CLASSIFICATION OF WOUNDS

CLASSIFICATION OF WOUNDS

Wounds are diverse and there is no standard classification system that incorporates all relevant aspects for di ff erent clinical contexts. A wide variety of classifications ( Summary box 3.3 are used and descriptors from more than one system are required to accurately describe a given wound. A widely accepted wound classification was first introduced 1 to describe the in 1964 by the US National Research Council degree of bacterial load or contamination of surgical wounds ). at the time of surgery . It was subsequently adapted by the 2 US Centers for Disease Prevention and Control to classify wounds as clean, clean–contaminated, contaminated and dirty ( Table 3.1 ). Although the simplicity of this classification has led to its widespread use, the definitions are not entirely clear 3,4 and low interobserver reliability has been reported. Various grading and scoring systems exist for specific condi - tions such as pressure ulcers and diabetic ulcers. The National Nosocomial Infections Surveillance (NNIS) score is commonly used to predict surgical site infections (SSIs). It was established in recognition of the e ff ectiveness of infection surveillance in 5 reducing SSIs. The NNIS score stratifies surgical wound infec - tion rates by risk factors. This risk index score ranges from 0 (lowest SSI risk) to 3 (highest SSI risk) with a point allocated for the presence of each of the following risk factors: )

Figure 3.5 Multiple keloid scars. TABLE 3.1 US Centers for Disease Prevention and 2 Control surgical wound classi /f_i cation. Class I Uninfected operative wounds No in /f_l ammation is encountered Clean Respiratory, alimentary, genital or uninfected urinary tracts are not entered Primarily closed and, if necessary, drained using a closed system Respiratory, alimentary, genital or urinary Class II tracts are entered under controlled conditions Clean– and without unusual contamination contaminated No evidence of infection or major break in technique is encountered Class III Open, fresh, accidental wounds Operations with major br eaks in sterile Contaminated technique (e.g. open cardiac massage) or gross spillage fr om the gastrointestinal tract Incisions in which acute, non-purulent in /f_l ammation is encountered Class IV Old traumatic wounds with retained devitalised tissue and those that involve Dirty existing clinical infection or perforated viscera

/uni25CF American Society of Anesthesiologists score ≥ 3; /uni25CF operative time longer than the expected duration for simi lar procedures (>75th percentile). Summary box 3.3 Synopsis of wound classification systems /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Aetiology Complexity Clean, surgical Simple Shearing or degloving Complex Crush Signi /f_i cant soft-tissue loss Blast Open fracture or joint Burn (thermal, electrical, chemical, radiation, Visceral involvement mechanical) Complicated Cold injury Infection Avulsion or traction Necrosis Low or high energy Haematoma Bite Gas gangrene Depth Compartment syndrome Epidermal Dermal (super /f_i cial or Chronic deep) Vascular ulcers (venous or arterial) Full thickness Contamination Pressure ulcers Clean Diabetic ulcers Clean–contaminated Contaminated Dirty Implant or non-implant

CLASSIFICATION OF WOUNDS

Wounds are diverse and there is no standard classification system that incorporates all relevant aspects for di ff erent clinical contexts. A wide variety of classifications ( Summary box 3.3 are used and descriptors from more than one system are required to accurately describe a given wound. A widely accepted wound classification was first introduced 1 to describe the in 1964 by the US National Research Council degree of bacterial load or contamination of surgical wounds ). at the time of surgery . It was subsequently adapted by the 2 US Centers for Disease Prevention and Control to classify wounds as clean, clean–contaminated, contaminated and dirty ( Table 3.1 ). Although the simplicity of this classification has led to its widespread use, the definitions are not entirely clear 3,4 and low interobserver reliability has been reported. Various grading and scoring systems exist for specific condi - tions such as pressure ulcers and diabetic ulcers. The National Nosocomial Infections Surveillance (NNIS) score is commonly used to predict surgical site infections (SSIs). It was established in recognition of the e ff ectiveness of infection surveillance in 5 reducing SSIs. The NNIS score stratifies surgical wound infec - tion rates by risk factors. This risk index score ranges from 0 (lowest SSI risk) to 3 (highest SSI risk) with a point allocated for the presence of each of the following risk factors: )

