Wound

A wound is a damage to a biological tissue, like skin, mucous membrane, or organ. This article deals with skin wounds.

Types of wounds

• Mechanical wounds
  • Vulnus abrasum (abraded wound, scratch) – Due to rough rubbing of the skin. Affects superficial part of the epidermal layer. Heals well.
  • Vulnus scissum (cut wound) – Due to a sharp object which is dragged along the skin, like a knife or sword. Heals well.
  • Vulnus caesum (cut wound) – Due to a sharp object which is inserted perpendicular to the skin, like an axe.
  • Vulnus contusum (rupture, crush wound) – Due to blunt trauma which rips the skin open, like a hammer. Has a typical wound shape, with irregular and contaminated edges.
  • Vulnus lacerum (lacerated wound) – Due to great pulling forces, causes tearing of skin and great injury.
  • Vulnus punctum (stab wound) – Due to stabbing with knife or another sharp object. Narrow but deep wound. May damage deeper structures.
  • Vulnus sclopetarium (gunshot wound) – Due to gunshot. May be low energy (similar to stab wound) or high energy, when a cavitation zone is formed.
  • Vulnus morsum (bite wound) – Due to bite. Highly contaminated, irregular edges.
• Chemical wounds
  • Acid
  • Base
• Radiation wounds
• Thermal wounds
• Pressure wounds

Wound management

Primary wound closure

Primary wound closure, also called healing by primary intention, refers to the early closure of wounds by using sutures, staples, or other similar equipment to approximate (make come into contact) the wound edges. This can only be performed in wounds where all the following apply:

• The wound is recent (< 12 – 24 hours)
• The wound has a low risk of infection
• The wound edges can be approximated without tension

This is the case for surgical incisions and most traumatic wounds, most commonly vulnus scissum.

Wound edge approximation may be achieved by:

• Sutures (most common)
• Staples
• Sterile strips
• Wound glue (tissue adhesive)

It’s important to leave no gap or dead space. The latter two may only be used in case of superficial low-tension wounds. In cases of deeper wounds or high-tension wounds, sutures or staples are necessary. A sterile dressing is then applied.

Primary closure allows the wound to heal with minimal inflammation and no granulation tissue formation. Only a thin scar is left behind.

Secondary wound closure

Secondary wound closure, also called healing by secondary intention, refers to allowing a wound to heal without approximating the wound edges. In other words, the wound is intentionally left open to heal by itself. The wound is cleaned and debrided. If the wound is deep, a drain should be placed to drain any fluid or pus. A sterile, moist dressing is then applied.

By removing dead tissue and keeping the wound clean, it will eventually heal by itself, although this takes longer than healing by primary intention, and leaves a bigger scar.

Healing by secondary intention is the only option in wounds for which any of the following apply:

• The wound is contaminated (with soil, bodily fluids, etc)
• There is a foreign body in the wound
• There is extensive tissue loss
• The wound is an infected postoperative wound
• The wound is too old to be closed by primary closure
• The wound edges cannot be approximated without tension

After approximately 3 – 5 days, the wound may be re-evaluated for the possibility for delayed primary closure.

Delayed primary closure

Delayed primary closure, also called healing by tertiary intention, is a mix of the previous two. If a wound which is managed by secondary intention is re-evaluated after 3 – 5 days and is found to be clean and there are no signs of infection, it may be closed with the same methods as primary closure.

Tetanus prophylaxis

For all wounds which are or may be contaminated, administering tetanus prophylaxis is obligatory. There are two types of prophylaxis, active immunisation (tetanus vaccine booster) and passive immunisation (TETIG or HTIG).

We generally administer both active and passive immunisation, depending on the risk of tetanus contamination. The exact guidelines vary from region to region. In Hungary, the following apply:

• Patient born after 01/01/1941: Only active immunisation
• Patient which is actively immunised: Only active immunisation
• All other cases: Both active and passive immunisation

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