Promotes tissue granulation and wound healing antiseptic. Granulation of wounds: features and complications of the natural process

Wound healing of various areas and organs, similar in general characteristics, proceeds according to general patterns, but their morphological characteristics vary depending on the nature of the damage, the size of the defect, the presence of infection, etc.

According to long ago rooted According to ideas, wound healing is carried out in two ways: according to the type of primary and according to the type of secondary intention. Both of them lead to the replacement of the defect with young connective tissue, which later acquires the character of cicatricial tissue, and nevertheless, both of these processes not only quantitatively, but also qualitatively differ from each other (IV Davydovsky, 1959). Each of them is preceded by a different state of the tissue, especially with regard to the nature of the inflammation that always accompanies the wound process; they have a different length in time, and the young connective tissue that arises during this period has functional and structural differences. Not all young connective tissue is granulation; the latter characterizes only the secondary intention and is not typical for the primary tension of wounds.

This classification is more complete and is now widely used by everyone. Usually the hole is on the outside. There is a slight lesion of the soft parts. It is especially characterized among sportsmen and military men. Most often the tibial segment. This is due to unusual, intense and repetitive restrictions. In this case, bone scan, which is very sensitive, shows localized hyperfixation. Fracture stage or actual fracture of fatigue, when acute facultative pressure pain occurs, inability to continue sports activities.

Primary Tension is is a process of organization (that is, replacement by connective tissue) of the contents of the wound channel (blood clots, partly necrotic masses that have not undergone decay - I. E. Esipova, 1964).

The condition of the tissues pre-primary tension, can be characterized as serous inflammation or traumatic edema, accompanying to some extent each injury. Swelling of the walls of the wound channel or defect leads to their convergence and partly to the displacement of foreign bodies, that is, to mechanical cleansing of the wound. Nevertheless, in the latter there are always free masses of coagulated blood, and, consequently, fibrin, which is a nutrient medium for the development of cellular elements of the mesenchyme. The proliferation of the latter begins already at the very beginning of the wound process, that is, it coincides in time with the development of wound inflammation.

In this case, x-rays show a fracture line, associated or not with images of the bone structure. The treatment combines sports recreation, orthopedic treatment at the stage of preliminary fracture. Surgical treatment is indicated in cases of delayed consolidation, recurrence, or in the specific case of an isolated fracture of the anterior cortical tibia that has a bad reputation for non-return.

The importance of the meniscus in articular and well-known physiology. General menisectomy includes the onset of well-known articular degenerative phenomena. Currently, most of the sightings of a syringe in the meniscus are as follows. While contraindications are presented.

Wound inflammation is is the first step in the wound healing process. Its morphological manifestations include the expansion of the vascular network in the circumference of the wound, the phenomena of exudation and edema of the edges of the wound defect, leukocyte infiltration. Active expansion of arterioles occurs very quickly, almost instantly, and the closer to the edge of the wound, the more pronounced it is. The venules also dilate in the early period. Capillaries react somewhat later (F. Marchand, 1901).

Vascular disorders of systemic metabolic diseases that affect the synthesis of collagen congenital disorders of the collagen syndrome of the kidneys in the post-lateral region of the lateral meniscus. But not all meniscus injuries need to be sutured, spontaneous healing has been described. The meniscus is a suture and some warnings must be followed. The sutures should not be wide so as not to choke the synovium and therefore limit the blood supply to the meniscus. Other proposed methods to speed up and facilitate the healing process of the meniscus is to reverse the synovial all internal leaflets of the injury before the suture, to interrupt the fibrin clot, possibly by associating it with the fascia flap in complex meniscal lesions.

Following hyperemia begins exudation of serous fluid, which impregnates the edges of the defect and penetrates the wound. On the wound surface, the exudate mixes with blood and lymph, which poured out during the injury, and with torn tissue particles. It soon collapses. This is how a scab is formed.

Leukocyte infiltration begins 2-3 hours after injury. First, in small vessels and capillaries, leukocytes located parietal are observed. Then they actively penetrate through the capillary wall. Polymorphonuclear neutrophilic leukocytes emigrate earlier than others and in greater numbers. Simultaneously with the emigration of polynuclear cells, monocytes, polyblasts, and lymphoid elements of tissue origin accumulate in the edges of the wound; further cellular elements differentiate towards macrophages, absorbing decay products, and fibroblasts.

You can use absorbable or non-absorbable wires for suturing. According to Miller, there are no significant differences in the type of seam. Meniscal cartilage requires healing over a longer period of time than other tissues; however, you don't know exactly how long a full healing lasts. Arnocki and Warren showed that scarring is completed between 8 and 12 weeks with disorganized fibrocartilaginous tissue that is mechanically and less valid than the original structure.

The seam can be done with horizontal or vertical dots. The latter are mechanically more efficient. The suture points must be evenly spaced above and below the meniscus so that the lesions are completely repaired and in contact. According to Lindelfeld, it is preferable to place suture points on the surface of the tibia, as there is no movement between the meniscus and the lamina of the tibia. According to Pouget, the dots can protrude uniformly on the two surfaces of the outer meniscus, since they are concave; in the inner meniscus, only the femoral and concave surface, therefore, it is preferable that dots be applied to it.

