Wound healing Practice Questions

Q: A 35-year-old woman with known deficiency in Ehlers-Danlos syndrome presents with recurrent wound dehiscence following multiple abdominal surgeries. Genetic testing confirms a mutation affecting type III collagen synthesis. She now requires another laparotomy for adhesive bowel obstruction. The surgical team must decide on closure technique. Synthesizing knowledge of collagen biochemistry and surgical principles, which approach best addresses her specific wound healing defect?

Retention sutures with permanent mesh reinforcement. ***Retention sutures with permanent mesh reinforcement*** - In patients with **Vascular Ehlers-Danlos syndrome (Type IV)**, deficiency in **Type III collagen** results in inherently weak connective tissue that never reaches normal tensile strength. - **Retention sutures** distribute tension across a larger surface area, and **permanent mesh** provides life-long mechanical reinforcement to compensate for the permanent **collagen synthesis defect**. *Vacuum-assisted closure followed by skin grafting* - While useful for infected wounds, this approach does not provide the **structural integrity** required to prevent future dehiscence or incisional hernias. - **Skin grafts** do not address the primary issue of **fascial weakness** and tensile failure in deep tissue layers. *Standard layer closure with permanent sutures only* - Standard techniques are insufficient because the patient's tissues are too **fragile** to hold individual sutures under the stress of abdominal pressure. - Permanent sutures may "cheese-wire" through the weak **collagen-deficient fascia**, leading to immediate or early **wound dehiscence**. *Delayed primary closure after 5-7 days* - This technique is primarily used to reduce **surgical site infection** risk in contaminated wounds but does not alter the biochemical quality of collagen. - It fails to address the fundamental problem of **poor wound healing** and mechanical fragility seen in **Ehlers-Danlos syndrome**. *Biological mesh with early suture removal* - **Biological meshes** are designed to be resorbed and replaced by host collagen, which in this patient would still be defective **Type III collagen**. - **Early suture removal** is contraindicated as these patients require prolonged or permanent mechanical support due to delayed and **incomplete wound maturation**.

Q: A 58-year-old man with chronic kidney disease (creatinine 4.2 mg/dL) and uremia undergoes arteriovenous fistula creation for dialysis access. Four weeks postoperatively, the wound continues to show poor healing with minimal tensile strength. Laboratory studies show elevated blood urea nitrogen. Considering the multiple factors affecting wound healing in uremia, evaluate which intervention would most comprehensively address the wound healing deficit?

Initiation of hemodialysis to reduce uremia. ***Initiation of hemodialysis to reduce uremia*** - **Uremia** inhibits wound healing by impairing **fibroblast proliferation**, **collagen synthesis**, and **neoangiogenesis**, thus reducing the **tensile strength** of the wound. - Initiating **hemodialysis** directly reduces the concentration of **uremic toxins**, which is the most comprehensive way to reverse the cellular and metabolic dysfunction hindering the healing process. *Systemic corticosteroid therapy to reduce inflammation* - **Corticosteroids** actually impair wound healing further by inhibiting **inflammatory cells**, **angiogenesis**, and **fibroblast activity**. - Using them in a uremic patient would increase the risk of **wound dehiscence** and **infection**, rather than improving healing outcomes. *High-dose vitamin C and zinc supplementation* - While **vitamin C** and **zinc** are essential for **collagen cross-linking**, supplementation alone cannot overcome the broad systemic inhibitory effects of **uremic toxins**. - These nutrients are only beneficial if a documented **deficiency** exists and do not address the primary pathophysiology of **uremic wound failure**. *Hyperbaric oxygen therapy sessions* - **Hyperbaric oxygen** therapy is primarily indicated for **hypoxic wounds** or **chronic non-healing ulcers** in diabetic patients with vascular compromise. - It does not address the metabolic inhibition caused by **uremia** and would be an inappropriate and expensive primary intervention in this clinical scenario. *Local application of platelet-derived growth factor* - **Growth factors** are specialized interventions that target specific signaling pathways but do not correct the **environment of uremia** that suppresses overall cell function. - Without addressing the patient's **azotemia**, the local cellular response to exogenous **PDGF** remains blunted and ineffective.

