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Ug wound healing

basic concepts of tissue injury and healing process. emphasis placed on primary and secondary type of wound healing.

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Ug wound healing

  1. 1. TISSUE REPAIR
  2. 2. LEARNING OBJECTIVES: • Repair, steps involved in it. • Granulation tissue • Types of wound healing • Complications • Factors influencing • Fracture healing
  3. 3. • REGENERATION is restoration to original tissue by proliferation of parenchymal cells Structure and function is retained • REPAIR is healing of proliferation of connective tissue resulting in fibrosis and scaring Only structure is preserved.
  4. 4. REPAIR The replacement of injured tissue by fibrous tissue. Two processes are involved in repair: 1. Granulation tissue formation 2. Contraction of wounds
  5. 5. STEPS INVOLVED IN REPAIR: • Formation of blood clot • Inflammation • Granulation tissue formation • Fibroblast proliferation and matrix accumulation • Angiogenesis • Wound contraction • Remodelling
  6. 6. GRANULATION TISSUE • Migration and proliferation of fibroblasts & deposition of loose connective tissue, together with vessels and leukocytes • New connective tissue with microscopic blood vessels that forms the surface of the wound during healing process. • Grows from the base of the wound and fill out the wound. • Gross – pink, soft, granular, seen beneath scab of skin wound. • Microscopically – fibroblast proliferation, capillaries, loose extracellular matrix, inflammatory cells & macrophages.
  7. 7. Classification of Wounds Closure • Healing by Primary Intention: – All Layers are closed. The incision that heals by first intention does so in a minimum amount of time, with no separation of the wound edges, and with minimal scar formation. • Healing by Secondary Intention: – Deep layers are closed but superficial layers are left to heal from the inside out. Healing by second is appropriate in cases of infection, excessive trauma, tissue loss, or imprecise approximation of tissue. • Healing by Tertiary Intention: – Also referred to as delayed primary closure.
  8. 8. WOUND HEALING • 2 TYPES PRIMARY INTENTION SECONDARY INTENTION
  9. 9. PRIMARY INTENTION • CHARACTERISTICS OF WOUND: CLEAN AND UNINFECTED SURGICALLY INCISED WITHOUT MUCH LOSS OF CELLS AND TISSUE EDGES OF WOUND APPROXIMATED BY SURGICAL SUTURES • END RESULT RAPID HEALING NEAT SCAR
  10. 10. PRIMARY INTENTION • SEQUENCE 1. INITIAL HEMORRHAGE 2. ACUTE INFLAMMATION RESPONSE 3. EPITHELIAL CHANGES 4. ORGANISATION 5. SUTURE TRACKS
  11. 11. PRIMARY INTENTION 1. INITIAL HEMORRHAGE SPACE B/W APPROXIMATED SURFACES IS FILLED WITH BLOOD BLOOD CLOTS WOUND IS SEALED
  12. 12. PRIMARY INTENTION 2. ACUTE INFLAMMATION RESPONSE WITHIN 24 HRS APPEARANCE OF POLYMORPHS BY 3rd DAY – REPLACED BY MACROPHAGES
  13. 13. PRIMARY INTENTION 3. EPITHELIAL CHANGES PROFILERATION OF BASAL CELLS OF EPIDERMIS MIGRATING TOWARDS INCISIONAL SPACE MIGRATED EPIDERMAL CELLS SEPARATE THE UNDERLYING VIABLE DERMIS FROM OVERLYING NECROTIC DEBRIS AND CLOT BY FORMING A SCAB. NEW EPIDERMIS IS FORMED BY THE 5th DAY.
  14. 14. PRIMARY INTENTION 4 . ORGANISATION BY 3RD DAY - INVASION OF FIBROBLASTS. BY 5TH DAY - INVASION OF COLLAGEN FIBRILS
  15. 15. PRIMARY INTENTION 5 . SUTURE TRACKS EACH SUTURE TRACK IS A SEPARATE WOUND. AND UNDERGOES THE SAME PHENOMENA. 7TH DAY – SUTURE IS REMOVED.
  16. 16. PRIMARY INTENTION
  17. 17. SECONDARY INTENTION • CHARACTERISTICS OF WOUND: • LARGE TISSUE DEFECT • EXTENSIVE LOSS OF CELLS AND TISSUES • WOUND NOT APPROXIMATED BY SUTURES AND LEFT OPEN • END RESULT: LONGER TIME TAKEN FOR HEALING LARGE SCAR
  18. 18. SECONDARY INTENTION • SEQUENCE 1. INITIAL HEMORRHAGE 2. INFLAMMATION RESPONSE 3. EPITHELIAL CHANGES 4. GRANULATION TISSUE 5. WOUND CONTRACTION
  19. 19. SECONDARY INTENTION 1. INITIAL HEMORRHAGE SPACE B/W APPROXIMATED SURFACES IS FILLED WITH BLOOD BLOOD CLOTS WOUND IS SEALED
  20. 20. SECONDARY INTENTION 2. ACUTE INFLAMMATION RESPONSE APPEARANCE OF POLYMORPHS INITIALLY REPLACED BY MACROPHAGES WHICH CLEARS OFF THE DEBRIS
  21. 21. SECONDARY INTENTION 3. EPITHELIAL CHANGES PROFILERATION OF BASAL CELLS OF EPIDERMIS MIGRATING TOWARDS INCISIONAL SPACE BUT GRANULATION TISSUE FROM BASE ALSO FILLS THE WOUND SPACE. REGENERATED EPIDERMIS BECOMES STRATIFIED AND KERATINISED.
