The wound healing process: an overview of the cellular and molecular mechanisms

Wound healing remains a challenging clinical problem and correct, efficient wound management is essential. Much effort has been focused on wound care with an emphasis on new therapeutic approaches and the development of technologies for acute and chronic wound management. Wound healing involves multiple cell populations, the extracellular matrix and the action of soluble mediators such as growth factors and cytokines. Although the process of healing is continuous, it may be arbitrarily divided into four phases: (i) coagulation and haemostasis; (ii) inflammation; (iii) proliferation; and (iv) wound remodelling with scar tissue formation. The correct approach to wound management may effectively influence the clinical outcome. This review discusses wound classification, the physiology of the wound healing process and the methods used in wound management.

[Aortic valve insufficiency due to rupture of the cusp in a patient with multiple trauma]

Lesions of the heart valve caused by blunt chest trauma is rare, but when it does occur it can significantly injure the patient. On the basis of autopsy studies, research shows that heart valves are injured in less than 5% of patients who have died due to impact thoracic trauma. Among the heart valves, the aortic valve is the most often lacerated, which has been proved by relevant autopsy and clinical studies. Aortic valve lesions can be the only injury, but it is possible that additional heart or large vessel injuries are also present (myocardial contusion, rupture of the atrial septum, aortic rupture, rupture of the left common carotid artery). The force that causes such an injury is often great and often causes injuries to other organs and organ systems. In a multiple trauma patient, it is very important to specifically look for heart-related injuries because it is possible that they may be overlooked or missed by the surgeon, because of other obvious injuries. We describe the case of a 41-year-old man with multiple trauma who was diagnosed with aortic valve insufficiency due to rupture of the left coronary cusp 6 weeks after a road accident. Valvuloplasty was performed. Seven years later the patient is free of symptoms and is in good physical condition. Echocardiography showed normal dimensions of the heart chambers, a normal thickness of the heart walls, and normal systolic and diastolic function of the left ventricle. Heart valves are morphologically normal, and only an unimportant aortic insufficiency was noticed by echocardiography.

[Traumatic jejunal entrapment in a patient with Bechterew disease]

We report an unusual case of incarceration of small bowel between the 4th and 5th lumbar vertebrae in a patient with rheumatoid spondylitis. Incarceration of the loop of jejunum within the fracture or between dislocated lumbar vertebrae is an uncommon entity. The cases of traumatic jejunal entrapment have been previously reported in the literature [1, 2, 3, 4, 5, 6, 7, 8, 9, 11]: 2 cases occurred in adults and 8 in children. There has been no report on this injury in patients with rheumatoid spondylitis (Bechterew arthritis).

[Percutaneous tibiotalar arthrodesis]

We report on a 50-year-old female patient with bimalleolar fracture and subsequent posttraumatic arthrosis who was treated by minimally invasive nonresection tibiotalar compression arthrodesis using internal fixation and cancellous bone grafting. The advantages of this technique include minimal exposure of tissues, good control of the relationship between the tibia and the talus, and short hospital stay.

The strength of percutaneous methods of repair of the Achilles tendon: a biomechanical study

PURPOSE

A study on 36 cadaveric Achilles tendons was undertaken to compare different Achilles tendon repairs.

METHODS

The strength of the repair and the gapping resistance were tested under different standardized experimental conditions. Each matched pair of cadaveric Achilles tendons was randomly repaired in the original Ma-Griffith configuration and in the new modified configuration and loaded to failure. Using a special equipment, the force displacement curve was measured.

RESULTS

Under different experimental conditions, the new modified technique presented in the paper provided significantly greater tensile strength and gapping resistance than the original Ma-Griffith repair configuration.

CONCLUSION

The results of this study may be clinically relevant in terms of choice of the percutaneous method used for the repair of the ruptured Achilles tendon.