Question 1

A 45-year-old woman presents to the emergency department with sudden-onset tearing chest pain radiating to her back. She has a history of hypertension and is a current smoker. Blood pressure is 178/96 mmHg in the right arm and 142/80 mmHg in the left arm. Heart rate is 96 bpm. She is diaphoretic but alert and oriented. Chest radiograph shows a widened mediastinum. CT chest with IV contrast demonstrates a Stanford Type A aortic dissection with an intimal flap involving the ascending aorta. After initiating IV beta-blockade for immediate heart rate and blood pressure control, which of the following is the most appropriate next step in definitive management?

Accepted Answer

Emergent cardiothoracic surgery consultation for operative repair

Answer

Initiate IV labetalol to achieve a heart rate below 60 bpm and systolic BP below 120 mmHg

Answer

Administer IV thrombolytics and admit to the cardiac care unit

Answer

Perform urgent transesophageal echocardiography to confirm the diagnosis

Answer

Arrange for endovascular thoracic aortic stent grafting as the primary intervention

Question 2

A 42-year-old man sustains a deep laceration requiring surgical debridement. The wound care team debates between primary closure versus healing by secondary intention. The wound is 6 cm long, 2 cm wide, located on the lower leg with mild contamination from soil exposure, and the patient is a heavy smoker with peripheral vascular disease. Evaluate which approach best synthesizes the risk-benefit analysis for optimal outcome?

Accepted Answer

Delayed primary closure after 3-5 days of wound observation

Answer

Skin grafting after granulation tissue formation

Answer

Immediate primary closure with prophylactic antibiotics

Answer

Healing by secondary intention with negative pressure therapy

Answer

Primary closure with tension-relieving retention sutures

Question 3

A 35-year-old woman with known deficiency in Ehlers-Danlos syndrome presents with recurrent wound dehiscence following multiple abdominal surgeries. Genetic testing confirms a mutation affecting type III collagen synthesis. She now requires another laparotomy for adhesive bowel obstruction. The surgical team must decide on closure technique. Synthesizing knowledge of collagen biochemistry and surgical principles, which approach best addresses her specific wound healing defect?

Accepted Answer

Retention sutures with permanent mesh reinforcement

Answer

Vacuum-assisted closure followed by skin grafting

Answer

Standard layer closure with permanent sutures only

Answer

Delayed primary closure after 5-7 days

Answer

Biological mesh with early suture removal

Question 4

A 58-year-old man with chronic kidney disease (creatinine 4.2 mg/dL) and uremia undergoes arteriovenous fistula creation for dialysis access. Four weeks postoperatively, the wound continues to show poor healing with minimal tensile strength. Laboratory studies show elevated blood urea nitrogen. Considering the multiple factors affecting wound healing in uremia, evaluate which intervention would most comprehensively address the wound healing deficit?

Accepted Answer

Initiation of hemodialysis to reduce uremia

Answer

Systemic corticosteroid therapy to reduce inflammation

Answer

High-dose vitamin C and zinc supplementation

Answer

Hyperbaric oxygen therapy sessions

Answer

Local application of platelet-derived growth factor

Question 5

A 50-year-old woman undergoes wide local excision of a melanoma from her back. The pathologist reports that the wound healing specimen shows granulation tissue with parallel capillary loops perpendicular to the wound surface, active fibroblast proliferation, and myofibroblast presence causing wound contraction. Analysis of these findings indicates the wound is in which phase, and what is the primary cellular source of the contractile forces?

Accepted Answer

Late proliferative phase; contractile forces from myofibroblasts

Answer

Mid-proliferative phase; contractile forces from pericytes

Answer

Early proliferative phase; contractile forces from smooth muscle cells

Answer

Early remodeling phase; contractile forces from fibroblasts

Answer

Late inflammatory phase; contractile forces from macrophages

Wound healing — MCQs

Wound healing — MCQs

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