Granulating wounds. Granulation tissue - young connective tissue formed during wound healing Excessive granulation in the wound that

One of the phases of healing of damaged tissue is wound granulation. A wound is a violation of the integrity of the skin, muscles, bones or internal organs. The type of wound complexity varies depending on the degree of damage. On this basis, the doctor makes a prognosis, prescribes treatment. A huge role in the healing process is played by granulation tissue, which is formed during wound healing. How is it formed, what is it? Let's take a closer look.

What does granulation tissue look like?

Granulation tissue is called young connective tissue. It develops during the healing of a wound, ulcer, with the encapsulation of a foreign body.

Healthy, normal granulation tissue is pink-red, granular, and firm in texture. A cloudy grayish-white purulent exudate is separated from it in small quantities.

Such tissue arises at the borders between the dead and the living, after being wounded on the 3-4th day. The granulation tissue consists of many granules that are closely pressed to each other. They include: amphora substances, loop-shaped vascular capillaries, histiocytes, fibroblasts, polyblasts, lymphocytes, multinuclear wandering cells, argyrophilic fibers and segmented leukocytes, collagen fibers.

Formation of granulation tissue

Already after two days, on areas free of blood clots and necrotic tissue, pink-red nodules can be seen - the size of a millet grain granule. On the third day, the number of granules increases significantly, and already on the 4-5th day, the surface of the wound is covered with young granulation tissue. Well, this process is noticeable on an incised wound.

Healthy strong granulations of a pinkish-red color, they do not bleed, have a uniform granular appearance, a very dense texture, emit a small amount of purulent cloudy exudate. It contains a large number of dead cellular elements of the local tissue, purulent bodies, erythrocyte impurities, segmented leukocytes, one or another microflora with its own waste products. Cells of the reticuloendothelial system, white blood cells migrate into this exudate, vascular capillaries and fibroblasts also grow here.

Due to the fact that in the gaping wound it is impossible for the newly formed capillaries to connect with the capillaries of the opposite side of the wound, they, bending, form loops. Each of these loops is a framework for the above cells. Each new granule is formed from them. Every day, the wound is filled with new granules, so the entire cavity is completely contracted.

Layers

The layers of granulation tissue are separated:

on superficial leukocyte-necrotic;
the layer of granulation tissue itself;
fibrous deep layer.

Over time, the growth of capillaries and cells declines, and the number of fibers increases. Granulation tissue begins to turn first into fibrous, and then into scar tissue.

The main role of granulation tissue is barrier functions, it prevents microbes, toxins, decay products from entering the wound. It inhibits the vital activity of microbes, liquefies toxins, binds them, and helps to reject necrotic tissues. Granulations fill the cavity of the defect, wound, a tissue scar is created.

wound healing

Granulations are always formed at the boundaries between living and dead tissue. They form faster when there is good blood circulation in the damaged tissue. There are cases when granulations are formed at different times, develop unevenly. It depends on the amount of dead cells in the tissue and the timing of their rejection. The faster the granulation occurs, the faster the wound healing. After cleansing the wound of dead tissue and inflammatory exudate, the granulation layer becomes clearly visible. Sometimes in medical practice, the removal of granulation tissue is required, most often this is used in dentistry for gingivotomy (gingival incision).

If there are no reasons preventing healing, the entire wound cavity is filled with granulation tissue. When the granulations reach the level of the skin, they begin to decrease in volume, become slightly paler, then covered with skin epithelium, which grows from the periphery to the center of the damage.

Healing by primary and secondary intention

Wound healing can occur by primary or secondary intention, depending on their nature.

Primary tension is characterized by a reduction in the edges of the wound due to the connective tissue organization of granulation. It firmly connects the edges of the wound. After the initial tension, the scar remains almost invisible, smooth. Such tension is able to tighten the edges of a small wound if the opposite sides are at a distance of no more than one centimeter.

Secondary tension is characteristic of the healing of large wounds, where there are many non-viable tissues. Significant defects or all purulent wounds pass the way of healing by secondary intention. Differing from the primary type, the secondary tension has a cavity, which is filled with granulation tissue. The scar after secondary tension has a pale red color, protrudes slightly beyond the surface of the skin. As the vessels gradually thicken in it, fibrous and scar tissue develops, keratinization of the skin epithelium occurs, the scar begins to turn pale, becomes denser and narrower. Sometimes scar hypertrophy develops - this is when an excess amount of scar tissue is formed.