Recurrent adrenocortical carcinoma in a child

An 8-month-old girl presented with clitoromegaly, cushingoid features and a large abdominal tumour. Ultrasonography (US) and computed tomography (CT) of the abdomen revealed a tumour of the left suprarenal gland, 12x11x7 cm in size. Serum levels of cortisol, testosterone and DHEA-S, and urinary extretion of 17-ketosteroids and 17-hydroxycorticoids were increased. Complete removal of the tumour was accomplished through a transabdominal approach. The diagnosis of adrenocortical carcinoma was confirmed histologically. Three months after the first operation, a recurrent tumour of the left renal hilus, 23x15 mm in size, was identified by US and verified by aspiration biopsy. The tumour was removed by the transabdominal route. In this report, we discuss the diagnosis and the treatment of this rare disease.

Results of treatment of 17 patients with heart tumour

BACKGROUND

Between 1989 and 1997, 17 patients underwent surgery for excision of primary cardiac tumour at the Department for Cardiovascular Surgery in Ljubljana.

PATIENTS AND METHODS

There were 13 female (76.5%) and four male (23.5%) patients with an average age of 49+/-14 years (mean+/-SD). The study was retrospective. Special attention was paid to clinical presentation, method of diagnosis, elapsed time between the confirmed diagnosis and excision of the tumour, operatively determined location of tumour and post-operative course-diuresis in first 48 h, levels of CK and CK-MB, on first and on second day after operation and time of hospitalization.

RESULTS

Thirteen patients (76.5%) had cardiac symptoms at the time of presentation (dyspnoea, syncope, vertigo, palpitations) and four (23. 5%) had embolic complications. In all the patients diagnosis was made by echocardiography. Average elapsed time between the confirmed diagnosis and the operation was 26+/-40 (mean+/-SD) days. Histological examination revealed myxoma in 15 patients (88.2%), one patient had lipoma and one malignant haemangiosarcoma. The most common location of tumour was in the left atrium (12 patients; 70. 6%). Post-operative complications occurred in four patients (23.5%); 76.5% of patients had diuresis in the range between 0.8 and 2.0 ml/h/kg; there was no post-operative oligouric renal failure. Average levels of both CK and CK-MB were statistically significantly lower on the second day after operation, there was no case of peri-operative myocardial infarction and post-operative death did not occur. One patient with multiple myxoma had two recurrences.

CONCLUSIONS

Symptoms in patients with heart tumours, especially at the beginning of illness, are often uncharacteristic. Due to the non-specific presentation of cardiac tumours, a high index of suspicion is needed. The diagnostic method of choice is echocardiography. Operative removal of tumour is a safe procedure and recurrences in patients with benign tumours are rare.

[Successful surgical revascularization after 18 hour ischemia below the knee due to complete avulsion of the popliteal artery]

We report the case of a 33-year-old man after knee luxation and disruption of a popliteal artery, which was missed after repositioning at the first clinic. Eighteen hours later complete discontinuity of the popliteal artery was confirmed by arteriography and an immediate reversed, end-to-end auto-venous graft was interposed under general anesthesia with anterior and posterior fasciotomy prior to blood flow restoration. Forced diuresis with a diuretic mixture and balanced fluid intake were used, and the patient was discharged from the intensive care unit on the 10th postoperative day in good condition with normal diuresis.

[Bridging an extensive bone defect with cortico-spongious transplants in femoral fracture caused by gunshot injury]

The treatment of a 12-cm bone defect after shotgun fracture of the femur is described. Semitubular corticospongious bone grafts from both iliac crests, 6 cm long and 0.8 cm wide, were tied into two bundles with an absorbable suture and were laid successively into the diaphyseal defect. With another absorbable suture the bundles were anchored to the condylar 95-deg plate. Two months later the condylar plate was removed and an external fixator placed because of inflammation; the bone implants survived. By 18 months after the injury the bone defect was cured, no inflammation was present, and the patient was able to walk with full weight bearing. Four conditions have to be fulfilled in the treatment of an open comminuted fracture with soft tissue defect: thorough necrectomy, rigid fixation, bone grafting and improvement of the blood supply by means of a microvascular musculocutaneous flap.

