Wound: An injury to living tissue (especially an injury involving a cut or break in the

skin).

Pathophysiology of a Wound Infection

• Most wounds are contaminated except for surgical wounds made under aseptic

conditions.

• Wound infection follows contamination by dirt, damaged tissue, and foreign bodies.

• The bacteria invade tissues and cause more damage while tissues that have not been

damaged resist infection by a process called inflammation.

• When a wound is inflamed, blood vessels dilate to bring more blood to the injured part.

• The capillary walls change so that antibodies and white cells can pass through more

easily.

• The result is the part becomes warmer and redder because there is more blood in it, and

swollen because there are more white cells and fluid.

• Pain is partially due to increased swelling in the part, and partially due to the effects of

the inflammation process.

Signs of Acute Inflammation (Cardinal Signs of Inflammation)

• Heat (Calor )

• Redness (Rubor )

• Pain (Dolor )

• Swelling (Tumor )

• Loss of function (Functio laesa )

Classification of Wounds

• There are several classifications of wounds.

• Each classification can direct treatment modality.

• Classification by degree of contamination:

Clean wounds are mostly those made in the operating rooms in hospitals.

They have clear sharp edges, not contaminated and have minimal tissue damage.

Contaminated wounds occur outside the operation rooms, they are potentially

contaminated thus liable to develop infection.

Tissue damage may be extensive.

Infected wounds show obvious signs of infection like pus and necrotic tissue.

Management of Wounds

Wound Assessment

• History

How long ago was the wound sustained?

How was the wound sustained?

What is the status of active immunization against tetanus?

• Examination of the wound; look for:

Active bleeding

Contamination

Depth and describe tissues involved

Edges

Site

Cleansing the Wound (Social Toilet)

• Clean the wound and surrounding skin with soap and water.

• Do not use hard brush, sponge should suffice.

Surgical Toilet

• All contaminated wounds need to undergo surgical toilet.

• Clean the wound by debridement (remove dead and damaged tissues using a knife and

apply antiseptic solution).

Classes and Indications for Wound Closures

• Primary wound closure

Clean post operative wounds

Surgically clean wounds after surgical toilet

• Delayed primary closure

Done for contaminated wounds after surgical toilet

Wound is observed for three to four days observing for onset of infection

If there is no infection then wound closure is performed

• Secondary closure

Indicated for obviously infected wounds

Closure is deferred until infection is under control

Complications of Wounds and their Management

• Cellulitis

Non suppurative invasive infection of surrounding tissues by organisms such as ßhaemolytic

streptococci, staphylococci and Clostridium perfringens.

Cellutitis is managed by application of local antiseptic and systemic antibiotics.

• Septicemia

Multiplication of bacteria in the blood with the production of severe systemic symptoms such as fever and hypotension.

It has an extremely high mortality and demands immediate and appropriate attention.

It is managed by adequate rehydration, systemic antibiotics and antipyretics.

Management of Soft Tissue Injuries

• Soft tissue injuries are those injuries excluding fractures, affecting the joints and

muscles of the limbs.

• Sprains and strains are considered soft tissue injuries.

• Sprains: Ligamentous injuries associated with the overextension of a joint.

Ligaments connect bone to bone

Damage to ligaments can range from microscopic to complete disruption

• Strains: Injuries to the musculotendonous unit (tendons connect muscle to bone)

May range from microscopic to complete disruption.

• The treatment of soft tissue injuries is based on resting the injured part, applying

ice packs to limit swelling and reduce pain by prescribing analgesics or local

analgesic cream or gel.

• RICE: The application of a firm compression bandage as support, and elevation

of the limb.

• The acronym ‘RICE’ can be remembered as follows:

ü  R= Rest I= Ice C= Compression E= Elevation

• The application of ice and compression causes vasoconstriction and tamponades

the blood vessels and elevation of the limb improves venous drainage.

Complications of Soft Tissue Injuries and Their Management

Compartment Syndrome

• Increased tissue pressure within a muscle compartment compromising the blood

supply and the function of structures within that space.

• Causes

Tight casts or dressings

External limb compression

Burn eschar

Fractures

Soft tissue crush injuries

Excessive exertion

• Clinical presentation

Pain out of proportion to the injury

Puffy/tense muscle compartments to palpation

Parasthesia (decreased sensation)

Paralysis (weakness of the involved muscle groups)

Pallor

Pulselessness (decreased capillary refill, late finding)

• Management

Split the cast and remove dressings, if present

Place limb in neutral position; elevation may be harmful

Support circulation with IV fluids or blood where indicated

Observe carefully for improvement i.e. colour, pulse and pain

If signs and symptoms persist, refer for immediate surgical decompression

(fasciotomy)

Fasciotomy must be performed early, ideally within six hours of the onset of

symptoms

Myositis Ossificans

• Myositis ossificans is an unusual condition that often occurs in athletes who sustain a

blunt injury that causes deep tissue bleeding.

• Severe bleeding into the muscle creates a hematoma, which may trigger a healing

pathway that leads to formation of ectopic bone in the muscle.

• Treatment of myositis ossificans consists of:

Rest

Immobilization in a stretched position

Pain relief with acetaminophen; NSAIDS are avoided in order to limit bleeding.

References

• Bewes P. (1984). A Manual for Rural Health Workers. Nairobi: African Medical and

Research Foundation.

• Burkitt G. & Quick C. (2002). Essential Surgery, Problems, Diagnosis and Management.

(3rd ed.), Churchill Livingstone.

• Russell R.C.G., Norman S.W. & Bulstrode C.J.K. (2004). Bailey and Love’s Short

Practice of Surgery (24th ed.). London: Edward Arnold.

• Steadman T.L. (1999). Steadman’s Medical Dictionary (27th ed.). USA: Lippincott

Williams & Willkins.