Wounds and Wound Healing

Question 1

What is primary wound healing?

What is the advantages of this approach?

Answer 1

When wound is created by clean incision and wound edges are approximated (brought together)

Quicker healing, decreased infection risk, minimal scar

Question 2

What is secondary wound healing?

What are the downfalls of this approach?

When is it a preferred method?

Answer 2

No artificial wound closure; healing ONLY via physiologic closure

Wound is left open and granulation tissue forms (consists of new capillaries, fibroblasts, ECM)

Longer healing, increased infection (?), scaring

Puncture wounds due to infection risk

Question 3

What is tertiary wound closure?

Answer 3

AKA Delayed primary closure

Usually secondary to concern for infection in a “dirty wound”

Question 4

What are the four stages of wound healing?

Answer 4

1. Hemostasis: seconds to hours after wound
2. Inflammation: Inflammatory phase; hours to days
3. Proliferation: Proliferative phase; days to weeks
4. Remodeling: weeks to months

Question 5

In what phase of wound healing is the compliment system activated?

Answer 5

Inflammatory phase

Question 6

What is essential for complete wound healing?

Answer 6

Granulation tissue

Question 7

What are the 3 main functions of granulation tissue?

Answer 7

Immune (protection from infection)
Proliferation (filling the gap)
Replacement (removal of non-viable tissue)

Question 8

What cell type makes up the “scaffolding” of granulation tissue?

Answer 8

Fibroblasts

Question 9

What is the management for clean wounds?

What is a “clean wound”

What Class of Surgical Wounds is a “clean wound”

Answer 9

Primary closure, normal post-op course

Clean (not infected) or the result of a non-penetrating, blunt trauma

Class I

Question 10

What is the management of clean-contaminated wounds?

What is a clean-contaminated wounds

What class of surgical wounds is a clean-contaminated wound?

Answer 10

Delayed primary closure (tertiary)

Evidence of infection or major break in technique

Class II

Question 11

What is the management for contaminated wounds and dirty wounds?

Answer 11

Secondary Intention

Question 12

What suture material requires removal if external?

Answer 12

Non-absorbable

Question 13

What suture material can “spit out” or lead to a sinus tract?

Answer 13

Non-absorbable

Question 14

In patients with a history of or risk of keloids to reduce inflammatory reaction what should be used for wound closure?

Answer 14

Surgical glue

Question 15

What are some advantages to surgical glue?

Answer 15

• Less painful procedure
• More rapid repair time
• Creation of a waterproof and antimicrobial barrier
• Better acceptance by patients
• No need for suture removal or follow-up
• Cosmetically similar results post-repair
• Safer for the provider than sutures because needlesticks are avoided

Question 16

Can surgical glue be used on the hands and feet?

Answer 16

No contraindicated, unless the affected areas are immobolized

Question 17

Can surgical glue be used on areas that require a high level of precision (i.e. Vermilion border)?

Answer 17

No

Question 18

What are the goals of wound dressings?

Answer 18

• Hemostasis
• Infection prevention (mechanical barrier)
• Absorb drainage/exudate
• Keep wound moist

Question 19

What genetic conditions are associated with delayed wound healing?

Answer 19

• Ehlers-Danlos
• Osteogenesis imperfecta

Question 20

What are the preventative measures of wound healing complications in Ehler’s Danlos?

Why are they at risk for delayed wound healing?

Answer 20

• Multilayer closure
• Sutures left in place 2x longer
• Other interventions to reduce tensile forces

Easy bruising, slow wound healing, and abnormal scar formation

due to overly elastic skin

Question 21

Why is Osteogenesis Imperfecta associated with poor wound healing?

Answer 21

Gene mutation of COL1A1 or COL1A2 causes decreased collagen production and abnormal collegen crosslinking

Question 22

What are some causes of delayed wound healing?

Answer 22

• Infection
• Anti-inflammatory/steroids/immunomodulators
• Anticoagulants
• DM (especially poorly controlled)
• Obesity
• Malnutrition
• Smoking/ETOH use
• Arterial insufficiency/poor cardiac status
• Stress states

Question 23

What are Keloids?

Who is at higher risk?

Answer 23

Excess wound healing - from any tissue insult

Firm, rubbery flesh-colored nodule of various sizes

African Americans

Question 24

What are common locations of keloids?

Answer 24

• Deltoids
• Anterior Chest
• Back
• Earlobe

Question 25

What is the treatment for keloids?

Answer 25

Intralesional steroid first line
Cryotherapy (prone to pigment changes)
Surgical excission (prone to recurrance)

Question 26

What are the risk factors for developing a pressure ulcer?

What are the highest risk areas?

Answer 26

• Increasing age
• Think skin or low body weight
• Malnutrition
• Immobility
• Medical co-morbidities that delay wound healing

Heels, sacrum/coccyx, greater trochanters

Question 27

Describe a Stage I Pressure Ulcer?

When does it move to a Stage II?

Answer 27

• Nonblanchable erythema
• Painful
• No other color change

When the dermis exposed and partial thickness of skin is lost

Question 28

Describe a Stage III Pressure Ulcer?

What deferentiates a Stage IV from Stage III Ulcer?

Answer 28

• Full thickness skin loss
• Visible adipose tissue
• No deep structures visible
• Presence of granulation
• +/- undermining or tunneling

In stage IV, there is full thickness skin AND tissue loss

Additionally, there is exposed fascia, muscle, ligament or bone

Question 29

What is the treatment for pressure ulcers?

Answer 29

Debridement, wound cleansing, and antibiotics

Efforts to improve mobility

Question 30

When is amputation considered in diabetic ulcers?

Answer 30

If there is no healing in 4+ weeks