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89 Cards in this Set
- Front
- Back
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Healing by 1st intent
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-healing of a clean unifected surgical incision
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After an incision is made, the area is filled with clotted blood and a scab forms, what cells appear next
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-with in 24 hours neutrophils appear at the margin of the skin (most abundant WBC of the body)
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neutrophils appear in the first 24 hours to heal a wound, then for the next 48 hours...
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the edges thicken when epithelial cells migrate along the cut margins of the dermis depositing basement membrane as they move
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in a wound, neutrophils appear in 24 hours, epithelial cells migrate in the next 48 hours...then
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-by day 3, neutrophils are replaced by macrophages
-increased granualtiont tissue -collagen forms at the edges -epithelial cell layer thickens |
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By day 5 what happens in a wound
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-neovascularization
-collagen fibers bridge the gap -epidermis is its original thickness |
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During the 2nd week of a wound
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increased collagen and fibroblasts
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what effects does age and race have on scar formation
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-young pts and blacks are more likely to hypertrophy
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what effect does tension have on a scar
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it hypertrophies a scar
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what effect does wound length have on scar formation
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-multiple incisions heal better then one long uninterrupted inscision
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what effect does skin tension lines have on scar formation
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-paralell lines give fine scars
-anti tension lines hypertrophy |
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define each type of skin graft (auto, iso, allo, xeno)
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-autograft (same person)
-iso (identical twins) -allo (human to human) -xeon (fxn only as biologic dressings and dotn incorporate into the host's tissue) |
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what is a split thickness graft (STSG) (thin, thick, mesh or 0.008-0.012-0.016- 0.020 inches)
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-partial thickness graft
-contains full epidermal layer and part of the dermis -not usually used on hands and feet bc they are areas of WB |
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Pro and cons of thin STSG(0.008-0.012)
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-good host incorporation, low tissue demand
-contracts the most |
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cons of thick STSG(0.016-0.020)
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-the thicker the graft the less chance of incorporation due to greater tissue demands
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why do you mesh STSG
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-allows the graft to expand and increase SA of the tissue
-prevents seroma and hematoma under the graft |
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what is a full thickness graft
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-includes the full epidermis, dermis and part of the superficial fascia (superfical fascia must be removed before graft is placed)
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where are full thickness grafts usually placed
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-WB areas or flexion points
-they have lower incorporation rates then STSG |
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how long is a harvested skin graft viable for
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-21 days in a saline or antibiotic solution, refrigerated
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list steps in application of a skin graft
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-graft should slightly overlap the wound edges
-suture graft inplace -prevent shearing of revascularized graft by bulk dressings -immobilize limb -leave post op dressing on for 3 days, then moisten to remove |
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what is the MC cause of skin graft failure
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seroma (transudate fluid)
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Stent tie-over dressing used in skin grafts
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-bulky dressing overtied with suture material, creates a pressure dressing
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how can seroma be prevented
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-pie crusting (placing multiple small incisions in a graft)
-stent dressing |
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what is Apli-graft
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-bilayered skin construct
-epidermal layer is formed by human keratinocytes -dermal layer is formed by human fibroblasts in a Bovine collagen lattice -made from neonatal foreskin |
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when is apligraft used
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-usually on DM ulcers and venous ulcers that havent healed after 1 month
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what size is apligraft
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75 mm in diameter, 0.75 mm thick
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how do skin flaps differ from skin grafts
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-skin flaps have their own vascualr supply
-grafts must rely on the host tissue for blood |
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what are indications for use of a skin flap
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-cover areas of poor vascularity (bone, tendon)
-padding boney prominences -restoring sensation to an area |
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Free flap
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transferred from a distant site
