INTRODUCTION TO SURGERY

Clinical surgery : History & Physical Examination in Surgery

Prof. Dr Karim AL-Araji
Learning objectives
To discuss
Principles of surgery
History & physical examination
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What is surgery?
The art or practice of treating injuries, deformities and other disorders by manual operation or instrumental
appliances
Oxford English Dictionary
Or : The branch of medical science that treats disease or injury by operative procedures.
The surgeon is one who makes people better chiefly by the exercise of manual skills in performing invasive
procedures.
The principles of surgery are based on proven techniques that help to optimize the healing environment.
Principles of surgery.
1. Good patient preparation regarding diagnosis & proper evaluation.
2. Surgical asepsis: Surgical asepsis describes the efforts & precautions aimed at preventing microbes from
gaining access into surgically created wounds to decrease infections. Universal precautions are applied
to prevent sepsis and efforts fall under the following headings.
a. Instrument sterilization.
b. Operatory disinfection.
c. Surgical staff preparation.
d. Hand and arm preparation.
e. Clean delicate technique.
f. Sterile technique.
3. Adequate visibility: Adequate visibility is based on adequate access- mouth opening, surgical exposure,
retraction ,adequate light ,surgical field free of excess blood and other fluids.
4. Assistance: Good assistance is essential & the job of the assistant is to show the field of the surgery
5. Surgical Incisions : The following principles apply.
a. a. Incision should be extendable, with good strength & cosmetic.
b. b. Use a sharp blade of proper size.
c. Avoid cutting vital structures.
d. Incise perpendicular to the epithelial surface.
e. Intraoral incisions should be properly placed.
6. Hemostasis( means arrest of bleeding) :No effort should be spared to minimize blood loss. Wound
hemostasis can be obtained by: a. Assisting natural clotting processes by applying pressure on a bleeding
vessel or a hemostat.2.Using of heat- thermal coagulation.3.Suture ligation.4.Pressure on the
wound.5.Vasoconstrictors
7. Tissue handling: Careful handling of the tissues is also necessary for optimal and uncomplicated healing.
Excessive crushing, pulling, extremes of temperature, desiccation and harsh chemicals damage tissues
and these should be avoided. Toothed forceps and skin hooks are preferred to forceps that crush the
wound edges. Avoid excessive pulling forces to retract tissue. Use copious irrigation when drilling or
cutting bone. Protect soft tissue when drilling or cutting.
8. Surgical terminology
-ectomy: excision or removal of .. e.g. : Appendectomy
-lysis: destruction of e.g. :Electrolysis
-orrhaphy: repair or suture of .e.g.: Herniorrhaphy
-oscopy: looking into inside.e.g.: Endoscopy
-ostomy: creation of opening intoe.g.: Colostomy

 -otomy: cutting into or incision of..e.g.: Tracheotomy
-plasty: repair or reconstruction of..e.g.: Pyeloplasty
History and physical examination
Evaluation(work up) of patients : The following steps should be followed in patient's evaluation
1. History taking
2. Physical Examination
After H&PE there will be
3. 'Provisional diagnosis'. This may have similar features with others, this form 'Differential Diagnosis'
4. Investigations: After finishing investigations we may reach to:
5. Final(Definitive) diagnosis. Sometimes , even after all the above-mentioned steps , final diagnosis may
not be established , in this condition we depend on
6. Postmortem . After we reach final diagnosis , we have to put
7. Management plan which may be conservative , surgical or interventional, curative or palliative
,restorative or cosmetic surgery.
Palliative surgery, which makes the patient more comfortable
Cosmetic surgery, which reconstructs the skin and underlying structures
History taking :
The principles of history taking : Listen: What is the problem? (Open questions) , Clarify: What does the
patient expect? (Closed questions), Narrow: Differential diagnosis (Focused questions),Fitness:
Comorbidities (Fixed questions) and includes :
Patients data : Name, Age, Sex or gender ,Marital status, Occupation, Address, Blood group & Rh.
Chief Complaint & Duration : One or more symptoms or concerns causing the patient to seek care ,
Patients own words, Do not use complicated medical terminology ; Pain, Bleeding, Swelling, Esthetic
problems, etc , Regular check up. E.g.; I have Pain in the lower right side I have pain on drinking cold
water
Symptoms are the complaints told by the patient while signs are the features seen by the clinician on
clinical examination.
History of Present Illness: In analyzing any symptom : OPQRST: O:Onset, P: Previous occurrences,
P:Provoking factors, P:P alliative factors (including prescribed and home treatments attempted), Q:Quality
(such as characteristics of (pain), R:Radiation (site of onset and any radiation), S:Severity, and T:Timing
(duration).
Pain is the most common symptom: determine
1. Site (where is the pain is worstask the patient to point to the site with one finger)
2. Radiation (does the pain move anywhere else?)
3. Character (i.e., dull, aching, stabbing, burning)
4. Severity (scored out of 10, with 10 being the worst pain imaginable)
5. Mode and rate of onset (how did it come onover how long?)
6. Duration
7. Frequency
8. Exacerbating factors
9. Relieving factors
10. Associated symptoms (e.g., nausea, dyspepsia, shortness of breath)
System Reviews : Head, Eyes, Ears, Nose, Throat (HEENT), Neck. Lumps, swollen glands, goiter, pain,
or stiffness in the neck., CVS ( Chest pain, difficulty in breathing, palpitation, clubbing finger ) , Respiratory
( Cough, wheeze, difficulty in breathing ) , GIT ( Diarrhea, constipation, difficulty in swallowing, vomiting,
jaundice, bleeding ) , Endocrine system ( Polyurea, thirst, polyphagia, weight loss, hair loss, heat
intolerance) ,Genitourinary system ( Burring on urination, blood with urination ), Hematopoietic system (
Fatigue, brittle nail, eccyhmosis, bruising, gingival enlargment, ) , Central nervous system ( Seizure,
numbness, confused, disoriented)
Past history: Past surgical( operations & anesthesia) , medical( hypertension & DM) , drugs( Allergy,
Steroids) and dental history ( Frequency of visiting dentist ,Past caries / restorative experience ,L.A ,Causes
of loss teeth),

Family history: Hereditary and familial disorders ,Diabetes mellitus, HTN, Hemophilia, Allergy.
Social history: Habit , Smoke, Alcohol ,Teeth brushing , Other parafunctional habit like thumb sucking, nail
biting.
Physical Examination: Inspection, palpation, percussion & auscultation.
General Physical Examination:
How does the patient look? Ill , in pain, vital Signs :Temperature ,Pulse rate ( 60-100 beats per minute ),
Respiratory rate ( 16- 18 per minute ),Blood pressure ( 120/ 80 mm Hg ). (JACCOL): J: JVP, A:
Anemia, C: Cyanosis, Clubbing, O: Oedema, L: Lymphadenopathy.
Local Examination : Focus on problem areas identified by the patients history on all body systems
affected by the surgical procedure.
Head, Eyes, Ears, Nose, Throat (HEENT) , Cranial nerves
1. I : Smell
2. II: Visual acuity, visual fields, and ocular fundi
3. II, III : Pupillary reactions
4. III, IV, VI : Extraocular movements
5. V : Corneal reflexes, facial sensation, and jaw movements
6. VII : Facial movements
7. VIII : Hearing
8. IX, X: Swallowing and rise of the palate, gag reflex
9. V, VII, X, XII : Voice and speech
10. XI : Shoulder and neck movements
11. XII : Tongue symmetry and position
Neck. Inspect and palpate the cervical lymph nodes. Note any masses or unusual pulsations in the neck. Feel
for any deviation of the trachea . Inspect and palpate the thyroid gland.
Chest : Inspect, palpate, and percuss the chest. Listen to the breath sounds.
Cardiovascular System. Observe the jugular venous pulsations, and measure the jugular venous pressure in
relation to the sternal angle. Inspect and palpate the carotid pulsations. Listen for carotid bruits.
Abdomen : Inspect, palpate , percuss & auscultate the abdomen. Palpate lightly, then deeply. Assess the
liver and spleen by percussion and then palpation. Try to feel the kidneys, and palpate the aorta and its
pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles.
Neurological: Conscious level, any pre-existing cognitive impairment or
confusion, deafness, neurological status of limbs
Investigations
1. Full blood count: Hemoglobin : anemia. Total and differential leucocyte count: rises in acute
infections.ESR: rises in chronic infections.
2. Blood glucose and HbA1c: in diabetes.
3. Urea and electrolytes: rises in renal failure.
4. Electrocardiography
5. Thyroid function tests: in case of thyroid pathology.
6. Liver function tests: deranged in liver dysfunction.
7. Clotting screen.: Bleeding time, clotting timefor bleeding disorders
8. Urine examination: Pus cells , RBC, Sugar, Proteins.
9. Stool examination: Parasites , worms.
10. Imaging :
a. Plain X-ray: the best first-line test for bone lesions and fractures bones , fractures.
b. Ultrasound: the best method of distinguishing solid from cystic lesions, is the only method for
locating non-metallic foreign bodies, first test to evaluate any swelling, First-line investigation for
hepatic, biliary and renal disease, it depends on us waves not radiation so can be used during
pregnancy.
c. CT Scan with contrast enhancementfor solid organs, Allows assessment of the abdomen and pelvis,
it utilizes radiation so should not be used during pregnancy like x-rays.
d. MRIfor joints, spine. It does not utilizes radiation so it can be used during pregnancy.