During 1-2 days among fibrin fibers that stick together the wound, strands of fibroblasts and crevices appear due to the drying of fibrin, which are further lined with endothelium proliferating from cut, injured vessels (I. K. Esipova, 1964). In the formation of such vessels, as well as in the very process of germination by fibroblasts, there is much in common with recanalization and the organization of blood clots.

The inside-out technique, developed by Henning and used by many authors, allows the placement of suture points under direct arthroscopic control. Use straight needles or other bending radius, single or double cannula. This method can be dangerous for neighboring noble structures, since it is not possible to perfectly control the exit point of the needle. To avoid such complications, it is recommended to make a small skin incision at the exit point of the needle, knocking out the main tissues until the capsule and follow some technical devices, recalling that the risk group structures are: in the middle part of the nerve and saphenous vein, which side is the common peroneal nerve, posterior-laterally to the popliteal artery, some authors use a femoral distractor for augmentation. joint space, which improves endocytic vision, facilitates suture tissue, and reduces the risk of cartilage damage.

As it germinates fibrinous masses fibroblasts, fixing the edges of the wound instead of fibrinous gluing, the latter (fibroblasts) are gradually replaced by collagen and argyrophilic fibers, which are much more than cellular elements, already in the early period of wound healing. This is what distinguishes the contents of a wound that heals by primary intention from granulations, which are characterized by a long-term predominance of cells over the paraplastic substance.

The external technique was proposed by Warren and was less used than the previous one. Small incision 10 mm. practiced after medially in the lesion. The capsule is cut through the skin incision, and then a special cannula needle is pulled into the capsule, so that under arthroscopic control it penetrates the joint at the posterior end of the lesion, and then crosses the flap to the desired point. The suture wire is inserted into the extra-articular end of the needle and glided until it appears at the intra-arterial junction.

The second needle is first inserted first with the same technique so that it crosses the lesion to 6-7 mm. from this. A special spindle with an end "metal end" is introduced inside. The wire passes through a metal bend that retracts outward from the joint, carrying it along with the filament itself. The two ends of the thread, as extracapsular, are then stretched and tied.

By the end of 5-7 days phagocytosis and resorption of dead tissue elements ends, the wound gap is filled with young connective tissue. At the same time, the regeneration of nerve fibers begins. Epithelialization of the wound occurs quickly, since wounds glued with fibrin and fibroblasts reduce the defect, the conditions for epithelization are favorable.

The operation is repeated several times until the seam is completed. When using the all-in-one method, the risks of damage to the neurovascular side are canceled, since the suture is completely intracapsulated. The method uses an appropriate instrument, consisting of curved needles that pass through the meniscus of the lesion without exceeding the capsule, and instruments that allow "knotting all" expansion of the hinged wires. This method is suitable for the most central meniscus lesions.

Postoperative treatment of meniscal sutures, as can be seen from the literature in this regard, is very diverse. Avoid exercise over 90° for 3 months. Scott immobilizes the knee at 30° flexion by stretching the load for two months to cancel the shear forces acting on the meniscus. After the third month and allowed to use the bike, race after 5-6 months, sports recovery after 9-12 months.

During wound healing primary intention and healing under the scab, which fundamentally differs little from healing by primary intention, all processes of reparative regeneration occur in the depth of the wound, that is, below the level of its edges, which also distinguishes primary intention from healing by secondary intention.

One of the phases of healing of damaged tissue is wound granulation. A wound is a violation of the integrity of the skin, muscles, bones or internal organs. The type of wound complexity varies depending on the degree of damage. On this basis, the doctor makes a prognosis, prescribes treatment. A huge role in the healing process is played by granulation tissue, which is formed during wound healing. How is it formed, what is it? Let's take a closer look.

Knee removal after 8 weeks. Partial load at 4 weeks, total load at 6 weeks, muscle improvement at 8 weeks, stallion at 9 weeks, squat at 4 months, race at 5 months, sport at 6 months. Jacob turns white at 30° for 5-6 weeks. with partial load. Morgan is immobilized for 4 weeks at full stretch because in this position he has the best injury healing and gives immediate loading.

Partial load for 6 weeks with retractable knee. In case of unstable damage, such as bucket handles, rehabilitation protocol and more careful: reduction from 20 ° to 70 ° C for 1 month without load, car racing straight for 4-5 months, winding and jumping up to 7-8 months. Sommerlat, in a 7-year review of arthrotocomic sutures, ends with a recommendation for early functional rehabilitation in order not to have a flexible expansion deficit.

What does granulation tissue look like?

Granulation tissue is called young connective tissue. It develops during the healing of a wound, ulcer, with the encapsulation of a foreign body.

Healthy, normal granulation tissue is pink-red, granular, and firm in texture. A cloudy grayish-white purulent exudate is separated from it in small quantities.

This patient was again operated on with a meniscal suture and then immobilized for 6 weeks, thus healing. Partial load for 5 weeks with retractable knee. In the case of unstable injuries such as dental pens, the most reassuring and cautious protocol is bending between 10° and 80° for 1 month without loading and then partial loading for another 30 days. Complete motion capture in the first 3 months.