Healing under the scab

The third type of wound healing is the simplest - the wound heals under the scab. This is typical for minor wounds, damage to the skin (abrasions, scratches, abrasions, burns of the 1st, 2nd degree). The scab (crust) on the surface of the wound is formed from the blood that has coagulated there, lymph. The role of the scab is a protective barrier that protects the wound from infection, under this shield skin regeneration occurs. If the process goes well, no infection has got in, after healing, the crust leaves without a trace. There is no sign left on the skin that a wound was once present here.

Pathologies of granulation

If the wound process is disturbed, pathological granulations may form. Possible insufficient or excessive growth of granulation tissue, disintegration of granulations, premature sclerosis. In all these cases, and if the granulation tissue bleeds, special treatment will be required.

The development of granulations and epithelialization processes fade away if there are such unfavorable factors as deterioration in blood supply, decompensation of any systems and organs, oxygenation, repeated purulent process. In these cases, granulation pathologies develop.

The clinic is as follows: there is no wound contraction, the appearance of the granulation tissue changes. The wound looks pale, dull, loses turgor, becomes cyanotic, covered with a coating of pus and fibrin.

Tuberous granulations are also considered pathological when they protrude beyond the edges of the wound - hypergranulations (hypertrophic). Hanging over the edges of the wound, they impede the process of epithelialization. In these cases, they are cauterized with concentrated solutions of potassium permanganate or silver nitrate. The wound continues to be treated by stimulating epithelialization.

Importance of granulation tissue

So, summing up, we highlight the main roles played by granulation tissue:

Replacement of wound defects. Granulation - plastic material that fills the wound.
Protection of the wound from foreign bodies, penetration of organisms, toxins. This is achieved due to the large number of leukocytes, macrophages, as well as a dense structure.
Rejection and sequestration of necrotic tissue. The process is facilitated by the presence of macrophages, leukocytes, as well as proteolytic enzymes that secrete cellular elements.
In the normal course of healing, epithelialization begins simultaneously with granulation. Granulation tissue is transformed into coarse fibrous tissue, then a scar is formed.

Wound healing of various areas and organs, similar in general characteristics, proceeds according to general patterns, but their morphological characteristics vary depending on the nature of the damage, the size of the defect, the presence of infection, etc.

According to long ago rooted According to ideas, wound healing is carried out in two ways: according to the type of primary and according to the type of secondary intention. Both of them lead to the replacement of the defect with young connective tissue, which later acquires the character of cicatricial tissue, and nevertheless, both of these processes not only quantitatively, but also qualitatively differ from each other (IV Davydovsky, 1959). Each of them is preceded by a different state of the tissue, especially with regard to the nature of the inflammation that always accompanies the wound process; they have a different length in time, and the young connective tissue that arises during this period has functional and structural differences. Not all young connective tissue is granulation; the latter characterizes only the secondary intention and is not typical for the primary tension of wounds.

This classification is more complete and is now widely used by everyone. Usually the hole is on the outside. There is a slight lesion of the soft parts. It is especially characterized among sportsmen and military men. Most often the tibial segment. This is due to unusual, intense and repetitive restrictions. In this case, bone scan, which is very sensitive, shows localized hyperfixation. Fracture stage or actual fracture of fatigue, when acute facultative pressure pain occurs, inability to continue sports activities.

Primary Tension presents is a process of organization (that is, replacement by connective tissue) of the contents of the wound channel (blood clots, partly necrotic masses that have not undergone decay - I. E. Esipova, 1964).

The condition of the tissues pre-primary tension, can be characterized as serous inflammation or traumatic edema, accompanying to some extent each injury. Swelling of the walls of the wound channel or defect leads to their convergence and partly to the displacement of foreign bodies, that is, to mechanical cleansing of the wound. Nevertheless, in the latter there are always free masses of coagulated blood, and, consequently, fibrin, which is a nutrient medium for the development of cellular elements of the mesenchyme. The proliferation of the latter begins already at the very beginning of the wound process, that is, it coincides in time with the development of wound inflammation.

In this case, x-rays show a fracture line, associated or not with images of the bone structure. The treatment combines sports recreation, orthopedic treatment at the stage of preliminary fracture. Surgical treatment is indicated in cases of delayed consolidation, recurrence, or in the specific case of an isolated fracture of the anterior cortical tibia that has a bad reputation for non-return.

The importance of the meniscus in articular and well-known physiology. General menisectomy includes the onset of well-known articular degenerative phenomena. Currently, most of the sightings of a syringe in the meniscus are as follows. While contraindications are presented.

Wound inflammation presents is the first step in the wound healing process. Its morphological manifestations include the expansion of the vascular network in the circumference of the wound, the phenomena of exudation and edema of the edges of the wound defect, leukocyte infiltration. Active expansion of arterioles occurs very quickly, almost instantly, and the closer to the edge of the wound, the more pronounced it is. The venules also dilate in the early period. Capillaries react somewhat later (F. Marchand, 1901).

