Complications in Wound Healing Flashcards
What are Halsted’s principles of surgery?
H - haemosasis A - aseptic technique L - light touch (atraumatic) S - supply of blood preserved T - tension free closure E - even tissue apposition D - dead space obliterated
What were Esmarchs principles of wound management
- no introduction of anything harmful
- tissue rest
- wound drainage
- avoidance of venous stasis
- cleanliness
What is post-op haemorrhage usually due to? What else may cause it?
> usually due to inadequate haemostasis at Sx
- 1: slipped ligature
- delayed 1: breakdown of ligature
- 2* < LOOK THESE UP
may be due to coagulopathy
- pre-existing eg. vWF
- 2* due to consumption of clotting factors and platelets in massive bleeds
What effect may a haematoma have on wound healing?
- separates wound edges
- pressure on wound edges -> necrosis and dehiscence
- prevention of adherence of grafts and flaps
- physical barrier to leucocyte migration
- growth medium for bacteria
- pain
- organisation of haematoma may cause deformity (usually more cosmetic problem)
How may haemorrhage be managed?
- light pressure bandage 12hrs
- restrict movement (affected part or hole body - crate)
- investigate coagulopathy if suspicious
- supportive care (fluids +- blood prouducts)
How may haematoma be managed?
- none (may spontaneously resolve)
- aspirate + pressure
- warm compress tid 7d
Is swelling and oedema normal? What effects may this have on wound healing? DDX?
- normal accumulation of fluid in interstitial space but some wounds more prone to swelling than others
- may potentiate dehiscence (^ hydrostatic pressure in intersitium reduces vascularity and delays healing)
- DDx infection and cellulitits - local/regional/diffuse/dependant
What Tx may be used for swelling and oedema?
- Massage
- Support dressing
- Removal of constricting sutures
What is seroma and when may it occour?
- collection of serum and tissue fluid in dead space
- one step after oedema
How may seroma affect wound healing?
- tissue separation
- skin flaps and grafts
- tension on incision lines
- interference with blood supply
- WBC migration impaired`
DDx for seroma?
- haematoma
- oedema
- abscess
Tx of seroma?
> Usually resolve spontaneously
- try to avoid causing this in the first place!
conservative Tx includes
- aspiration (though may introduce infection)
- control of dead space with bandaging
- control movement
- drainage (active/passive)
- removal of sutures allowing second intention healing
surgical intervention possible but could end up with dehiscence and 2* infection
Causes of seroma
- inflame
- lymphatic injury
- poor haemostasis
- traumatic Sx eg. dissection
- implants - sutures and drains
- movement
- dead space
Give reasons for wound dehiscence
- 1* healing defect
- 2* to surgical technique, judgement, wound bed or trauma
When is dehiscence usually seen?
3-5d post surgery (unless self trauma)
Clinical signs of wound dehiscence
- serosanginous discharge
- swelling
- necrosis, bruising, discharge
Tx of wound dehiscence
- 2* intention healing
- surgical repair (though may end up in same position, find reason for initial dehiscence)
Why does wound dehiscence commonly occour following total ear canal ablation?
- sides of the wound uneven
- often infected
Which 3 factors influence wound infection?
- bacteria - presence and type [contamination does NOT always = infection]
- local wound environment
- local and systemic defence
Why may tissue necrosis occour?
- ischaemia (trauma, sx and postop, debridement)
- inadequate debridement -> inflammation, delayed wound healing and ^ risk of infection
What may excessive scarrign lead to?
- stenosis eg. anus
- functional incompetence
- restriction of movement eg. joints
- contracture -> loss of function
define sinus
blind ending tract extending from one epithelial surface (epidermal or mucosal)
deep site of infection, FB or sequestrum
define fistula
communicating tract extending from one epithelial surface to another eg. oronasal, rectovaginal, brochooesophageal
what may commonly cause draining sinus tracts in abdo wounds?
grass seed wedged in muscle laye r
how may exposed tendon or bone be encrouage to granulate?
- drill holes in bone to expose marrow and cause bleeding [forage holes]
- skin flap bringing additional blood supply eg. axial pattern flap, microvascular tissue transfer
Which stages of healing may be delayed in non-healing wounds?
- Inflammatory
- Proliferative (granulation formation, epithelisation, contraction)
- Maturation
Why may impairment of the inflammatory phase occour?
- necrotic/devitalised tissue
- excessive exudate
- poor blood supply
- absence of granulation tissue
- failure of epithelisation
- chronically painful wound
- recurrent breakdown
- infection
Why may impairment of the granulation phase occour?
- necrotic or devitalised tissue in wound
- infection
- movement
- poor blood supply
- mechanical abrasion
Tx of impaired granulation tissue formation
- further debridement
- excision of old granulation tissue
- enhance blood supply
- reconstruct using tissue with good blood supply
- support/mobilisation
Why may impairment of epithelialisation occour?
- necrotic tissue in wound
- infection
- eschar
- movement
- poor blood supply
- mechanical abrasion surface trauma
Tx of impaired epithelialisation
- further debridement
- Tx infection
- enhance blood supply (muscle, omentum vascular skin)
- protection
Why may impairment of contraction occour?
- tension in local skin
- lack of local skin
- restrictive fibrosis
- tight bandages
Tx of impaired contraction
- excision of restrictive scar
- wound reconstruction using skin flap or graft
What is an indolent/pocket wound?
Epithelium grows under wound edges -> dead space
how should indolent pocket wounds be dealt with?
- identify cause
- control infection
- excise wound
- tension free closure on reconstruction
- mamagement of dead space
- enhance local vascular supply (omentalisation)