We did not use orthopedic surgeons except in special cases. We advise you to resume racing in a straight line no earlier than 3 months and to play sports no earlier than 6 months later. The results of meniscal sutures reported in the literature are not uniform in lesion type, associated lesions, surgical technique, postoperative management, and remote evaluation. The results of arthrotomic sutures of the menstrual cycle are superimposed on the results of arthroscopic sutures. Crashes are more likely to occur in unstable knees.

Such tissue arises at the borders between the dead and the living, after being wounded on the 3-4th day. The granulation tissue consists of many granules that are closely pressed to each other. They include: amphora substances, loop-shaped vascular capillaries, histiocytes, fibroblasts, polyblasts, lymphocytes, multinuclear wandering cells, argyrophilic fibers and segmented leukocytes, collagen fibers.

Their incidence and 13% according to Ryu. The importance of the knee menu is known to everyone and does not require any confirmation. Similarly, it is well known that meniscus suture, when possible, is preferable to meninctomies, albeit partial ones. Some authors have shown that there is no difference in response. mechanical stresses between healthy and sutured meniscus good results of meniscus sutures persist for a long time, this is confirmed by a low percentage of articular degenerative phenomena, as the stone claims, which brings in 75% of cases, in the absence of signs of Fairbank distance four years after meniscus sutures.

Formation of granulation tissue

Already after two days, on areas free of blood clots and necrotic tissue, pink-red nodules can be seen - the size of a millet grain granule. On the third day, the number of granules increases significantly, and already on the 4-5th day, the surface of the wound is covered with young granulation tissue. Well, this process is noticeable on an incised wound.

In terms of results, there are no differences between arthrosomal and arthroscopic sutures; however, postoperative and minor pain symptoms in arthroscopic sutures, as well as minor ones, are problems associated with wound healing. This results in the patient being able to recover faster and faster, with fewer disruptions. The arthroscopic technique, which we prefer, allows more accurate diagnosis of the lesion and the possibility of repairing these central lesions without suture with arthroctectomy.

Healthy strong granulations of a pinkish-red color, they do not bleed, have a uniform granular appearance, a very dense texture, emit a small amount of purulent cloudy exudate. It contains a large number of dead cellular elements of the local tissue, purulent bodies, impurities of erythrocytes, segmented leukocytes, one or another microflora with its own waste products. Cells of the reticuloendothelial system, white blood cells migrate into this exudate, vascular capillaries and fibroblasts also grow here.

This may be due to endoscopic reconstruction of the anterior cruciate ligament without the need to practice arthrotomy. Ultimately and by far the most aesthetic benefit. On the one hand, it has undoubted advantages, it does not avoid neuro-vascular complications, but it is easily avoided with some technical details. In posterior horn swords, a small skin incision must be made to reach the capsule to prevent such complications. On the lateral side, it is preferable to identify and protect the peripheral nerve.

Due to the fact that in the gaping wound it is impossible for the newly formed capillaries to connect with the capillaries of the opposite side of the wound, they, bending, form loops. Each of these loops is a framework for the above cells. Each new granule is formed from them. Every day, the wound is filled with new granules, so the entire cavity is completely contracted.

The most difficult period for the purse-string suture of the meniscus is understood in the first weeks after interventions in the early stages of rehabilitation until complete healing is achieved. Vertical lesions have the best results. All authors agree that ligamentous location, especially the frontal pectinate ligament, is a fundamental requirement for the success of mandisk sutures. Rosenberg reports a complete healing rate of 96% for stable knee sutures versus 33% for an unstable knee. The Crusader must be reconstructed with an intra-articular plasty.

Layers

The layers of granulation tissue are separated:

on superficial leukocyte-necrotic;
the layer of granulation tissue itself;
fibrous deep layer.

Over time, the growth of capillaries and cells declines, and the number of fibers increases. Granulation tissue begins to turn first into fibrous, and then into scar tissue.

The main role of granulation tissue is barrier functions, it prevents microbes, toxins, decay products from entering the wound. It inhibits the vital activity of microbes, liquefies toxins, binds them, and helps to reject necrotic tissues. Granulations fill the cavity of the defect, wound, a tissue scar is created.

wound healing

Granulations are always formed at the boundaries between living and dead tissue. They form faster when there is good blood circulation in the damaged tissue. There are cases when granulations are formed at different times, develop unevenly. It depends on the amount of dead cells in the tissue and the timing of their rejection. The faster the granulation occurs, the faster the wound healing. After cleansing the wound of dead tissue and inflammatory exudate, the granulation layer becomes clearly visible. Sometimes in medical practice, the removal of granulation tissue is required, most often this is used in dentistry for gingivotomy (gingival incision).

If there are no reasons preventing healing, the entire wound cavity is filled with granulation tissue. When the granulations reach the level of the skin, they begin to decrease in volume, become slightly paler, then become covered with skin epithelium, which grows from the periphery to the center of the damage.

Healing by primary and secondary intention

Wound healing can occur by primary or secondary intention, depending on their nature.

