1. Wounds, ulcers, sinuses & fistulae
Dr. Fuad Ammari
Professor of Surgery, Medical School
Jordan University of Science and Technology
Consultant Surgeon,
King Abdullah University Hospital

2. Wounds Definition of wound
It is an epithelial discontinuity in skin or mucus membrane

3. Types Abrasion Contusion Hematoma Incised wound “tidy” clean
Lacerated wound “untidy” contaminated to dirty

4. Abrasion
Burn like

5. hematoma

6. Incised
Tidy

7. Lacerated wound

8. Classification
Clean: operative wound, no GIT, UG or resp.tract entered. Closed primarly
Clean contaminated: operative wound with GIT UGT or resp. tract are entered, closed primarily after cleaning or delayed 1ry.

9. classification
Contaminated: open fresh wounds with gross spillage from GIT, for delayed primary closure
Dirty: Old traumatic and purulent wounds and perforated viscus. For debridement and delayed primary or graft

10. Management Wound assessment and primary care
Patient history and physical examination
First aid: Compression dressing to stop bleeding
Anti-tetanus toxoid
Antibiotics “check sensitivity”
Anesthesia local or GA

11. Management Washout with sterile isotonic saline and
Brushing to remove sand and glass
X-ray for FBs and fractures
Debridement “excise dead tissue”
Explore for injuries to different structures
Dressing.
Suturing: immediate or delayed primary.

12. closure
Tidy clean wounds for immediate primary closure

13. Healing Healing by primary intention
Healing by secondary intention for wounds with loss of skin

14. Physiological stages of wound healing
1.) Inflammatory Phase Day 1-4
Initial response, with rubor, tumor, dolor, calor
Platelet aggregation and activation, Leukocyte migration, phagocytosis and mediator release
Venule dilation, Lymphatic blockade, Exudation
Primary intention, lasts 4 days
Secondary intention, continues until epithelial-ization is complete

15. stages 2.)Proliferative Phase Day 4-42
Fibroblast proliferation stimulated by macrophage-released growth factors
Increased production of collagen by fibroblasts, Granulation tissue and neo-vascularization
Gain in tensile strength

16. stages 3.) Remodeling Phase 6wks-1 year,
Intermolecular cross-linking of collagen via vitamin C-dependent hydroxylation
Increase in tensile strength, Type III collagen replaced with type I
Scar flattens

17. Wound Infection It becomes apparent
Between 2-4 days from operative day
Area of erythema “redness'” of more than 5cm
Indurations'

18. Ulcers Ulcer is a wound that takes a chronic course due to:
Physical or chemical injury
Ischemia
Neoplastic changes
Systemic diseases

19. History When first noticed
What brought it to attention pain, discharge, bleeding, smell
The progress of ulcer ‘size, shape, depth, discharge and response to any treatment
Previous similar lesions, systemic symptoms and what the pt. thinks.

20. Examination
Site: Sometimes it is characteristic e.g. the venous, arterial and diabetic ulcers of the leg and foot.
Venous is sited in the leg above the med. Malleolus
Arterial in the toes
Diabetic in the foot as neuropathic, arterial or infective traumatic

21. Venous Ulcer
Varicose veins

22. ulcer
Venous ulcer

23. Diabetic
Diabetic foot Infection

24. Neuropathic
Diabetic

25. Traumatic
paraplegic

26. Bed sore

27. Internal ulcers
Or it occurs in the stomach or duodenum “peptic ulcer” it becomes apparent in upGI endoscopy

28. Exam Shape: irregular, oval…. etc Size
Base and Floor covering, discharge, slough, perforation and fistula, scab, eschar, and granulation tissues.

29. Base & floor

30. exam Edge: sloping as in healing ulcer, punched out as in ischemic
Undermined in TB,
rolled in basal cell ca and
everted in sq. cell ca

31. Edge

32. edge

33. Exam
● Margin “surrounding tissues” redness, induration and pigmentations
●Draining lymph nodes

34. Sinuses
A sinus is a tract lined with granulation tissue “GT” connecting an abnormal cavity “an abscess” to an epithelial surface. GT may be exuberant and protrude through the sinus.
Symptoms: recurrent infection and discharge

35. sinuses Factors that can lead to sinus formation:
Inadequate drainage of an abscess
Chronic inflammation. TB, Syphilis, fungal and Crohn’s disease.
Foreign body stimulates prolonged and recurrent infection e.g. suture material,

36. Factors
Congenital sinus lined with epithelial tissues e.g. dermoid cyst, branchial cyst and preauricular sinus
Malignant disease may spread to present as a sinus in Paget’s disease of the nipple and sister Joseph’s nodule from a ca. stomach with 2ries into the umbilicus

37. sinus
preauricular

38. Fistulae
A fistula is an abnormal tract between two epithelial surfaces.
Most commonly, It occurs when an abscess breaks into two adjacent epithelial surfaces

39. Etiological factors as in sinuses Inadequate drainage of an abscess
Chronic inflammation.
Foreign body.
Congenital.
Malignant disease.

40. . Fistulas may occur in many parts :
Arteriovenous (between an artery and vein)
Biliary (created during gallbladder surgery, connecting bile ducts to the surface of the skin)
Cervical (either an abnormal opening into the cervix or in the neck)
Craniosinus (between the space inside the skull and a nasal sinus)
Enterovaginal (between the bowel and vagina)
Fecal or anal (the feces is discharged through an opening other than the anus) fistula in ano
Intestinal fistulas and stomas

41. Fistulas may occur in many parts
Gastric (from the stomach to the surface of the skin) gastrostomy
Metroperitoneal (between the uterus and peritoneal cavity)
Pulmonary arteriovenous (in a lung, the pulmonary artery and vein are connected, allowing the blood to bypass the oxygenation process in the lung)
Umbilical e.g. patent vitello-intestinal duct and patent urachus

42. Fistula
Entero-cut

43. Small intest