Figure 3.5 Multiple keloid scars. TABLE 3.1 US Centers for Disease Prevention and 2 Control surgical wound classi /f_i cation. Class I Uninfected operative wounds No in /f_l ammation is encountered Clean Respiratory, alimentary, genital or uninfected urinary tracts are not entered Primarily closed and, if necessary, drained using a closed system Respiratory, alimentary, genital or urinary Class II tracts are entered under controlled conditions Clean– and without unusual contamination contaminated No evidence of infection or major break in technique is encountered Class III Open, fresh, accidental wounds Operations with major br eaks in sterile Contaminated technique (e.g. open cardiac massage) or gross spillage fr om the gastrointestinal tract Incisions in which acute, non-purulent in /f_l ammation is encountered Class IV Old traumatic wounds with retained devitalised tissue and those that involve Dirty existing clinical infection or perforated viscera

/uni25CF American Society of Anesthesiologists score ≥ 3; /uni25CF operative time longer than the expected duration for simi lar procedures (>75th percentile). Summary box 3.3 Synopsis of wound classification systems /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Aetiology Complexity Clean, surgical Simple Shearing or degloving Complex Crush Signi /f_i cant soft-tissue loss Blast Open fracture or joint Burn (thermal, electrical, chemical, radiation, Visceral involvement mechanical) Complicated Cold injury Infection Avulsion or traction Necrosis Low or high energy Haematoma Bite Gas gangrene Depth Compartment syndrome Epidermal Dermal (super /f_i cial or Chronic deep) Vascular ulcers (venous or arterial) Full thickness Contamination Pressure ulcers Clean Diabetic ulcers Clean–contaminated Contaminated Dirty Implant or non-implant

CLASSIFICATION OF WOUNDS

Wounds are diverse and there is no standard classification system that incorporates all relevant aspects for di ff erent clinical contexts. A wide variety of classifications ( Summary box 3.3 are used and descriptors from more than one system are required to accurately describe a given wound. A widely accepted wound classification was first introduced 1 to describe the in 1964 by the US National Research Council degree of bacterial load or contamination of surgical wounds ). at the time of surgery . It was subsequently adapted by the 2 US Centers for Disease Prevention and Control to classify wounds as clean, clean–contaminated, contaminated and dirty ( Table 3.1 ). Although the simplicity of this classification has led to its widespread use, the definitions are not entirely clear 3,4 and low interobserver reliability has been reported. Various grading and scoring systems exist for specific condi - tions such as pressure ulcers and diabetic ulcers. The National Nosocomial Infections Surveillance (NNIS) score is commonly used to predict surgical site infections (SSIs). It was established in recognition of the e ff ectiveness of infection surveillance in 5 reducing SSIs. The NNIS score stratifies surgical wound infec - tion rates by risk factors. This risk index score ranges from 0 (lowest SSI risk) to 3 (highest SSI risk) with a point allocated for the presence of each of the following risk factors: )

Figure 3.5 Multiple keloid scars. TABLE 3.1 US Centers for Disease Prevention and 2 Control surgical wound classi /f_i cation. Class I Uninfected operative wounds No in /f_l ammation is encountered Clean Respiratory, alimentary, genital or uninfected urinary tracts are not entered Primarily closed and, if necessary, drained using a closed system Respiratory, alimentary, genital or urinary Class II tracts are entered under controlled conditions Clean– and without unusual contamination contaminated No evidence of infection or major break in technique is encountered Class III Open, fresh, accidental wounds Operations with major br eaks in sterile Contaminated technique (e.g. open cardiac massage) or gross spillage fr om the gastrointestinal tract Incisions in which acute, non-purulent in /f_l ammation is encountered Class IV Old traumatic wounds with retained devitalised tissue and those that involve Dirty existing clinical infection or perforated viscera

/uni25CF American Society of Anesthesiologists score ≥ 3; /uni25CF operative time longer than the expected duration for simi lar procedures (>75th percentile). Summary box 3.3 Synopsis of wound classification systems /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Aetiology Complexity Clean, surgical Simple Shearing or degloving Complex Crush Signi /f_i cant soft-tissue loss Blast Open fracture or joint Burn (thermal, electrical, chemical, radiation, Visceral involvement mechanical) Complicated Cold injury Infection Avulsion or traction Necrosis Low or high energy Haematoma Bite Gas gangrene Depth Compartment syndrome Epidermal Dermal (super /f_i cial or Chronic deep) Vascular ulcers (venous or arterial) Full thickness Contamination Pressure ulcers Clean Diabetic ulcers Clean–contaminated Contaminated Dirty Implant or non-implant