Primary tension is characterized by a reduction in the edges of the wound due to the connective tissue organization of granulation. It firmly connects the edges of the wound. After the initial tension, the scar remains almost invisible, smooth. Such tension is able to tighten the edges of a small wound if the opposite sides are at a distance of no more than one centimeter.

Secondary tension is characteristic of the healing of large wounds, where there are many non-viable tissues. Significant defects or all purulent wounds pass the way of healing by secondary intention. Differing from the primary type, the secondary tension has a cavity, which is filled with granulation tissue. The scar after secondary tension has a pale red color, protrudes slightly beyond the surface of the skin. As the vessels gradually thicken in it, fibrous and scar tissue develops, keratinization of the skin epithelium occurs, the scar begins to turn pale, becomes denser and narrower. Sometimes scar hypertrophy develops - this is when an excess amount of scar tissue is formed.

Healing under the scab

The third type of wound healing is the simplest - the wound heals under the scab. This is typical for minor wounds, damage to the skin (abrasions, scratches, abrasions, burns of the 1st, 2nd degree). The scab (crust) on the surface of the wound is formed from the blood that has coagulated there, lymph. The role of the scab is a protective barrier that protects the wound from infection, under this shield skin regeneration occurs. If the process goes well, no infection has got in, after healing, the crust leaves without a trace. There is no sign left on the skin that a wound was once present here.

Pathologies of granulation

If the wound process is disturbed, pathological granulations may form. Possible insufficient or excessive growth of granulation tissue, disintegration of granulations, premature sclerosis. In all these cases, and if the granulation tissue bleeds, special treatment will be required.

The development of granulations and epithelialization processes fade away if there are such unfavorable factors as worsening blood supply, decompensation of any systems and organs, oxygenation, repeated purulent process. In these cases, granulation pathologies develop.

The clinic is as follows: there is no wound contraction, the appearance of the granulation tissue changes. The wound looks pale, dull, loses turgor, becomes cyanotic, covered with a coating of pus and fibrin.

Tuberous granulations are also considered pathological when they protrude beyond the edges of the wound - hypergranulations (hypertrophic). Hanging over the edges of the wound, they impede the process of epithelialization. In these cases, they are cauterized with concentrated solutions of potassium permanganate or silver nitrate. The wound continues to be treated by stimulating epithelialization.

Importance of granulation tissue

So, summing up, we highlight the main roles played by granulation tissue:

Replacement of wound defects. Granulation - plastic material that fills the wound.
Protection of the wound from foreign bodies, penetration of organisms, toxins. This is achieved due to the large number of leukocytes, macrophages, as well as a dense structure.
Rejection and sequestration of necrotic tissue. The process is facilitated by the presence of macrophages, leukocytes, as well as proteolytic enzymes that secrete cellular elements.
In the normal course of healing, epithelialization begins simultaneously with granulation. Granulation tissue is transformed into coarse fibrous tissue, then a scar is formed.

Further in the material, we will consider these stages of tissue regeneration in detail. Let us find out which therapeutic methods are used to activate the processes of tissue granulation, the speedy restoration of damaged areas and the renewal of healthy epithelium.

The presented stage of tissue healing is also known as the period of scar formation or reorganization of scar structures. At the presented stage, there is no loose matter that can be released from the wound. Surface areas at the site of damage become dry.

The most pronounced epithelization manifests itself closer to the edges of the wound. Here, the so-called islands of healthy tissue formation are formed, which differ in a somewhat textured surface.

In this case, the central part of the wound may still be at the stage of inflammation for some time. Therefore, at this stage, most often resort to differentiated treatment.

It promotes active cell renewal closer to the edges of the wound and prevents its suppuration in the central part.

Depending on the complexity of the wound, final epithelialization may take up to one year. During this time, the damage is completely filled with new tissue and covered with skin. The initial number of vessels in the scar material also decreases. Therefore, the scar changes from a bright red color to the usual skin tone.

Cells involved in wound granulation processes

What causes healing and its acceleration? Granulation of the wound is carried out due to the activation of leukocytes, plasmacytes, mast cells, fibroblasts and histiocytes.

As the inflammatory phase progresses, tissue cleansing occurs. Restriction of the access of pathogens to the deep layers of damage occurs due to their conservation by fibroblasts and fibrocytes. Then platelets come into action, which bind active substances and enhance catabolism reactions.

Wound care at the initial stage of healing

The optimal solution for the speedy recovery of damaged tissue is the regular use of dressings. Disinfection here is carried out with solutions of potassium permanganate and hydrogen peroxide. These substances are applied in a warm form on a gauze swab. Next, a careful impregnation of the wound is performed, in which touching the damage with the hands is excluded - this can lead to the development of infections.

At the initial stages of wound healing, it is strictly forbidden to forcibly separate dead tissue. You can only remove flaky elements, which are easily rejected with a slight impact with sterile tweezers. For the speedy formation of a dead scab in other areas, they are treated with a 5% iodine solution.

Treatment of open wounds in any case involves the passage of three stages - primary self-cleaning, inflammation and granulation tissue repair.

