Wound Healing

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an interruption in the continuity of a tissue

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an injury

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repair targets:

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to reestablish that continuity with dense connective tissue (DCT) scarring. Regeneration of DCT does not occur in mammals.

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All tissues are capable of repair except...

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the teeth.

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phases of scar tissue formation:

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1)inflammatory phase
2) regenerative or proliferative phase
3) remodeling phase

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surgical wounds heal by either:

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1) primary intention
2) Delayed primary intention healing
3) Secondary intention healing

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-with no major loss of tissue.
-edges are drawn together to achieve smooth-clean edges.
-healed by 3-7 days

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primary intention

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- wound is left open for several days prior to closure.
-when wound is contaminated (high risk of infection)
-when large tissue is lost

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delayed primary intention healing

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-healing by scar tissue formation
-when large amounts of tissue are lost
-when wound margins are nonviable
-when wound has high bacterial bioburden

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secondary intention healing

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Inflammation

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A series of reactions by vascularized tissue in response to an injury with the goal of removing all foreign debris, dead tissue and infections. Thus, setting the stage (environment) for further stage of scar tissue formation.

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2 types of inflammation

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acute inflammation and chronic inflammation

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chronic inflammation

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is a long-lasting response caused by persistent injurious agent or unresolved acute inflammatory process.
it leads to proliferation of DCT cell.

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Acute inflammation

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response to an injurious agent,
composed of vascular and cellular response.

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Acute inflammation generally lasts:

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between 24 to 48 hours varies with size of the wound

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clinical signs of inflammation

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Pain
Redness
Swelling
Heat
Loss of function

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a brief description of the vascular response of acute inflammation:

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1) neural reflex causes transient vasoconstriction
)Chemicals releases
3)Coagulation/clotting at the injury site
4)Vasodilatation at the injury site
5) increased nutrients, oxygen and phagocytic cells

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Name the three plasma-derived systems that mediate the response:

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1) Kinin system
2) Complement system
3) Clotting system

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Which proteins is responsible for activating the three systems

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Hageman Factor(XII)

FIG 2-1

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Hageman Factor (XII) meadiates the activation of:

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1) Bradykinin (kinin system)
2)Plasmin (Complement system)
3) Thrombin which converts into fibrin (clotting system)

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Kinin system is responsible for:

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increased vasopermeability and pain sensation.

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Complement system is responsible for:

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-fibrinolysis
-activates complement cascade

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Complement cascades is

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- vasodilatation and vascular permeability(heat and redness)
-opsonization
-histamine release
-transudate
-exudate (swelling)

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Clotting system

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Clotting of the wound with fibrin to prevent infection

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Clinical considerations of pain in acute inflammation:

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1- caused by the pressure related to swelling, by Bradykinin and by chemical irritation of free nerve endings (pain)
2- cause the person to guard affected wound area resulting in loss of function

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the cellular response, chemotaxis is

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the process of cell migration along a chemically mediated concentration gradient.
that will result in phagocytosis.

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selective tissue destruction

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-does not have excessive movement or aggressive treatment.
- is confined to a loacal area
- is resolved in a timely fashion

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nonselective macrophages applies to

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aggressive treatmetn
(rest is advised)

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chronic inflammation results from

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unresolved acute information
repeated episodes of microtrtauma
persistent chronic irritation
hypersensitivity

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chronic inflammation lasts:

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months to years

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which substance is responsible for the self-perpetuating process in chronic response

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macrophages

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In chronic inflammation the predominant complaint is:

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stiffness

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in chronic inflammation pain is

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the secondary complaint

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stiffness is caused by:

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macrophages that results in infiltration of large numbers of activated fibroblasts that deposit increased amounts of collagen.

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What may cause prolonged chronic inflammation

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-persistant irritation
-local pressure
-poor oxygen supply
-poor surgical closure
-malnutrition
-vitamin A and C deficiencies
-radiation injury
-immunosuppression

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the manual therapist should focus on:

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proper wound management
providing clean and moist environment
RICE
receptor techniques( protecting, guarding, and pain-free exercise for edema reduction)

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the proliferative phase lasts:

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3 weeks

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the proliferative phase lasts

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3 weeks

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three major components occur simultaneously in the proliferative phase

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1) Re-epithelialization
2) Fibroplasia with neovascularization
3) Wound contraction

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What type of pain occurs with chronic inflammation vs in acute inflammation?

