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Plastic Surgery > Wounds > Flashcards

Wounds Flashcards

1
Q

What is a laceration?

A

Sharply cut tissue

Lacerations can vary in depth and location.

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2
Q

Define abrasion.

A

Superficial skin layer is removed, variable depth

Abrasions typically affect the outermost layers of skin.

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3
Q

What characterizes a contusion?

A

Injury caused by forceful blow to the skin and soft tissue; entire outer layer of skin intact, yet injured

Contusions are commonly known as bruises.

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4
Q

What is an avulsion?

A

Skin and soft tissue forcefully separated from deeper structures, potentially compromising blood supply or resulting in full detachment (amputation)

Avulsions can lead to severe complications if not treated promptly.

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5
Q

Describe puncture wounds.

A

Cutaneous opening relatively small as compared with depth (e.g. needle), including bite wounds

Puncture wounds can introduce bacteria deep into tissues.

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6
Q

What are crush injuries?

A

Injuries caused by compression

Crush injuries can lead to significant tissue damage.

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7
Q

List the types of burns.

A

Thermal, chemical, electrical

Each type of burn requires different treatment approaches.

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8
Q

What are ulcers?

A

Open sores on the skin or mucous membranes

Ulcers can result from various factors, including pressure and poor circulation.

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9
Q

What local factors influence wound healing?

A

Mechanical trauma, blood supply, technique and suture materials, retained foreign body, infection

Local factors can significantly impact the healing process.

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10
Q

What general factors influence wound healing?

A

Age, nutrition, tobacco smoking, alcohol consumption, chronic illness, immunosuppression, genetic predisposition

General factors can affect the overall healing capacity of an individual.

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11
Q

Fill in the blank: _______ affects the healing rate of wounds.

A

Age

Older individuals may experience slower healing rates.

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12
Q

True or False: Venous hypertension can influence wound healing.

A

True

Venous hypertension can lead to poor circulation and delayed healing.

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13
Q

What are some chronic illnesses that affect wound healing?

A

Diabetes mellitus, cancer, dyslipidemia, renal failure, stroke

These conditions can impair various aspects of the healing process.

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14
Q

What is the role of nutrition in wound healing?

A

Nutrition supports cellular repair and immune function

Adequate nutrition is essential for optimal healing.

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15
Q

What is the impact of immunosuppression on wound healing?

A

It can delay healing and increase the risk of infection

Immunosuppressive therapies, such as steroids and chemotherapy, can compromise the healing response.

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16
Q

List some factors that can lead to abnormal healing.

A

Genetic predisposition, hypertrophic scarring, keloid scarring, collagen vascular disease

These factors can result in complications during the healing process.

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17
Q

Fill in the blank: _______ can increase the infection rate in wounds.

A

Hematoma/seroma

Retained fluid can create an environment conducive to infection.

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18
Q

What is the effect of tobacco smoking on wound healing?

A

It can impair blood flow and oxygen delivery to tissues

Smoking is known to negatively affect wound healing outcomes.

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19
Q

What role do growth factors play in wound healing?

A

They are released by tissues and play an important role in the healing process.

Growth factors orchestrate various phases of healing, including collagen production.

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20
Q

How long does it typically take for a scar to mature?

A

1-2 years.

Scar maturation is completed after the final stage of wound healing.

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21
Q

What is the duration of the Inflammatory Phase of wound healing?

A

Days 1-10.

This phase limits damage and prevents further injury.

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22
Q

What are the main processes involved in the Inflammatory Phase?

A
  1. Hemostasis
  2. Chemotaxis
  3. Inflammatory response

Neutrophils: cell debris and pathogen cleanser
macrophages: cell cleaner and releases collagen 3
and platelets: clot formation

Cytokines
Proinflammatory: TNF-alpha, IL-1, PDGF

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23
Q

What is the role of neutrophils in the Inflammatory Phase?

A

They clear debris and organisms within the first 24-48 hours.

Neutrophils are part of the body’s initial response to injury.

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24
Q

What is the primary role of macrophages in wound healing?