Primary self-cleaning

As soon as a wound occurs and bleeding opens, the vessels begin to narrow sharply - this allows the formation of a platelet clot, which will stop the bleeding. Then the narrowed vessels expand sharply. The result of such a "work" of the blood vessels will be a slowdown in blood flow, an increase in the permeability of the walls of the vessels and a progressive swelling of the soft tissues.

It was found that such a vascular reaction leads to the cleansing of damaged soft tissues without the use of any antiseptic agents.

Inflammatory process

This is the second stage of the wound process, which is characterized by increased swelling of the soft tissues, the skin turns red. Together, bleeding and inflammation provoke a significant increase in the number of leukocytes in the blood.

Tissue repair by granulation

This stage of the wound process can also begin against the background of inflammation - there is nothing pathological in this. The formation of granulation tissue begins directly in the open wound, as well as along the edges of the open wound and along the surface of the closely located epithelium.

Over time, granulation tissue degenerates into connective tissue, and this stage will be considered completed only after a stable scar forms at the site of the open wound.

Distinguish between the healing of an open wound by primary and secondary intention. The first option for the development of the process is possible only if the wound is not extensive, its edges are brought close to each other and there is no pronounced inflammation at the site of injury. And secondary tension occurs in all other cases, including purulent wounds.

Features of the treatment of open wounds depend only on how intensively the inflammatory process develops, how badly the tissues are damaged. The task of doctors is to stimulate and control all the above stages of the wound process.

Physiotherapy treatment

Among physiotherapeutic methods, ultraviolet irradiation can be prescribed at the stage when wound granulation is actively carried out. What it is? First of all, UVR assumes a moderate thermal effect on the damaged area.

Such therapy is especially useful if the victim has stagnation of granulations, which have a sluggish structure. Also, a gentle effect on the wound with ultraviolet rays is recommended in cases where a natural discharge of purulent plaque does not occur for a long time.

In the presence of a simple injury, in which only the superficial extreme layers of the epithelium are affected, alternative methods of treatment can be resorted to for recovery. A good solution here is the imposition of gauze bandages soaked in St. John's wort oil. The presented method contributes to the early completion of the granulation phase and active tissue renewal.

To prepare the above remedy, it is enough to take about 300 ml of refined vegetable oil and about 30-40 grams of dried St. John's wort. After mixing the ingredients, the composition should be boiled over low heat for about an hour. The cooled mass must be filtered through cheesecloth. Then it can be used to apply bandages.

It is also possible to heal wounds at the granulation stage with the help of pine resin. The latter is taken in its pure form, rinsed with water and, if necessary, softened by gentle heating. After such preparation, the substance is applied to the damaged tissue area and fixed with a bandage.

Drug treatment

Often, wound granulation is a rather lengthy process. The rate of healing depends on the state of the body, the area of damage, and its nature. Therefore, when choosing a medication for the treatment of a wound, it is necessary to analyze at what stage of healing it is currently.

Among the most effective drugs, it is worth highlighting the following:

ointment "Acerbin" - is a universal remedy that can be used at any stage of the wound process;
ointment "Solcoseryl" - contributes to the speedy granulation of damage, avoids tissue erosion, the appearance of ulcerative neoplasms;
Dairy calf blood hemoderivat - is available in the form of a gel and ointment, is a universal highly effective drug for wound healing.

Finally

So we figured it out, wound granulation - what is it? As practice shows, one of the determining conditions for accelerating the healing process is differentiated treatment. The correct selection of medications is also important. All this contributes to the speedy granulation of the damaged area and the formation of a new, healthy tissue.

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Pathogenesis: The action of the damaging factor -> Spasm, dilatation of blood vessels -> increased permeability of the vascular wall -> increase in edema -> acidosis -> stimulation of phagocytosis by histamine -> maturation of connective tissue elements -> formation of a connective tissue scar (just in case, in detail: The biological processes occurring in the wound are complex and diverse. They are based on cell death, protein breakdown, the predominance of anaerobic glycolysis over aerobic, the accumulation of biologically active substances (histamine, serotonin, kinins, etc.), microcirculation disturbance and, as a result, insufficient oxygen supply to the wound and the accumulation of toxic products of tissue decay, metabolism and death of microbes.

The formation of lactic and pyruvic acids under conditions of anaerobic glycolysis, as well as the accumulation of carbon dioxide due to microcirculation disorders, lead to changes in the acid-base state in the inflammation focus. At the very beginning of inflammation, these changes are compensated due to the alkaline reserves of the tissues, and the pH of the tissues does not change (compensated acidosis). Further depletion of alkaline reserves leads to a change in pH and the development of decompensated acidosis. Under normal conditions, the pH in the connective tissue is 7.1, in a purulent wound - 6.0-6.5 and even 5.4. Acidosis causes exudative changes in the wound, increases capillary permeability; migration of leukocytes, macrophages begins with a shift in pH to the acid side. Phagocytosis begins when there is a difference in pH between the wound and the blood.

With inflammation, especially purulent, the composition of electrolytes in the wound changes. During the decay of cells, potassium is released, the content of which can increase by 50-100 times, as a result, the ratio of potassium and calcium is disturbed, which increases the degree of acidosis.