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-aching pain with chronic inflammation
-throbbing pain with acute inflammation

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Re-epithelialization involves:

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the re-establishment of the epidermis across the surface of the wound

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Re-epithelization occurs within

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48 hours

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RE-epithelialization of deep wounds takes:

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several weeks for differentiation of strata

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scab impedes:

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rapid re-epithelialization

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Maximize re-epithelialization with:

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- a clean, moist with ample blood supply
-proper dressings
-good hydratation

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A temporary surface barrier against bacteria and foreign matter

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a scab

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an appropriate dressing:

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-maintains adequate wound moisture and temperature
-protects wounds from contaminants and trauma

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the process of fibroblast migration and proliferation

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fibroplasia

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the process by which new blood vessels originate from the pre-existing vessels at the wound margin and grow into the wound space

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neovascularization or angiogenesis

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fibroplasia with neovascularization is marked by

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bulky scar (granulation tissue)

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Angioblasts and fibroblasts are attracted by

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macrophages

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fibroblasts roles are

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proliferation and production of new collagen, elastin ,GAGs, proteoglycans, and glycoproteins.
in other words, it is responsible for the reconstruction of the connective tissue matrix.

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bulky scar are desbribed as

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fragile,
collagen fibers are randomly aligned,
having weak hydrogen bonds
reddish with grannular appearance

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Angioblasts are realeased within

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24 hours to 5 days

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Edema at fibroplasia with neovascularization step is due to

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plasma proteins leaking from the new capillaries into the extravascular space

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wound tissue of chronic inflammation appears:

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very pale or dark red

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signs of infection of the wounds are:

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excessive, malodorous, viscous, and purulent

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chronic inflammation progresses through the fibroplasia and angiogenesis step with either:

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hypogranulation or hypergranulation

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it is recommended for hypergranulated wound to:

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rubs silver nitrate sticks or dry gauze across the wound surface

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the centripetally drawn in of a wound due to forces generated within that wound

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wound contraction

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wound contraction is limited by:

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- how much cells can contract
-capacity of the extracellular fibers and ground substance to be compacted
-by the tension in surrounding tissues

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wound contraction lasts

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-as long as fibroplasia (starts 4 and ends at 21 days)
-except for large burn scars

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Myofibroblasts are

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specialized fibroblasts containing muscle-like contractile proteins which anchor to each other and the extracellular matrix.

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What substance mediates the wound contraction:

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myofibroblasts

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Fibronexus is

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is the wound contractile unit formed by the interaction of the granulated tissue and the extracellular matrix.

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the goal of wound contraction is

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to create to a stable wound with a constant turnover of collagen as the matrix is remodeling.

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Wound can contracts up to:

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50 percent for large wounds

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the rate of wound contraction is

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5 to 10 percent per 6 weeks

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Linear, squares, and rectangular wounds contract more rapidly than

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circular wounds

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scar contracture vs wound contraction

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-scar contracture does not occur in a normal wound healing process.
-scar contracture occurs on a healed scar
-scar contracture causes fixed, rigid scar, functional and cosmetics deficits.

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Range of motion and proper positioning are critical to prevent

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scar contracture

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scar contractures are caused by:

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wound contraction
adhesions
fibrosis
other tissues damages

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scar contractre occurring at ___ are the most functionally limiting

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the head,
the neck,
the hand,
the joint surfaces.

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the remodeling phase goal is to:

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strengthen the wound along appropriate lines of stress, and the return of function.

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The two stages of scar tissur remodeling are:

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consolidation and maturation.

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consolidation stage is marked by

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-the change from a predominantly cellular tissue to a fibrous tissue
- the decrease in the cell population.

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In consolidation stage, myofibroblasts disappear first, and followed by:

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fibroblasts.

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The remaining fibroblasts are

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highly active in bringing about substantial change in the structure and strength of the scar.

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The consolidation stage lasts from:

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day 21 to day 60. (minimum is 4 weeks or 28 days)

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maturation phase lasts from :

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day 60 to day 360

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Describe the process of maturation

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-after day 60:connective tissue cells activity are greatly diminishes
-collagen turnover are gradually tapers off
- between 180 and 360 days, the tissue becomes tendon-like

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at the end of maturation stage (full scar healing), the tissue is:

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fibrous as opposed to cellular,
lessened in vascularity,
composed of strong covalent bonding rather than hydrogen bonds.

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Stress affects the ___ of the scar

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shape, strength, and pliability

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Mechanical forces additionally to oriented the collagen fibres also:

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increase the metabolic activity of fibroblasts (within 24 hours, release of GAGs, and proteoglycans)

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compression is not beneficial to tissue healing because

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it decreases the aggregation of fiber.

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Excessive strain will cause

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increase inflammation and decrease fibroplasia

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For remodelling to occur the tissue must have:

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sufficient population of active connective tissue and appropriate malleability.

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Innervation in scar is

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less than in normal skin

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splints is useful in scar management to :

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maintain the stretch on the scar and to counter scar contraction.

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What increase collagen extensibility

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heat application and stretching

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local factors that impairs wound healing:

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table 2-3

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systemic factors that delays wound healing:

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table 2-4

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steroids affect

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all phases of wound healing.

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Age is

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a critical factor in wound healing.

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delayed wound closure or chronic wounds might involve:

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1- internal factor such as patient's physical and mental health
2- external factors such as medications
3- iatrogenic factors such as therapist wound managements.