5 The Wounds

Question 1

• Loss of skin on the body as a result of trauma or injury is called “____‟.

Answer 1

Wound

Question 2

Partial loss of skin is called “____‟

Answer 2

Abrasions

Question 3

 Traumatic wounds are classified mainly in two categories which forms the basis of management. They are:

Answer 3

1. Tidy wound, such as clean incised wounds.
2. Untidy wounds, such as lacerated wounds.

Question 4

Another classification in four categories is based on the status of contamination of surgical sites. Examples are:

Answer 4

1. Clean wounds
2. Clean contaminated wounds
3. Contaminated wounds
4. Dirty wounds

Question 5

• when no viscous is opened.

Answer 5

Clean wounds

Question 6

when viscous is opened but with minimal spillage of its contents.

Answer 6

Clean contaminated wounds

Question 7

. - when spillage is from inflamed viscous.

Answer 7

Contaminated wounds

Question 8

which are clearly infected.

Answer 8

Dirty wounds

Question 9

Most surgical patients have wounds. Wounds require _________. Clean wounds can be _____,____,___ and sealedby _____^.

Answer 9

dressings
cleaned, dried, closed and sealed by dressings

Question 10

• should not be closed or sealed. They should be allowed to breathe and ventilate through porous dressings; they may require frequent dressings.

Answer 10

Clean contaminated and oozing wounds

Question 11

• __________ require cleaning, de-sloughing and debridement, till they become clean. Wounds contaminated with dirt, dust and soil require ___________.

Answer 11

Dirty wounds
tetanus prophylaxis

Question 12

• _______ close by themselves slowly. Epithelium grows at an average rate of ___ per day; hence large wounds may take a long time to close. They may either be closed by ______ and _____; or may be covered by ___.

Answer 12

Healthy small wounds
1mm
sutures or clips and staples

Covered by skin grafts

Question 13

• _______ are closed by primary suturing; unhealthy wounds are closed by ________ suturing or delayed closure after they are rendered healthy. Sutures, clips in wounds along stress lines and in vascular areas can be removed between _____. Those across the lines must be left for _________. Supportive measures are essential for healing. Metabolic states like diabetes must be controlled, infections must be eradicated, and nutritional status should be restored to normal. Other than that, all wounds must be protected from further trauma and re-infections. Clean wounds heal by primary intention; that is by regeneration of epithelium and minimum repair by fibrous tissue. They leave minimum scar.

Answer 13

Healthy wounds
secondary
3-7 days
2-3 weeks

Question 14

• Repair of wounds require healthy granulation tissue which is composed of newly forming capillaries and proliferating fibroblasts. It is therefore red, uniform and velvety in appearance and bleeds on touch. Tissues rich in vascular supply heal better and faster. Infection, ischemia, tension and foreign bodies, which include pus and necrotic dead tissue, are the worst enemies of healing. Similarly wounds in diabetics, immuno-compromised and nutritionally deficient patients take a long time to heal. Certain drugs like steroids and chemotherapeutic agents have similar delaying effect.

Question 15

• Wounds along stress lines in body [Langer‟s lines] heal faster with minimum scar. Those across these lines take longer time to heal and leave ugly scars. Wounds start gaining strength from third day onwards. They are strong enough to withstand normal stress within two weeks. However, remodeling and further gaining of strength continues for up to six months.

Question 16

All wounds, when they heal, leave scars. ___ is fibrous tissue, covered by epithelium.

Answer 16

Scar

Question 17

are deficient, devoid of nerves and vessels. Most of them are symptomless and fade away with time.

Answer 17

scars

Question 18

In some cases scar may become _______ and give an unpleasant cosmetic appearance; however this hypertrophy remains confined to the scar. Such scars may need revision.

Answer 18

hypertrophied

Question 19

, on the other hand is a complication of scar. Even a small scar of ear piercing can lead to outgrowing keloids. These keloids mainly grow outwards, are only disfiguring, and have minimal symptoms. Other type of keloids grows inwards and extends beyond the scar, deep into the tissues and has symptoms like severe itching and burning pain. It has racial and genetic tendencies. Recurrence, even after extensive excision is common.

