KURSUS ASAS PENJAGAAN

LUKA

CLASSIFICATION OF WOUND

Dr Shamsuddin Abdul Aziz

Pakar Ortopedik
Hospital Sultanah Aminah
Johor Bahru
 DEFINITION

Wound:

Separation/ discontinuity of skin, mucous membrane or

soft tissue caused by physical, chemical or biological
insult
WOUND
 PURPOSE OF WOUND
DOCUMENTATION
Accurate documentation of site/size/nature of wounds
are important:

For proper wound management

For better communication between wound care team

For assessment of wound healing progress

As a legal documentation
 PURPOSE OF WOUND
CLASSIFICATION

Grading of severity

Predictor of infection rates

Analyses of surgery and outcomes

Comparisons of management outcomes

 OPEN WOUND

Discontinuity in the skin and other covering tissue of

varying depth
 OPEN WOUND

Incised wound:
Caused by sharp cutting instrument
Minimum loss of tissue
Edges are regular
Heals by primary intention healing
INCISED WOUND
 OPEN WOUND

Laceration:
Caused by tearing of soft tissue
Irregular jagged edges
Loss of tissue limited to skin and subcutaneous tissue
LACERATION
 OPEN WOUND

Penetrated wound:

Caused by sharp pointed objects eg. Nail

Small opening
More depth
Contamination to deeper tissues
Opening inadequate for drainage
PENETRATED WOUND
 OPEN WOUND

Perforated wound:

Have two openings- entrance and exit

PERFORATED WOUND
 OPEN WOUND

Punctured/Stab wound:

Deep wounds communicating with cavities eg.

thorax/abdomen/joints
OPEN WOUND

Others:

Gunshot wound

Abrasion wound

Bite wound

Ulcerating wound
ABRASION
CLOSED/INTERNAL WOUND

Only deeper tissues barring the skin or mucous

membrane are damaged
 CLOSED/INTERNAL WOUND

Contusion/Bruises:

Caused by blunt objects

Damage to subcutaneous tissue without breaking the

continuity of skin surface

Classified according to severity of damage;

BRUISES
 Contussion/Bruises Classification
1st Degree: Echymosis damage to capillaries to skin
and subcutaneous tissue

2nd degree: Hematoma- damage to larger vessels

3rd degree :tissue/organ damage, may cause gangrene

and shock
CLOSED/INTERNAL WOUND

Hematoma:

Blood accumulation under the skin

Caused by injury to superficial veins

Subcutaneous/ submucousal
HEMATOMA
 SURGICAL WOUND
CLASSIFICATION

Class I: Clean

non traumatic, no inflammation,

Intact techniques, GU/GIT/Resp tracts not breached

eg. : Lump excision

 Class II: Clean contaminated

Non traumatic
Minor break in techniques
Tracts breached without spillage

eg. : appendicectomy
 Class III: Contaminated

Fresh traumatic wound

Major break in techniques
Tracts entered with spillage

eg. : open fracture

 Class IV: Dirty-infected

Traumatic wound- dirty/delayed

Perforated viscus/fecal contamination

eg. : perforated bowel with peritonitis

Open fracture with severe dirty wound
LEG ULCER CLASSIFICATION

Ulcer:

A lesion that is eroding away the skin or mucous

membrane usually complicated by delayed healing or
recurrence
ULCER
 LEG ULCER

Types (Cause):

Venous stasis

Neurotrophic (Diabetic)

Arterial (ischaemic)
 Venous Stasis Ulcer

Associated with varicose veins

Below the knee, inner part of leg just above ankle

Border: irregular, discolored surrounding skin, swelling

Base: red covered by yellowish fibrous tissue

VENOUS STASIS ULCER
 Neurotrophic Ulcer

Associated with Diabetes Mellitus

Pressure areas at plantar aspect of foot

Border: punched out, callousity

Base: variable: pink/brown/black

NEUROTROPHIC ULCER
 Arterial Ulcer

On the feet: Heel, tip of toes, nailbed

Border: punched out

Base: grey/ brown/ black

Painful especially at night

ARTERIAL ULCER
 BURNS

1st degree: fiery red, very painful, not blistered

2nd degree : partial thickness, extend tru epidermis and

dermis, full healing expected

3rd degree: full thickness, extend tru dermis and

subcutaneous layer. Hair follicles/ sweat and sebaceous
glands damaged. Healing tru scar formation
 4th degree: complete burns

Extend to subcutaneous tissue, muscle,fascia or bone

May cause systemic toxicity, infection/sepsis

BURN
 DIABETIC FOOT ULCER

Wagners classification

Grade 0 (Pre or post ulcerative lesion)

Grade 1 (partial/ full thickness ulcer, i.e. superficial
ulcer)
Grade 2 (Probing to tendon or capsule, i.e. deep ulcer)
Grade 3 (Presence of osteomyelitis)
Grade 4 (Partial foot gangrene)
Grade 5 (Whole foot gangrene)
University Texas Classification
Grade 0 (pre or post ulcerative ulcer that has healed)
Grade 1 (Superficial wounds not involving tendon,
capsule or bone)
Grade 2 (Wound penetrating to tendon or capsule)
Grade 3 (Wound penetrating bone or joint)

Within each grade, there are 4 stages

A (Clean wounds)
B (Non ischemic infected wounds)
C (Ischemic non infected wounds)
D (Ischemic infected wounds)
 PRESSURE ULCER
National Pressure Ulcer Advisory Panel (1992)

Stage I: Non-blanchable erythema of intact skin

(heralding lesion or skin ulceration)

State II: Partial-thickness skin loss involving

epidermis and/or dermis; ulcer is superficial and
present clinically as an abrasion, blister, or shallow
crater
 PRESSURE ULCER

Stage III: Full-thickness skin loss involving damage or

necrosis of subcutaneous tissue that may extend down
to, but not through, underlying fascia; ulcer presents
clinically as a deep crater with or without undermining
of adjacent tissue
Stage IV: Full-thickness skin loss with extensive
destruction, tissue necrosis, or damage to muscle, bone,
or supporting structures (e.g. tendon, joint, capsule,
etc.)
PRESSURE ULCER
 PRESSURE ULCER

BRADEN SCALE: used to predict pressure ulcer risk

 BRADEN SCALE (1987)
Sensory Perception: Impaired Normal (1-4)

Skin Moisture: Moist Dry (1-4)

Activity: Bedbound- Ambulant (1-4)

Mobility: Immobile- No Limitation (1-4)

Nutrition: Poor- Excellent (1-4)

Friction/Shear: Maximum- Minimum (1-3)

Very High Risk: Total Score less than 9

High Risk: Total Score 10-12

Moderate Risk: Total Score 13-14

Mild Risk: Total Score 15-18

THE END