 e. Doppler imagingfor blood flow .
f. PET Scan-for metastases. It depends on isotopes.
11. Endoscopy & Biopsy including FNA.
Examination of a lump( Mass)
Any lump should be examined by inspection, palpation , percussion & auscultation for:
1. Position
2. size
3. Color
4. Shape
5. Surface
6. Edge
7. nature of the surrounding skin,
8. tenderness,
9. consistency,
10. temperature
11. mobility.
12. Regional lymph nodes.
When examining a lump, there are some points to pay particular attention to.
Which layer is the lump in?
1. Does it move with the skin? (epidermal or dermal)
2. Does the skin move over the lump? (subcutaneous)
3. Does it move with muscular contraction? (muscle/tendon)
4. Does it move only in one direction? (tendon or nerve)
5. If the lesion belongs to a nerve, the patient may feel pins and needles in the distribution of the nerve
when the lump is pressed.
6. Is it immobile? (bone)
Additional characteristics to consider
1. Consistency: e.g., stony hard, rubbery, spongy,soft .
2. Fluctuation: Press one side of the lump by displacing finger , waves are felt by watching finger. It
indicates presence of fluid usually pus. Fluid thrill: This can only be elicited if the fluid-filled lesion
is very large. Examine by tapping on one side and feeling the impulse on the other, much as you
would for ascitis.
3. Translucency: Darken the room and press a light to one side of the lumpit will shine from other
side , illuminating the whole lump in the presence of water, serum, fat, or lymph. Solid lumps will
not transilluminate.
4. Resonance: This is only possible to test on large lumps. Percuss as you would any other part of the
body and listen (and feel) if the lump is hollow (gas-filled) or solid.
5. Pulsatility: Can you feel a pulse in the lump? Consider carefully if the pulse is transmitted from an
underlying structure or if the lump itself is pulsating. Use two fingers and place one on either side of
the lump. If the lump is pulsating, it will be expansile and your fingers will move up and outward,
away from each other. If the pulse is transmitted from a structure below, your fingers will move
upward but not outward
6. Compressibility: Attempt to compress the lump until it disappears. If this is possible, release the
pressure and watch for the lump reforming. Compressible lumps may be fluid-filled or vascular
malformations. Note that this is not reducibility.
7. Reducibility: This is a feature of hernias. Attempt to reduce the lump by maneuvering its contents
into another space (e.g., back into the abdominal cavity). Ask the patient to cough and watch for the
lump reforming.
8. Auscultation You should always listen with a stethoscope over any lump; you could gain important
clues regarding its origin and contents. Listen especially for the following: Vascular bruits& Bowel
sounds.
Examining an ulcer

Ulcer is loss of continuity of overlying epithelium. Ulcers should be examined the position, distribution,
color, shape, size, surface, edge, nature of the surrounding skin, tenderness, consistency, and temperature.
Some of the following characteristics particular to ulcers need to be considered.
1. Base : If the base of the ulcer can be seen (i.e.not covered with mucus, blood, or crust), it should be
carefully examined and described. Ulcers usually have either slough or granulation tissue at the base.
Look especially for bone, tendons, and blood vessels.
2. Foor : It may be indurated .
3. Edge: Look carefully at the edgeit may help to make a quick drawing of the edge in cross-section.
Some typical edges are described as follows (also see Fig. 4.4):
a. Sloping: These ulcers are usually shallow and a sloping edge implies that it is healing (e.g., venous
ulcers).
b. Punched out: This is full-thickness skin loss and typical of neuropathic ulceration and vasculitic
lesions.
c. Undermined: These extend below the visible edge, creating a lip. This is typical in TB.
d. Rolled: Here the edge is mounded but neither everted or undermined and implies proliferation of the
tissues at the edge of the ulcer. Basal cell carcinoma typically has a rolled edge.
e. Everted: The tissues at the edge of the ulcer are proliferating too fast, creating an everted lip. This is
typical of neoplastic ulceration.

Types of edges of ulcer

4. Depth ( Floor) :Determine what layer (of skin or underlying tissues) the ulcer extends to. If possible,
estimate the depth in mm.
5. Discharge :Any discharge (e.g., serous fluid, pus, blood) from the ulcer should be examined and noted.
If there is an overlying scab or crust (dried discharge or scale), this should be carefully removed in
order to examine the base of the ulcer.
6. Regional lymph nodes: If enlarged , either secondary infection or neoplastic.

 SURGICAL WOUND AND INFECTIONS
Prof. Dr Karim AL-Araji
Learning objectives
To discuss To understand
Types of wounds Types of surgical infections
Management of wounds Pathology of infection
Complications of wounds Principles of sterilization and antisepsis
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A wound is defined as disruption of the normal continuity of bodily structures due to trauma, which
may be penetrating or non-penetrating ( blunt ).
8. Types : Wounds can be classified into:
A. Acute wounds including surgical wound
B. 11.Chronic : Bed sores , Chronic venous ulcer , chronic arterial ulcer.
Acute wounds : For practical purpose , They can be divided into two main types
1. Tidy ( Incised )wounds: These are most commonly encountered by surgeons , superficial or deep
acute traumatic or surgical wounds that is suitable for primary closure by direct approximation of the
wound edges, produced by a sharp objects such as knive or glass. They are characterized by sharp
regular edges, clean , healthy tissues , seldom there is tissue loss. They can be sutured primarily & heal
by primary intention.

Tidy wound
2. Untidy ( Lacerated ) wounds: These are produced by blunt objects , characterized by crushed or
avulsed , irregular edges, contaminated ,devitalized tissues ,often there is tissue loss , associated with
tearing of tissues .They cannot be sutured primarily & usually heal by secondary intention or delayed
primary suturing

Untidy wound
Specific types of acute wound : These can be classified according to the mechanism of injury into
1. 1.Abrasions:These are superficial wounds caused by scraping tangential application of blunt force
producing friction damage . They involve only the epidermis and a portion of the dermis and frequently

Abrasions
heal secondarily within 1 to 2 weeks. Dirt and foreign bodies are frequently embedded in the tissues and can
give rise to traumatic tattooing.
2. Puncture wounds: They are produced by sharp penetrating objects, they should be explored . e.g.:
Needle-stick may spread infection in hepatitis & AIDS. There is risk to deeper organs as well as
infection due to contamination along the track of the wound. X ray is needed to exclude retained
foreign body. When the wound pierces a body cavity, it is called penetrating; if it passes through a
viscous, it is perforating.

 3. Degloving :by shearing forces when the skin and subcutaneous fat are stripped from its underlying
fascia, such as ring avulsion with loss of skin delving wound

4. Hematoma : Collection of blood in tissues , if it is large , painful or causing pressure effect may
require release , aspiration or drainage if untreated it may get infected or calcify .
5. Crush injuries: These are due to severe pressure if a limb get compressed . Even though the skin may
not be breached, there can be massive tissue destruction leading to release of myoglobulin into
circulation which may be complicated by renal failure.
6. Compartment syndrome: This occur after closed fracture of long limbs e.g.; leg . There is tissue
injuries with compartments with increasing pressure within fascial compartments , can cause increase
in compartment pressure with ischemic necrosis of muscle and other structures .They are
characterized by severe pain, pain on passive movement of the affected compartment muscles, distal
sensory disturbance and, finally, absence of distal pulses which is a late sign. They can occur in an
open injury if the wound does not extend into the affected compartment. Compartment pressures can be
measured. It is treated by fasciotomy. Treatment is by fasciotomy. Compartment syndrome can also
occur as a complication of burn due to compression by escar
7. Gunshot wounds: These may be low-velocity (e.g. shotguns) or high-velocity (e.g. military rifles).

High-velocity missiles cause Gunshot wound massive

tissue destruction beyond the tract bullet due to shock wave and infection due to cavitation & negative
pressure that suck dirt , FB & clothes inside the wound which contaminate wounds and cause infection.
8. Bites : Most bites involve either puncture wounds or avulsions by animals or human. Ear, tip of nose
and lower lip injuries are most usually seen in victims of human bites. A boxing-type bite(fighting
injury) of the metacarpophalangeal joint . Anaerobic and aerobic organism prophylaxis is required in
addition to cleansing. Dog bites should not be sutured except wounds of face.
9. High-pressure injection injuries: The use of high-pressure devices in cleaning, degreasing and
painting can cause extensive closed injuries through small entry wounds. The liquid injected spreads
along fascial planes. Treatment is surgical with wide exposure, removal of the toxic substance and
thorough debridement.
10. Burns : These are caused not only by heat but also by electricity, chemicals.
Management of acute wound in general
1. When treating traumatic wounds, remember to obtain a thorough history & perform a proper physical
examination to exclude more serious injuries which need priority in management such as head , chest,
abdominal injuries etc . Obtain radiographs to assess fractures and foreign bodies before treating
wound and after patient becomes stable.
2. General management & resuscitation of patient according to Advanced Trauma Life Support(ATLS);
ABCDE( A: Airways ,B : Breathing ,C: Circulation, D:Disability , E: Exposure).
3. Antiseptic such as povidine-iodine or chlorhexine for skin surrounding skin the wound in circular
manner , not in the wound due to toxicity. Chlorhexidine is toxic to the cornea and should be avoided
around the eyes or face.

4. Haemostasis: Arrest of bleeding by pressure by pack for 15 minutes. Tourniquets can be helpful for
fingertip injuries and some extensor tendons by a drain held by hemostat but it is dangerous in limb&
only used in operating theatre.
5. Local anesthesia by 1% Lidocaine w or w/o adrenaline infiltration at edges of the wound.
6. Wound irrigations with normal saline using syringe with jet to remove FB, dead tissue.
7. Wound exploration under good lighting , to determine depth , configuration , deep structures likely to
be injured
8. Suturing (Approximation) or not : This depends on type of wound & its duration . Closure should be
done if the wound is tidy & within 6 to 8 hours of the injury, though simple non-contaminated wounds
of the face can be safely closed as long as 24 hours after the injury due to good blood supply. Use
anatomic landmarks such as hair or artificial landmarks to guide closure such as Tattoos, scars. Several
methods of skin closure are available such Tapes , Glues ,Staples but sutures are mostly used. The
finest sutures that will hold the wound edges together should be used , 5/0 or 6/0 sutures are
appropriate for the face, (3/0 or 4/0) are needed for incisions near joints and still stronger ones for the
abdominal wall. The aim of suture is to hold wound until tensile strength has recovered sufficiently to
prevent breakdown. Human and animal bites should not be sutured except that of the face which may
often be loosely closed primarily if seen in a timely manner, and appropriately irrigated and debrided
9. Management of untidy wounds : Untidy , infected wounds are managed by frequent debridement(
Wound excision) & daily change of dressing). Debridement means that devitalized tissue such as skin,
muscles are excised until bleeding is encountered & muscle is contracting ,free unattached pieces of
bone are excised, repair of blood vessels , repairing, marking & approximation of nerves and the
wound is left open or just approximated to be closed 3-5 days after becoming clean by delayed primary
(Tertiary) suture or by skin grafting or to heal by secondary suture. Primary closure is avoided in
untidy , delayed > 6 hrs. , contaminated wounds due to increased risk of wound infection ,tetanus and
gas gangrene .

Wound debridement
10. Dressing : The wound is covered by the traditional dressing or the newly introduced vacuum-
assisted closure dressing which has simplified the closure of large traumatic wounds.
11. Tetanus prophylaxis for tetanus-prone wounds( i.e. old than 6 hours, deep 1 cm, devitalized, and
contaminated, especially those involving rusty metal, feces, or soil). Patient with previous full
immunization , booster dose of tetanus toxoid is given , patient without previous immunization,
passive immunization with human antitetanus immunoglobulin and full course of active immunization
should be given using different needles, syringes, and sites of injection.
12. Rabies vaccine: This is given for dog bite if the doge is rabid or unknown or had been killed.
13. Antibiotics: In acute traumatic wounds, prophylactic antibiotics are not routinely essential but only
required for deeply penetrating wounds, dog and human bites , wounds caused by nails and if there has
been a delay in the treatment .
14. Postoperative care : Closed wounds should be kept clean and dry for 24 to 48 hours after repair.
Epithelialization begins within hours after wound approximation and forms a barrier to contamination.
In the first 6 weeks after repair, the wound's tensile strength increases rapidly; after this period, tensile
strength increases more slowly, eventually reaching a maximum of 75% to 80% of normal skin
strength . Wounds at risk for infection should be assessed by a medical provider within 48 hours of
care.