Vascular disorders of systemic metabolic diseases that affect the synthesis of collagen congenital disorders of the collagen syndrome of the kidneys in the post-lateral region of the lateral meniscus. But not all meniscus injuries need to be sutured, spontaneous healing has been described. The meniscus is a suture and some warnings must be followed. The sutures should not be wide so as not to choke the synovium and therefore limit the blood supply to the meniscus. Other proposed ways to speed up and facilitate the healing process of the meniscus is to reverse the synovial all internal leaflets of the injury before the suture, to interrupt the fibrin clot, possibly by associating it with the fascia flap in complex meniscal lesions.

Following hyperemia begins exudation of serous fluid, which impregnates the edges of the defect and penetrates the wound. On the wound surface, the exudate mixes with blood and lymph, which poured out during the injury, and with torn tissue particles. It soon collapses. This is how a scab is formed.

Leukocyte infiltration begins 2-3 hours after injury. First, in small vessels and capillaries, leukocytes located parietal are observed. Then they actively penetrate through the capillary wall. Polymorphonuclear neutrophilic leukocytes emigrate earlier than others and in greater numbers. Simultaneously with the emigration of polynuclear cells, monocytes, polyblasts, and lymphoid elements of tissue origin accumulate in the edges of the wound; further cellular elements differentiate towards macrophages, absorbing decay products, and fibroblasts.

You can use absorbable or non-absorbable wires for suturing. According to Miller, there are no significant differences in the type of seam. Meniscal cartilage requires healing over a longer period of time than other tissues; however, you don't know exactly how long a full healing lasts. Arnocki and Warren showed that scarring is complete between 8 and 12 weeks with disorganized fibrocartilaginous tissue that is mechanically and less valid than the original structure.

The seam can be done with horizontal or vertical dots. The latter are mechanically more efficient. The suture points must be evenly spaced above and below the meniscus so that the lesions are completely repaired and in contact. According to Lindelfeld, it is preferable to place suture points on the surface of the tibia, as there is no movement between the meniscus and the lamina of the tibia. According to Pouget, the dots can protrude uniformly on the two surfaces of the outer meniscus, since they are concave; in the inner meniscus, only the femoral and concave surface, therefore, it is preferable that dots be applied to it.

During 1-2 days among fibrin fibers that stick together the wound, strands of fibroblasts and crevices appear due to the drying of fibrin, which are further lined with endothelium proliferating from cut, injured vessels (I. K. Esipova, 1964). In the formation of such vessels, as well as in the very process of germination by fibroblasts, there is much in common with recanalization and the organization of blood clots.

The inside-out technique, developed by Henning and used by many authors, allows the placement of suture points under direct arthroscopic control. Use straight needles or other bending radius, single or double cannula. This method can be dangerous for neighboring noble structures, since it is not possible to perfectly control the exit point of the needle. To avoid such complications, it is recommended to make a small skin incision at the exit point of the needle, knocking out the main tissues until the capsule and follow some technical devices, recalling that the structures of the risk group are: in the middle part of the nerve and saphenous vein, which side is the common peroneal nerve, posterior-laterally to the popliteal artery, some authors use a femoral distractor for augmentation. joint space, which improves endocytic vision, facilitates suture tissue, and reduces the risk of cartilage damage.

As it germinates fibrinous masses fibroblasts, fixing the edges of the wound instead of fibrinous gluing, the latter (fibroblasts) are gradually replaced by collagen and argyrophilic fibers, which are much more than cellular elements, already in the early period of wound healing. This is what distinguishes the contents of a wound that heals by primary intention from granulations, which are characterized by a long-term predominance of cells over the paraplastic substance.

The external technique was proposed by Warren and was less used than the previous one. Small incision 10 mm. practiced after medially in the lesion. The capsule is cut through the skin incision, and then a special cannula needle is pulled into the capsule, so that under arthroscopic control it penetrates the joint at the posterior end of the lesion, and then crosses the flap to the desired point. The suture wire is inserted into the extra-articular end of the needle and glided until it appears at the intra-arterial junction.

The second needle is first inserted first with the same technique so that it crosses the lesion to 6-7 mm. from this. A special spindle with an end "metal end" is introduced inside. The wire passes through a metal bend that retracts outward from the joint, carrying it along with the filament itself. The two ends of the thread, as extracapsular, are then stretched and tied.

