Wound healing complications Flashcards
Outline some general complications of wound healing
Haemorrhage and haematoma Swelling and oedema Seroma Dehisence Infection - tissue necrosis Scarring and contracture Draining tracts Exposed bone Non-healing wounds
What are the different types of wound? 5
Elective incisional Elective excisional Traumatic complications Acute Chronic
What are Halsted’s Principles of Surgery?
H - haemostasis A - aseptic technique L - light touch (atraumatic surgery) S - supply of blood preserved T - tension free closure E - even tissue apposition D - dead space obliteration
What are Esmarch’s principles of wound management? 5
Non-introduction of anything harmful Tissue rest Wound drainage Avoidance of venous stasis Cleanliness
When can haemorrhage and haematoma occur?
Post-operatively:
Primary
Delayed primary
Secondary
What effect does a haematoma have on wound healing? 7
physical separation of wound edges
pressure on wound edges (necrosis and dehisence)
prevention of adherence of grafts and flaps
physical barrier to leukocyte migration
growth medium for bacteria
pain
organisation of haematoma may cause a deformity
How do you manage haemorrhage?
Pressure - light bandage, 12 hours
Restrict movement
Investigate coagulopathy
Supportive (fluids +/- blood products)
How do you manage haematoma?
none
aspirate - but infection risk
warm compress
What are DDx for swelling and oedema? 2
infection and cellulitis
What therapy is appropriate for swelling and oedema?
massage, support dressing, remove constricting structures
What is an axial pattern flap?
a myocutaneous flap containing an artery in its long axis
Define seroma
a collection of serum and tissue fluid in dead space
What are the effects of a seroma?
tissue separation skin flaps skin grafts tension on incision lines interference with blood supply interferes with WBC migration
What are DDx for seroma? 3
haematoma, oedema, abscess, wound dehisence and herniation
What is best treatment for seroma?
Most resolve but prevention better than cure - no sepcific therapy.
CONSERVATIVE: aspirate, control dead space, control movemement, drainage (avoid suction), remove sutures
SURGICAL INTERVENTION: dehisence, secondary infection
What contributing factors may lead to seroma? 7
inflammation lymphatic injury poor haemostasis traumatic surgery implants movement dead space
What are reasons for dehisence?
primary healing defect
surgical technique, judgement, wound bed, trauma
When is dehisence usually seen? Exception?
3-5 days after surgery (unless self-trauma)
What are signs of dehisence?
serosanguinous discharge
swelling
necrosis, buising, discharge
What is appropriate therapy for dehisence? 2
second intention healing or surgical repair
What broad factors affect whether a wound will become infected?
bacteria
local wound environment
local and systemic defence
What are the 2 main reasons for tissue necrosis?
Inadequate blood supply
Inadequate debridement
When are scarring and contracture beneficial? 1
shear injuries
What might happen if you have excessive scar formation? 4
stenosis
functional incompetence
restriction of movement
contracture –> loss of function
What is a sinus?
blind ending tract that extends from one epithelial surface (epidermal or mucosal). Deep site of inection, FB, sequestrum
What is a fistula?
a communicating tract that extends form one epithelial tract to another (e.g. oronasal, rectovaginal, bronchooesophageal)
What are forage holes?
When you have an injury involving bone, you might assess the BM’s supply of BVs in order to perform microvascular tissue transfer
What is forage?
= osteostixis = subchondral drilling
numerous holes are drilled with a fine Kirshner wire or microdrill burr through to subchondral bone so that bleeding is encountered. Particularly useful if bone with the defect is sclerotic or eburnated.
Name 2 skin repair techniques that brings additional blood supply back.
axial pattern flapp
microvascular tissue transfer
What is the main reason for delayed healing and non-healing wounds?
inflammatory phase of healing is impeded.
What are the clinical features of a wound that has delayed healing or non-healing? 8
necrotic/devitalised tissue excessive exudate poor blood supply absence of GT failure of epithelialisation chronic painful wound recurrent breakdown infection
Why might GT formation be impaired?
necrotic or devitalised tissue in wound infection movement poor blood supply mechanical abrasion
What are good therapeutic approaches to impaired GT formation? 5
remove impediments (further debridement) excise old GT bed enhance blood supply reconstruct using tissue with good blood supply support/immbolise
Why might epithelialisation be impaired?
necrotic or devitalised tissue in wound infection exchar movement poor blood supply mechanical abrasion surface trauma
What is an eschar?
a slough of dead tissue that is cast off from the surface of the skin, especially after a burn injury
Why might wound contraction be inhibited? 4
tension in local skin
lack of local skin
restrictive fibrosis
tight bandages
What therapy might be suitable for impaired epithelialisation? 4
remove impediments (further debridement)
treat any infection
enhance blood supply
protect
What therapy might be suitable for a wound that is failing to contract? 2
excision of restrictive scar
wound reconstruction using skin flap or graft
What is an indolent wound?
one that is slow to heal
What should you consider with indolent/pocket wounds? 3
Identify cause
Infection?
How healthy is tissue?
Do we need to bring a flap for blood supply?
How can an indolent pocket wound be treated? 4
excise wound
tension free closure - reconstruction
manage dead space
enhance local vascular supply - omentalisation
When might post-operative haemorrhage occur?