 15. Removal of stiches: This depends on site of wound .Generally ,sutures in the face& neck should be
removed by day 5 to prevent train tracks, Scalp 7 days , Abdomen and chest 710 days, Limbs 7
days , Feet 1014 days.
Chronic wounds :
1. Leg ulcer: The causes of leg ulcer include Venous disease leading to local venous hypertension (e.g.
varicose veins), Arterial disease, either large vessel (atherosclerosis) or small vessel (diabetes),
Arteritis associated with autoimmune disease (rheumatoid arthritis, lupus, etc.), Trauma could be
self-inflicted , Chronic infection tuberculosis/syphilis& Neoplastic squamous or basal cell
carcinoma, sarcoma
2. Pressure sores (bed sores, trophic , pressure ulcers, and decubitus ulcers ): These can be defined as
tissue necrosis with ulceration due to prolonged pressure. There is a higher incidence in paraplegic
patients, in the elderly and in the severely ill patient. The most common sites are ischium , greater
trochanter, sacrum , heel , malleolus (lateral then medial) ,occiput .They are preventable by good skin
care, special pressure cushions or foams & frequent turning of the patient every 2 hrs. Treatment
includes adequate debridement, and the use of vacuum-assisted closure (VAC) may help to provide a
suitable wound for surgical closure .
Vacuum-assisted closure dressings: This is a recent method of dressing to assist in closure of large
traumatic and chronic wounds. The wound must be clean, a foam dressing is cut to size to fit the wound. A
perforated wound drain is placed over the foam, and the wound is sealed with a transparent adhesive film. A
vacuum is then applied to the drain at negative pressure of approximately 125 mmHg. It may act by
decreasing edema, removing interstitial fluid and increasing blood flow. It encourages debridement and the
formation of granulation tissue in chronic wounds and ulcers so it hastens wound healing .
16.
General notes
Suture materials: The purpose of suture material is to hold tissue until retaining enough tensile strength.
Types: For practical point of view they are divided into:
1. Fast absorbing sutures: Plain & chromic cat gut. They are absorbed & lose tensile strength in less than
7 days. Chromic take 3 weeks, used for suturing of mucosa.
2. Intermediate absorbable sutures: Vicryl (polyglycolic acid) or other braided absorbable are useful for
closing muscle and dermis. Lose tensile strength in 2 weeks.
3. Permanent sutures such as nylon are useful for skin closure because they are nonreactive and do not
promote scarring. Use 50 in the hand and 60 or finer in the face.
The suture material may be monofilament (propylene) or polyfilament (silk). The advantage of
monofilament suture is that it does not allow the bacterial lodgment and thus can be used in presence of
infection
The size or diameter of suture
We consider 0 size as a baseline. As size decreased below 0, the numbers are added with zero, e.g., 5-0
or 00000 suture is smaller in diameter than 4-0 or 0000 suture. As suture diameter increases above 0,
numbers are assigned to the suture size, e.g. 1, 2, 3, 4, are increasing diameters of the suture. Its fibers are
either monofilament or multifilament.
Methods(Technique ) of suturing
Several different skin suturing methods may be used, depending on the nature of the wound. Simple
interrupted sutures ( one entry) are useful for irregular wounds. Vertical mattress sutures( multiple entries)
are good for either thick (e.g., scalp) or thin (e.g., eyelid) skin. A simple continuous suture should be used
only for linear wounds. Simple suturing or mattress can be used in the following ways
1. Continuous suturing: It is used for closure of long wounds (e.g. rectus sheath closure in
laparotomy). Disadvantage , if wound gets infected the whole suture need to be removed.

Continuous suturing

 2. Interrupted suturing: It is used for closure of skin wounds.

. Interrupted suturing
3. Subcuticular suturing: It is used in for cosmetic e.g. face

4. Subcuticular suturing
Needles Needle
Parts of needle are :Tip, body and eye .
The eye is the weakest part of the needle. Hence, needle should never be held near its eye
Types of needle: Needle may be straight or curved , round needle( atraumatic) which has a rounded tip that
separates the tissue fibers rather than cutting them. It is used in suturing of soft tissues (vessels, intestines,
mucosa of oral cavity ). It is marked on its packet as round or cutting needle( traumatic ) which has two
opposing cutting edges on outside and third edge on inside curve of the needle. Thus, its point looks
triangular in cross-section. It is used for suturing tough tissues (skin, fascia).It is marked by triangle. Other
types: reverse cutting or taper cut needle.
Dressing
It is a piece of material placed directly over the wound or ulcer to provide cover, comfort and support so as
to encourage healing and to prevent infection from outside.
Parts of a dressing
1. Inner contact layer :It is made of sterile mesh gauze placed directly over the wound. It is non-absorbent
and allows secretions to pass through its grid. e.g. sofra-tulle to prevent pain and trauma during removal
of the dressing.
2. Intermediate layer: It is made of fluffy cotton gauze sponges so that wound secretions are absorbed in
this layer and do not reach up to the outermost layer. In case there is soaking of outer layer, it leads to
bacterial migration into the wound from outside through capillary action apart from soiling of the
clothes.
3. Outer layer : It is the bandage or plaster that help in supporting inner two layers and keeping them in
persistent contact with the wound.
Basis of selection surgical incision: Ideally, when incision is done for operation, it should fulfill the
following characteristics
1. Access :The skin incision should be planned in a way that it gives good view of the structures to be
operated upon
2. Cosmetic :The skin incision should be done in natural skin crease (Lines of Langer) i.e.; skin incisions
are placed in the line of least tissue tension so that final scar is less visible and gives good cosmetic
result
3. The skin incision should avoid damage to important underlying structures like nerves and vessels. So
incision should be parallel and not across the long axis of these structures.
4. Strength : It gives a good strength of surgical incision to prevent hernia.
5. Extendable :The skin incision should be put in a way that can be extended in case of need.
Types of surgical wounds according to incidence of wound infection
Type of surgery Infection rate (%)
1. 1.Clean (no viscous opened) e.g. thyroid surgery 12
2. Clean-contaminated (viscous opened, minimal spillage) <10
3. Contaminated (open viscous with spillage or inflammatory disease) egg; perforated appendix 1520
4. Dirty (pus or perforation, or incision through an abscess) egg; perforated large bowel) <40

 WOUNDS OF THE FACE AS AN EXAMPLE
Types : They are brought by blunt or penetrating trauma such road traffic , home accidents etc
Management : It includes the following in addition to same principles of wound management in general.
1. Maintaining an airway& stabilization of cervical spines constitute the primary consideration in facial
trauma. Airway may be compromised by displacement of facial bones, expanding edema or hematoma,
loose detention and debris, FB or laryngeal injuries. So oropharyngeal airway , endotracheal intubation
or cricothyrotomy may be needed.
2. Hemostasis: Hemorrhage may be profuse (arterial & venous) & can be controlled by firm pack
pressure , from scalp laceration (controlled by single layer suture ) or from nose ( controlled by anterior
and posterior nasal pack or Foley's catheter ) or embolization or ligation due to facial artery bleeding.
Definitive ligation or cautery of a single bleeding point is sometimes necessary. Blind clamping and
suture ligation in deep wounds should be avoided in areas where the facial nerve or parotid duct may
be injured. Reduction and fixation of bony injuries are often not effective at controlling significant
bleeding .Ligation of external carotid artery(ECA) is unreliable because of the rich collateral vascular
supply to head and face.
3. Injuries of deep structures such as facial n., parotid duct should be excluded.
4. Suturing of wound: Facial injuries should be closed whenever possible even delayed >6hrs, clean the
wound with normal saline jet irrigation and look carefully for clues to re-approximate (skin creases,
anatomic landmarks). For the cheek; start from mucosa by absorbable suture size 60 & then the outer
skin. Lip: use vermilion as land mark , eye lid edge, hairs of eye brows. Dirty wounds and dog bites
should be thoroughly cleansed and loosely closed with fine sutures.
5. Bony skeleton fractures : Fractures of mandible , maxilla are identified ; deformity , malocclusion;
may need stabilization.
6. Vision abnormality such as diplopia may indicate orbital fracture.
INFECTIONS
Infection is defined as the presence or invasion of microorganisms in host tissue or the bloodstream
following breakdown of local and systemic host defenses .
Classification of infection in general
Depending on infectious causative agents
1. Bacterial (a) Gram-positive organisms (e.g., Staphylococcal sp) (b) Gram-negative organisms (e.g.,
enteric organisms, Pseudomonas).
2. Fungal which is often related to nosocomial, opportunistic infections in immunocompromised hosts
3. Viral which is seen in immunocompromised patients, mostly recipients of solid organ allografts.
Depending on sources of infection: It may a cross - infection from elsewhere on the patient s body or
from other infected cases in the ward during dressing changes or wound inspection or new infection from
health care providers. It has the following types:
1. Primary or endogenous (Auto infection) : Infections present in the host(patient) acquired from an
endogenous source (such as an superficial surgical site infection following contamination of the wound
from a perforated appendix)
2. Secondary (exogenous), Hospital acquired infection , health care-associated infection (HAI) ,
Nosocomial infection(Cross infection) : Infections acquired from a source outside patient's body in
the hospital, may be in the operating theatre (inadequate air filtration, poor antisepsis) or the ward (e.g.
poor hand washing ) usually after 48 hrs of admission. There are four main groups:
a. Respiratory infections including ventilator-associated pneumonia.
b. Urinary tract infections mostly related to urinary catheters.
c. Catheter- related infections with bacteraemia mostly related to indwelling vascular catheters.
d. Surgical site infections(SSIs): Wound & deep space/organ.
Inflammation : It is the local response of living tissues to cell injury due to any agent as a body defense
mechanisms to limit or eliminate the agent causing injury.
Types of cell injuries:
1. Physical agents :Heat, cold, radiation, trauma.
2. Chemical agents :Organic and inorganic poisons.