A

They orchestrate growth factors for collagen production.

Macrophages play a critical role in the healing process.

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25
Q

What is the duration of the Proliferative Phase of wound healing?

A

Day 4 to Week 3.

This phase includes key processes like collagen synthesis and angiogenesis.

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26
Q

What are the key processes in the Proliferative Phase?

A
  1. Collagen synthesis (mainly type III)
  2. Angiogenesis
  3. Epithelialization

These processes are essential for tissue repair.

Lymphocytes – Protectors
Fibroblasts – Builders -> collagen

Cytokines:
PDGF: platelets derived growth factor
FGF: fibroblast growth factor
EGF: epidermal growth factor
VEGF: vascular endothelial growth factor

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27
Q

When does tensile strength begin to increase during wound healing?

A

At 4-5 days.

This marks the transition into the stronger phases of healing.

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28
Q

What is the duration of the Remodeling Phase of wound healing?

A

Week 3 to Year 1.

This phase focuses on the organization of collagen and scar remodeling.

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29
Q

What happens to collagen during the Remodeling Phase?

A

Type I collagen replaces Type III until a normal 4:1 ratio is achieved.

This transition strengthens the scar tissue.

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30
Q

What is the peak tensile strength of the scar and when is it achieved?

A

80% of pre-injury strength at 60 days.

This reflects the scar’s capacity to withstand stress.

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31
Q

What is the main goal of the Remodeling Phase?

A

To remodel the scar and increase tensile strength.

This phase is crucial for restoring skin integrity.

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32
Q

True or False: Lymphocytes play a well-defined role in the Inflammatory Phase.

A

False.

The role of lymphocytes is poorly defined in this phase.

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33
Q

What is Primary (1°) Healing?

A

Wound closure by direct approximation of edges within hours of wound creation

Examples include using sutures, staples, or skin grafts.

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34
Q

What is the indication for Primary (1°) Healing?

A

Recent wounds (6-8 hours old, longer for facial wounds)

This type of healing is most effective shortly after the injury occurs.

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35
Q

What are the contraindications for Primary (1°) Healing?

A
  • Animal/human bites
  • Crush injuries
  • Infection
  • Long time lapse since injury (>6-8 hours)
  • Retained foreign body

These factors can complicate the healing process.

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36
Q

What is Secondary (2°) Healing?

A

Wound left open to heal spontaneously with epithelialization, contraction, and granulation

Epithelialization occurs at 1 mm/day from wound margins.

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37
Q

What are the key cells responsible for wound contraction in Secondary (2°) Healing?

A

Myofibroblasts

These specialized cells play a critical role in the healing process.

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38
Q

What is the indication for Secondary (2°) Healing?

A

When Primary (1°) closure is not possible or indicated

This could be due to the nature of the wound or other health factors.

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39
Q

What is Tertiary (3°) Healing?

A

Intentionally interrupting the healing process, then closing the wound primarily after granulation tissue has formed

This occurs at 4-10 days post-injury.

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40
Q

What are the indications for Tertiary (3°) Healing?

A
  • Contaminated wounds (high bacterial count)
  • Long time lapse since initial injury
  • Severe crush component with significant tissue devitalization
  • Closure of fasciotomy wounds

This method helps manage infection risk and promotes healing.

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41
Q

What is the importance of prolonging the inflammatory phase in Tertiary (3°) Healing?

A

Decreases bacterial count and lessens chance of infection after closure

This is crucial for successful wound healing.

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42
Q

What is a Hypertrophic Scar?

A

A scar that remains within the boundaries of the original scar, characterized by being red, raised, widened, and frequently pruritic.

Common sites include the back, shoulder, and sternum.

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43
Q

What are the treatment options for Hypertrophic Scars?

A
  • Scar massage
  • Pressure garments
  • Silicone gel sheeting
  • Corticosteroid injection
  • Surgical excision if other options fail

Recurrence may still occur even after surgical excision.

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44
Q

What is a Keloid Scar?