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deroational skin plasty and its indications
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-clinodactyly, arthroplasty of 5th toe
-skin wedge placed perpendicular to the axis of rotation of the toe (ellipse skin insicion from m to l on the 5th digit) |
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Z plasty
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-indicated for soft tissue contracture (scars, wound) for gain in length
-central line with 60 degree trangles on opposite sides -then triangles are transposed (swap places with each other) |
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what angle would the triangles in a Z plasty have to be to get a 25%, 50% and 75% inc in length
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-60 degrees for 75% inc
-45 degrees for 50% inc -30 degrees for 25% inc |
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Z plasty is a method of skin lengthening, list two more
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V-Y plasty
Y-V plasty |
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what are the pros and cons of using staples for wound closure
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-reduced incidence of infection
-cheaper -worse cosmesis |
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how long should plantar sutures be left intact, NWB
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3 weeks
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what is a keloid or hypertrophic scar
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-overabundance of collagen deposition
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what is the difference b/w a keloid and hypertrophic scar
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-keloid extends beyond the initial incision site
-keloids may worsen in appearance, hypertrophy scars improve |
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when should a double S incision be used
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when the incision is very large
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how can you prevent keloids and hypertrophic scars
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-use non absorbable sutures (less reactivity; polypropylene, nylon, SS)
-atraumatic technique -maintain hemostasis |
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how can you treat keloids and scars
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-surgical excision with zplasty to reduce tension
-steroids along the scar -pressure over the scar |
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when does skin strength equal suture strength
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day 14
-so remove sutures (unless plantar sutures) |
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Cortisone delays formation of granulation tissue and wound closure,thinning of the dermis and atrophy of collagen fibers, decrease in fibroblast and new blood vessel proliferation. This effect can be reduced by
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Vit A supplements
-Vit A can help in wound healing but may interfer with what the steroids were prescribed for, so topical may be better |
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list the phases of wound healing
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1. inflammatory
2. proliferative 3. remodeling |
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Note: Only after 6 months and preferably not before a year do you really
know what a scar will look like, therefore, any attempt at scar revision should wait at least this long. |
Only after 6 months and preferably not before a year do you really
know what a scar will look like, therefore, any attempt at scar revision should wait at least this long. |
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why does protein interfer with wound healing
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Protein depletion results in alterations in collagen
synthesis and cross-linking |
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how can edema interfer with wound healing
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Interferes with tissue perfusion and leads to tissue destruction
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Vit C and wound healing
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-failure of collagen synthesis
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how do steroids specifically interfer with wound healing
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Steroids slow protein synthesis when given exogenously. Steroids
interfere with capillary budding, slow fibroblast proliferation as well as the rate of epithelialization |
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how does venous stasis play a role in ulcers and wound healing
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-Poor venous return leads to an increase in tissue pressure.
-The increase in tissue pressure results in underperfusion of the skin and wounds, as well as accumulation of inhibitory metabolites |
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Dexon-S and Vicryl
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- absorbable
-synthetic -multi filament |
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PDS and Maxon
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-absorbable
-synthetic and mono filament |
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Non absorbable MONO filament
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-Dermalon®, Ethilon® (nylon)
- Surgilene® (polypropylene) -Novafil® (polybutester) |
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Non absorbable MULTI filament
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-Neurolon®, Surgilon® (nylon)
-Mersilene®, Dacron®, Tevdek®, Ethibond®, Ticron® (polyester) |
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list contraindications for tourniquet use
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-Open fractures
-Post-traumatic hand reconstruction -Severe crushing injuries -Elbow surgery (with excess swelling) -Severe hypertension -With skin grafts in which all bleeding points must be readily distinguished -Compromised vascular circulation or in the presence of an arterial graft -Diabetes mellitus -Sickle cell disease |
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why do you exsanguinate the limb prior to tourniquet
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-to prolong the pain free tourniquet time
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In the presence of malignant tumors, painful fractures, or infection elastic bandage (Esmarch) exsanguination must not be done...
