Wound Management: Classification, Syndrome for Surgery Notes

Wound management is an important topic for NEET PG/NExT exam preparation as it is a crucial aspect of patient care in the field of surgery. In the exam, you may encounter questions related to the classification of wounds, wound healing, and management of surgical wounds, including the selection of appropriate wound dressings and wound care practices.

Therefore, it is advisable to have a good understanding of the topic to perform well in the NEET PG exam and also to provide the best possible patient care.

Read this blog further to get an overview of the topic.

Wound Overview

Wound refers to a breach in continuity of skin or surface epithelium. It can be caused by various factors, including physical trauma, surgical incisions, cuts, burns, and puncture wounds. Depending on the cause and severity of the wound, the healing process can take several days to several weeks.

Surgical wound Classification 

Surgical wound classification is a system used to categorize surgical wounds based on their appearance and healing process. There are several commonly used surgical wound classifications, including:

• Class I: Clean wound 
  • Respiratory tract, GIT, GUT: not entered
  • Uninfected operated wounds Without inflammation 
  • Closed primarily 
  • E.g., Inguinal hernia operation, Mastectomy, Thyroidectomy, Joint replacement, Abdominal aortic aneurysm repair    
• Class II: Clean, contaminated wound 
  • Respiratory tract, GIT, GUT is entered under controlled condition 
  • Without unusual contamination 
  • E.g., Cholecystectomy, CBD exploration, Elective GI surgery (like elective colonic resection, elective gastrectomy)
• Class III: Contaminated wounds 
  • Open, fresh accidental wounds
  • Operations with major break in sterile techniques or gross spillage from GIT
  • Acute non purulent inflammation is encountered
  • E.g. Appendicular perforation, Gastric perforation, Enterotomy during bowel obstruction, Open fracture  
• Class IV: Dirty wound 
  • Infection or organism causing infection already present in the wound
  • Old traumatic wound with retained devitalized tissue
  • Wound with clinical infection or perforated viscera with high degree of contamination 
  • With Severe purulent inflammation
  • E.g., Perforated diverticulitis, Fecal peritonitis, Frank pus, Necrotizing soft tissue infection  

Wound Classification	Risk of Infection	Antibiotic Prophylaxis
Clean	5%	Not required
Clean contaminated	10%	Required (usually)
Contaminated	20 - 30%	Required (in all cases)
Dirty wound	30 - 40%	Treatment is required (Not the prophylaxis)

• Chronic wound 
  • Any wound that does not heal within 3 months 
  • Delay usually occurs in inflammatory phase 
  • E.g. bed sore / pressure sore 
• Degloving Injury / Avulsion injury 
  • Skin + subcutaneous fat is stripped from underlying fascia by avulsion 
  • After degloving injury exposed parts are
    • Bone 
    • Neuromuscular structure 
    • Tendon 

Compartment syndrome 

Compartment syndrome is a medical condition that occurs when pressure within a confined space (a muscle compartment) increases, leading to reduced blood flow and potential damage to the muscles and nerves within the compartment. 

This can be caused by a variety of factors, including trauma, fractures, swelling, and certain medical procedures. 

Symptoms may include pain, swelling, tightness, and impaired movement, and if left untreated, it can lead to permanent muscle and nerve damage.

• Pressure in affected compartment: > 30 mm of Hg 
• Generally seen in closed lower limb injury 
• Clinical features 
  • Severe pain
  • Pain on passive movement 
  • Distal sensory disturbance
  • Absence of distal pulses (late sign)
  • Paralysis (worst prognosis) 
• Fasciotomy
  • Indications: Pressure > 30 mm Hg; signs and symptoms of compartment syndrome 
  • Longitudinal incision on both medial and lateral side 
  • Structures incised: skin, subcutaneous fat, fascia 

Pressure Ulcer

• Pressure sore / Bed sore  
• Ulcer because of prolonged pressure 
• Tissue necrosis + Ulceration
• Staging 
  • Stage I: non blanch able erythema of skin without any breach in the skin; early superficial ulcer 
  • Stage II: partial thickness skin loss with involvement of epidermis and dermis; late superficial ulcer
  • Stage III: full thickness skin loss with involvement of subcutaneous tissue; early deep ulcer
  • Stage IV: full thickness skin loss with involvement of subcutaneous tissue, muscle,bone; late deep ulcer

• Bed bound patient: should turn every 2 hourly
• Wheelchair bound: should lift for 10 sec every 10 min 
• Most common used Flap for pressure sore: Extensor Fascia Lata Flap with lateral cutaneous nerve of thigh

Negative pressure wound therapy (NPWT)/ vacuum assisted closure (VAC) 

• Vacuum: Draws the fluid and increases the blood flow; Thus, helps in faster healing 

• Negative pressure created: - 125 mmHg 

• Dressing changed 2-3 times/week 

• Advantages of negative wound therapy
  • Suck the excessive fluid collected
  • Promote the vascular supply: Improve wound healing

• Effects of Negative Pressure Wound Therapy/ VAC on Wound Healing 
  • Causes Macro deformation 
  • Causes Micro deformation 
  • Reduces Edema 
  • Causes Stabilization of wound environment 

• Contraindications of Negative Pressure Wound Healing (MUNNa)
  • M - Malignancy in the wound 
  • U - Untreated osteomyelitis 
  • N - Non -enteric & undrained fistula 
  • N - Necrotic tissue with eschar

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