TOPIC 12. OPEN TRAUMA – WOUNDS AND WOUND HEALING
1. Definition and classification
A wound is a disruption of the normal continuity of skin, mucosa or deeper tissue. Open wounds communicate with the external environment and may be contaminated.
- By depth: superficial, partial-thickness, full-thickness and deep wounds involving muscle, tendon, vessels, nerves, bone or body cavities.
- By contamination: clean, contaminated or infected; operative wounds may also be classified as clean, clean-contaminated, contaminated and dirty/infected.
- By mechanism: incised, lacerated, contused, puncture, avulsion, crush, bite and firearm wounds.
2. Initial wound assessment
- Control haemorrhage first; assess airway, breathing and circulation in major trauma.
- Establish mechanism, time, environment, object involved, contamination, foreign body possibility and tetanus immunisation history.
- Inspect wound location, length, depth, tissue viability, contamination, bleeding and involvement of tendons, joints, vessels, nerves or bone.
- Perform and document distal neurovascular examination before and after manipulation or repair.
- Do not blindly probe deep wounds or remove an embedded object that may be tamponading major bleeding; stabilise it and obtain surgical help.
3. Wound management
Haemostasis: direct pressure, elevation where appropriate, ligation/cautery in a controlled setting or other definitive vascular control.
Irrigation: copious irrigation with appropriate fluid to remove debris and reduce bacterial load.
Debridement: remove foreign material and clearly devitalised tissue while preserving viable structures; repeat debridement may be needed in crush or contaminated wounds.
Assessment for deeper injury: image or explore under appropriate conditions if fracture, foreign body, joint penetration, tendon, nerve or vascular injury is suspected.
Closure: primary closure for suitable clean wounds; delayed primary closure or healing by secondary intention for heavily contaminated, infected or tissue-deficient wounds.
Antibiotics: not needed for every simple wound; consider for bites, open fractures, gross contamination, deep puncture wounds, immunocompromise or established infection according to guidance.
Tetanus: assess immunisation status and wound category; provide vaccine and tetanus immunoglobulin when indicated by local recommendations.
4. Phases of wound healing
5. Types of wound healing
Primary intention: clean wound edges are approximated (e.g. sutured incision); less granulation tissue and smaller scar.
Secondary intention: wound is left open and fills with granulation tissue, contracts and epithelialises; used for tissue loss or selected infected wounds; slower and produces a larger scar.
Delayed primary (tertiary) closure: wound is initially left open for observation, drainage and debridement, then closed when contamination/infection risk is controlled.
6. Factors affecting healing
Local: infection, poor perfusion/oxygenation, foreign bodies, necrotic tissue, haematoma, oedema, excessive tension, repeated trauma and radiation.