Changes in the acid-base state, the composition of electrolytes, the accumulation of toxic products in the wound lead to a violation of the composition of colloids, accumulation of fluid in the intercellular spaces, and swelling of colloids in cells. The transition of colloids from the gel state to the sol causes a rupture of the cell membrane, cell destruction and the development of secondary necrosis (primary necrosis is due to the action of a traumatic factor). Cell breakdown, in turn, leads to the accumulation of free ions, an increase in osmotic pressure, circulatory disorders, exudation and cell infiltration, thereby closing one of the vicious circles that determine the inflammatory process in the wound.

During the period of inflammation in the wound, serious changes occur in the metabolism of proteins. In the inflammatory phase of the wound process, catabolic processes predominate over anabolic ones, and anabolic processes prevail in the regeneration phase.

The catabolic process is determined by primary and secondary tissue necrosis, phagocytosis, active proteolysis and is manifested by the accumulation of protein breakdown products in the wound - polypeptides, nucleoproteins.

Anabolic processes are manifested by the prevalence of protein synthesis over its breakdown. Numerous amino acids accumulate in the wound (tyrosine, leucine, arginine, histidine, lysine, tryptophan, leucine, proline, etc.). An important role in regeneration belongs to proline, which is converted into hydroxyproline of collagen proteins.

The state of regenerative processes in the wound is determined by the synthesis and accumulation of acid mucopolysaccharides, which are determined already in the first days of wound healing. Preliminary accumulation of mucopolysaccharides precedes the formation of collagen, which is included in the composition of collagen fibers.

Chemical compounds that accumulate in the wound and cause an increase in vascular permeability and migration of leukocytes are adenylic acids and adenosine. Their most important derivatives are adenosine diphosphoric (ADP) and adenosine triphosphoric (ATP) acids, which easily pass into each other in rephosphorylation reactions with the release of a large amount of energy used for regenerative processes. Adenic acids stimulate the migration of leukocytes, their phagocytic activity, activate regenerative processes in the wound.

The course of the inflammatory process is influenced by biologically active substances, the accumulation of which is facilitated by acidosis, active proteolysis, and catabolic processes. Biological active substances such as histamine, serotonin, sodium heparin, bradykinin, kallikreins, kinins, prostaglandins affect inflammation, vascular permeability and migration of leukocytes.

Enzymatic processes play a certain role in inflammation in the wound. Their importance is especially important in the first phase of inflammation, its course and completion are determined by the severity of proteolysis. The wound contains both endogenous and exogenous enzymes with a wide spectrum of action. Endogenous include enzymes that are released during the breakdown of leukocytes and other cells (proteases, lysozyme, lipase, oxidase, etc.), exogenous - enzymes of bacterial origin (deoxyribonuclease, cathepsins, collagenase, streptokinase, hyaluronidase, etc.). The specific action of enzymes depends on the pH of the medium: peptases show their activity in an acidic environment, and tryptases in an alkaline environment. Proteolytic enzymes act on necrotic tissues, lead to the breakdown of proteins - from proteins to amino acids. Enzyme systems reach their maximum effect at the height of inflammation. Proteolytic enzymes play an important role in the wound healing process, as they lyse necrotic tissues, accelerate the cleansing of wounds from pus and devitalized tissues)

Wound regeneration refers to creparative regeneration . Distinguish: complete regeneration, or restitution, is a complete structural and functional restoration by the cells of an organ; incomplete regeneration, or substitution, partial recovery due to connective tissue. During the regeneration of connective tissue, stages III are distinguished.

I. Formation of a young, immature connective - granulation - tissue.

II. The formation of fibrous connective tissue (a large number of fibroblasts, thin collagen fibers and numerous blood vessels of a certain type.

III. The formation of scar connective tissue, which contains thick coarse collagen fibers, a small number of cells (fibrocytes) and single blood vessels with thickened sclerotic walls.

There are 3 types of wound healing: Healing by primary intention occurs with linear wounds; regeneration at the same time goes through the same phases as the course of the wound process.

Healing by secondary intention observed in cases where the edges and walls of the wound do not touch, are separated from each other by a certain distance (more than 10 mm); there is a pronounced purulent inflammation, necrotic tissues undergo necrolysis.

Healing under the scab occurs with small superficial skin wounds (abrasions, abrasions, burns); the wound defect is covered with a crust (scab) of dried blood, lymph, interstitial fluid, necrotic tissues; the scab performs a protective function - under it there is a process of filling the tissue defect due to the formation of granulation tissue .

