Principles of Wound Principles of Wound ManagementManagement

Abdelrahman S-E Imbabi, FRCSEd

Assistant Professor of SurgeryUniversity of Khartoum

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Traumatic WoundsTraumatic Wounds

Usually untidy– Damage to tissues is extensive, and extent

unclear – such as gunshot or blast injuries, crush injuries, lacerations or burns

And contaminated– Most traumatic wounds are potentially

contaminated, and hence likely to be infected

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Aim of managing woundsAim of managing wounds

To obtain healing by primary intention– Quick and easy– Smaller scars– Less contracture and deformity– Better looking

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Healing of untidy woundsHealing of untidy wounds

With untidy or infected wounds, loss of tissue is extended, and primary healing cannot be achieved

Such wounds heal by secondary intention– Prolonged and complicated healing process– Involves much fibrous tissue and scarring– Gross contractures and deformity– Ugly appearance

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Dealing with untidy Dealing with untidy woundswounds The prime aim is to convert untidy

and contaminated or infected wounds to tidy clean wounds which can heal by primary intention

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How can this be achievedHow can this be achieved

All dead and devitalized tissues MUST BE REMOVED

All dirt and gross contamination should be physically washed out, or picked up by forceps

Avoid further injury to surrounding healthy tissues

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How can this be achievedHow can this be achieved

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Wounds less than 6 hoursWounds less than 6 hours

Generally, wounds less than 6 hours old may be closed primarily (preferably with drain), however, it is safer practice to leave the wound open, and re-evaluate after 3-5 days, whence if the wound is clean perform a delayed primary closure.

Broad spectrum antibiotic cover Anti-tetanus prophylaxis

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Wounds more than 6 Wounds more than 6 hourshours For wounds older than 6 hours, or there is

evidence of gross infection, or vitality of surrounding tissues is in doubt:– Keep the wound open– Take culture swabs and start broad spectrum

antibiotics, modified later according to culture and sensitivity

– Anti-tetanus prophylaxis– Re-evaluate the wound daily and debride as

necessary (may require more frequent dressings)

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Then what ?Then what ?

If loss of tissues prevents non-tense primary closure, then preferably resort to either:– Skin grafting– Local or distant flaps, with or without muscle– Combination of muscle flap with skin grafting

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What else ?What else ?

For proper wound healing:– Surrounding tissues must be well vascularized, hence

good debridement down to bleeding tissues– Adequate oxygenation, hence improve tissue perfusion

and oxygen-carrying capacity– Moisture; dehydration kills cells and tissues– Balanced nutrition with positive nitrogen balance and

calories– Non-compromised immune system

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