A

A scar that grows outside the boundaries of the original scar, characterized by being red, raised, widened, and frequently pruritic.

Highest rates occur in Black and Asian individuals.

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45
Q

What factors contribute to the formation of Keloid Scars?

A
  • Genetic factors
  • Excess tension on the wound
  • Delayed closure

Common sites include the central chest, back, shoulders, deltoid, ear, and angle of the mandible.

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46
Q

What are the treatment options for Keloid Scars?

A
  • Multimodal therapy
  • Pressure garments
  • Silicone gel sheeting
  • Corticosteroid injection
  • Fractional carbon dioxide ablative laser
  • Surgical excision if radiation is to be performed within the next 48 hours

Surgical excision is typically very unsuccessful, and recurrence is common.

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47
Q

What characterizes a Spread Scar?

A

It has the same order of collagen fibers as normal scars and is typically flat, wide, and often depressed.

Treatment usually involves surgical excision and closure.

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48
Q

What defines a Chronic Wound?

A

A wound that fails to achieve primary wound healing within 4-6 weeks.

Common types include diabetic, pressure, and venous stasis ulcers.

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49
Q

What is the treatment approach for Chronic Wounds?

A

Addressing the underlying cause of chronicity, which may include infection, ischemia, metabolic conditions, immunosuppression, or radiation.

All chronic wounds should be biopsied to rule out Marjolin’s ulcer.

50
Q

What is Marjolin’s ulcer?

A

A squamous cell carcinoma that arises in a chronic wound secondary to genetic changes caused by chronic inflammation.

All chronic wounds should be biopsied to rule out this condition.

51
Q

Whats the critical depth of scar formation ?

A

0.5 cm or 33% of skin thickness

52
Q

Compare between keloid and hypertrophic scar:

A
53
Q

What are the two categories of efficacy in scar management?

A

High efficacy, Low efficacy

54
Q

Name three methods for scar prevention (high efficacy)

A
  • Silicone
  • Tension reduction
  • wound edge eversion
55
Q

What are two technologies used in scar prevention? (Low efficacy)

A
  • Pulsed-dye laser
  • Pressure garments

Onion extract
Scar massage

56
Q

List two treatments for scars.

A
  • Silicone
  • Pulsed-dye laser

CO2 laser, corticosteroids

57
Q

What is an adjunct treatment for keloid excision?

A
  • Corticosteroid

Radiotherapy + mitomycin

58
Q

Fill in the blank: _______ is used in scar treatment alongside corticosteroids and fat grafting.

A

[Onion extract]

59
Q

What is a common method for managing keloids?

A
  • Radiation
60
Q

Which treatments are associated with low efficacy in scar management?

A
  • 5-FU
  • Bleomycin
  • Scar massage

Onion extract
Fat grafting

61
Q

Name a surgical adjunct used in keloid management.

A
  • Mitomycin C
62
Q

True or False: Scar massage is only effective for scar treatment.

A

False

63
Q

What is the primary focus of evidence-based scar management?

A

Improve results with technique and technology

64
Q

Scar management

A
65
Q

Scar management

A
66
Q

Factors that delays wound healing ?

A
67
Q

What are the grades of pressure ulcer?

A
68
Q

What are the grades of pressure ulcer?

A
69
Q

How to treat pressure ulcer?

A
70
Q

Types of dressings:

A
71
Q
A

Initial managment:
1. Stabilise the patient: ABCDE + inspection + look for signs of inhalation therapy.
- airway and breathing: any sign of inhalation injury + RDS => intubation
- circulation: fluid resuscitation (parkland formula) to prevent hypovolemic shock => insert two large pores of IV line (ringers lactate).
- pain management: IV opioids
- wound care: cover wounds with clean dry dressing.
- insert a Foley catheter: to monitor the urine output

Confirming the inhalation injury:
1. Facial burns
2. Hoarseness of the voice or stridor and carbonaceous sputum
3. Bronchoscopy => visualise airway damage
4. Measure the carboxyhemoglobin levels to asses for carbon monoxide exposure

Whats the treatment: provide 100% oxygen Nina non rebreather mask or intubation.
Whats the initial rate for administering fluids?
The formula for fluid resuscitation in burn patients: 4ml x TBSA% x body weight (kg).
For this patient: 4 x (40%) x 80 kg => 12,800 ml (total for 24 hours)
In the first 8 hours administer half of the amount and the remaining half over next 16 hours.
(Adjust the fluid rates based on urine output aiming 0.5/1ml/kg/hr

Next day in ICU:
Acute respiratory distress syndrome and acute kidney injury => result from systemic inflammatory response syndrome resulting from excessive burn and inhalation injury.

