What are the soft tissue phases of healing?
- Coagulation (clotting) phase
- Beings immediately
- Vessels first spasm and contract
to limit bleeding - platelet plug - Platelet replaced with fibrin
(secondary haemostasis) and
then replaced with collagen
- Inflammatory phase
- Also begins immediately and
lasts 3-5 days - Neutrophils dominate this phase
and remove necrotic tissue and
protect against bacteria - Leucocytes release inflamm
mediators and damage cells
activate circulator cells
important in proliferative phase
- Also begins immediately and
- Proliferative (healing) phase
- Characterised by granulation
tissue and starts day 3-5 days
and last 3 weeks - Main cells are fibroblasts and
developing collagen matrix:
important for wound strength,
macrophages and developing
blood vessels - As it matures myofibroblasts
produce myocollagen to contract
wound
- Characterised by granulation
- Maturation (reorganisation) phase
- 2-4 weeks post injury -
remodelling of collagen and
confers strength to the wound - Months to years after injury
- 2-4 weeks post injury -
What are the criteria for wound classification?
- Location
- Cause
- Depth of injury
- Type of injury
- Degree of contamination
- Amount of discharge/exudate
- Age on injury/wound
What are the stages of initial wound management?
- Pain relief
- Clipping
- Wear gloves, cover wound with water soluble jelly
- Clip widely around wound
- Clean peri wound skin - dilute hibi
- Change gloves at the end - Wound lavage:
- Flush wound with minimum 1L sterile hartmanns/saline
(giving set/3 way tap/21g needle) - Wound cytology/swabs
- Flush wound with minimum 1L sterile hartmanns/saline
- Abs depending on contamination then de-escalate
depending on culture - Wound exploration
- Bite wounds/penetrating wounds can have lots of dead
space and need exploring - Probing with blunt instrument
- Bite wounds/penetrating wounds can have lots of dead
- Debridement
- Sharp selective removal of dead or contaminated tissue
- Mechanical debridement using dressing - wet to dry
- Autolytic debridement using dressing to maintain moist
environment that facilitates the bodies natural
debridement process and lavage away during dressing
changes - Enzymatic - proteolytic enzymes applied to wound
surface - Biosurgical - maggots
- Closure
- Primary wound closure - for non-contaminated wounds
which can be closed with minimal tension - Delayed wound closure - until granulation bed
- Second intention healing
- Primary wound closure - for non-contaminated wounds
What dressings are best for which healing phase?
Inflammatory phase
- Debridement
- Absorption of exudate
- Control or avoiding promotion of infection
- Allevyn
Early proliferative phase
- Non-adherent dressing
- Maintain moist environment
- Protection of blood vessels and epithelial cells
- Alginates (kaltostat) - allow moist wound healing
- Allevyn/hydrogels
Late proliferative stage
- Maintain moist environment
- minimal exudate at this stage
- Melolin + primapore
A moist wound environment optimises healing, speeds up debridement, granulation tissue formation and epithelialisation - also makes the wound less painful, pruritic and reduce scar formation
How to do a wet-dry bandage?
Lavage, debride
- Apply moist surgical swabs and then a thick layer of wet
swabs on top to ‘wick’ fluid from wound afterwards
- To be removed under sedation/anaesthesia as very
painful
- Generally change ever 24hrs, no longer than 48 hours
What are alternatives to wet-dry dressings?
Hydrogel (intrasite, citrugel) - designed to liquefy dead material so that it can be lavaged away
What and when is best to use non-adherent dressings?
Wound is minimally contaminated and appears viable - dressing provides protection
- Polyurethane foam - allevyn, advazorb, silicone dressing,
paraffin gauze) - Honey dressing - antibacterial properties (inflam phase)
- Silver containing dressings - bactericidal
Can be left in place for 3-4 days but in acute siutation generally re-evaluate every 24-48hrs
What are priorities with a thoracic bite wound?
- Is the thoracic wall penetrated?
- S/C emphysema
- Rib fractures
- Pneumothorax present?
- Intercostal defect or a true flail segment
- Diaphragmatic rupture?
- Pulmonary contusions
Stabilising thoracic wounds?
- Analgesia
- Penetrating chest wounds: smear with aqueous or
petroleum jelly to create and aqueous barrier and then
cover with dressing (cling film) - Thoracocentesis
What are techniques for treating thoracic wall injuries?