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elevating for 3-5 minutes is sufficient
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what should the tourniquet pressure be
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Published literature suggests an effective tourniquet setting be 75-100 mm Hg above preoperative systolic pressure
- (usually 250 in LE sx) |
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what % of the skin thickness does the epidermis and dermis represent
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-epidermis is 95% of the thickness
-dermis is 5% |
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directions for a stent tie-over (bolster) dressing for skin graft
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-bolster is built by first placing Xeroform® on the wound then normal saline soaked gauze in the center. The nylon suture used at the wound's periphery
are then crossed over and tied to each other, forcing out the water in the cotton. This allows the graft to conform exactly to the recipient site |
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what is the time line for neurotization of a full thickness graft
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Neurotization occurs in the following order: pain, light touch, then
temperature -Sensory recovery starts at 4 weeks and can take up to 1-2 years |
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local flap
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Local flaps are adjacent to the defect and are either rotated on a pivot point or are advanced forward from their base to cover a defect
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etiology of hemosiderin staining
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-due to chronic leakage of RBC into the soft tissue
-classic sign of venous insufficiency -reddish brown color |
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hemosiderin skin is classic in venous insufficiency and venous ulcers, list classic signs of arterial insufficiency/ulcers
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-hair loss
-weak/absent pulse -thin, taut, shiney skin |
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partial thickness wound effects which layers of skin, give examples of that type of wound
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-epidermis and part of the dermis
-abrasions, skin tears, blisters and skin donor graft sights |
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how should the size of a wound be measured
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-widest head to toe length
-widest side to side length |
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why should you palapate the area around an ulcer
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-to look for induration or fluctuance; an abnormal fluid build up could indicate tissue damage or abscess
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what is induration
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Induration is abnormal firmness of tissues with margins. Assess by gently pinching the tissues. Induration results in an inability to pinch the tissues
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list the classic signs of infection in a wound
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-pain
-erythema -edema -heat -purulent exudate -delayed healing |
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Levine technique for culture swab
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-rotating the swab over a 1 cm area with sufficient pressure to express fluid from the wound
-most comparable to tissue sampel which is the gold std |
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Z stroke method for wound culture
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-swab from margin to margin in 10 point zigzag
-may collect surface contamination rather then bioburden |
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which bacteria invade wounds first
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-gram positive, then gram neg, then anaerobes
-infected wound less then 1 month old, assume Gpos |
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how many organisms per gram of tissue need to be present to consider a wound infected
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10^6
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what causes a scar
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-disordered collagen
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why is debrideing ulcers on the heels or toes controversial
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-because of their low perfusion
-also bc the calcaneus is covered with very little tissue |
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when should you not debride pyoderma gangrenosum
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-when there is a raised active border
-this indicates acute inflammation adn debridement would stimulate the infiltrate even more |
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if a pt has palpable pulses in the foot, what does this suggest about their ABI, pressures and healing
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-they are capable of healing and their pressure is atleast 80mm in the foot
-also they have an ABI of atleast 0.6 |
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process when an chronic wound is turned into an acute wound to stimulate healing
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debridement
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what is a drawback of wet-to-dry mechanical debridement of a wound
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-it removes both necrotic and healthy viable granulation tissue
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what ankle pressure is needed for healing
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greater then 80mm Hg
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what toe pressure is needed for wound healing
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greater then 30 mm Hg
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what anatomical structure can be confused with slough when debriding bc both are yellow in color
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-tendon
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how should the wound bed be prepared before an enzymatic debriding topical is added ot the bed
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-crosshatching the wound with a sclapel for better penetration
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list some enzymatic wound debriders
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-papin-urea combination
-collegenase -panafil -accuzyme -santyl |
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what is autolytic debridement and give examples
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-uses the bodies own enzymes to slowly remove necrotic tissue from the wound bed
-apply a moisture retaining or semi-occlusive dressing (transparent films, hydrogels, calcium alginate dressings) |
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if a wound is infected which is the best debridement choice (sharp, mechanical, enzymatic, autolytic)
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anything but autolytic
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if a pt has a bleeding problem or coumadin use which is the best debridement choice (sharp, mechanical, enzymatic, autolytic)
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sharp or enzymatic
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list methods of mechanical debridement
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-pulse lavage
-wet to dry -hydrotherapy -(scalpel is classified as sharp or surgical debridement) |
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why is a moist environment imp for wound healing
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-faciliates the leap frogging of epithelial cells across the wound bed
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what is a normal protein (albumin) level (essential for wound healing)
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5.5 g/dL
-you need 0.8 g/kg/day |
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Pain in a normally painless foot might suggest
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-disruption of the deeper structures and strong possibility of OM, Charcot or both occurring together
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