 3. Infective agents: Bacteria, virus, parasites, fungi.
4. Immunological agent
Cardinal signs of inflammation :Classical cardinal signs of inflammation are: Redness (Rubor) ,Heat
(Calor),Swelling (Tumor),Pain (Dolor)&Loss of function (Functio laesa). Inflammation is indicated by
adding the suffix itis to the Latin name of the organ or tissue involved, e.g. Glossitis: Inflammation of
tongue, Gingivitis: Inflammation of gum, Osteomyelitis: Inflammation of bone
Inflammatory cells
1. Neutrophils : (N:40-75%), increases during acute bacterial infections (Neutrophilia).
2. Eosinophils :(N: 6% ), Increased (eosinophilia) in Allergic conditions , Skin diseases , Parasitic
infections
3. Basophils(N: 1% ) have a Role in immediate and delayed type of hypersensitivity.
4. Lymphocytes ( N:20-40% ) , B-lymphocytes help in antibody formation , T-lymphocytes play role in
cell mediated immunity, increases in chronic infection like tuberculosis (Lymphocytosis).
5. Plasma Cells : Normally not seen in peripheral blood, develop from lymphocytes
6. Macrophages : derived from reticulo-endothelial system. Their functions are: Phagocytosis
7. Giant Cells :When macrophages fail to remove foreign particles, they fuse together to form
multinucleated giant cells, e.g.
a. Foreign Body Giant Cells , seen chronic infections.
b. Langhans Giant Cells :The nuclei are arranged at periphery to form a horseshoe appearance ,seen
in tuberculosis, sarcoidosis.
c. Reed-Sternberg Cells Mirror image nuclei, seen in Hodgkins lymphoma.
Pathophysiology of infection(Host versus parasite relationship)
Normally there is a balance relationship between host defense and parasite virulence. If this relationship is
impaired , either host resistance is depressed or virulence increases , infection will get established
Mechanisms of host defense
1. Physical : Skin & mucous membrane
2. Chemical: Low gastric PH
3. Humeral: Antibodies, complement and opsonins
4. Cellular: Phagocytic cells, macrophages, polymorphonuclear cells and killer lymphocytes.
Causes of reduced host resistance to infection: Generalized systemic & local factors
1. Metabolic: Malnutrition (including obesity), diabetes, uremia, jaundice
2. Disseminated disease with immunosupression: Cancer and acquired immunodeficiency syndrome
(AIDS)
3. Iatrogenic: Radiotherapy, chemotherapy, steroids
4. Local tissue factors such as devitalized tissue, excessive dead space or hematoma( all are the results of
poor surgical technique), fat, FB, sutures, cautery etc
Parasite(Bacterial) factors :
Pathogenicity of the organisms depends on virulence and size of the bacterial inoculums; some bacteria are
strongly pathogenic , others are less pathogenic . Bacteria may be pathogenic by itself or opportunistic i.e.;
In circumstances of reduced host resistance to infection or disturbance of normal flora, microorganisms that
are not pathogenic; may become pathogenic e.g.; Fungal infection(candidacies) in patient with prolonged
antibiotics , Psudomembranous colitis.
1. Dose , inoculums :Number usually 100 000 organisms per milliliter of exudates, gram of tissue or
square millimeter of infected surface area.
2. Virulence :Bacteria cause some of their ill effects by releasing various compounds such as:
a. Enzymes (e.g. haemolysins, streptokinase, hyaluronidase)
b. Exotoxins :They are proteins released from intact bacterial cell wall of (mostly) gram-positive
bacteria such as clostridia ( tetanus , gas gangrene, diphtheria) . They spread via the bloodstream or
in some infection (e.g. tetanus) via nerves to produce their effects. Exotoxins can be attenuated with
formaldehyde to produce attenuated non-pathogenic toxin called toxoid that is used as a vaccine.
c. Endotoxins : They are composed of lipopolysaccharide (LPS) in the bacterial cell wall of gram-
negative bacteria and liberated only on the death of the bacterium. Endotoxins(LPS) stimulates

 macrophages and endothelial cells to release cytokines, which mediate the inflammatory response
such as fever& rigors, tachycardia and leucocytosis and play an important role in the pathogenesis
of septic shock.
Release of endotoxin Macrophage Cytokine release (IL-6, TNF, etc.) SIRS &
MODS
Systemic(Generalized) features of infection
Systemic inflammatory response syndrome (SIRS) is a systemic immune system response &
manifestations of sepsis, the syndrome may also be caused by multiple trauma, burns or pancreatitis without
infection.Its pathogenesis is due to the release of lipopolysaccharide endotoxin from the walls of dying
gram-negative bacilli (mainly Escherichia coli) or other bacteria or fungi. This and other toxins stimulate the
release of proinflammatory cytokines such as interleukin-1 (IL-1) and tumor necrosis factor alpha (TNF)
which induce fever, tachycardia, tachypnea & leukocytosis. These also stimulate neutrophils which are
involved in killing of the invading bacteria but may also damage adjacent cells. This response is usually
beneficial to the host and is an important aspect of normal tissue repair and wound healing but it may
become harmful to the host if it occurs in excess when it is known as SIRS. The activated neutrophils in turn
will lead to cellular damage within the organs, which become dysfunctional and give rise to the clinical
picture of multiple organ dysfunction syndrome(MODS). In its most severe form, MODS may progress into
multiple system organ failure (MSOF) such as respiratory, cardiac, intestinal, renal and liver failure in
combination with circulatory failure and septic shock.
Notes : Definitions of systemic inflammatory response syndrome (SIRS) and sepsis.
SIRS: It is diagnosed by two of:
Hyperthermia (>38C) or hypothermia (<36C)
Tachycardia (>90/min, no B-blockers) or tachypnoea (>20/min)
White cell count >12 109/l or <4 109/l
Sepsis : SIRS with an identified infection
Severe sepsis: Sepsis with associated end-organ dysfunction such as respiratory ,CVS, Blood
coagulation.
Septic shock: Sepsis with arterial hypotension despite adequate fluid resuscitation.
Bacteraemia: It is the presence of bacteria in the blood stream without toxin or clinical manifestations . It is
usually transient and may follow dental procedures , instrumentation in infected bile or urine). It can be
dangerous when patient has prosthetic implant since the implant can get infected. Hence, a surgical or dental
procedure should be done under cover of antibiotics
Septicemia : It is the presence of bacteria as well as their toxins circulating in the blood. It has systemic
manifestation in form of fever, rigors, chills, tachycardia and hypotension. It is caused by streptococci,
staphylococci and gram negative bacilli such as tooth extraction in abscess.
Toxemia: Toxins are circulating in the blood without presence of bacteria such as clostridia of gas
gangrene.
Pyemia: It is septicemia in which bacteria and their toxins are carried in the blood stream and subsequently
they produce multiple focal abscesses in different parts of the body
SURGICAL INFECTION
An infection that typically requires operative treatment or results from operative interference: So it is of two
types:
1. Infections need surgical treatment (Non-operative associated infections)
2. Infections resulting from surgical procedure(Postoperative infections):
Infections need surgical treatment (Non-operative associated infections)
A. Localized acute infections include
1. Cellulitis: It is non-suppurative inflammation of subcutaneous tissues .There may be minor trauma.
Strepococcus and staphylococcus infections are most common causative organisms. Gram-negative
rods may be present, especially in patients with diabetes.
CF : It presents with redness and blisters , swelling, pain, often patient has fever and chills. Failure to
improve after 72 hours of antibiotics suggests abscess formation or necrotizing process, requiring
incision and drainage. It is usually associated with lymphangitis & lymphadenitis.

 Treatment: Antibiotics , Elevation
Examples :Neck cellulitis (Ludwig angina) &orbital cellulitis.
Neck cellulitis(Ludwig angina) : Cellulitis of submandibular region with extension to floor of mouth
and the tongue is elevated and pushed backward or may be accompanied by laryngeal edema that may
lead to respiratory obstruction and suffocation. It may be precipitated by 4 C( Carious teeth, Cancers,
Chronic sialadenitis (involving submandibular gland),Chemotherapy).
CF :Patient has general features of infection such as fever , tachycardia , putrid halitosis (foul
smelling breath). etc with brawny swelling of the submandibular region & edema of floor of the
mouth accompanied with difficulty in respiration.
Treatment: It is treated by heavy antibiotics , surgical drainage under LA or GA by incision under
mandible & patient may need tracheastomy.
2. Lymphangitis :It is inflammation of lymphatic channels manifested by erythematous streaks
extending to regional LN .It often accompanies cellulitis and is associated with strep infection.
Appropriate antibiotic is often sufficient.
3. Lymphadenitis: It is inflammation of regional lymph nodes. The lymph nodes are enlarged and
tender. Treatment : Antibiotic and if abscess forms, it needs incision & drainage.
4. Erysipelas(Red Skin):It is an acute spreading streptococcal cellulitis of skin & subcutaneous tissue
and lymphangitis. Milians ear sign helps in distinguishing erysebalas from cellulitis where erysebalas
involves pinna of the ear. It responds well to antibiotics
5. Furuncle or 'boil': It is an abscess in a sweat gland or hair follicle. Treatment by drainage. A boil on
the face especially the dangerous area ( Lower part of nose & upper lips ) may spread intracranially
along the facial veins leading to cavernous sinus thrombosis with exophthalmous.
6. Carbuncle: It is a multilocular suppurative extension of a furuncle into adjacent subcutaneous tissue;
mostly seen in diabetic , usually caused by staph infection. Common site is nape of neck. Treatment
by antibiotics and drainage.DM should be controlled.
7. Impetigo: It is intraepithelial abscesses, usually caused by staph or strep
8. Abscess: It is a localized collection of pus which consists of neutrophils, dead tissue and organisms
surrounded by a dense, fibrous tissue called pyogenic membrane. The commonest pathogen is
Staphylococcus aurous.
CF : An abscess commences as a hard, indurated ,fluctuant, red, tender swelling associated with
features of bacterial infection, namely a swinging fever, malaise, anorexia and sweating with a
polymorph leucocytosis. If not drained, it may discharge spontaneously onto the surface forming a
sinus or into an adjacent viscous or body cavity.
Treatment :An abscess is treated by incision & drainage. Antimicrobial agents cannot diffuse in a
sufficient quantity to sterilize an abscess completely , if used abscess will change to sterile pus
surrounded by thick fibrous tissue as a hard lump called antibioma .The principle of drainage is to
open abscess by scalpel , breakdown all loculi & allow dependant drainage by gauze wick or drain.
Deep seated abscesses can be drained under US or CT guidance. Hilton method of drainage of
abscess; in order to avoid important deep structures, it is done by incising skin and subcutaneous
tissue (only) & enlarging the incision by using a sinus forceps which is opened with the direction of
deep structures such as drainage of parotid abscess to avoid facial nerve.
9. Necrotizing fasciitis , Synergistic spreading gangrene (subdermal gangrene) : It is a spectrum of
life-threatening necrotizing infections of soft tissues mainly the fascia, more common in diabetic
patient, characterized by necrosis of fascia, erythematous skin, edema at the margins, crepitus, and
possible hemodynamic instability because of sepsis. This usually occurs in immunocompromized
patients such as diabetic . The causal organisms are usually polymicrobial such as anaerobic strep,
staph, and bactericides, may be by single organism & not caused by clostridia may be precipitated by
a trivial skin trauma such as abrasions and ischemia.
Diagnosis depends on presence of serosanguineous exudates, necrotic fascia, and confirmed by gram
stain and culture & sensitivity. It includes: (1) Meleny's synergistic gangrene : It is necrotizing
fasciitis of abdominal wall. (2) Fourniers gangrene: It is necrotizing fasciitis of the perineum &
scrotum.

