Wound Healing, Tissue Repair and Scar
CHAPTER 32
MULTIPLE CHOICE QUESTIONS WOUND HEALING
1. Wound healing is aected by: a. Age b. Nutrition c. Dryness or wetness of wound d. Drugs e. Temperature
(PGI Dec 2007)
2. Prevention of wound infection is done by: (PGI June 2005) a. Pre-op shaving b. Pre-op antibiotic therapy c. Monolament suture d. Wound apposition 3. True about wound healing: (PGI June 2009) a. Infected wound heal by primary intention b. Deep dermal wound heal heal by scar formation c. Wound contraction is found found in healing by secondary intention d. More intense intense inammatory inammatory response in primary intention 4. True about chronic wound: (PGI Nov 2009) a. Found in DM b. Always require surgical treatment c. May be associated with vascular compromise d. Monolament sutures prevent infection e. Any wound wound that that does not heal heal within 3 month month 5. Cell not involved in healing of clean wound: a. Macrophages (PGI Nov 2011) b. Platelet c. Fibroblasts d. Polymorphonuclear leukocytes e. Myobroblasts 6. Management of an open wound seen 12 hours aer the injury: (DPG 2011) a. Suturing b. Debridement and suture c. Secondary suturing d. Heal by granulation
11. Primary closure of incised wounds must be done within: (Kerala 87) a. 2 hours b. 4 hours c. 6 hours d. 12 hours e. 16 hours 12. The tensile strength of wound reaches that of normal tissue by: (PGI 88) a. 6 weeks b. 2 months e.None c. 4 months d. 6 months 13. Following are required for wound healing except: (All India 93) a. Zinc b. Copper e.None c. Vitamin C d. Calcium 14. Patient has lacerated untidy wound of the leg and aended the casualty aer 2 hours. His wound should be: (AIIMS 84) a. Sutured immediately b. Debrided and sutured immediately c. Debrided and sutured secondarily d. Cleaned and dressed 15. When is the maximum collagen content of wound tissue? (PGI 81, Rohtak 87) a. Between 3rd to 5th day b. Between 6th to 17th day c. Between 17th to 21st day d. None of the above 16. A patient with grossly contaminated wound presents 12 hours aer an accident, his wound should be managed by: a. Thorough cleaning and primary repair (UPSC 96) b. Thorough cleaning with debridement of all dead and dede vitalized tissue without primary closure c. Primary closure over a drain d. Covering the defect with split split skin gra aer aer cleaning 17. Delayed wound healing is seen in all except: (APPG 96) a. Malignancy b. Hypertension c. Diabetes d. Infection
7. The vitamin which has inhibitory eect on wound healing (MAHE 2005) is: a. Vitamin A b. Vitamin E c. Vitamin C d. Vitamin B-complex
18. In the healing of clean wound the maximum immediate immediate strength of the wound is reached by: a. 2–3 days b. 4–7 days c. 10–12 days d. 13–18 days
8. The tensile strength of the wound starts and increases aer: (WBPG 2012, MAHE 2005) a. Immediate suture of the wound b. 3–4 days c. 7–10 days d. 6 months
(DPG 92) 19. A clean incised wound heals by: a. Primary intention b. Secondary intention c. Excessive scaring d. None of the above
9. In a sutured surgical wound, the process of epithelialization (UPSC 2007) is completed within: a. 24 hours b. 48 hours c. 72 hours d. 96 hours 10. Factors that may adversely aect the healing of wounds include all the following except: a. Exposure to UV light b. Exposure to radiation c. Obstructive jaundice d. Advanced neoplasia
20. Which one of the following surgical procedures is considered to a have a clean-contaminated wound? a. Elective open cholecystectomy for cholelithiasis b. Herniorrhaphy with mesh mesh repair c. Lumpectomy with axillary node dissection d. Appendectomy with walled o abscess 21. Fibroblasts in healing wound are derived from: (UPSC 2008, PGI 98) a. Local mesechyme b. Epithelium c. Endothelium Endothelium d. Vascular brosis
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802 Surgery Essence 22. Tensile strength of wound becomes normal aer: a. 6 weeks (Recent Questions 2013) b. Never c. 4 months d. 6 months