ARDS: ventilators support + PEEP
AKI: fluid resuscitation or renal support therapy (dialysis)

72
Q
A

Initial managment:
1. Stabilise the patient: ABCDE + inspection + look for signs of inhalation therapy.
- airway and breathing: any sign of inhalation injury + RDS => intubation
- circulation: fluid resuscitation (parkland formula) to prevent hypovolemic shock => insert two large pores of IV line (ringers lactate).
- pain management: IV opioids
- wound care: cover wounds with clean dry dressing.
- insert a Foley catheter: to monitor the urine output

Confirming the inhalation injury:
1. Facial burns
2. Hoarseness of the voice or stridor and carbonaceous sputum
3. Bronchoscopy => visualise airway damage
4. Measure the carboxyhemoglobin levels to asses for carbon monoxide exposure

Whats the treatment: provide 100% oxygen Nina non rebreather mask or intubation.
Whats the initial rate for administering fluids?
The formula for fluid resuscitation in burn patients: 4ml x TBSA% x body weight (kg).
For this patient: 4 x (40%) x 80 kg => 12,800 ml (total for 24 hours)
In the first 8 hours administer half of the amount and the remaining half over next 16 hours.
(Adjust the fluid rates based on urine output aiming 0.5/1ml/kg/hr

Next day in ICU:
Acute respiratory distress syndrome and acute kidney injury => result from systemic inflammatory response syndrome resulting from excessive burn and inhalation injury.

ARDS: ventilators support + PEEP
AKI: fluid resuscitation or renal support therapy (dialysis)

73
Q
A

Answer

74
Q

What is contamination in the context of infected wounds?

A

The presence of non-replicating microorganisms within a wound

Contamination does not lead to infection.

75
Q

Define colonization in infected wounds.

A

The presence of replicating microorganisms within a wound

Colonization can lead to infection if not controlled.

76
Q

What does critical colonization indicate?

A

Increasing bacterial burden; have delayed healing

Critical colonization may lead to infection if not addressed.

77
Q

When is a wound considered infected?

A

The presence of >10^5 microorganisms in a wound without intact epithelium

Infection is characterized by delayed healing and classic signs.

78
Q

What are the classic signs of infection?

A
  • Redness
  • Swelling
  • Pain
  • Clinically unwell

These signs indicate a possible infection in the wound.

79
Q

What is the first step in the management of acute contaminated wounds?

A

Cleanse and irrigate the open wound with at least 150 cc of physiologic solution

Use sufficient pressure (4 to 15 PSI) for effective cleansing.

80
Q

What is the purpose of debridement?

A

Removal of foreign material, devitalized tissue, and old blood

Always take a swab if infection is suspected.

81
Q

Describe serous drainage.

A

Thin, clear or light yellowish fluid

Indicates a normal healing process without infection.

82
Q

What does sanguineous drainage indicate?

A

Fresh blood; bright red in color

This type of drainage may suggest active bleeding.
Its normal in the early healing phases but should decrease over time
Excessive saguineous drainage indicate uncontrolled bleeding
Sudden increase in sanguineous drainage after decrease could suggest reopening of blood vessels due to wound dehiscence (opening)

83
Q

What is serosanguineous drainage?

A

A mix of blood and serous fluid; thin and watery, pale red to pink

Commonly seen during the healing process.

84
Q

What characterizes purulent drainage?

A

Thick and opaque; white, yellow, or pale green

Typically indicates an infection.