Failure of intra-operative haemorrhage (usually)
coagulopathy (sometimes)
What circumstances dictate surgical management of bleeding?
severe arterial bleeding or arterial bleeding that isn’t responsive to conservative management
wound dehisence due to pressure
development of compartment syndrome
secondary infection of haematoma
What may aid the resolution of a haematoma once formed?
application of a warm compress for 10 minutes, 3 times daily, over 7 days
Are traumatic or surgical wounds generally more affected by oedema?
traumatic wounds generally more eaffected
Give some examples of wounds where post-op odemea may be more marked
regional mastectomy with tissue undermining
reverse saphenous conduit flap
free skin graft during the phase of plasmatic imbibition
large distal wound allowed to heal by second intention
LN excision
What should you do in in the case of regional oedema?
investigate veins and lymphatics and LNs draining the region for pathological processes causing occlusion
What should you investigate with generalised oedema?
investigate for the presence of:
hypoproteinaemia
cardiac disease
How would your treat mild and moderate oedema?
MILD - may not require specific therapy
MODERATE - massage, hot and cold packing and physio, bandaging carefully, remove sutures if they are contributing to vascular occlusion
How do you treat a small seroma?
generally of no consequence
don’t require treatment
resolve with time (usually 2-3 weeks)
How might a large seroma be treated?
drainage by aspiration
+/- corticosteroid injection
management of dead space with bandage
limitation of movement
drainage by an indwelling drain (passive or active suction)
removal of sutures and healing by second intention
Perform all with strict aseptic technique
How should dead space within a wound be managed?
ONE OR MORE OF THE FOLLOWING:
suture closure and tacking of tissue planes
use of a drain
compression of dead space with bandage
What is the usual cause of wound dehisence?
rarely a primary problem caused by inability of tissue to heal but usually secondary to another problem associated with the wound bed and the surgical technique and judgement
What are the two broad causes of wound dehisence?
Excessive forces
Poor wound holding strength
What may be the initial signs of wound dehisence?
serosanguinous discharge from wound edges
non-painful SC wound swelling
What may precede wound dehisence in some wounds?
necrosis of wound edge
extensive cutaneous bruising
presence of serum below skin
serosanguinous discharge
True/false - in some wounds, the deeper wound layers may dehisce while the skin remains intact.
Why is this important?
True - thus the appropriate treatment depends on the tissue layer that has suffered dehiscence and the cause of this.
What are the 4 classical signs of inflammation?
heat, redness, pain and swelling
What are local signs of wound infection?
4 classical signs of inflammation
serosanguinous - purulent discharge
How long is some local inflammation and sometimes pyrexia after surgery present for?
should resolve within 48 hours. If it carries on longer than this, it may indicate infection (a serosanguinous discharge from the wound 3-5 days after surgery is a strong indicator of wound infection).
Where is infection prone to establishing?
the site of invasive devices (e.g. IV catheters)
Outline the different colours of necrotic tissue
red -brown - black - purple
as the tissue becomes progressively dehydrated
Define wound contracture
the loss of function of a body part, usually as a result of excessive scarring
What is the best way to prevent wound contracture?
early recognition of wounds at risk
Which wounds are unlikely to heal by second intention?
if they are more than half the circumference of the limb
What might be required treatment if contracture occurs?
z-plasties scar excsiion with reconstruction partial myotomies temporary splintage physio early return to normal activity
Why are adhesions uncommon in small animals?
more efficient fibrinolytic system that prevents adhesions developing
What factors disrupt the equilibrium between normal fibrin deposition and fibrinolysis? 4
ischaemia
haemorrhage
FBs
infection
What is sclerosing encapsulating peritonitis?
represents a particular type of extensive adhesion development, where the entire intestinal tract is encased and tethered within a sheet of fibrous tissue
What is useful to create a bloodless field for the exploration of draining tracts affecting the distal limbs?
ESMARCH BANDAGE (avoid in presence of suppuration, DVT or neoplasia) and TOURNIQUET (avoid in traumatised limbs, vascular injury, circulatory compromise)
What extends form the holes created in forage or osteostixis?
leucocytes
fibroblasts
new capillaries
DONT WEAKEN ALREADY TRAUMATISED BONE (especially metacarpal and metatarsal)
When should bone be excised?
If exposed bone protrudes above wound surface, it isn’t likely to be covered by GT and, if not critical to salvage of the body part, it should be excised to the level of or below the GT tissue bed.
Suggest ways of improving wound vascularity - 3
muscle flaps
omentalisation
local skin flaps
(distant skin flaps and free skin grafts are ultimately dependent on revascularisation form the recipient bed so are poor options in this case)
What are the two main reasons for failure of wound contraction?
peripheral countertension (due to lack of loose skin around wound) restrictive fibrosis (mechanically impairs skin advancement from local wound edges)
What happens in indolent pocket wounds?
in these wounds, GT forms with pliable skin around the wound, but the surrounding skin becomes elevated from the wound bed and doesn’t adhere to the margins of the defect. a cavity lined by GT forms in the hypodermal space. Epithelial cells from skin edges may migrate to line the dermal surface and the skin edges will not advance, but tend to curl under. The GT becomes chronic with increases in the amount of fibrous tissue and reduction in vascular tissue. It may become infected.
Where are indolent pocket wounds most frequently seen?
inguinal, axillary and flank regions
particularly in cats
How are indolent pocket wounds successfully managed?
infection control
excision of scar border
excision of restrictive dermal scar to allow skin to advance
closure of wound with suturing of skin edges directly to each other
anchoring skin edges to underlying GT bed
management of dead space with drains
use of local skin flaps (if primary closure cannot be achieved)
omentalisation (if vascular supply to wound is affected)