32. The worst position for scars is: a. Back b. c. Sternum d.
KELOID AND HYPERTROPHIC SCAR
23. True statement(s) regarding hypertrophic scar: a. Grow beyond wound margin (PGI Dec 2008) b. More common in female c. Not familial d. Rarely subsides e. Not race related
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24. All are true about keloid except: a. Grows beyond would margin b. Excess collagen deposition c. Precancerous leading to cancer d. More common in female e. Whites are at high risk
(PGI Dec 2007)
25. Most common site of hypertrophic keloid is: (AIIMS Nov 93) a. Face b. Leg c. Presternal area d. Arm 26. First line treatment for keloid is: a. Intralesional injection of keloid b. Local steroid c. Radiotherapy d. Wide excision
(AIIMS Dec 94)
27. Drug used for intralesional injection of keloid is:
(AIIMS June 95) a. Prednisolone b. Triamcinolone c. Androgen d. Hydrocortisone 28. Keloid scar is made up: a. Dense collagen b. Loose brous tissue c. Granulamatous tissue d. Loose areolar tissue 29. What is true about keloids? (JIPMER 95) a. It appears immediately aer surgery b. It appears a few days aer aer surgery c. It is limited in its distribution d. It is common in old people 30. Keloid is best treated: a. Intralesional injection of trimacinolone b. Wide excision and graing c. Wide excision and suturing d. Deep X-ray therapy
31. The following statement about keloid is true: a. They do not extend into normal skin b. Local recurrence is common aer excision c. They oen undergo malignant change d. They are more common in whites whites than in blacks
(UPSC 95, 2001)
(PGI 88) Shoulder Abdomen
33. Keloid fornation is not seen over: a. Ear b. Face c. Eyelids d. Neck
(DNB 2004, 2001)
MISCELLANEOUS
34. The best scars are seen in: a. Infants c. Adults
(PGI 88) b. Children d. Very old people 35. If suture marks are to to be avoided, skin sutures should be (JIPMER 81, AMC 89) removed by: a. 72 hours b. 1 week c. 2 weeks d. 3 weeks (Kerala 2000) 36. Degloving injury is: a. Surgeon made wound b. Lacerated wound c. Blunt injury d. Avu Avulsion lsion injury e. Abrasive wound 37. In treatment of hand injuries, the greatest priority is: a. Repair of tendons (All India 96) b. Restoration of skin cover c. Repair of nerves d. Repair of blood vessels
(AIIMS 83) 38. During the surgical procedure: a. Tendons should be repaired before nerves b. Nerves should be repaired before tendons c. Tendons should not be repaired at the same tim timee d. None is true (AIIMS 97) 39. ‘Lims salvage’ primarily depends on: a. Vascular injury b. Skin cover c. Bone injury d. Nerve injury 40. In an open injury during toileting and debridement, muscle viability is detected by: (PGI June 2003) a. Colour of the muscle b. Muscle size c. Muscle function d. Muscle contractility e. Punctate bleeding spots on cut edge
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Wound Healing, Tissue Repair and Scar 803
EXPLANATIONS WOUND HEALING
1. Ans. a. Age, b. Nutrition, d. Drugs, e. Temperature (Ref: Sabiston 19/e p151-164; Schwartz 10/e p241-268, 9/e p219; Bailey 26/e p24, 25/e p24; Robbins 8/e p106) Factors that inhibit Wound Healing
Local Factors • • • • • • •
Systemic Factors
InfectionQ IschemiaQ Foreign bodyQ HematomaQ Movement Mechanical stress Necrotic tissue
• • • • • • •
Diabetes mellitusQ Ionizing radiationQ, temperatureQ Advanced ageQ, MalnutritionQ Vitamin C and A deciencyQ Mineral (Zinc and Mineral (Zinc and Iron IronQ) defciencies Drugs (SteroidsQ, Doxorubicin) JaundiceQ, UremiaQ, MalignancyQ
2. Ans. b. Pre-op antibiotic therapy, c. Monolament suture, d. Wound apposition (Ref: Bailey 26/e p62, 25/e p42) •
