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Modified Essay Questions, MEQs in General Surgery - Wound

WOUND 

1. A 9 yr old boy was hit by a vehicle while going to school a few hours back. He was carried to the emergency in a stable state with wound on right calf.         (15 marks) 
a. Define wound.
Wound is the discontinuity or break in the surface epithelium

b. Describe the local pathophysiology of wounds.
- Stage of hemostasis - Stage of  inflammation - stage of granulation - stage of maturation

On examination, 15 cm x 6 cm wound defect was noticed over the postero-lateral aspect of rt leg which had ragged, unhealthy margins and there was skin loss as well. 

2. Classify open wounds.
i. Incised wound: superficial wound with a sharp edge and caused by sharp objects less contaminated
ii. Lacerated wounds: caused by blunt objects or RTA. Ragged unhealthy edges,  crushing or tissue may be present
iii. Penetrating wounds: caused by sharp objects, depth of wound greater than length. Internal organs, blood vessels, nerves might be damaged
iv. Crushed wounds: Caused by blunt trauma eg RTAs. Might cause severe hemorrhage,
more prone for gangrene, tetanus etc.

3. Define Abrasion and Laceration.
- Abrasion: Scraping or peeling off of the epidermis with the exposure of the dermis.
- Laceration: Laceration is the tearing or splitting of skin, mucous membranes, muscles or internal organs caused by either a shearing or a crushing force, and produced by application of a blunt force to a broad area of the body.

Parents of the boy are anxious. They want to know how you will manage their son.

4. Outline the treatment plan.
 i. Resuscitation if the patient unstable. Not required here as the patient is stable
ii. Anagesics if the patient is in pain -WHO step ladder. NSAIDs followed by opoids
iii. Cleaning of wound
iv. Exploration and diagnosis
v. Debridement
vi. Repair of Structures, splinting of fractures
vii. Replacement of lost tissue where indicated
viii. Skin cover if required
ix. Skin closure without tension
x. Tetanus Toxoid, Antibiotics (broad spectrum including anaerobic coverage)

5. What is the most important point that you will consider while doing a primary closure:
- presence of infection (if present it cannot be done)

6. Define Healing by primary intension.
- It is the healing of clean incised wounds such as surgical incision by re-epithelialization across the wound producing a neat thin scar.

7. Somehow you have managed to close the wound by primary closure but the next day you findthat the wound edges have turned black. What will you do next?
- Open the sutures, take swabs for cultures debride necrotic tissue and leave the wound open. Continue antibiotics.

8. Define Granulation tissue. 
- It is a soft, pink, granular tissue that is formed during wound healing. It consists of small new blood vessels and proliferation of fibroblasts.

9. What is healing by secondary intention?
- It is the type of healing that takes place in wounds with unopposed edges where there is granulation, contraction, and epithelialization.

10. What is the next best alternative if one cannot close the wound primarily? 
- Repair by delayed primary repair: Wound initially left open and edges later apposed when the healing conditions are favorable. 

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