Treatment: Broad-spectrum antibiotics mainly against anaerobic bacteria. Broad-spectrum antibiotic
therapy must be combined with aggressive circulatory support. Locally, there should be wide excision of
necrotic tissue and laying open of affected areas. The debridement may need to be extensive, and patients
who survive may need large areas of skin grafting.
10. MRSA (multiply resistant coagulase-negative staphylococci): These bacteria are resistant to
flucloxacillin & methicilin antibiotic in addition to already possessing a beta - lactamase that confers
resistance to penicillin , now, other antibiotics, including cephalosporins and gentamicin . They are
sensitive to vancomycin. They form problems in relation to surgical infections.
11. Cancrum oris : It is severe ulcerative form of stomatitis involves alveolar margin of the gum ,
underlying bone , check & lips which will lead to hole in cheek &lip , affecting malnourished
children and spreads rapidly. Commonest predisposing cause is measles, but it may follow other acute
illness as well (typhoid, gastroenteritis).Causative organism is Borrelia vincentii that starts as
Vincents stomatitis. It is treated by antibiotics& general supportive measures.
12. Gas gangrene :Soft tissue infection occurs in deep penetrating military , traumatic and after
colorectal operations, caused by C. perfringens which is Gram-positive, anaerobic, spore-bearing
bacilli found in soil and faeces , produces powerful exotoxins. The toxins have various activities,
including phospholipase, collagenase, proteinase and hyaluronidase, which facilitate aggressive local
spread of infection along tissue planes, with liberation of gases.
CF: The incubation period is about 24 hours. Severe sudden onset of pain & severe toxemia with
fever, tachycardia, shock .The affected tissues are swollen, muscle gangrene and crepitus due to gas
with a thin, brown, sweet-smelling exudate .
Diagnosis : Isolation of the organism by gram stain & culture of the exudates.
Treatment : Antibiotics by large doses of intravenous penicillin, hyperbaric oxygen and aggressive
debridement and amputation.
13. Tetanus: Infection caused by Clostridium tetani , an anaerobic, exotoxin- secreting, gram- positive
bacillus , spore-formation of a terminal spore ( drumstick ),which is a normal inhabitant of soil and
faeces. It follows wound (which may have been trivial or unrecognized and forgotten by patient) but
more common in traumatic civilian or military wounds.
CF: The average incubation period is 7-10 days. The first symptom is trismus (lock jaw). It is
followed by reflex spasm of the muscles. Risus sardonicus is painful smiling appearance due to spasm
of facial muscles. Tonic contraction of all the body muscles (opisthotonus).
Diagnosis : Isolation of the organism by gram stain & culture of the wound.
Treatment: Injection human anti-tetanus globulin (250- 500 units I/M) , care of respiration.
B. Chronic specific infections
1. Tuberculosis: The infection is caused by acid fast bacillus- Mycobacterium tuberculosis.
Modes of Spread :Droplet Infection :Coughing , airborne infection , By Ingestion in case of bovine
tuberculosis, infected milk of a tuberculous cow. After inhalation the organisms spread, then become
dormant but remain viable. They are reactivated when systemic host defenses (especially cell-mediated
immunity dysfunction (e.g. advanced age, malnutrition, AIDS, lymphoma).
Types: Pulmonary & Extra-pulmonary TB( TB Lymphadenitis, Intestinal TB, Bone, spines (Pot's
disease),Skin(Lupus vulgaris), TB meningitis& encephalitis,
Tuberculous lymphadenitis(Scrofula): Both bovine and human tuberculosis may be responsible. In
most cases, the tubercular bacilli gain entrance through the tonsil of the corresponding side as the
lymphadenopathy. The condition most commonly affects children or young adults, but can occur at
any age. The deep upper cervical nodes are most commonly affected, but there may be a widespread
cervical lymphadenitis with many matting together. If treatment is not instituted, the caseated node
may liquefy and break down with the formation of a cold abscess in the neck. The pus is initially
confined by the deep cervical fascia, but after weeks or months, this may become eroded at one point
and the pus flows through the small opening into the space beneath the superficial fascia. The process
has now reached the well-known stage of a collar-stud abscess due to its shape. The superficial
abscess enlarges steadily and, unless suitably treated, a chronic discharging sinus results.

 Formation of TB collar-stud abscess
Investigations: Fine-needle aspirate taken from enlarged neck nodes for acid-fast bacilli with Ziehl-
Neelsen stain shows tuberculosis in >90% cases.. Chest x-ray. Lymph node biopsy shows caseating
granulomas with Langerhan's giant cells (Horseshoe nucleolus ) , the aspirated pus may be tested for
PCR (polymerase chain reaction) to pick DNA strands of tubercular bacilli .Pus culture and
sensitivitygrowth of bacteria takes six weeks ,By Bactac method positive culture can be obtained
in two weeks time.
Treatment : Anti-tuberculous drugs and surgery to drain pus & to excise lymph nodes.
3. Leprosy (Hansens disease): It is a chronic infection caused by the acid fast bacilli Mycobacterium
leprae..
Clinical types: Lepromatous , tuberculoid leprosy.
4. Syphilis :It is a sexually transmitted infection caused by Treponema pallidum, a spirochaete.
The disease is divided into 4 stages:
Primary Syphilis : The lesion is Hunterian chancre.
Secondary Syphilis: It is characterized by condyloma lata.
Latent Syphilis : There are no clinical signs only serology is positive.
Tertiary Syphilis : The typical lesion in this stage is gumma.
Diagnosis: VDRL
Treatment :IM injection procaine penicillin or tetracycline.
5. Fungal infection ; Actinomycosis: Fungal disease caused by actinomycosis Israelii. It is present in
normal oral flora and invades the tissues in presence of carious teeth or following trauma. It has four
clinical types : Facio-cervical, Thoracic , Right Iliac Fossa, Cervicofacial , abdominal. It forms sinus
with secretion contains sulfur granules which represent clumps of fungi.
6. Viral diseases ; Hepatitis, AIDS :The relationship of these diseases to dentist , these patients have
more risks for certain diseases especially malignancy and case health care providers gets prick during
work on infected patients. If a dentist get prick during work on patient with hepatitis, blood should be
allowed to flow under water , squeezing may be helpful , testing for HBsAg & antibodies , if immune
no need for vaccination , if not immune , hepatitis immunoglobulin and IM vaccine should be given in
deltoid region.
Infections resulting from surgical procedure(Postoperative infections):
1. Surgical Site Infection(SSIs) can be classified into two categories: Incisional (Wound) infection
which includes superficial incisional SSIs ) , (involving only skin and subcutaneous tissue), deep
incisional SSIs (involving deep soft tissue), and organ/space SSIs (involving anatomic areas other than
the incision itself) that are opened or manipulated in the course of the procedure
A. Surgical (Incisional) wound infection: It is defined as collection of pus in the wound that is
discharging spontaneously or requires surgical drainage. It is either superficial or deep wound
infections. Staph. Aurous is the most common causative m.o .Its incidence varies according
likelihood of wound contamination as clean', 'clean-contaminated and contaminated 'or dirty . A
major SSI is defined as a wound that either discharges significant quantities of pus spontaneously or
needs a secondary procedure to drain it . The patient may have systemic signs, such as tachycardia,
pyrexia and a raised white count. Minor wound infections may discharge pus or infected serous fluid
but should not be associated with excessive discomfort, systemic signs or delay in return home.
Risk factors for increased risk of wound infection

 1. Malnutrition (obesity, weight loss)
2. Metabolic disease (diabetes, uraemia, jaundice)
3. Immunosuppression (cancer, AIDS, steroids, chemotherapy and radiotherapy)
4. Colonisation and translocation in the gastrointestinal tract
5. Poor perfusion (systemic shock or local ischaemia)
6. Foreign body material
7. Poor surgical technique (dead space, haematoma)
Clinical features :Wound infection usually becomes evident 34 days after surgery. In superficial
wound infection the first signs are usually superficial cellulitis around the margins of the wound, or
swelling of the wound with some serous discharge from between the sutures. Fluctuation is
occasionally elicited when there is an abscess or liquefying hematoma. Crepitus may be present if gas-
forming organisms are involved. In deep wound infection, there are no local signs, although the patient
may have pyrexia and increased wound tenderness and leucocytosis.
Diagnosis: Clinical findings , gram stain, culture and sensitivity & images such as US or CT for deep
infection.
Management : A wound swab or specimen of pus is routinely sent for gram stain, bacteriological
culture and sensitivity. Spreading cellulitis is an indication for empiric antibiotic therapy according to
most expected m.o i.e.; best guess then changed according to culture& sensitivity and patient's
response. Few skin stitches are removed to allow drainage of pus, frequent dressing and wound will
heal spontaneously or need secondary suturing. Deep seated abscess is drained under US or
radiological guide or open surgical drainage.
Prevention: It is prevented by careful patient preparation, asceptic technique , the prophylactic use of
antibiotics in high-risk patients, and meticulous attention to good surgical techniques.
A. Organ/space infection: It includes infection at site of operation & abdominal cavities such as
intrabdominal abscess , pleura etc..
2. Superficial thrombophlebitis :Inflammation of superficial veins at site of canula . The patient may
have fever & pain at the site of the canula. The site of canula looks red , vein may feel tender& cord-
like. Treatment is by changing of the canula, NSAIDS , antibiotic may be needed. Thrombophlebitis
migrans may be associated with certain cancer.
3. Acute bacterial(postoperative) parotitis: It is an acute ascending bacterial infection of parotid gland
that occurs in dehydrated elderly patients following major surgery due to dehydration & reduced
salivary flow. The infectious m.o is usually Staphylococcus aureus or Streptococcus viridans
Clinical features :The patient presents with postoperative fever associated with a tender, painful
parotid swelling several hours after operation . Abscess formation occasionally occurs.
Treatment : Prevention is by well hydration by intravenous fluids and treated by intravenous
antibiotics , if abscess occurs, it should be drained .
Management of surgical infections
1. Diagnosis
A. History and physical examination to identify the focus of infection.
B. Laboratory tests :Complete blood cell count with differential ,GUE, pus culture& sensitivity , Blood
culture .
C. Images :US,CT scan.
2. Treatment of surgical infection
1. Surgical source control: It is the foremost principle of surgical infection by incision and drainage of
fluid collections, debridement of necrotic tissue and foreign bodies & removal of contaminated foreign
bodies
2. Therapeutic antibiotics therapy : Here ,an infection is established but antibiotics are almost
inevitably used as an adjunct to surgical control of focus of infection & do not replace surgical drainage
of infection .Only used when there is spreading infection or signs of systemic infection .Selection first
is empirical depending on best guess and hospital policy then reviewed according to patient response
and result of culture & sensitivity. Duration of treatment depends on patient response , no fever &
normal WBC count.