Bailey says “Preoperative shaving should be avoided except for aesthetic reasons or to prevent adherence of dressingsQ. If it is to be undertaken, it should be undertaken immediately before surgery as the SSI rate aer clean wound surgery may be doubled if it is performed the night before , because minor skin injury enhances supercial bacterial colonization Q. Cream depilation is messy and hair clipping is best , with the lowest rate of infection Q.” Avoiding Surgical Site Infections • • • • • • • • • •
Sta should always wash their hands between patientsQ Length of patient stay should be kept to a minimumQ Preoperative shaving should be avoided if possible Q Antiseptic skin preparation Q should be standardized Bowel preparation for intra-abdominal surgeries Q Pre-operative antibiotics given IV at the time of inductionQ Aention to theatre technique and discipline Avoid hypothermia perioperatively and ensure supplemental oxygenation in recoveryQ Monolament sutures are used over polylament sutures to prevent infectionQ Proper apposition of the wound and prevention of any dead space and hematomaQ
3. Ans. b. Deep dermal wound heal by scar formation, c. Wound Wound contraction contraction is is found in healing by secondary intention: (Ref: Sabiston 19/e p151-164; Schwartz 10/e p234, 1820, 9/e p210-214; Bailey 26/e p24-25, 25/e p24-25; Robbins 8/e p102-106) CUTANEOUS WOUND HEALING •
Epidermal appendages do not regenerate Q
•
There remains a connective tissue scar in place of the mechanically ecient meshwork of collagen in the unwounded dermis.
•
Very supercial wounds: Lile scar formation Q.
•
In marked contrast with wound healing in adults, fetal cutaneous wounds heal without scar formation Q , up to mid-gestation age in some animals. These wounds show lile inammation and practically no brosis Q.
Cutaneous wound healing is divided into three phases •
Inammation (early and late)
•
Granulation tissue formation and re-epithelialization
•
Wound contraction, ECM deposition and remodeling
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S e c t i o n
6 : P l a s t i c S u r g e r y
804 Surgery Essence Wound Healing
By First Intention •
•
By Second Intention
When wound wound is is sutured primarily with primarily with clips, sutures or sutures or adhesive adhesive materials, materials, the wound healing occurs healing occurs with minimal scarring, known scarring, known as healing by rst intentionQ Occurs in Clean and and uninfected uninfected woundsQ
•
When there is extensive loss of cells and cells and tissues tissues and and infection infection is is presnt, primary suturing is suturing is not possible, wound possible, wound heals with more scar tissue, known tissue, known as healing by second intentionQ • More intense More intense inammatory reactionQ • Much larger amounts of granulation tissue are formedQ • Takes longer time to heal • Wound contraction is presentQ
4. Ans. a. Found in DM, c. May be associated with vascular compromise, d. Monolament sutures prevent infection, e. Any wound that does not heal within 3 month: (Ref: Bailey 26/e p28, 25/e p28) CHRONIC WOUND • •
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Wounds that do not heal within 3 months Q are oen considered chronic. Surgical treatment is only indicated if non-operative treatment has failed or if the patient suers from intractable pain Q
5. Ans. b. Platelet, e. Myobroblasts: (Ref: Sabiston 19/e p151-164; Schwartz 10/e p234,1820, 9/e p210-214; Bailey 26/e p24-25, 25/e p24-25; Robbins 8/e p102-106) CUTANEOUS WOUND HEALING • •
•
Wound contraction: Most clearly dierentiates primary from secondary healing Q Permanent wound contraction requires the action of myobroblasts, altered broblasts that have the ultrastructural characteristics of smooth muscle cellsQ. Contraction of these cells at the wound site decreases the gap between the dermal edges of the wound.