An unusual lawn mower injury

The authors report a case of foot trauma produced by a piece of the lawn mower blade, which was fired projectile-wise from the machine while it was in operation. At hit the calcaneous and remained trapped in the bone. The wound healed after removal of the foreign body, wound debridement and systemic and local antibiotic prophylaxis. In the professional literature available, no report has been found on a missile injury produced by a piece of rotating lawn mower knife.

Comminuted avulsion fractures of the inferior pole of the patella

Treatment of comminuted avulsion fractures of the inferior pole of the patella is still an unsolved problem. Different methods of treatment have been introduced, some quite controversial, including immediate total patellectomy; a variety of partial patellectomies, and fixation by tension band wiring. Yet the problem of early development of arthrosis and a certain degree of limitation of motion due to the changed biomechanics, retropatellar incongruity and postoperative immobilization must still be resolved. We report two cases with comminuted avulsion fractures of the inferior pole of the patella, treated by fixation with a basket plate. The method allows for immediate postoperative mobilization of the knee joint and early weight bearing.

Intracranial injuries by a screwdriver

Two patients with unusual intracranial foreign bodies are presented. Intracranial injuries produced by a piece of screwdriver as a wounding agent have not yet been reported in the literature. In one of our two cases we had to deal with homicide and in another with accidental self-inflicted injury. Both patients died, 5 and 14 days, respectively, after successful removal of the foreign body. In both cases death was due to brain ischaemia and the resulting oedema secondary to arterial injury.

[Repeat fracture of the femur shaft in Gaucher disease]

A case of pathologic femoral fracture in a patient with Gaucher's disease is presented. The fracture occurred at the site of bioptic trepanation performed 1 month previously. After fracture healing and removal of a Küntscher nail, pathologic fracture recurred at the same site. The paper emphasizes the value of "biological" internal fixation for the preservation of compromised blood flow in the bones of patients with Gaucher's disease.

Avulsion of the anterior superior iliac spine in two adolescent sisters: operative versus conservative treatment

We compared the results of treatment of identical injuries to the anterior superior iliac spine in two adolescent sisters, one treated conservatively and the other operatively. The functional results of both treatments were good, but the rehabilitation period was shorter with operative treatment, allowing an earlier return to athletic activity. Treatment by open reduction and internal fixation should be considered in patients requiring a short convalescence. Familial coincidence of avulsion fracture of the anterior superior iliac spine has not previously been described in the literature.

Perforation of the small intestine caused by fixation plate penetration into the abdomen

The authors report a case of intestinal loop penetration and peritonitis caused by penetration of the tip of the fixation into the abdominal cavity after internal fixation of an unstable intertrochanteric fracture. Complete regression of acute infection was achieved by suturing the intestinal wound, removing the internal fixation device and administering systemic and local antibiotic therapy.

Avulsion of the anterior-superior iliac spine in athletes: case reports

Avulsion of the anterior-superior iliac spine rarely occurs in adolescents. The condition is commonly encountered in athletes. Despite the resulting caudal dislocation of the apophysis, the injury is as a rule treated by conservative means. We report on avulsion in two young athletes treated by open reduction and internal fixation, which enabled them to resume sports: one 3 weeks and the other 4 weeks after the injury. Treatment by open reduction and internal fixation is also indicated in patients requiring a short convalescence.

Incomplete femoral fracture produced by a wooden projectile: case report

We report on a case of incomplete fracture of the metaphyseal portion of the femur produced by a wooden missile, a part of which remained stuck in the bone after wound management. The wooden foreign body in the bone was detected with xeroradiography and computed tomography. Complete regression of acute inflammation was achieved through removal of the wounding agent, wound debridement, and systemic and local antibiotic therapy.