Prevention of surgical infection
1. Asceptic technique should be followed during surgical technique: Antiseptic for patient's skin
preparation, hand washing , scrubbing, treating of nasal carriers, face mask, head cap.
2. Delicate surgical technique & gentle handling of tissues to prevent hematma , seroma, avoidance of
excessive cautery
3. Avoiding long admission before surgery i.e.; day case surgery.
4. Postponing elective operations in the presence of local or remote infection.
5. Removal of hair with clippers and not a razor at nearest time to operation.
6. Appropriate drain use not through the wound.
7. Avoidance of hypothermia.
8. Maintenance of blood sugar.
9. Antimicrobial prophylaxis (Prophylactic antibiotics): Here, there is no an established infection &
antibiotics are implemented to prevent infection.
Sterilization and antisepsis in surgery
Sterilization: It is a process of killing all living microorganisms including spores. It is intended to kill living
organisms.
Disinfection: It is a process of killing or removal or inactivation of sufficient microbes to render an object
safe for its intended purpose.
Antiseptics: Chemicals which are used to kill or inhibit the growth of microbes except spores.
Methods of sterilization & antisepsis in a hospital are.
A. Physical: It includes
1. Hot steam ,Vapor (Autoclaving):This is the preferred method of sterilization. It uses steam at a pressure
of 750 mmHg above atmospheric pressure and temperature of 120-130 C for 15-30 minutes. The steam
is helpful for penetration even into spores. Appropriate indicators must be used each time to show that
the sterilization is accomplished. It is used for sterilization of drapes &surgical instruments.
2. Dry heat, hot air( Oven ):This is a poor alternative but suitable for metal instruments. It uses a
temperature of 170C for two hours.
3. Boiling is an unreliable means of sterilization and it is not recommended.
B. Chemical such as antiseptics.
C. Ultraviolet to used to sterilize suture materials , syringes.
Commonly used antiseptics
1. .Alcohols (70%): Broad spectrum, rapid action, most active against bacteria.
2. Chlorhexidine: Good activity against staphylococci and streptococci, moderate activity against gram
negative bacteria, non-toxic.
3. Povidone iodine: Broad spectrum, may cause hypersensitivity, rapid inactivation by blood.
4. Iodine :Broad spectrum.
5. Quaternary ammonium compounds :( e.g. cetrimide in benzalkonium chloride). Poor gram-negative
activity, non-toxic.
Mechanism of action
Antimicrobials(antibiotics) in surgical practice
Antibiotics: The term "antibiotics" refers to chemicals excreted by micro-organisms, but the term is used loosely to
include synthetic antimicrobials and all antimicrobial agents , are used for prophylactic or therapeutic purposes.
Mechanism OF ACTION OF ANTIBIOTICS
Mechanism Examples Cidal or Static
Cell wall synthesis. All pen.. , Cephal., Carbapenems, Vanco, Bactracin All cidal

Protein synthesis AG, Macrolides, Clinda., Tetra.. AG:C Others :S

Nucleic acid synthesis Rifamp., Metronida., Quinolones, Cidal
Trimeth, Sulfon. S

Types of antibiotic
1. Bacteriostatic acts by prevention of bacterial growth and multiplication without killing; reliance on host
defense mechanisms to clear infection such as clindamycin, tetracycline.
2. Bactericidal to kills bacteria; must be used in immunocompromised patients such as penicillins &
cephalosporins.
Minimum inhibitory concentration (MIC): lowest drug concentration that inhibits microbe growth in vitro, It
measures drug potency against an organism. MIC may not reflect in vivo action, which many factors affect e.g
bacterial concentration, local pH/O2, devitalized tissue
Therapeutic antibiotic means that there is an established infection & antibiotic is used to treat it.
Prophylactic antibiotic: Prophylaxis consists of the administration of an antimicrobial agent or agents prior
to initiation of certain specific types of surgical procedures in order to reduce the number of microbes that
enter the tissue or body cavity i.e. to prevent development of infection
Selection of antibiotics
1. Empiric choices is based on most likely causative organism and source i.e.; Best guess.
2. Specific choices depends on results of culture & sensitivity and patient response.
Indications:
1. Operation with clean-contaminated ,contaminated & dirty wounds.
2. Clean operations but the results of infection if occurs is catastrophic such as implantation of implant
(prosthesis) in orthopedic surgery & cardiac surgery.
3. Patients with rheumatic heart valvular diseases or valve replacement should be protected from
bacteraemia caused by dental work, urethral instrumentation or visceral surgery to prevent subacute
infective endocarditis. Single doses of broad-spectrum penicillin, for example amoxicillin, orally or
intravenously administered, are sufficient for dental surgery. In urological instrumentation, a single
dose of gentamycin is often used.
4. Operation with clean wounds in immunosupressed patient such as DM & steroid therapy.
How& when is it given? By single IV dose 30 minutes before operation with induction of anesthesia or
before operative procedure such as dental procedure so adequate antibiotic level is available in tissue during
surgical dissection , dose is repeated in long operations for < 4 hrs or if there is a profuse bleeding.
Complications of antibiotic therapy
1. Drug toxicity includes :Drug fever, rashes, anaphylaxis
2. Neurologic complications, gastrointestinal symptoms, renal dysfunction, blood/bone marrow
dyscrasias, visual and auditory losses
3. Emergence of multidrug-resistant strains of organisms.
4. Superinfection with opportunistic microorganisms (e.g., Pseudomembranous colitis caused by
Clostridium difficile , fungus monilial infections)

 FRACTURES OF BONES AND DISLOCATIONS
Prof. Dr Karim AL-Araji
Learning objectives
To discuss
Fractures and dislocation
Management of injuries of the face
_________________________________________________________________________________
Fracture : It is a break in continuity of bone continuity.
Dislocation : It is a complete disruption of a joint surfaces with no remaining contact between articular
surfaces.
Subluxation :It is a partial disruption of a joint surfaces with some contact remaining between articular
surfaces.
Fracture-dislocation(Subluxation): It is a fracture with complete or partial joint disruption.
Sprain: It is a painful condition due to tearing of a ligament and soft tissue injury.
Classification of fractures : Fractures are usually classified according to :
1. Their shape& mechanism : Spiral or oblique (where the fracture curves in a large spiral around the long
axis of the bone) caused by twisting or rotational injury or transverse (straight across the bone ) caused
by direct violence , avulsion fracture caused by traction injury by tendon or ligament ,crush fracture from
direct compression to cancellous bone such as spine, impacted , burst fracture caused by direct to short
bone such as vertebra with wedging of the disc , comminuted fracture (in multiple pieces) caused by,
comminuted ( more than two pieces) which indicates severe violence & union is usually delayed.
2. State of soft tissues , the skin surface & mucous membrane adjacent to fracture ; Open(Compound) i.e.;
there is a skin wound communicated with the fracture or not (closed /simple ) or with cavity lined by
mucous membrane such as fracture of maxilla communicating with maxillary sinus. Severity of soft
tissues injury is classified according to Gustillo's classification. This increases incidence of infection.
Compound fractures are a surgical emergency and require appropriate measures to prevent infection,
including tetanus prevention.
3. Complicated by other injuries; complicated fracture when there is some other structure also damaged
(e.g. a nerve , blood vessel or internal organs).
4. Anatomical site: for example, intra-articular (involving the joint surface), metaphyseal, diaphyseal
epiphyseal . Epiphseal injury occurs in children & involve epiphyseal growth plate so it may interfere
with growth. Salter & Harriss classification is used to grade this fracture into four types 1,11,111,&1V.
5. Health of bone :Pathological fracture : Fracture is weakened by disease such as ; Tumor, Osteoporosis,
Osteomyelitis. Stress fracture : Fracture after repeated trauma egg; Fracture of 2nd metatarsal (March
fracture)
6. Displacement & stability: Displaced or undisplaced fracture. Displaced fracture is in a form of rotation ,
shortening etc. Impaction. Impacted fracture indicates that the fragments are pushed toward each another
& become stable. Unstable fracture is displaced fracture.
7. Age of patient: Greenstick fractures, in which the cortex of the bone bend does not break completely but
bends instead as in children i.e.; incomplete fracture
Diagnosis of fracture
History & Physical examination :
1. The patient should be examined & resuscitated as a whole according to ATLS to exclude more serious
injuries such as head, abdominal , chest injuries etc. then examination of injured limb which includes:
2. Bone : Symptoms: Pain : Commonest symptom, Swelling , Mal-alignment of bone .Loss of function,
i.e.; difficulty to move affected part & adjacent joints.
Signs: Look: Deformity , Swelling: It takes some time to appear & may increase over12-24 hours,
associated with blisters of skin. It is partly due to hematoma, exudates. ,Bruising. Feel: Tenderness,
Edema, increased local temperature Move: Abnormal mobility , Crepitus, not to be ascertained
3. Skin : Ascertain whether any skin breaks communicate with any underlying fracture.