HEALING BY FIRST INTENTION (WOUNDS WITH OPPOSED EDGES) •
•
Healing of a clean, uninfected surgical incision approximated by surgical sutures is referred as primary union or healing by rst intention Q. Narrow incisional space immediately lls with cloed blood containing brin and blood cells; dehydration of the surface clot forms the well-known scab that covers the wound. • •
•
• •
•
Within 24 hours, neutrophils appear at the margins of the incision, moving toward the brin clot. In 24–48 hours, spurs of epithelial cells move from the wound edgesQ along the cut margins of the dermis, depositing basement membrane components as they move. By day 3, the neutrophils have been largely replaced by macrophagesQ. Granulation tissue progressively invades the incision space.
By day 5, the incisional space is lled with granulation tissue Q. Neovascularization is maximal During the second week, there is continued accumulation of collagen and proliferation of broblasts Q. The leukocytic inltrate, edema, and increased vascularity have largely disappeared. By the end of the rst month, the scar is made up of a cellular connective tissue devoid of inammatory inltrate, covered now by intact epidermisQ.
6. Ans. b. Debridement and suture (Ref: Sabiston 19/e p245; Schwartz 10/e p234,1820, 9/e p219; Bailey 25/e p25-27; Robbins 8/e p102) •
If the blood supply to the wound is adequate and bacterial invasion is absent, wound can be safely closed anytime following proper debridement and irrigation Q. •
•
•
If there is established infection and tissue is of doubtful viability has been le in-situ, then the wound is le open and re-explored aer 48 hoursQ. If there is infection , and the doubtful viable tissue is now healthy, the deep tissues can be repaired and the wound is closed Q. If however there is further necrosis and infection, the wound is again debrided and le openQ.
7. Ans. b. Vitamin-E
8. Ans. b. 3–4 days
10. Ans. a. Exposure to UV light http://vip.persianss.ir/
9. Ans. b. 48 hours
Wound Healing, Tissue Repair and Scar 805 11. Ans. c. 6 hours (Ref: Sabiston 19/e p245; Schwartz 9/e p219; Bailey 26/e p25-27, 25/e p25-27; Robbins 8/e p102-104) WOUNDS CAN BE CLOSED BY •
•
•
Primary suture: − Clean woundsQ − Selected contaminated wounds aer thorough wound toileting and debridementQ Delayed primary suture: − Heavily contaminated woundsQ − Wou Wounds nds in which which wound toileting has been delayed for 6–8 hoursQ Le open to heal by secondary closure
12. Ans. None: (Ref: Sabiston 19/e p163-164; Schwartz 9/e p214; Bailey 25/e p24; Robbins 8/e p105-106)
The tensile strength of wound never equals that of unwounded skin. WOUND STRENGTH •
At the end of the 1st week, wound strength is approximately 10% of that unwounded skinQ.
•
Strength increases rapidly over the next 4 weeksQ. •
•
This rate of increase then slows at approximately the third month aer the original incision, and reaches a plateau at about 70–80% of the tensile strengthQ of unwounded skin, a condition that may persist for life.
The recovery of tensile strength results from the excess of collagen synthesis over collagen degradation during the rst two months of healing and later from structural modication of collagen bres Q (cross linking, increased ber size) aer collagen synthesis ceases.
13. Ans. None
14.
Ans. b. Debrided and sutured immediately
15. Ans. c. Between 17th - 21st day •
Over the rst three weeks, strength and collagen content both increases but aer 21 days collagen content remain static and only wound strength increasesQ.
16. Ans. b. Thorough cleaning with debridement of all dead and devitalized tissue without primary closure
17. Ans. b. Hypertension
18.
Ans. d. 13–18 days
20. Ans. a. Elective open cholecystectomy for cholelithiasis
19.
Ans. a. Primary intention
21.