Granulation tissue. 6 layers are distinguished: 1) superficial leukocyte-necrotic layer (consists of leukocytes, detritus from desquamated cells); 2) a layer of vascular loops (contains vessels and polyblasts, with a long course of the process, a number of fibers can form, located parallel to the surface of the wound) , the layer is most pronounced in the early period of wound healing) 4) maturing layer (essentially the deeper part of the previous layer. Fibroblasts take a horizontal position and move away from the vessels, between them are coli fibers and argyrophilic fibers. 5) a layer of horizontal fibroblasts ( a direct continuation of the previous layer.It consists of more monomorphic cellular elements, is rich in fibers and gradually thickens 6) fibrous layer (reflects the process of maturation of granulations)

Circular (circular) bandage is the beginning of any soft bandage and is used on its own to close small wounds in the forehead, neck, wrist, ankle, etc. With this bandage, each subsequent round completely covers the previous one. The first round is applied somewhat obliquely and more tightly than the subsequent ones, leaving the end of the bandage uncovered, which is folded back for the 2nd round and fixed with the next circular motion of the bandage. The disadvantage of the bandage is its ability to rotate and at the same time displace the dressing.

spiral bandage used to close large wounds on the trunk and limbs. It starts with a circular bandage above or below the injury, and then the bandage moves in an oblique (spiral) direction, covering the previous move by two thirds. A simple spiral bandage is applied to cylindrical parts of the body (thorax, shoulder, thigh), a spiral bandage with kinks is applied to cone-shaped parts of the body (shin, forearm). The inflection is produced as follows. Lead the bandage somewhat more obliquely than the previous spiral tour; with the thumb of the left hand, hold its lower edge, roll out the head of the bandage a little and bend it towards you so that the upper edge of the bandage becomes the lower one, and vice versa; then again go to the spiral bandage. In this case, the bends should be made along one line and away from the damage zone. The bandage is very simple and is applied quickly, but can easily slip off during walking or movement. For greater strength, the final rounds of the bandage are fixed to the skin with cleol.

What does granulation tissue look like?

Granulation tissue is called young connective tissue. It develops during the healing of a wound, ulcer, with the encapsulation of a foreign body.

Healthy, normal granulation tissue is pink-red, granular, and firm in texture. A cloudy grayish-white purulent exudate is separated from it in small quantities.

Formation of granulation tissue

Layers

The layers of granulation tissue are separated:

on superficial leukocyte-necrotic;
the layer of granulation tissue itself;
fibrous deep layer.

Over time, the growth of capillaries and cells declines, and the number of fibers increases. Granulation tissue begins to turn first into fibrous, and then into scar tissue.

wound healing

Healing by primary and secondary intention

Wound healing can occur by primary or secondary intention, depending on their nature.

Healing under the scab

Pathologies of granulation

Importance of granulation tissue

So, summing up, we highlight the main roles played by granulation tissue:

Replacement of wound defects. Granulation - plastic material that fills the wound.
Protection of the wound from foreign bodies, penetration of organisms, toxins. This is achieved due to the large number of leukocytes, macrophages, as well as a dense structure.
Rejection and sequestration of necrotic tissue. The process is facilitated by the presence of macrophages, leukocytes, as well as proteolytic enzymes that secrete cellular elements.
In the normal course of healing, epithelialization begins simultaneously with granulation. Granulation tissue is transformed into coarse fibrous tissue, then a scar is formed.

Everyone knows that any wounds heal. This is because nature created granulation tissue. To understand how and when it begins to form, what role it plays in replacing a skin defect, how to ensure faster healing and, if possible, avoid a disfiguring scar, let's talk about wounds.

Unfortunately, our skin is not as strong as we would like, and everyone had to deal with its mechanical damage. A wound is a violation of the integrity of the skin or mucous membrane due to mechanical damage. Getting a wound is accompanied by pain, bleeding, gaping of the edges of the broken integrity of the skin, and a decrease in function.

What are wounds

Wounds can be divided into 2 large groups: those received by chance and under the influence of a surgeon (operating). Stab wounds are obtained from exposure to a piercing object, there are cut and chopped, from bites of animals and people - bitten, there are gunshot wounds. According to the degree of infection - aseptic, freshly infected and purulent.

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Incised surgical clean (aseptic) wounds behave best. With them, the wound cavity is closed, the walls are closed, the skin defect is sutured with surgical sutures. Such healing closes small shallow incised wounds with a small distance between the edges, sutures are not applied. The sides of the wound stick together due to the fibrin threads formed from the wound exudate. At the same time, the surface epithelium grows, blocking access to bacteria inside. The surgeons say the wound healed by first intention.

The other type is called sub-eschar healing. With small superficial wounds, a certain amount of blood, lymph and tissue fluid is poured onto the surface of the body, which undergo clotting and subsequent drying. The resulting crust is called a scab. It protects against contamination, acting as an aseptic dressing. Under the crust, epithelialization is actively taking place, after its completion, the scab disappears.

Healing damage by secondary intention

It is for this type of healing that a special type of connective tissue is formed in the wound - granulation tissue. By secondary intention, large festering wounds, gaping with jagged edges, heal. After a pronounced phase of inflammation that arose after the primary infection and the absorption of a large amount of tissue necrosis products, cellular detritus, granulations are formed on the bottom and walls of the wound on 3-4 days, which gradually fill the wound cavity.

Histologically, 6 layers are distinguished in the formation of granulation tissue:

on the surface a layer of necrosis and leukocytes;
loops of vessels with polyblasts;
vertical vessels;
maturation layer;
horizontally arranged fibroblasts;
fibrous layer.