4. Circulation: The most common cause of absent pulses is kinking or compression of the artery by the
fracture. Often, a reduction of the fracture (realigning the fracture into the anatomical position) or
application of traction results in the return of perfusion.
5. Nerves: Certain injuries may have a high associated risk of neurological injury, manifest by loss of
power and/or sensation. For example, the axillary nerve is at risk from shoulder fracture dislocation and
its integrity should be documented prior to reduction .
6. Joint above and below: Often fractures can involve the joint immediately above or below. Joint may
show hemarthrosis .A complete examination of these joints is required as it may influence definitive
treatment of the injury
Investigations
1. X-ray : Two views at right angles , AP& lateral, whole bone with two joints ;one above & one below
because they may be involved by dislocation. These x-rays may show lucencies at the site of fractures,
discontinuity in the cortex or surface of a bone or joint, displacement, number of fragments, FB,
unsuspected fractures. It may not show fracture , patient is treated on clinical suspicion , fracture may
appear later after bone resorption occurs such as scaphoid fracture.
2. CT, MRI may be needed, angiography for vascular injuries.
Complications of fractures
Complications may be general & local , Early or late
Early complications
1. Shock : Hypovolaemic due to blood loss, Neurogenic due to spinal cord injury with spinal cord
interruption , Cardiogenic shock due to pericardial temponad, Septic shock occurs late due to infection.
2. Infection: Osteomyelitis , tetanus, gas gangrene , septicemia , Mainly with compound fracture ,
3. Fat embolism syndrome : It usually begins within 24 to 48 hours after trauma , most commonly
associated with fractures of long bones of the lower extremity. The classic clinical triad consists of
respiratory distress, cerebral dysfunction, and petechial rash. The pathophysiology is not clear, but there
is some evidence to suggest that extravasation of fat particles from long bone fractures may play an
important part. Fat droplets may appear in urine and can be used for diagnosis. Treatment is primarily
prophylactic and supportive, consisting of early fracture fixation, careful volume replacement, analgesia,
and respiratory support. The role of corticosteroids in this setting is controversial
4. Crush syndrome : If limb with massive soft-tissue injury due to being trapped for prolonged periods ,
Myonecrosis, myoglobulinuria & Renal failure. Creatinine phosphokinase enzyme may increase.
Treatment is by aggressive intravenous fluids, debridement and even amputation may be indicated.
5. Deep venous thrombosis and pulmonary embolism( Venous thromboembolic disease ' VTE').
6. Compartment syndrome: This occurs in closed fractures of long bones , tissues injury , edema ,rise of
compartment pressure which leads to decrease blood supply of the leg compartment with ischemia &
damage to nerves & muscles. It is characterized by pain, pallor , parasthesia & paralysis, Perishing cold,
pulses. Pain on passive stretching of fingers is characteristic. It is diagnosed by measuring compartment
pressure. Treatment is by fasciotomy.
7. Injuries to other structures : Vascular( Division, spasm, thrombosis ), Nerves ( Neurapraxia
,Axonotmesis, Neurotmesis), Joints dislocations & subluxations etc..
Late complications
1. Delayed union means failure of fracture to unite within expected time e.g. 10 weeks for upper limb &
20 weeks for lower limbs. Delayed union is caused by Infection, Ischemia, Distraction , Interposition of
soft tissue, Excessive movement of bone ends.
2. Non-union may be defined as failure of fracture to show progressive clinical or radiographic signs of
healing. The principle types of non-union are atrophic, hypertrophic and infected. In atrophic nonunion,
the problem is often poor blood supply. Hypertrophic nonunion usually occurs when there is excessive
movement at the fracture site, leading to abundant periosteal bone formation. If stability is improved,
union is likely.
3. Malunion.: It is union with incorrect abnormal positions e.g. rotational deformity, angulation, shortening
4. Growth arrest if it involves epiphysis in children.
5. Infection , mainly in osteomyelitis in compound fracture

6. Osteoarthritis.
7. Post-traumatic sympathetic (reflex) dystrophy
8. Joint stiffness
9. Muscle atrophy
10. Myositis ossificans
Management of fracture
A. General management of patient as a whole according to ATLS, management of life-threatening
problems first , Exclude other more serious injuries such as head, chest, abdomen, pain relief etc
B. Management of fracture itself by:
1. Reduction: The purpose of reduction are to restore functions, appearance of bone, preserve blood
supply such as subcapital fracture of femur ,to remove interposed soft tissues .Not all fracture need
reduction such as fracture of clavicle & scapula. Accurate alignment is essential. Reduction is needed
for displaced fracture. Reduction is achieved by :
a. Closed method i.e. manipulation under analgesia or anesthesia (LA or GA); most common method.
b. Traction: When manipulation is not suitable such as fracture of femur. It is of two types; Skin &
skeletal traction).
c. Open surgical reduction with/out internal fixation(ORIF) : It gives very accurate reduction , its
disadvantage is infection.
2. To hold reduction with immobilization( Stabilization) by:
a. Casting i.e. plaster of Paris (POP)
b. Internal stability & no need for stabilization.
c. Continuous traction
d. Functional bracing
e. Internal fixation by Plate held with screws ,Transfixation screws, intra-medullary nail ,
circumferential wires etc
f. External fixation.
3. Maintaining fixation: Fractures of long bones in adults need 12 weeks, in children up to 2-3 weeks for
shaft of long bones in baby.
4. Rehabilitation: It begins immediately after treatment by movement to prevent joint stiffness which
aims to restore the patient to pre-injury level of function with physiotherapy and occupational therapy.
Retraining may be needed.
Notes
Plaster of Paris( POP) Application :POP is applied to hold fracture in position. Usually there is significant
swelling or there is a danger of compartment, the initial cast should not encircle the whole circumference of
the limb. Use of a back slab of plaster allows the limb to swell and avoids the potential risk of
compartment syndrome. Once the acute swelling has settled, the cast can be completed to become a
circumferential (full) cast.
Traction: Traction is the process of putting a stretching force by a weight on a limb to pull a fracture
straight. The Thomas splint for transporting a patient with a fractured femur is a typical example of static
traction, creating tension between two fixed points . Traction can be applied either using the skin (skin
traction) or by direct coupling to the bone with pins or wires (skeletal traction).
Open reduction and internal fixation(ORIF) is the term used to describe the operation of reducing a
fracture under direct vision during operation and then applying plates, screws, wires or intramedullary nails
to hold the fracture in reduction.
External fixation: In external fixation, each side of the fracture is connected to the main fixator which lies
outside the patient. The connection of the frame to the bone is via either half-pins (that is, stiff metal rods
typically 56 mm in diameter) or tensioned wires (typically 1.8 mm in diameter), which are then secured to
the frame by clamps .
Management of compound fractures :These should be treated within 6 hours to prevent infections.
Definitive treatment should involve:
1. Wound debridement: Excision of all the damaged and dead tissue.

2. Thorough cleaning of the wound, with at least 3 liters of fluid depending on the degree of contamination
(the solution to pollution is dilution).
3. Intravenous antibiotics to prevent infection.
4. Anti-tetanus prophylaxis.
5. The wound should be left open and dressed regularly and closed by delay primary closure when it
becomes clean.
6. Treatment of fracture: ORIF should be avoided due to danger of infection, POP cast but preferably
external fixators are often attached by means of pins to the bones either sides of the fracture site to allow
access to the wound for change of dressing while maintaining stability.
Management of joint dislocation: Reduction of the joint dislocation must be performed as soon as
possible to prevent complications, either in the accident and emergency department under sedation (e.g.
anterior dislocation of the shoulder), or in the operating theatre under general anesthesia. In some cases
where closed reduction fails, open surgical reduction is performed.
INJURIES THE FACE
The most common life-threatening considerations in the facial trauma patient are
1. Airway maintenance & cervical spine injury
2. Control of bleeding
3. Identification and treatment of aspiration
4. Identification of other injuries such as head injuries, chest injuries
Initial evaluation should include consideration of airway management, , visual assessment, control of
bleeding, identification of CSF leaks and neurologic injury .
Diagnosis : H&PE & evaluation of CT imaging
Initial survey
1. Airway: Airway caliber can decrease subsequent to displacement of facial bones, expanding edema or
hematoma, loose detention and debris, FB or laryngeal injuries If patient cannot maintain their own
airway intubation is indicated . With midrace and skull base fracture, an airway is more safely
established by or tracheal intubation or cricothyrotomy not nasotracheal intubation to minimize the
likelihood of inadvertent submucosal or intracranial tube placement
2. Hemorrhage( Homeostasis ):Control of hemorrhage can be achieved by the following maneuvers
a. Firm compression is an effective way to stop most arterial and venous facial bleeding.
b. Definitive ligation or cautery of a single bleeding point is sometimes necessary
c. Blind clamping and suture ligation in deep wounds should be avoided in areas where the facial nerve
may be injured
d. Blood loss from scalp lacerations can be severe causing hypovolemic shock . It can controlled by
single-layer running suture closure.
e. Nasal hemorrhage can be controlled by direct pressure with anterior nasal packing to provide
sufficient direct pressure . Foley catheters can be helpful .If packing is ineffective , embolization is
usually required .
f. Early transarterial embolization is the most effective treatment for significant persistent facial
hemorrhage that does not respond to direct pressure or other methods .In unstable patients with
ongoing significant facial hemorrhage that cannot be controlled by packing, embolization should be
considered as soon as possible.
g. Reduction and fixation of bony injuries are often not effective at controlling significant bleeding
h. Ligation of external carotid artery is unreliable because of the rich collateral vascular supply to head
and face .
3. Vision: Eye ball movement can be decreased with orbital fractures .True inferior rectus muscle
entrapment prevents any movement in superior gaze .Ocular pain, decreased vision and appearance of
spots is highly suggestive of globe damage . Gross visual acuity and presence of diplopia assessed for
each eye separately and both eyes together. Check pupils for symmetry, hyphema and subconjunctival
ecchymoses
4. Bony trauma: Facial swelling or asymmetry is a sign of underlying bony injury. If the bite feels
abnormal to the patient, a mandibular or midface fracture is likely. Periorbital ecchymoses are associated

 with zygomatic, orbital or skull base fracture. Battle sign: Pinkish discoloration behind auricle is a sign
indicative of fracture base of skull.
Fractures of the mandible :Types:
1. Fracture of condylar neck is the most common because it is the weakest point.
2. Fracture of the angle of the mandible.
3. Fracture the body through the saucet.
Types of mandibular fractures