  22. 22. SECONDARY INTENTION 4. GRANULATION TISSUE FORMED BY PROLIFERATION OF FIBROBLASTS AND NEOVASCULARISAION. NEW- RED, GRANULAR, FRAGILE OLD- PALE, WHITE NO REPLACEMENT OF HAIR FOLLICLES AND SWEAT GLANDS.
  23. 23. SECONDARY INTENTION 5. WOUND CONTRACTION BY ACTION OF MYOFIBROBLASTS. CONTRACTS TO 1/3RD TO 1/4TH OF ORIGINAL SIZE.
  24. 24. • PRESENCE OF INFECTION: DUE TO BACTERIAL TOXINS LEADS TO NECROSIS, SUPPURATION, THROMBOSIS DELAYED HEALING NEED FOR DEBRIDEMENT
  25. 25. SECONDARY INTENTION
  26. 26. S.NO FEATURES PRIMARY INTENTION SECONDARY INTENTION 1 CLEANLINESS CLEAN UNCLEAN 2 INFECTION MOSTLY UNINFECTED MAY BE INFECTED 3 MARGINS SUGICAL CLEAN MARGINS IRREGULAR 4 SUTURES USED NOT USED 5 HEALING SCANTY GRANULATION TISSUE IN THE GAP EXUBERANT GRANULATION TISSUE IN THE GAP 6 OUTCOME NEAT LINEAR SCAR CONTRACTED IRREGULAR WOUND 7 COMPLICATIONS EPIDERMAL INCLUSION CYST SUPPURATION
  27. 27. COMPLICATIONS OF WOUND HEALING: • DELAYED HEALING: • INFECTION: • DEFICIENT SCAR FORMATION: inadequate granulation tissue • INCISIONAL HERNIA:
  28. 28. HYPERTROPHIED SCAR & KELOID: excessive formation of collagen in healing leads to keloid
  29. 29. • EXCESSIVE CONTRACTION: exaggeration of wound contraction results in formation of contractures. Eg- dupuytren’s contracture • NEOPLASIA: Eg- squamous cell carcinoma in Marjolin’s ulcer.
  30. 30. • EPIDERMAL CYST: persistence of epithelial cells in the wound after healing • PIGMENTATION: due to staining with haemosiderin
  31. 31. FACTORS INFLUENCING HEALING: • LOCAL 1. INFECTION 2. POOR BLOOD SUPPLY 3. FOREING BODIES 4. MOVEMENT 5. IONISING RADIATION 6. ULTRAVIOLET LIGHT 7. TYPE, SIZE AND LOCATION OF INJURY
  32. 32. FACTORS INFLUENCING HEALING: • SYSTEMIC 1. AGE 2. NUTRITION 3. ADMINISTRATION OF GLUCOCORTICOIDS 4. UNCONTROLLED DM 5. SYSTEMIC INFECTION 6. HEMATOLOGICAL ABNORMALITIES
  33. 33. FRACTURE HEALING: • Depends on i. Nature of fracture – traumatic or pathological ii. Type of fracture – complete or incomplete iii. Simple (closed), comminuted (splintering of bone), compound (communicating to skin surface)
  34. 34. STAGES OF FRACTURE HEALING • PRIMARY UNION • SECONDARY UNION • PROCALLUS FORMATION • OSSEOUS CALLUS FORMATION • REMODELLING
  35. 35. PRIMARY UNION • Ends of fracture are approximated • By application of compression clamps • Union takes place by the formation of Medullary callus without periosteal callus formation • Seen only in special conditions
  36. 36. SECONDARY UNION • More common process • Continuous • It includes: • PROCALLUS FORMATION • OSSEOUS CALLUS FORMATION • REMODELLING
  37. 37. PROCALLUS FORMATION • It includes: 1) HAEMATOMA 2) LOCAL INFLAMMATORY RESPONSE 3) INGROWTH OF GRANULATION TISSUE 4) CALLUS COMPOSED OF WOVEN BONE AND CARTILAGE
  38. 38. HAEMATOMA • Bleeding from torn vessels • Fills the space • Loss meshwork by blood and fibrin clot is formed • This acts as framework for granulation tissue formation
  39. 39. LOCAL INFLAMMATORY RESPONSE • Exudation of fibrin, polymorphs & macrophages. • Macrophages clears the fibrin, red cells, exudate and debris and necrosed bone
  40. 40. INGROWTH OF GRANULATION TISSUE • Neovascularisation • Proliferation of mesenchymal cells from periosteum and endosteum • Results in soft tissue callus
  41. 41. CALLUS COMPOSED OF WOVEN BONE AND CARTILAGE • Cells of periosteum lays down collagen and osteoid matrix in granulation tissue • Osteoid matrix undergoes calcification – woven bone callus. This covers the fracture end on both sides and bridges the gap.
  42. 42. OSSEOUS CALLUS FORMATION • Procallus acts as scaffolding on which osseous callus is formed. • Woven bone is cleared by incoming osteoclasts • Calcified cartilage disintegrates. • These are replaced by new blood vessels and osteoblasts which in turn forms lamellar bone by developing Haversian system around the blood vessels.
  43. 43. REMODELLING • Osteoblastic laying and osteoclastic removal takes place simultaneously. • External callus is cleared away • Compact bone is formed in place of callus • Bonemarrow cavity develops
  44. 44. COMPLICATIONS: • FIBROUS UNION: when immobilization is not done. • NON-UNION: if soft tissue is interposed b/w fractured ends. • DELAYED UNION: due to infection, inadequate blood supply, poor nutrition, old age.
  45. 45. THANKYOU
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basic concepts of tissue injury and healing process. emphasis placed on primary and secondary type of wound healing.

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