The first layer is represented by an accumulation of leukocytes, desquamated cells, lifeless tissues. Further, loop-shaped vessels and polyblasts appear, here the formation of collagen structures begins. The layer of vertical vessels is developed and serves as a support for fibroblasts. In the maturing layer, they begin to move into a horizontal position, move away from the vessels, collagen and argyrophilic fibers appear between them. Further, horizontal fibroblasts form many thickening collagen fibers. Ripe granulations appear in the last row.

Granulation lasts about a month. In the early stages of healing, its role is to create a barrier between the wound cavity and the external environment, to protect the wound from the penetration of microorganisms. Detachable from the wound has pronounced bactericidal properties. Granulations outwardly resemble small red-pink grains that bleed during rough manipulations, so care should be taken when caring for a wound. Damage to granulations opens access to a variety of microorganisms.

If microbes enter the wound, then repeated suppuration occurs with its inherent inflammatory reactions in the form of pain, redness, swelling, and fever.

The epithelialization phase is activated after the completion of granulation. Epithelial cells, multiplying, close the skin defect, covering the granulation tissue from the periphery to the center of the wound. If the granulations are tender, clean, without signs of suppuration, then an even dense scar is formed. If the wound is complicated by suppuration, then the time for its healing increases, coarse fibrous tissue develops, the scar is rough, deforming the skin, and sometimes ulcerates.

Primary surgical treatment

Timely and correctly performed primary surgical treatment is the key to rapid wound healing. PHO is performed by a doctor, local anesthesia is indicated. The edges and skin around the wound are treated with an antiseptic, for example, 5% tincture of iodine. It is unacceptable to get iodine into the wound! Next, a thorough revision, examination of the wound is performed. Crushed and necrotic areas, particles of dirt, bone fragments, foreign bodies are removed. It is imperative to ensure complete hemostasis, that is, stop bleeding. The doctor decides on the need for drainage - ensuring outflow from the wound and suturing.

In some cases, wound revision requires entry into the abdominal cavity in order to exclude the penetrating nature of the wound and damage to internal organs, and, if necessary, restore their integrity. This is especially true of injuries received from an object of stabbing action in the abdomen.

With extensive deep wounds, prevention of the development of anaerobic infection (gas gangrene) should be carried out. In addition to drainage, it is necessary to provide abundant washing of the wound with solutions that provide a sufficient supply of oxygen, for example, a solution of potassium permanganate, hydrogen peroxide. Broad-spectrum antibiotics are introduced in massive dosages: Tienam, semi-synthetic penicillins (Ampicillin), Amoxiclav, polyvalent anti-gangrenous serum, anaerobic bacteriophage.

What determines the intensity of granulation

In fact, we are talking about speeding up healing. The initial state of health of the patient, the activity of his immune system, the nature of the damage necessarily affect the rate of reparative reactions.

The presence of concomitant pathology, such as diabetes mellitus, significantly inhibits the development of granulation tissue in the wound.

In young people, the restoration of integrity is more intensive than in the elderly. Improper nutrition, especially the lack of protein foods, prevents the formation of collagen structures necessary for the formation of a full-fledged scar. Hypoxia or oxygen starvation, regardless of the cause of its occurrence, slows down the restoration of the integrity of the skin. The state of dehydration, a decrease in the volume of circulating fluid, significant blood loss accompanying the injury, also slow down regeneration. Late treatment, untimely primary treatment, the addition of a secondary wound infection adversely affect the quality and speed of scar formation.

The surgeon repeatedly changes dressings, during the dressing process, assesses the severity of the inflammation stage, the quality of the granulation tissue and the rate of epithelialization.

At the stage of inflammation, in addition to drainage, hydrophilic ointments are applied topically. Often used Levomekol, Mafenida acetate, Levosin. The advantage of these ointments is that, in addition to the antibacterial component that easily passes into the wound, they have the ability to attract wound contents to themselves, cleansing the wound. The effect of their use lasts about a day, which makes it possible to carry out dressings 1 time per day. From physiotherapy - wound quartzing, UHF, hyperbaric oxygenation, high-energy surgical laser for evaporating lifeless masses. To speed up the cleansing of the wound, proteolytic enzymes are used on dressings or included in ointments, such as Iruxol. Be sure to use modern antiseptic drugs: Iodopyrone, Dioxidine, Sodium hypochlorite.
At the granulation stage, fatty ointments with healing-accelerating components are used, such as Methyluracil, Troxevasin, as well as rosehip and sea buckthorn oil. Well support the development of granulation juices of Kalanchoe, aloe. A therapeutic low energy laser can be used.
The stage of epithelialization requires the suspension of the development of granulations and the acceleration of the division of epithelial cells. Apply aerosols, jelly (Troxevasin), water-salt antiseptics, therapeutic laser.

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Very large defects, difficult-to-heal wounds, ulcerative lesions require plastic surgery using artificial skin or autodermoplasty after cleansing the wound cavity from necrotic masses.

Many wounds require long-term therapy, result in temporary disability, hospitalization, and significant discomfort. Domestic and industrial injuries can be prevented if you follow the safety rules when working with dangerous objects and mechanisms.