Answer 19

Keloid

Question 20

Haemorrhages
Haemorrhage can be internal or external; and are of three types.

Answer 20

• Primary haemorrhage
• Secondary hemorrhage

Question 21

• occurs due to trauma or during operations, and must be stopped. Reactionary hemorrhage is the term used for early hemorrhage in post trauma/operative period when collapsed small vessels open up following resuscitation, and start to bleed.

Answer 21

Primary haemorrhage

Question 22

• occurs in infected wounds when blood vessels are eroded by inflammatory process. Similar measures will work in both these situations. As first aid, in hemorrhages of extremities, elevation of the limb above the level of heart, direct compression on the bleeding area can be effective. Temporary proximal compression by bands or tourniquet can also be used; however it must be released intermittently so as not to cause distal ischaemia. Finally the bleeding points may have to be ligated or sutured.

Answer 22

Secondary hemorrhage

Question 23

 Spontaneous bleeding in skin and mucous membranes is called .

Answer 23

Ecchymosis

Question 24

 Bleeding and extravasations of blood in tissues due to injury or trauma is called __________. In these conditions, blood is diffusely spread and cannot be drained.

Answer 24

Bruise or Contusion

Question 25

 Collection of blood in tissues is called _______. Aspiration or drainage of blood collection is possible as long as blood remains fluid. Eventually blood clots and cannot be drained; it may need evacuation of clots.

Answer 25

Haematoma

Question 26

are the commonest pathology dealt by surgeons. It is considered as a major complication in surgery.

Answer 26

Infections

Question 27

Surgical Infections
Infections are the commonest pathology dealt by surgeons. It is considered as a major complication in surgery. In addition to primary infective conditions, these include:

Answer 27

1. Surgical site infections [SSI],
2. Nosocomial infections, and
3. Cross infections.

Question 28

are the usual organisms in surgical infections.

Answer 28

Staphylococci, streptococci, E. Coli, proteus, pseudomonas and anaerobes

Question 29

produce localized necrotizing inflammations and may end in collection of thick pus, due to their coagulase positive nature.

Answer 29

Staphylococci

Question 30

, are examples of such lesions.

Answer 30

Abscesses, boils, carbuncles

Question 31

is an infected hair follicle and is self limiting condition. It may spread and become an abscess, requiring drainage.

Answer 31

Boil or furuncle

Question 32

______ is infection of many hair follicles in a group at one place, and occurs usually on nape of neck or on back. It is common in diabetics. Wide excision and drainage maybe required in addition to control of diabetes and infection. Streptococci produce spreading lesions due the presence of enzyme hyaluronidase.
Examples are

Answer 32

Carbuncle
erysipalas, cellulitis, fasciitis and myositis.

Question 33

______ is infection of many hair follicles in a group at one place, and occurs usually on nape of neck or on back. It is common in diabetics. Wide excision and drainage maybe required in addition to control of diabetes and infection. Streptococci produce spreading lesions due the presence of enzyme hyaluronidase.
Examples are

Answer 33

Carbuncle
erysipalas, cellulitis, fasciitis and myositis.

Question 34

indicates pseudomonas infection;

Answer 34

Blue or green pus

Question 35

indicates presence of anaerobes.

Answer 35

foul smelling pus

Question 36

____ is spreading inflammation of subcutaneous tissues. ________ are required. Surgery is not necessary unless abscess develops.

Answer 36

Cellulitis
Antibiotics

Question 37

In humans __________ presents as red streaks in white skinned people; difficult to see in dark skin ones.

Answer 37

Lymphangitis

Question 38

is inflammation of superficial veins and may follow as complication of venipuncture. Treatment is conservative.

Answer 38

Thrombophlebitis

Question 39

is localized collection of pus. Usually caused by staphylococcus, mixed organism may be present. Fluctuation can be elicited in superficial abscesses. Deep ones require ultrasound to diagnose.

Answer 39

Abscess

Question 40

is digestive product of dead and dying bacteria, blood cells and local tissue.

Answer 40

Pus

Question 41

Dead tissue must be _____________, and thick fibrotic edges must be debrided to promote healing in chronic wounds and ulcers.

