Classification of Wounds

Tidy vs Untidy wound

Open wounds

The skin has been breached and underlying tissue is exposed

Closed wounds

The skin is intact, but the underlying tissue has been damaged

Mechanism of injury

Primary, Secondary, and Tertiary intention

Types of wound healing

Healing by primary vs secondary intention

Ulcer

An ulcer is a chronic wound that is defined as a break in the continuity of the covering epithelium in either skin or mucous membranes due to molecular death. The most common ulcers are venous, arterial, or mixed ulcers. These three account for 70% of all ulcers while 50% are caused by venous stasis alone.

Location of ulcers based on etiology

• Features suggestive of malignancy in ulcers
  • Margins: Irregular with nodules
  • Egde: Everted edges
  • Floor: red and bleeds easily on palpation
  • Surrounding skin: inflammed and indurated (hard)
• Investigations for patients with chronic ulcers
  • CBC: look for anemia
  • ESR: monitor for infection
  • RBS and HbA1C: for glycemic control
  • U/E/Cs: for uremia
  • VDRL: for syphillis
  • HIV: for HIV
  • Chest X-ray: for TB
  • EKG: to rule out IHD if atherosclerosis is suspected
  • Local smear for culture
  • X-ray of the affected part
  • 4 quadrant edge biopsy
• Stigmata of Tuberculosis to look out for in a patient with an ulcer
  • Phlyctenular conjunctivitis
  • Matted Lymphadenopathy
  • Scars and Sinuses in the neck
• Stigmata of Leprosy to look out for in a patient with an ulcer
  • Hypopigmented, anesthetic patches
  • Thickened ulnar posterio tibial, and great auricular nerves
  • Trophic ulcers (pressure ulcer)
  • Deformed phalanges
  • Leonine facies (due to collapse of the nasal bridge and lateral 1/3 of eyebrows)

Diabetic ulcer

• 4 ways in which diabetes impairs healing of ulcers
  1. Hyperglycemia promotes the proliferation of bacteria and glycosylates collagen making it brittle
  2. Decreases blood supply to the ulcer due to small and large vessel disease
  3. Ulcer is prone to repeated, unnoticed trauma as a result of neuropathy
  4. Deficient fibroblast reaction

Wagner Grading of diabetic foot ulcers

Decubitus (Pressure) ulcers

Staging of decubitus ulcers

• Risk factors for development of pressure ulcers
  • Sensory deficits
  • Moisture
  • Immobility
  • Inactivity
  • Malnutrition
  • Friction and shear
• Prevention of pressure ulcers
  • Reduce external pressure
    • Reposition every 2 hours
    • Pillows or thick padding areas at risk
  • Keep the skin clean and dry
  • Adequate pain relief to allow for activity and mobility
  • Manage systemic conditions that place the patient at risk of developing pressure ulcers

Gunshot Wound (GSW)

The higher the projectile velocity of a missile, the greater the damage. Low velocity missiles from pistols drill only narrow tracks with little damage around them. in addition to causing extensive cavitation, high velocity missiles form a partial vacuum in their path that sucks in debris. Missile wounds may take curious paths. They may be deflected by bone, or be influenced by the position of the patient at the time of injury. A multi-disciplinary care team is required for GSW. GSW should not be closed primarily. Delayed primary closure after initial debridement, or healing by secondary intention is preferred. Bullets and fragments are removed only where indicated. Gunshot wounds are discussed more in depth in the forensic medicine cheat sheets.

Types of injury

• Complications of GSW
  • Compartment syndrome: common after high velocity wounds. More common with proximal fractures of the forearm
  • Vascular injury: findings include pulsatile bleeding, absent pulse, bruit, thrill. ABI and angiography can be performed if there is concern.
  • Spinal injury: GSW is the 3rd most common cause of spinal injury. Cervical spine GSW can be associated with airway compromise (84%)
  • Infection: GSW tracts are non-sterile. 24 hours IV antibiotics (1st gen cephalosporins) for low-velocity injuries (Gustillo I/II) and 72 hours IV antibiotics (1st gen cephalosporin + gentamicin) for high-velocity injuries (Gustillo III)
  • Fractures: Low velocity injuries can be treated as Gustilo I/II while high velocity injuries can be treated as Gustilo III. GSW has increased comminution and greater soft-tissue stripping and bone loss.
  • Retained projectiles and fragments: retained fragments can be left in situ. Indications for removal include: intra-articular, intra-vascular, subcutaneous, lead toxicity, peri-spinal and peri-neural
• Compartment syndrome
  • Common after high velocity wounds due to soft-tissue trauma/bleeding/oedema
  • More common with proximal fractures of the forearm
• Vascular injury and hemorrhage
  • Findings include pulsatile bleeding, absent pulse, bruit, thrill
  • Damage control surgery e.g. shunting can be performed
  • ABI and Angiography can be performed if there is concern
• Peripheral nerve injury
  • Majority of nerve dysfunction is neuropraxia, particularly in low velocity wounds
• Life-saving interventions in GSW
  • Hemorrhage control and resuscitation
  • Chest tubes (even bilateral chest tubes)
  • Laparotomy

Classification Surgical Wounds

Colonized body cavities = respiratory, alimentary,, genital, or urinary tracts