A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying disease processes such as diabetes mellitus, venous/arterial insufficiency, or immunologic disease. Wounds can vary greatly in their appearance depending on wound location, injury mechanism, depth of injury, timing of onset (acute vs chronic), and wound sterility, among other factors. Treatment strategies for wounds will vary based on the classification of the wound, therefore it is essential that wounds be thoroughly evaluated by a healthcare professional for proper management. In normal physiology, all wounds will undergo a series of steps collectively known as the wound healing process, which include hemostasis, inflammation, proliferation, and tissue remodeling. Age, tissue oxygenation, stress, underlying medical conditions, and certain medications are just a few of the many factors known to affect the rate of wound healing.
Classification Wounds can be broadly classified as either acute or chronic based on time from initial injury and progression through normal stages of wound healing. Both wound types can further be categorized by cause of injury, wound severity/depth, and sterility of the wound bed. Several classification systems have been developed to describe wounds and guide their management. Some notable classification systems include the CDC's Surgical Wound Classification, the International Red Cross Wound Classification, the Tscherne classification, the Gustilo-Anderson classification of open fractures, and the AO soft tissue grading system.
Acute wounds An acute wound is any wound which results from direct trauma and progresses through the four stages of wound healing along an expected timeline. The first stage, hemostasis, lasts from minutes to hours after initial injury. This stage is followed by the inflammatory phase which typically lasts 1 to 3 days. Proliferation is the third stage of wound healing and lasts from a few days up to a month. The fourth and final phase of wound healing, remodeling/scar formation, typically lasts 12 months but can continue as long as 2 years after the initial injury. Acute wounds can further be classified as either open or closed. An open wound is any injury whereby the integrity of the skin has been disrupted and the underlying tissue is exposed. A closed wound, on the other hand, is any injury in which underlying tissue has been damaged but the overlying skin is still intact.
Open wounds Incisions or incised wounds – caused by a clean, sharp-edged object such as a knife, razor, or glass splinter. Lacerations – irregular tear-like wounds caused by some blunt trauma. Lacerations and incisions may appear linear (regular) or stellate (irregular). The term laceration is commonly misused in reference to incisions. Abrasions (grazes) – superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough surface such as asphalt, tree bark or concrete. Avulsions – injuries in which a body structure is forcibly detached from its normal point of insertion; a type of amputation where the extremity is pulled off rather than cut off. When used in reference to skin avulsions, the term 'degloving' is also sometimes used as a synonym. Puncture wounds – caused by an object puncturing the skin, such as a splinter, nail, knife or sharp tooth. Penetration wounds – caused by an object such as a knife entering and coming out from the skin. Gunshot wounds – caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a "through-and-through." Critical wounds – Including large burns that have been split. These wounds can cause serious hydroelectrolytic and metabolic alterations including fluid loss, electrolyte imbalances, and increased catabolism.
Closed wounds Hematomas (or blood tumor) – caused by damage to a blood vessel that in turn causes blood to collect under the skin. Hematomas that originate from internal blood vessel pathology are petechiae, purpura, and ecchymosis. The different classifications are based on size. Hematomas that originate from an external source of trauma are contusions, also commonly called bruises. Crush injury – caused by a great or extreme amount of force applied over a long period of time.
Fractures Fractures can be classified as either open or closed, depending on whether the integrity of the overlying skin has been disrupted or preserved, respectively. Several classification systems have been developed to further characterize soft tissue injuries in the setting of an underlying fracture:
Tscherne classification – Used to describe external appearance of wounds in both open and closed fractures. Gustilo-Anderson classification – Classifies open fractures based on wound size, extent of soft tissue loss, and degree of contamination. Hannover Fracture scale – Used in open fractures as an extremity salvage assessment. AO Classification – adapted from the Tscherne classification, provides separate grading system for skin, muscles/tendons, and neurovascular structures.
Chronic wounds Any wound which is arrested or delayed during any of the normal stages of wound healing is considered to be a chronic wound. Most commonly, these are wounds which develop due to an underlying disease process such as diabetes mellitus or arterial/venous insufficiency. However, any acute wound has the potential to become a chronic wound if any of the normal stages of wound healing are interrupted. Chronic wounds are most commonly a result of disruption of the inflammatory phase of wound healing, however errors in any phase can result in a chronic wound. The exact duration of time which distinguishes a chronic wound from an acute wound is not clearly defined, although many clinicians agree that wounds which have not progressed for over three months are considered chronic wounds.
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