wound healing and closure gil c. grimes, md 2003-03-06
TRANSCRIPT
Wound Healing and Closure
Gil C. Grimes, MD2003-03-06
Goals Review anatomy of skin Basics of wound healing One and two handed tie Instrument ties and deep ties
Brief Anatomy
Lines of Tension Static lines
Langer’s Lines Reflects natural skin tension Worst along anterior tibia Best along volar surface of hand Can be tested with pinch test Wound gap >5 mm demonstrates
significant tension
Lines of Tension Dynamic
Kraissl’s lines Formed by
movement Compression of
skin Everyone smile If you can cut
parallel to these then lessen scar
Wound Healing Hemostasis
Tissue retraction Tissue
compression Vasoconstriction Clotting cascade Vascular dilation Wound exudate
Wound Healing Inflammation
First phase Compliment attracts
granulocytes Peaks in 12-24 hours Over by 72 hours
Second phase Macrophage driven Begins 24 hours Peaks 5 days Phagocystosis
Returns nutrients Stimulates fibroblasts
and endothelial cells
Wound Healing Epithelialization
Begins at 12 hours In closed wound
seal formed by 24 hours
Unclosed wounds close slower
Remember road rash
Wound Healing Neovascularization
Evident by day three Most active by day 7 Decreases by day 21 New capillary loops
are surrounded by active fibroblasts
Give granulation tissue its color
Wound Healing Collagen Synthesis
Mitosis fibroblasts begin day 1
New collagen laid down day 2
Peak synthesis day 5-7
Initial pattern random
Remodeled over time
Wound Healing Return of tensile
strength Weakest at day 7-10
due to remodeling At 35% of original
strength at 30 days At 70 % of original
strength at 70 days Never completely as
strong as the original
Comorbidities to healing Age
Dermal component Muscle mass Inflammatory response Collagen deposition Tensile component Circulation
Comorbidities to healing Weight and Nutrition
Increases stress Adipose has poor blood supply Malnutrition
Blood Supply Oxygen delivery Smokers CHF and CAD
Comorbidities to healing Immune system
HIV Steroids Allergies
Chronic Disease Diabetes Peripheral vascular disease Malignancies
Infection
Types of Wounds Shearing Force
Incisions Due to sharp
objects Minimal collateral
tissue damage Sharply defined
margins Minimal localized
devitalized tissue
Types of Wounds Tension Force
Laceration Tearing forces Blunt or semi-
blunt object strikes at an acute angle
Creates a flap Shearing force
transmitted to surrounding tissue
Type of Wounds Compression
Blunt object strikes at a right angle
Lots of collateral tissue damage
Significant devitalization of surrounding tissue
Subcutaneous tissue very susceptible to injury
Adipose necrosis
Wound Closure Primary
Within the first 6-8 hours May delay longer in select locations
Face and scalp may be delayed to 24 hours
Lower extremities may need to be closed sooner
Must have a fresh wound May freshen wound If it is clean and bleeding it can close
Wound Closure
Wound Closure
Wound Closure
Steps to Closure Asses patient
Wounds can wait if other problems exist
Prevent further injury Clean the wound Allergies Anesthesia Tetanus
Steps to Closure
Steps to Closure
Steps to Closure
Steps to Closure
Steps to Closure
Steps to Closure
Steps to Closure
Steps to Closure
Good Knots
Square Knots
Square Knots
Instrument Tie
One Handed Tie
One Handed Tie