Diagnosis of mandibular fractures can usually be made on physical examination. Common findings include
malocclusion, intraoral lacerations, and mobility at the fracture site. Radiographs are useful for planning
treatment
Treatment :Mandibular fractures are not an emergency (Open fracture within 2 to 3 days ,Closed 7 to 10
days) . Mandibular fractures can be repaired by closed reduction with maxilla-mandibular fixation or by
open reduction and fixation with wire osteosynthesis. However, newer techniques with rigid internal fixation
with miniature plates and screws may be used.
4. Maxillary fractures :In 1901, Rene Le Fort demonstrated that blunt force can cause fractures to the
midface along certain lines of inherent weakness .
Le Fort I :Horizontally separates the palate and tooth-bearing maxilla from the rest of the midface.
Le Fort II: Pyramidal fracture, includes lower maxilla + medial infraorbital rim, orbital floor and nasal
bones.
Le Fort III : craniofacial disjunction pass through upper portions of the orbits and include the zygomas
Investigation: CT
Treatment of skeletal injuries : For multiply-injured patients, early treatment may not be possible because
of the higher priority of other injuries. Two windows for optimum treatment of maxillofacial injuries. The
first 6 to 12 hours post-injury, before edema onset, is typically reserved for urgent comorbities & optic nerve
compression, uncontrolled bleeding . The most common timing for repair is 3 to 7 days post-injury, after the
initial edema has subsided and patient is stabilized . The usual treatment is mobilization and reduction and
stable internal fixation of the fractured segments especially along the facial buttresses
Dislocation of mandible: It is easily diagnosed.
Causes :Yawing ,Prolonged dental treatment or intubation, Trauma.
Presentation: Malocclusion, open bite, palpable empty articular sockets
Mechanism : Anterior displacement
Reduction: Hippocrates method , Wrist-pivot reduction , Interdental block
Complications: Inability to reduce Supracongylar fracture of mandible , Early redislocation.
Pos-reduction care: Limitation of mouth opening for two months , Circular fixation bandage for 24 hrs.
Soft tissue injuries: Facial nerve injuries are identified by asking the patient to lift the eyebrows, close the
eyes and purse the lips. If there is a clean, sharp division of one of the five major trunks or of the proximal
main nerve trunk, it can be repaired immediately with microanastomotic techniques. If there is substantial
nerve loss, the nerve ends should be identified and appropriately tagged for future nerve grafting. If a nerve
laceration occurs anterior to the region of the lateral canthus, nerve repair is generally unnecessary because
there is sufficient crossover from the opposite side. Diminished sensation around the lips and cheeks from
the trigeminal nerve is a sign of fracture.

 Facial nerve
Parotid duct extends anteriorly 2 to 3 cm from the anterior parotid gland and drains saliva into the mouth
through an orifice found on the buccal mucosa just opposite the 2nd maxillary molar. Deep lacerations
between the anterior parotid gland and this orifice can potentially damage the parotid duct. If there is a
possibility that the parotid duct is injured, the orifice of Stensen's duct should be probed. Should the probe
enter the wound, division of the duct is verified. The proximal cut end of the duct can be located by
expressing saliva from the gland. A catheter should then be passed through Stensen's duct and through the
area of laceration, and the duct should be repaired over the catheter.
Treatment of soft tissue injuries :
1. All wounds should be inspected for presence of FB or broken teeth prior to irrigation, cleansing and
conservative debridement due to rich blood supply even dusky tissues on small pedicles will often
survive
2. Antibiotics :Routine antibiotic use for simple non-bite facial soft tissue injuries is not indicated. In
more complex and grossly contaminated wounds, antibiotic coverage should be considered for
maxillofacial fractures
Complications of faciomaxillary injuries :
1. Infection of maxillary sinus , Osteomyelitis , Meningitis due to CSF leak ,Cavernous sinus thrombosis
2. Malocclusion of teeth , Ankylosis of TM joint.
3. Anesthesia and parasthesia : In lower lip (inferior dental nerve injury).In upper lip, side of nose, lower
eyelid (infraorbital nerve injury) , Facial nerve injury , superior orbital fissure syndrome: Third, fourth
and fifth cranial nerves are affected leading to ophthalmoplegia, proptosis and retrobulbar pain
4. Malunion, nonunion and delayed union
5. Nasal blockage due to deviated nasal septum
6. Epiphora due to damage to nasolacrimal duct , anosmia due to olfactory nerve damage.

 HEALING
Prof. Dr Karim AL-Araji
Learning objectives
To discuss
Wound healing and healing of different structures
Types and phases of wound healing
Complications of wound healing
_________________________________________________________________________________

Healing is a mechanism whereby the body attempts to restore the integrity of the injured part. Tissue
regeneration by pluripotent cells, seen in some amphibians or by same tissue as liver.
Repair : Healing by fibrous ( scar ) tissue as muscle , CNS by glial tissue , tendon by fibrosis.
Healing of special organs: Bone: Callus ,Tendon :Fibrosis Peripheral n: Wallerian degeneration CNS:
Fibrosis by glial tissues
WOUND HEALING
Classification ( Types ) of wound healing
1. Healing by first( Primary ) intention: It means healing after direct closure of the wound; it is the most
efficient method such as healing of clean incised wound.
a. a Wound edges are meticulously apposed together by suturing
b. Normal healing
c. Minimal scarring & leaving a neat nice scar.

Types of wound healing

2. Healing by secondary intention e.g.; Healing of delayed contaminated , infected or untidy wounds or
wound with tissue loss .
a. Wound left open i.e.; edges are not apposed together
b. Heals by granulation, contraction and epithelialization
c. Increased inflammation and proliferation
d. Poor unsightly scar
3. Delayed primary closure healing by tertiary intention e.g.; Healing of lacerated wound.
a. Wound is treated first by debridement ; excising its margins and then suturing them after 3-5 days or
covering the area with a skin graft when they become clean.
b. The final cosmetic result may be better than if the wound had been left to heal by secondary
intention.
Process of wound healing : Sutured & un-sutured wounds heal by same mechanism which consists of:
1. Filling of gap by fibrous tissue in three phases: Inflammatory ,Proliferative & Remodeling phase

 2. Wound contraction: Reduction in size of wound especially un-sutured produced by myoepithelial cells.
It generally begins in the 4- to 5-day period after wounding and continues for 12 to 15 days or until the
wound edges meet.
3. Epithelialization of wound :Starts immediately (12 hrs )&completed within 48 hrs from basal layer of
the dermis of skin at the edges of wound and skin appendeges . Eventually forming normal epithelial
cover for the scar.
Phases of wound healing 1. Inflammatory 2. Proliferative 3. Remodeling ( Maturation )
Inflammatory phase: It begins immediately after wounding and lasts 23 days . It starts with hemostasis,
followed by the arrival first of neutrophils(which is the first cell to appear) and then of macrophages.
Hemostasis ( arrest of bleeding) consists of vasoconstriction , platelets adhesiveness & coagulation .When
bleeding stops growth factor (cytokines), platelet factor IV and transforming growth factor beta (TGF) are
released. These attract inflammatory cells such as PMN , lymphocytes and macrophages which act as
granules scavengers to remove dead tissues ,clot , mo. then ,fibroblasts starts to lay down granulation
tissues which will be later converted to fibrous tissues.
Proliferative phase : 3rd day-3rd week
1. Fibroblast migration with synthesis of collagen and ground substance( glycosaminoglycans and
proteoglycans) with corresponding increase in tensile strength.
2. Capillary ingrowth (angioneogenesis).
3. Collagen synthesis type 111 with rapid gain in tensile strength. Fibroblasts require vitamin C to
produce collagen.

Phases of wound healing

Remodeling ( Maturation ) phase : It is characterized by
1. 1. Maturation cross linking of collagen (type I replacing type III until a ratio of 4:1)
2. 1. Organization of scar
3. Slow final gain in tensile strength but it does not reach the original normal tensile strength but only
80% of original tensile strength of wound.
Healing in special tissues
Bone : Healing starts by periosteal and endosteal proliferation leads to callus formation, which is immature
bone consisting of osteoid (mineralized by hydroxyapatite and laid down by osteoblasts). Then , in the
remodeling phase, cortical structure and the medullary cavity are restored.
Nerve : When the nerve is cut , the distal part undergoes Wallerian degeneration , proximally, the nerve
suffers traumatic degeneration as far as the nearest node of Ranvier. Then, proximal nerve fiber regenerates
to be attracted to their distal receptors , which is mediated by growth factors &hormones. Overgrowth of
these fibers coupled with poor approximation, may lead to neuroma formation. The speed of growth of nerve
fiber is 1 mm/day.
Tendon: Tendon healing follows normal pattern of wound healing by collagen & fibrous tissue. The random
nature of the initial collagen produced means that the tendon lacks tensile strength for the first 36 weeks.
There are two mechanism for tendon nutrition, intrinsic vascularity & synovial fluid and extrinsic from
adhesions. Active mobilization prevents adhesions limiting range of motion.
Factors affecting wound healing: These include local & general( Systemic) factors that include:
1. Site of the wound

 2. Structures involved
3. Mechanism of wounding : Incision , Crush , Avulsion
4. Contamination (foreign bodies/bacteria)
5. Loss of tissue
6. Other local factors
a. Vascular insufficiency (arterial or venous)
b. Previous radiation
c. Pressure
7. Systemic factors
a. Malnutrition or vitamin and mineral deficiencies
b. Disease (e.g. diabetes mellitus)
c. Medications (e.g. steroids)
d. Immune deficiencies (e.g. chemotherapy, acquired immunodeficiency syndrome (AIDS)
e. Smoking
Complications of wound healing (Abnormal healing)
1. Wound infection: Common infecting organisms include staphylococci, streptococci, coliforms and
anaerobes. The most common m.o is staphylococcus aureous.
CF : The patient has fever , generalized malaise & complains of throbbing pain at the wound .The
wound is swollen, tense ,hot , tender ,the skin may be red with purulent discharge .
Treatment : Few skin sutures need to be removed and wound laid open to allow free drainage. Pus is
sent for culture sensitivity. The wound is dressed regularly and appropriate antibiotics are given if
there is cellulitis. Once all the inflammation disappears, wound is closed by delayed primary suturing
or by secondary suturing.
2. Necrotizing fascitis
3. Hypertrophic scar: This is excessive scarring but does not extend beyond edges of the wound , it may
regress with time ,not progress after 6 months. Resolution can be hastened by elastic pressure
garments, steroid injections or the application of silicone gel. These scars should not be excised.
4. Keloid (like a Claw): There is excessive growth of the scar tissue so that it spreads like a claw which
extends into adjoining normal skin beyond limit of the scar .They are most likely to occur across the
upper chest, shoulders and earlobes, and are common in black patients. It causes itching, erythematous
and spreading margins. The keloid continues to grow even after 1 year and sometimes even progress
for 5-10 years. Treatment is extremely difficult. Surgical excision is usually followed by recurrence.
Use of pressure garments and intralesional injection of triamcenolone might help in controlling its
growth.
5. Atrophic scar: The scar looks flat & weak.
6. Failure of wound healing with disruption , Burst abdomen
7. Skin pigmentation.
8. Contractures: Due to fibrosis and scarring which will lead to deformity if it occurs around joint.
To prevent contracture, the incision should be placed parallel to the line of wrinkle and skin creases.
The treatment is by doing plastic procedures like Z plasty, Y-V plasty or scar excision with skin
grafting.

Neck contracture
9. Marjolins ulcer: Squamous cell carcinoma developing in long standing scar such as of burn .