ أﺑﯾض اﻟﻠون‬،ً‫ﯾﺻﺑﺢ اﻟﻣظﮭر اﻟﺧﺎرﺟﻲ ﻟﻠﻧدﺑﺔ ﺷﺎﺣﺑﺎ‬ ً ً.‫ ﻟﻛن اﻟﻧدﺑﺔ ﺗﺳﺗﻣر ﻓﻲ اﻟﻧﺿﺞ ﻟﻣدة ﺳﻧﺔ أو ﺳﻧﺗﯾن‬،‫اﻷﺷﮭر اﻟﺛﻼﺛﺔ اﻷوﻟﻰ‬.‫اﻟﻧدﺑﺔ اﻟﺿﺎﻣرة ﺗﻛون ﺷﺎﺣﺑﺔ وﻣﺳطﺣﺔ وﻣﻣﺗدة اﻟﻣظﮭر‬ ‫ وﯾﻧﺗﺞ ﻋن‬.‫ﯾﺗم ﺗﻌرﯾف اﻟﻧدﺑﺔ اﻟﻣﺗﺿﺧﻣﺔ ﻋﻠﻰ أﻧﮭﺎ ﻧﺳﯾﺞ ﻧدﺑﻲ ﻣﻔرط ﻻ ﯾﻣﺗد إﻟﻰ ﻣﺎ ھو أﺑﻌد ﻣن ﺣدود اﻟﺟرح اﻷﺻﻠﻲ‬ ‫ﻣرﺣﻠﺔ اﻟﺗﮭﺎﺑﯾﺔ طوﯾﻠﺔ ﻣن اﻟﺗﺋﺎم اﻟﺟروح وﻣن ﻣواﻗﻊ اﻟﻧدﺑﺎت ﻏﯾر اﻟﻣواﺗﯾﺔ‬.‫ﯾﺗم ﺗﻌرﯾف ﻧدﺑﺔ اﻟﺟدرة ﻋﻠﻰ أﻧﮭﺎ ﻧﺳﯾﺞ ﻧدﺑﻲ ﯾﻣﺗد إﻟﻰ ﻣﺎ وراء ﺣدود اﻟﺟرح اﻷﺻﻠﻲ‬ 8 9 10