85
Q

List risk factors for infection in wounds.

A
  • Wound >8 h
  • Severely contaminated
  • Immunocompromised host
  • Involvement of deeper structures (e.g., joints, fractures)

These factors increase the likelihood of infection.

86
Q

What should be done if wound cultures are positive and there are signs of infection?

A

Use systemic antibiotics; tailor antibiotics as cultures return

This approach helps to effectively manage the infection.

87
Q

What is the management for late contaminated wounds (>24 h)?

A
  • Tetanus prophylaxis
  • Irrigation and debridement
  • Systemic antibiotics if there are clinical signs of infection
  • Closure options: secondary intention, delayed wound closure, skin graft, or flap

Late management aims to reduce infection risk and promote healing.

88
Q

What are the characteristics of a wound that is considered tetanus-prone?

A
  • Time since injury >6 h
  • Depth of injury >1 cm
  • Mechanism of injury: crush, burn, gunshot, puncture
  • Devitalized tissue present
  • Contamination (e.g., soil, dirt, saliva, grass) present
  • Retained foreign body present

These factors significantly increase the risk of tetanus infection.

89
Q

What characteristics define a wound that is not tetanus-prone?

A
  • Time since injury <6 h
  • Depth of injury <1 cm
  • Mechanism of injury: sharp cut (e.g., clean knife, clean glass)
  • No devitalized tissue
  • No contamination (e.g., soil, dirt)
  • No retained foreign body

Such wounds carry a lower risk of tetanus infection.

90
Q

the presence of bacteria within a wound may be divided into 4 categories:

A

■ contamination: the presence of non-replicating microorganisms within a wound
■ colonization: the presence of replicating microorganisms within a wound
■ critical colonization: increasing bacterial burden; have delayed healing
■ infection: the presence of >10(5) microorganisms in a wound without intact epithelium or small
amounts of a very virulent organism (e.g. GBS); have delayed healing and exhibit classic signs of infection

91
Q

When there’s injury you need to control and evaluate?

A

Control bleeding, irrigation, debridement (take a swab if you suspect infection).

Evaluate the injury (skin, muscles, nerves, vessels, tendons, bones)

92
Q

Managment of acute contaminated wound < 24 hours

A
93
Q

Managment of contaminated wound more than 24 hours ?

A
94
Q

True or false: The proliferative wound healing phase is delayed in individuals with copper and vitamin C deficiency.

A

True

———————-
Zinc deficiency can delay wound healing because the collagenases responsible for collagen remodeling require zinc to function properly.

95
Q

Definition: Hypertrophic scar

A

Hypertrophic scar

Cutaneous condition characterized by high (fibroblast proliferation and collagen production) that leads to a raised scar that does not grow beyond the boundaries of the original lesion.

96
Q

Keloid is known to be claw-like” appearance, true or false

A

True

97
Q

Hemorrhage control in wounds?

A
  1. Mechanical hemostasis: local pressure over the wound, packing the wound, or application of a tourniquet proximal to the site of bleeding.
  2. Pharmacological hemostasis: local hemostatic agents (e.g., epinephrine or fibrin) or systemic antifibrinolytics (e.g., tranexamic acid)
  3. Hemorrhagic shock: Resuscitate with blood products.
98
Q

What are the indications of Primary wound closure?

A

Recent wound
clean
uninfected wounds that have edges that can be easily approximated.

99
Q

Consider secondary wound closure or tertiary wound closure for all other wounds:

