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Orthopaedic Essentials

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Wound Healing

Carol Harvey

Wound healing in orthopaedic care is affected by the causes of the wound, as well as concomitant therapies used to repair musculoskeletal structures. Promoting the health of the host and creating an environment to foster natural healing processes is essential for helping to restore skin integrity. Normal wound healing physiologicprocesses, factors affecting wound healing, wound classification systems, unique characteristics of orthopaedic wounds, wound contamination and drainage characteristics, and potential complications are important to understand in anticipation of patient needs. Accurate wound assessment and knowledge of nursing implications with specific wound care measures (cleansing, debridement, and dressings) isimportant for quality care. New technologies are enhancing traditional wound care measures with goals of effective comfortable wound care to promote restoration of skin integrity.

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Skin: Review of Anatomy

The integumentary system comprises the skin, hair, nails, and glands of the skin. It is the largest organ in the body and provides protection and sensation, regulates fluid balance andtemperature, and produces vitamins (vitamin D) and immune system components (Smeltzer & Bare, 2004). It is important to review this system, particularly the layers of the skin, to understand the principles of wound healing (see Figure 1).

Epidermis
The epidermis is the outermost layer of the skin, lines the ear canals, and is contiguous with the mucous membranes. The cells are continuouslydividing in this layer. The outer surface is made up of dead epithelial cells that were originally in the dermis but were pushed upward as new cells developed. This layer is replaced every 3 to 4 weeks. These epithelial cells contain kei'atin, which is an insoluble fibrous protein. Keratin is the principal component that hardens the hair and nails. It is the keratin that prevents excessive fluid lossfi-om the body and repels pathogens. The epidermis contains larger amounts of keratin in the palms and the soles of the feet. Melanin is the pigment; the more melanin, the darker the color of the skin and haii; The epidermis and dermis interlock and produce ripples on the surface of the skin. These ripples form characteristic unique fingeiprints (Smeltzer & Bare, 2004).

ound healing in theorthopaedic patient is often complex because of the possible presence of a fracture, avulsion injury, foreign bodies, fixation hardware, or maybe even a total joint prosthesis {Whetzel & Stevenson, 2001). In addition, orthopaedics often involves use of "devices" that enter the bone percutaneously (through the skin) for (he purpose of repairing or stabilizing bone. Examples would be external fixationdevices or skeletal traction. These also present the potential for infection. Therefore, sterile procedures when creating or caring [or orthopaedic wounds are essential in most cases to minimize this infection risk. In addition, it is essential to protect the bone fi'om bacterial invasion to prevent osteomyelitis, which is difficult to treat. The general principles of wound healing particularlyapply to the orthopaedic patient. They involve promoting a healthy host (the patient), as well as an enviionment that enables the occurrence of natural skin healing processes. This article focuses on understanding wounds and the natural and medical/nursing factors that promote healing and the restoration of skin integrity.

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Dermis
The dermis is the largest portion of the skin. It providesstrength and structure. The upper papillary layer contains fibroblast cells, which produce collagen. This collagen is the basis of the connective tissue, which provides strength and structure to skin. The reticular layer also produces elastic bundles, which give skin nexibility. The blood vessels, lymph ducts, neiTes, sebaceous and sweat glands, and hair roots are also contained in the dermis.
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