Answer 41

desloughed

Question 42

When the pus collection is in deep tissues covered by dense fascia, such as the palm of the hand and parotid region, early decompression is essential to prevent necrosis. One should not wait for classical signs to appear. Presence of throbbing pain is enough to warrant early intervention. Timely interventions are essential. Treatment delayed is treatment denied.

Question 43

All foreign bodies that delay healing must be removed. Pus, dead tissue, slough and sequestrum act like foreign bodies. Thin watery pus discharge from ulcers and sinuses indicates chronic infections

Question 44

These are neoplastic growths that present as swellings or ulcers. In most cases, cause is unknown; although recent research in molecular biology and genetics is trying to unravel this mystery.

Answer 44

Tumors

Question 45

Tumors are either:

Answer 45

a. Benign, which are usually capsulated and grow slowly; or
b. Malignant, where growth is very fast

Question 46

Most benign tumors have high potential for malignant change. Tumors are the result of uncontrolled growth of tissues by cellular hyperplasia, dysplasia and anaplasia. These are either epithelial in origin [Carcinomas], or mesothelial [Sarcomas].

Question 47

________ have no capsule; they grow and spread by infiltration in surrounding tissues. Once vessels are infiltrated, lymphatic or blood spread occurs. In the abdomen cancers can spread all over the peritoneal surface by freely falling malignant cells, called ________^^.

Answer 47

Carcinomas
trans-coelomic spread

Question 48

Sarcomas usually grow by expansion, and spread by blood stream. Histologically carcinomas may be well differentiated in their cellular structure and glandular pattern; moderately differentiated, or completely undifferentiated when they are called „_______‟. This last group has the poorest prognosis.

Answer 48

Anaplstic

Question 49

Tumors of endocrine glands may involve more than one gland of Neuro-Endocrine origin. These are called „Multiple Endocrine Neoplasia‟ [MEN], and are divided into two main groups; MEN-1 and MEN-2. Complete evaluation of the patient before surgery on endocrine tumors is very important.
Surgical excision is the treatment of choice for Benign Tumors, if they are bulky, unsightly, causing symptoms, changing their growth pattern, or are known to be premalignant. Radical curative surgery is the treatment of choice for most Malignant Tumors in early stage.
Palliative surgery is required to relieve symptoms in advanced tumors which are not curably resectable. Certain tumors respond to cancer chemotherapy, either completely as in lymphomas; or partly, when tumor size and its stage can be reduced. This is called neo-adjuvant therapy, and is followed by surgical excision.
In other instances chemotherapy is used as adjuvant therapy after surgery, to deal with any remaining cancer cells. It can also be the only therapy in advanced tumors. Certain tumor cells are sensitive to radiations. Radiotherapy is indicated in such radio-sensitive tumors; pre-operative, post-operative, or as the sole treatment. At times both chemotherapy and radiotherapy are combined to enhance the anti tumor effect; it is then called „Chemo-radiation‟.

Question 50

are abnormal swellings containing air or fluid; clear thin or turbid & thick.

Answer 50

Cysts

Question 51

True cysts are lined by epithelium. False cysts, on the other hand, have no epithelial lining. [Pseudo-pancreatic cyst]. True cysts can be classified as follows.

Answer 51

a. Developmental cysts
b. Malformation cysts.
c. Retention cysts
d. Distention cysts
e. Pulmonary cysts
f. Degeneration cysts
g. Implantation cysts
h. Parasitic cysts

Question 52

a. Developmental cysts: Examples

Answer 52

are Branchial cyst, Thyroglossal cyst, Duplication cyst, Mesenteric cyst, Polycystic disease of liver, kidneys, pancreas, lungs, etc.