A

infected, contaminated, wide or irregular edges, delayed presentation

```````````````````````````
Consider skin grafting for wounds with extensive tissue loss.

100
Q

How to manage closed wounds?

A
  1. Analgesia
  2. Treat the injuries (tendons, fractures)
  3. Monitor complications (compartment syndrome, rhambdomyolisis and deep vein thrombosis)
  4. POLICE:
    P: protection from further harm.
    OL: optimal loading
    I: ice
    C: compression
    E: elevation (to promote venous return)
101
Q

Purpose of skin graft?

A
  1. close wounds
  2. prevent fluid and electrolyte loss
  3. reduce bacterial burden and infection.
102
Q

What are types of skin graft?

A
  1. Full thickness skin graft: Graft: epidermis and dermis (including dermal appendages), usually obtained from areas of redundant and pliable skin (e.g., groin, lateral thigh, lower abdomen, lateral chest)
  2. Partial thickness skin graft: epidermis and upper part (¼–¾) of the dermis (without dermal appendages)
103
Q

What are indications of full thickness skin graft ?

A
  1. small
  2. uncontaminated
  3. well-vascularized wounds
104
Q

What are the advantages and disadvantages of full thickness skin graft?

A

Advantages: good postoperative cosmetic outcome
Disadvantages: high risk of necrosis, secondary injury to the donor area

105
Q

What are the indications, advantages and disadvantages of (split thickness skin graft)?

A

Indications: many uses; resurface large wounds and mucosal deficits, line cavities, close donor sites of flaps, treat large chronic wounds
Advantages: heals well, only superficial secondary defect in donor area, which does not have to be covered
Disadvantages: scar formation when graft heals, skin pigmentation change, tendency to contract, more fragile

106
Q

What are complications of surgical incisions?

A
  1. Surgical site infection
  2. Intestinal fistula
  3. Wound dehiscence: the spontaneous separation of wound edges following surgical wound repair
    Can be superficial (skin and subcutaneous tissue) or deep (fascial)
  4. Hematomas and seromas
107
Q

What are the common pathogens associated with dog and cat bites?

A

Pasteurella multocida, Staphylococcus aureus, Streptococcus viridans

These pathogens are often responsible for infections following animal bites.

108
Q

What investigations should be conducted prior to therapy for animal bites?

A

Radiographs and culture for aerobic and anaerobic organisms, Gram stain

Radiographs help rule out foreign bodies or fractures.

109
Q

What is the recommended treatment for dog and cat bites?

A

Clavulin® (amoxicillin + clavulanic acid) 500 mg PO q8 h started immediately

This antibiotic is effective against the pathogens typically involved in these bites.

110
Q

When should rabies prophylaxis be considered for animal bites?

A

If the animal has symptoms of rabies or is of unknown status

Rabies Ig and rabies vaccines are part of the prophylaxis.

111
Q

What is the mainstay of treatment for dog and cat bites?

A

Healing by secondary intention

This method allows for proper healing in most cases of bite wounds.

112
Q

Under what circumstances is primary closure considered for bite wounds?

A

Only for large bite wounds on the face and done in the operating room

Primary closure is usually contraindicated for other locations.

113
Q

What are the common pathogens associated with human bites?

A

Staphylococcus aureus > GAS > Eikenella corrodens > Bacteroides

The mouth has a high concentration of microorganisms that can lead to infections.

114
Q

Why are human bites considered serious?

A

The mouth has 10^9 microorganisms/mL that can cause septic arthritis if trapped

This can happen when the fist unclenches and skin covers the area.

115
Q

What investigations should be conducted prior to therapy for human bites?

A

Radiographs and culture for aerobic and anaerobic organisms, Gram stain

These tests help assess the extent of the injury and potential infections.

116
Q

What is the treatment protocol if a joint is infected from a human bite?

A

Urgent surgical exploration, drainage, and debridement of infected tissue

This is critical to prevent further complications like septic arthritis.

117
Q

What is the treatment for non-infected human bites?

A

I & D and antibiotic treatment in ER

This approach helps manage the wound effectively.

118
Q

What antibiotic is used if the infection is due to MSSA?

A

Cefazolin 2 g IV q8h

Alternative treatment includes vancomycin for penicillin allergies or MRSA.

119
Q

What is the management for a human bite injury if there’s a penicillin allergy?

A

Vancomycin 15 mg/kg IV q12h + secondary closure

This is an appropriate alternative to Cefazolin.

120
Q

What supportive measure is recommended for human bite injuries?

A

Splint

A splint can help stabilize the affected area during healing.

Plastic Surgery (5 decks)

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