Ans. a. Local mesechyme
22. Ans. b. Never KELOID AND HYPERTROPHIC SCAR
23. Ans. c. Not familial, e. Not race related (Ref: Sabiston 19/e p164-165; Schwartz 10/e p261-263, 9/e p225-227; Bailey 26/e p30, 25/e p30-31; Robbins 8/e p106-107) Feature
Hypertrophic scar
Keloid
Genetic
Not familialQ
May be familialQ
Race
Not race relatedQ
BlackQ >white
Sex
Female =male
FemaleQ >male
ChildrenQ
10–30 yearsQ
Border
Remains within woundQ
Outgrows wound Outgrows wound area
Natural History
Subsides with Subsides with time
Rarely subsides
Site
Flexor surfacesQ
Sternum (MCQ), ), shoulder, shoulder, face
Etiology
Related to tensionQ
Unknown
Develop
Within 4 weeks
3 months to year after trauma
Age
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S e c t i o n
6 : P l a s t i c S u r g e r y
806 Surgery Essence 24. Ans. c. Precancerous leading to cancer, e. Whites are at high risk (Ref: Sabiston 19/e p164-165; Schwartz 10/e p261-263, 9/e p225-227; Bailey 26/e p30, 25/e p30-31; Robbins 8/e p106-107) KELOIDS • • • •
Keloids: Scars that grow beyond the borders of the original wounds, and rarely regress with time. More prevalent in blacksQ Keloids appear to have a genetic predisposition Q. Keloid scars tend to occur above the clavicles , on the trunk , on the upper extremities , and on the face. •
•
Keloids have thicker, more abundant collagen bundles that form acellular node like structures in the deep dermal portion of the keloid lesionQ. Oen refractory to medical and surgical intervention Q.
25. Ans. c. Presternal area
26.
Ans. a. Intralesional injection of keloid (Ref: Bailey 26/e p30, 25/e p30) TREATMENT OF HYPERTROPHIC AND KELOID SCARS
• • •
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• • •
Pressure: local moulds or elasticated garmentsQ Silicone gel sheeting Intralesional steroid injection (triamcinoloneQ) Excision and steroid injection Q Excision and postoperative radiation Q (external beam or brachytherapy) Intralesional excision (keloids only Q) Laser: To reduce redness (which may resolve in any event) (All excisions have high rates of recurrenceQ) Vitamin E or palm oil massage (unproven) • •
•
27. Ans. b. Triamcinolone
28.
Ans. a. Dense collagen
30. Ans. a. Intralesional injection of triamcinolone 32. Ans. c. Sternum
33.
29.
Ans. b. It appears a few days aer surgery
31.
Ans. b. Local recurrence is common aer excision
Ans. c. Eyelids
MISCELLANEOUS
34. Ans. d. Very old people 35. Ans. b. 1 week (Ref: Bailey 26/e p31, 25/e p31) • • • • •
Suture marks may be minimised by using monolament sutures that are removed early (3–5 days)Q. Sutures inserted under tension will leave marksQ. The wound can be strengthened post suture removal by the use of sticky strips. Fine sutures (6/0 or smaller) placed close to the wound margins tend to leave less scarringQ. Subcuticular suturing avoids suture marks either side of the wound or incisionQ.
36. Ans. d. Avulsion injury (Ref: Bailey 26/e p27, 25/e p27) •
Degloving occurs when the skin and subcutaneous fat are stripped by avulsion from its underlying fascia, leaving neurovascular structures, tendon or bone exposedQ.
37. Ans. d. Repair of blood vessels 38. Ans. a. Tendons should be repaired before nerves (Ref: Master Techniques in Orthopedic Surgery Series by Moran and Cooney (2008)/487) SEQUENCE OF REPAIR IN HAND INJURIES (BE FAN OF VEINS) • • •
Bone shortening and stabilization/xationQ Arterial anastomosesQ Skin/wound closureQ
• •
Extensor tendon repairQ Nerve repairQ
• •
Flexor tendon repairQ Venous anastomosisQ
39. Ans. a. Vascular injury 40. Ans. a. Colour Colour of the muscle, d. Muscle contractility contractility,, e. Punctate bleeding spots on cut edge (Ref: Bailey 25/e p354-356) MUSCLE VIABILITY IS DETECTED BY ‘4C’ • • • •
ColourQ: Dead muscle has dark unhealthy colour, has lost its sheen ContractilityQ: Dead muscles do not twitch when held by forceps. ConsistencyQ: Dead muscle has lost its turgor and is mushy in consistency Capillary bleedingQ: Dead muscle does not bleed at cut ends.
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