Question 53

b. Malformation cysts: Example, Cystic Hygroma. Sequestration cysts: Sequestration Dermoids. Germinal cysts: These arise from germinal layers and are common in testes and ovaries in the form of Dermoids and Teratomas.
c. Retention cysts: When ducts of small glands are blocked, secretions are retained forming a cystic swelling. Examples are epidermal cysts and ranula.
d. Distention cysts: When secretions in the acini of a ductless gland accumulate, they distend the acini forming cysts. Example is colloid cyst of thyroid gland.
e. Pulmonary cysts are also due to distension of alveoli with air.
f. Degeneration cysts: Solid masses may undergo ischaemic necrosis and degeneration in their center leading to cyst formation. Example is chocolate cysts of ovary.
g. Implantation cysts: A penetrating foreign body may implant a tiny piece of dermis in subcutaneous tissue causing sub-minimal aseptic inflammatory reaction and cyst formation called implantation dermoid cyst.
h. Parasitic cysts: Classical example is hydatid cyst. Parasite causes lesions where germinal layer secretes fluid leading to formation of cyst and floating daughter cysts which look Common Lesions of Skin and Subcutaneous Tissue Simple Benign Lesions Epidermal cysts, earlier called sebaceous cysts, are the commonest. They arise from sebaceous glands and occur in hairy areas such as scalp, scrotum, chest, etc. They are attached to the skin as a black spot from where the hair fell. They contain thick cheesy sebum. Complications include infection, ulceration, and rarely the sebaceous horn. Small ones can be left alone. Large, unsightly or infected ones require excision. Recurrence is common like grapes.

Question 54

Peri-Operative Care
An operation is merely a part of the holistic management of a patient. Success of operation depends on at least three factors.
 First factor is the art and technique of operation; appropriate choice of the procedure, and its execution with minimum collateral damage to the healthy tissues. A technically successful operation is meaningless for the patients if the final outcome is not as per their expectations. This also emphasizes the importance of informed consent and continued meaningful dialogue between patient and the managing team.
 Second factor is related to the patient in the form of pre-operative assessment and preparation for surgery, in order to achieve the most satisfactory outcome.
 Third factor is environment related; and includes sterility standards of the theater suit, antiseptic precautions, availability of appropriate instruments, optimally working equipment without any possible hazards, and trained support staff.
Peri-operative care includes pre-operative preparation, intra-operative care and post-operative complications and their management.

Question 55

Preoperative Preparation
This starts with obtaining “Informed consent‟ of the client and by evaluating the risk status of the patient like coexisting medical conditions, medications if any, and current haemo-dynamic and cardio-respiratory status.
Elective surgical procedure is postponed till near normal physiological state is achieved. Special preparations may be required before surgery, depending on the procedure, such as bowel preparation, exchange transfusion, etc.
In emergency surgery, high risk consent is taken and critical care monitoring is initiated.

Question 56

Intra-Operative Care
This includes guaranteeing a near normal physiological status of the patient while asleep, as well as after coming out of the effects of anaesthesia. It is important to keep a constant surveillance on monitoring screens, checking vital signs; pulse, respiration, blood pressures and body temperature.
Digital oxymetry for oxygen saturation and checking hourly urine output to regulate IV fluids are equally important. Alert monitoring avoids situations such as hypoxia, dehydration, and temperature fluctuations. Everyone should remain prepared for any sudden unwanted developments.
Postoperative care recognizes developing complications, if any, in time and takes steps to deal with them. In many situations surgeon has to use drains. Their function is to remove undesirable collections. Once drainage stops, drains can be removed.

Question 57

Postoperative Complications and Management
In immediate postoperative period [first 24 hrs] bleeding from operative site and pulmonary complications are likely events. Main causes for the „Post-operative pulmonary complications‟ are pre-existing pulmonary conditions, intubation trauma, effect of anesthetic gases, and inability to sit, move or cough due to pain. This leads to excessive trachea-bronchial secretions and their retention leading to atelactasis, bronchitis, and aspiration pneumonias.
Early mobilization of patient and chest physiotherapy, are preventive measures. During first postoperative week, infections, at surgical site, chest or urinary tract if catheter has been used, are likely.
Wound dehiscence, partial or complete can occur, requiring supportive or surgical approach. Infection is the most common cause of wound dehiscence in surgical wound. It can be suspected by thin serous discharge from fresh post-operative wounds. Few common causes include poor nutrition, poor closure and excessive intra-abdominal pressure. By the end of first week, deep vein thrombosis [DVT] can manifest by pain in the calf muscles, tenderness on squeezing, oedema of leg and unexplained fever.