Wound Management

Question 1

What is a wound?

Answer 1

It is any disruption of anatomic structure and function in any body part.

Healing is the restoration of structure and function.

Question 2

What are the phases of wound healing?

Answer 2

Primary healing:- Wound closure within hours of its creation. Done using stitches, staples, glues etc.

Secondary healing:- No wound closure is involved. The wound closes spontaneously by contraction and reepithelialization.

Tertiary wound healing:- Involves initial debridement for an extended period and then formal closure using skin graft or flap cover.

NB:- Skin graft does not come with blood supply and it is less technical while skin flap comes with blood supply and is more technical.

Question 3

What is regenerative healing

Answer 3

This is the healing without scarring. This is seen in injuries that affect only the dermis of the skin.

Question 4

What is reparative healing?

Answer 4

This is injury that usually heals with a scar due to formation of surrogate tissue. Seen in injuries that affect the semis and subcutis.

Question 5

What are the various ways of wound classification?

Answer 5

1) OPEN or CLOSE
2) LOW VELOCITY or HIGH VELOCITY
3) BLUNT or PENETRATING
4) CLEAN, CLEAN CONTAMINATED, CONTAMINATED or DIRTY
5) INCISION, LACERATION, AVULSION, CRUSH or DEGLOVING

Question 6

What are the 3 stages of wound healing?

Answer 6

Inflammatory phase
Proliferative phase
Maturation phase

Question 7

Briefly discuss the inflammatory phase of wound healing

Answer 7

It is characterized by hemostasis and inflammation.

Collagen is exposed from cell damage during wound formation. This activates clotting cascade room both intrinsic and extrinsic pathway leading to inflammation.

Damaged cell membrane releases ** thromboxane a2 and prostaglandin 2-alpha** which are potent vasoconstrictors. Also histamine release helps to secure hemostasis.

Clot formation is achieved from the release of chemokines (vWF, fibronectin, fibrinogen, serotonin etc) from platelets. They stabilize the wound.

Leukocytes and macrophages (monocytes) secrete numerous enzymes and cytokines (TNF, collagenases, collagen, TGF, interleukins) that helps in wound healing.

Question 8

What is the first cell that responds to wound formation?

Answer 8

Platelets

Question 9

Which cell is referred to as the orchestrator that is essential for wound healing?

Answer 9

Macrophages

Question 10

What is the function of collagenases in wind healing?

Answer 10

Debrides the wound

Question 11

What is the function of interleukins and tumor necrosis factor (TNF) in wound healing?

Answer 11

Stimulate fibroblast (produce collagen) and promote Angiogenesis

Question 12

What is the function of Transforming Growth Factor (TGF) in wound healing

Answer 12

It stimulates keratinocytes

Question 13

Tissue reconstruction occurs in which stage of wound healing?

Answer 13

Proliferative stage

Question 14

What are the principal steps in the anabolic Proliferative phase of wound healing?

Answer 14

Epithelialization
Angiogenesis
Tissue granulation formation
Collagen deposition

EAT Collagen

Question 15

Which cytokine stimulates angiogenesis?

Answer 15

Tumor necrosis factor alpha (TNF-alpha)

Question 16

How long does it take after wounding for fibroblasts to begin synthesizing collagen

Answer 16

5 - 7 days

Question 17

The net increase for collagen deposition plateaus at what day?

Answer 17

21 days

Question 18

How long does it take a wound to reach its maximal strength

Answer 18

1 year

Question 19

In contracture wounds, maximum tensile strength is achieved at what time?

Answer 19

12th week and it’s only about 80% of the original strength of the skin.

Question 20

List the factors that affect wound healing

Answer 20

GENERAL FACTORS
- Age
- Nutrition
- Medications (eg steroids causes healing retardation)
- Psychological state

LOCAL FACTORS
- Site of injury
- Blood supply
- Moist wound healing
- Wound infection
- Temperature

Question 21

List the role of vitamins and trace elements in wound healing

Answer 21

• Vitamin A reverses healing retardation caused by steroid
• Vitamin c deficiency causes scurvy
• Zinc is needed for epithelialisation and fibroblast formation
• Ferrous iron and copper are necessary for normal collagen metabolism

Question 22

What are some of the functions of oxygen in wound healing?

Answer 22

• Energy metabolism
• Neo-vascularization
• Oxygen and bacteria
• Collagen synthesis
• Oxygen and antibiotics

Question 23

List some of the aims of treatment in wound healing

Answer 23

• To produce rapid and cosmetically acceptable healing,
• To remove or contain odour,
• To reduce pain,
• To prevent or combat infection,
• To contain exudate,
• To cause minimum distress or disturbance to the patient,
• To hide or cover a wound for cosmetic reasons.

Question 24

What are the 3 layers of dressing design?

Answer 24

● Inner layer: called the contact layer-in direct physical approximation with the wound.
● Middle layer: directed towards physical protection or absorption
● Outer layer: used for compression, positioning and immobilsation

Question 25

What are the 4 components of wound bed preparation? AKA TIME preparation.

Answer 25

●T= tissue management (involves debridement)
●I=inflammation and infection control
●M=moisture balance
●E=epithelial(edge) advancement

Question 26

What are the aims of time framework

Answer 26

Optimize the wound bed by
- Reducing edema
- Reducing bacterial burden
- Correcting abnormalities contributing to wound healing

Question 27

Why is moisture balance important in the TIME framework?

Answer 27

Dry surfaces;
- Impedes delivery of nutrients and immune defenses to the wound surface.
- Markedly impedes the ability of cells to migrate across the wound surface

Question 28

What are the benefits of moisture in wound management?

Answer 28

Increase reepithelialization
Increase rate of reepithelialization
Increase collagen deposition
Decrease wound surface fluid loss

Question 29

What are the clinical benefits of vacuum assisted closure?

Answer 29

• Provides a closed moist wound healing environment.
• Decreases wound volume
• Removes excess fluids that can inhibit wound healing
• Helps remove interstitial fluid
• Promotes granulation.

Question 30

List 3 abnormal wound healings

Answer 30

Keloids
Hypertrophic scars
Contractures

Question 31

Which connective tissue disease can affect wound healing

Answer 31

Marfan’s syndrome
Ehlers danlos syndrome
Progeria

Question 32

In ascending order, list the reconstructive ladder.

Answer 32

• Healing by secondary retention
• Direct closure
• Skin graft
• Local flap
• Distant flap
• Free flap