Wound Healing and Closure

Gil C. Grimes, MD2003-03-06

Goals Review anatomy of skin Basics of wound healing One and two handed tie Instrument ties and deep ties

Brief Anatomy

Lines of Tension Static lines

Langer’s Lines Reflects natural skin tension Worst along anterior tibia Best along volar surface of hand Can be tested with pinch test Wound gap >5 mm demonstrates

significant tension

Lines of Tension Dynamic

Kraissl’s lines Formed by

movement Compression of

skin Everyone smile If you can cut

parallel to these then lessen scar

Wound Healing Hemostasis

Tissue retraction Tissue

compression Vasoconstriction Clotting cascade Vascular dilation Wound exudate

Wound Healing Inflammation

First phase Compliment attracts

granulocytes Peaks in 12-24 hours Over by 72 hours

Second phase Macrophage driven Begins 24 hours Peaks 5 days Phagocystosis

Returns nutrients Stimulates fibroblasts

and endothelial cells

Wound Healing Epithelialization

Begins at 12 hours In closed wound

seal formed by 24 hours

Unclosed wounds close slower

Remember road rash

Wound Healing Neovascularization

Evident by day three Most active by day 7 Decreases by day 21 New capillary loops

are surrounded by active fibroblasts

Give granulation tissue its color

Wound Healing Collagen Synthesis

Mitosis fibroblasts begin day 1

New collagen laid down day 2

Peak synthesis day 5-7

Initial pattern random

Remodeled over time

Wound Healing Return of tensile

strength Weakest at day 7-10

due to remodeling At 35% of original

strength at 30 days At 70 % of original

strength at 70 days Never completely as

strong as the original

Comorbidities to healing Age

Dermal component Muscle mass Inflammatory response Collagen deposition Tensile component Circulation

Comorbidities to healing Weight and Nutrition

Increases stress Adipose has poor blood supply Malnutrition

Blood Supply Oxygen delivery Smokers CHF and CAD

Comorbidities to healing Immune system

HIV Steroids Allergies

Chronic Disease Diabetes Peripheral vascular disease Malignancies

Infection

Types of Wounds Shearing Force

Incisions Due to sharp

objects Minimal collateral

tissue damage Sharply defined

margins Minimal localized

devitalized tissue

Types of Wounds Tension Force

Laceration Tearing forces Blunt or semi-

blunt object strikes at an acute angle

Creates a flap Shearing force

transmitted to surrounding tissue

Type of Wounds Compression

Blunt object strikes at a right angle

Lots of collateral tissue damage

Significant devitalization of surrounding tissue

Subcutaneous tissue very susceptible to injury

Adipose necrosis

Wound Closure Primary

Within the first 6-8 hours May delay longer in select locations

Face and scalp may be delayed to 24 hours

Lower extremities may need to be closed sooner

Must have a fresh wound May freshen wound If it is clean and bleeding it can close

Wound Closure

Wound Closure

Wound Closure

Steps to Closure Asses patient

Wounds can wait if other problems exist

Prevent further injury Clean the wound Allergies Anesthesia Tetanus

Steps to Closure

Steps to Closure

Steps to Closure

Steps to Closure

Steps to Closure

Steps to Closure

Steps to Closure

Steps to Closure

Good Knots

Square Knots

Square Knots

Instrument Tie

One Handed Tie

One Handed Tie