- Flail chest with no communication does not need surgical treatment or lateral thoracotomy to repair
- Omentum - tunnelled through s/c or via diaphragm from the abdominal cavity
- Mesh implants
- Diaphragmatic advancement so defect will be fixed from abdomen than chest
What should always be assessed with orthopaedic concerns?
- Distal pulses and neurological function (sensation) should
always be assessed with fractures
What can thoracic limb fractures be associated with?
Pulmonary contusions
Pneumothorax
Tracheal avulsion
Diaphragmatic rupture
What can pelvic limb fractures be associated with?
Urinary tract rupture
Neurological dysfunction
Prepubic tendon rupture
What framework can be used for fracture scoring?
PFAS (patient fracture assessment scores)
Gives a structural approach to the assessment of fractures. The areas considered are,
- Biological factors affecting fracture healing
- age, likelihood of infection (open v. closed), energy of
trauma, bloody supply, systemic disorder or medical
treatment affecting healing
- age, likelihood of infection (open v. closed), energy of
- Mechanical factors affecting fracture healing
- Size/weight/activity/temperament of patient
- other limbs injured or suffering
- Clinical factors affecting fracture healing
- Experience of surgeon availability of implant systems
- Owner compliance with exercise restriction
What are fractures that can be managed conservatively?
- Maxillary/skull fractures not causing neurological or resp
impairments - Mandibular fractures - where patient can eat or can be
supported with tube feeding - Minimally displaced spinal fractures
- Some pelvic fractures with minimal pelvic canal
compromise and not affecting the weight bearing axis
(especially cats) - Isolated ulnar/fibula fractures
- Metacarpal/metatarsal fractures of one or two bones
- Digit fractures
What is the weight bearing axis of the pelvis?
Acetabulum
Ilium
Sacro-iliac joint
How are open fractures categorised?
Type 1: Wound smaller than 1cm, minimal soft tissue
trauma and crushing - low energy, oblique
fracture
Type 2: Wound larger than 1cm, extensive soft tissue b
damage with crushing - comminuted fracture,
moderate energy
Type 3: Soft tissue injury to muscle, nerves, vessels
A - adequate soft tissue coverage
B - soft tissue/periosteal stripping/bone exposure
C - vascular injury requiring fixture - Not dogs/cats
Management of type 3 fractures requires a combo of wound management and stabilisation of the limb - external fixator
What are the main considerations with spinal patients?
Prognosis and need for referral
Management requirements for the patient under care
- Urine
- Reassessment every 4-6hrs
- Analgesia
Assessment of a spinal patient?
- History
- How have the signs progressed?
- What is the severity
- How many limbs are affected - is that the same as the
beginning? - Painful now or at any point?
- Examination
- Femoral pulses in cases of hindlimb paresis/paralysis -
thormbus? - Hindlimb orthopaedic disease? - severe OA/dysplasia
- Abdominal pain - can be confused with spinal pain
- Femoral pulses in cases of hindlimb paresis/paralysis -
- Neurological examination
- CN
- Localise the lesions: UMN/LMN, which limbs are
affected - Grade severity of the lesion - deep pain,
ambulatory/non-ambulatory
Managing Grade 1 spinal disease?
Pain only
Conservative management
Pain relief and exercise restriction for 2-3 weeks and further 3 weeks of lead exercise only and to continue to avoid stairs/jumping
Risk of progression
Some surgeons advocate for 6 weeks of strict cage rest to allow relatively avascular structures a chance to heal
Managing Grade 2 spinal disease?
Ambulatory paresis
Conservative management with analgesia, exercise restriction or non-urgent assessment for surgical treatment
Monitoring for progression of spinal disease
If hospitalised re-check every 4-6hrs
Managing grade 3 spinal disease?
Non-ambulatory paresis
Surgical intervention is indicated bit not immediately as long as deep pain is intact
If patient remains stable at this grade there should be no need to consider referal at night or weekend - but check with a clinician
Managing grade 4 spinal disease?
Deep pain positive with plegia
Some surgeons recommend immediate surgery to prevent deterioration
contact a referral center
Managing 5a spinal disease?
Deep pain negative <48hrs
Urgent surgery
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