Wound Healing

Stages of Wound Healing


Stage 1 (Immediate)
Haemostasis

• Vasoconstriction
• Platelet aggregation
• Thromboplastin makes clot

Stage 2 (immediate to 2-5days)
Inflammatory

• Vasodilation
• Phagocytosis

Stage 3 (2days to 3 weeks)
Proliferation
i.   Granulation

• Fibroblasts lay bed of collagen
• Fills defect and produces new capillaries

ii.  Contraction

• Wound edges pull together to reduce defect

iii.  Re-epithelization

• Crosses moist surface
• Cell travel about 3 cm from point of origin in all directions

Stage 4 (3weeks to 2 years)
Remodelling

• New collagen forms which increases tensile strength to wounds
• Scar tissue is only 80 percent as strong as original tissue

Skin Grafting

What is a skin graft?

 Transplantation of skin from its original site to another

Used to cover areas of tissue loss from :

•  trauma
•  infection
•  burns
•  surgical

Layer of Skin

Classification
Split-thickness skin graft (SSG)		Full-thickness skin graft (FTSG)
Epidermis and variable amounts of dermis Heals by re-eptheliisation from dermis & surrounding skin		Epidermis & all of dermis  Donor site closed directly with sutures
Advantages	Disadvantages	Advantages	Disadvantages
Better survival Less donor site morbidity	Secondary contracture Cosmesis	Cosmesis Closure of donor site	Less graft take  Size limit Pigment changes

Equipment for harvesting SSG

Dermatome

Gustilo Anderson classification

Gustilo Anderson classification

Classification used for open fracture
Important for prognosis

Based on 5 criteria
1. Size of the wound
2. Degree of contamination -
3. Degree of comminution - simple vs. comminuted
4. Soft tissue injury - mild, moderate, severe
5. Level of energy

Type	Size of the wound	Degree of contamination	Degree of comminution	Soft tissue injury	Level of Energy
1	<1cm	Clean	Simple #	Mild	Low
2	1-10cm	Moderate	Simple #	Moderate	Moderate
3	>10cm	Dirty	Comminuted #	Extensive	High
3a				Adequate soft tissue coverage
3b				Extensive soft tissue lost with periosteal stripping and bony exposure
3c				Major arterial injury requiring repair for limb salvage

Principle of Management for Open Fracture
1. Management of wound
2. Management of fracture

Management of wound
i.   Wound irrigation (to dilute microorganism)
ii.  Antibiotics

Type of Fractures	Empirical antibiotics
1	IV cloxacillin IV gentamycin
2	IV cloxacillin IV gentamycin OR IV cefuroxime
3	IV cefuroxime IV gentamycin IV metronidazole

iii. Analgesic
iv. Wound debridement

Management of fracture
i.  Reduction - open
ii. Immobalise - external vs. internal
   External - cast, splinting, external fixator, illizarov
   Internal - intamedullary vs. extramedullary
                  Extramedullary - K-wire, screw fixation, plating, tension band wire, circlage wire
                  Intramedullary - interlocking nail

Acromioclavicular Injury

Anatomy

Rockwood  Classification

Type I     - Sprain of the AC ligaments.

Type II    - Complete rupture AC ligaments.

Type III   - Complete rupture AC and CC ligaments.

Type IV   - Complete rupture AC and CC ligaments. with displacement of clavicle posteriorly through Trapezius

Type V    - Complete rupture AC and CC ligaments with gross displacement of ACJ and detachment of Deltoid    and Trapezius

Type VI  - Sub coracoid displacement

Managements

Type I	Non Operative
Type II	Non Operative
Type III	Controversial, very little difference
Type IV	Surgery
Type V	Surgery
Type VI	Surgery