By the end of 5-7 days phagocytosis and resorption of dead tissue elements ends, the wound gap is filled with young connective tissue. At the same time, the regeneration of nerve fibers begins. Wound epithelialization occurs quickly, since wounds glued with fibrin and fibroblasts reduce the defect, the conditions for epithelization are favorable.

The operation is repeated several times until the seam is completed. When using the all-in-one method, the risks of damage to the neurovascular side are canceled, since the suture is completely intracapsulated. The method uses an appropriate instrument, consisting of curved needles that pass through the meniscus of the lesion without exceeding the capsule, and instruments that allow "knotting all" expansion of the hinged wires. This method is suitable for the most central meniscus lesions.

Postoperative treatment of meniscal sutures, as can be seen from the literature in this regard, is very diverse. Avoid exercise over 90° for 3 months. Scott immobilizes the knee at 30° flexion by stretching the load for two months to cancel the shear forces acting on the meniscus. After the third month and allowed to use the bike, race after 5-6 months, sports recovery after 9-12 months.

During wound healing primary intention and healing under the scab, which fundamentally differs little from healing by primary intention, all processes of reparative regeneration occur in the depth of the wound, that is, below the level of its edges, which also distinguishes primary intention from healing by secondary intention.

Knee removal after 8 weeks. Partial load at 4 weeks, total load at 6 weeks, muscle improvement at 8 weeks, stallion at 9 weeks, squat at 4 months, race at 5 months, sport at 6 months. Jacob turns white at 30° for 5-6 weeks. with partial load. Morgan is immobilized for 4 weeks at full stretch, because in this position he has the best healing of injuries and gives immediate loading.

Partial load for 6 weeks with retractable knee. In case of unstable damage, such as bucket handles, rehabilitation protocol and more careful: reduction from 20 ° to 70 ° C for 1 month without load, car racing straight for 4-5 months, winding and jumping up to 7-8 months. Sommerlat, in a 7-year review of arthrotocomic sutures, ends with a recommendation for early functional rehabilitation in order not to have a flexible expansion deficit.

What does granulation tissue look like?

Granulation tissue is called young connective tissue. It develops during the healing of a wound, ulcer, with the encapsulation of a foreign body.

Healthy, normal granulation tissue is pink-red, granular, and firm in texture. A cloudy grayish-white purulent exudate is separated from it in small quantities.

This patient was again operated on with a meniscal suture and then immobilized for 6 weeks, thus healing. Partial load for 5 weeks with retractable knee. In the case of unstable injuries such as dental pens, the most reassuring and cautious protocol is flexion between 10° and 80° for 1 month without loading and then partial loading for another 30 days. Complete motion capture in the first 3 months.

We did not use orthopedic surgeons except in special cases. We advise you to resume straight line racing no earlier than 3 months and to play sports no earlier than 6 months later. The results of meniscal sutures described in the literature are not uniform in type of lesion, associated lesions, surgical technique, postoperative management, and remote evaluation. The results of arthrotomic sutures of the menstrual cycle are superimposed on the results of arthroscopic sutures. Crashes are more likely to occur in unstable knees.

Their incidence and 13% according to Ryu. The importance of the knee menu is known to everyone and does not require any confirmation. Similarly, it is well known that meniscus suture, when possible, is preferable to meninctomies, albeit partial ones. Some authors have shown that there is no difference in response. mechanical stresses between healthy and sutured meniscus good results of meniscus sutures persist for a long time, this is confirmed by a low percentage of articular degenerative phenomena, as the stone claims, which brings in 75% of cases, in the absence of signs of Fairbank distance four years after meniscus sutures.

Formation of granulation tissue

In terms of results, there are no differences between arthrosomal and arthroscopic sutures; however, postoperative and minor pain symptoms in arthroscopic sutures, as well as minor ones, are problems associated with wound healing. This results in the patient being able to recover faster and faster, with fewer disruptions. The arthroscopic technique, which we prefer, allows more accurate diagnosis of the lesion and the possibility of repairing these central lesions without suture by arthrotomy.

This may be due to endoscopic reconstruction of the anterior cruciate ligament without the need to practice arthrotomy. Ultimately and by far the most aesthetic benefit. On the one hand, it has undeniable advantages, it does not avoid neuro-vascular complications, but it is easily avoided with some technical details. In posterior horn swords, a small skin incision must be made to reach the capsule to prevent such complications. On the lateral side, it is preferable to identify and protect the peripheral nerve.

The most difficult period for the purse-string suture of the meniscus is understood in the first weeks after interventions in the early stages of rehabilitation until complete healing is achieved. Vertical lesions have the best results. All authors agree that ligamentous location, especially the frontal pectinate ligament, is a fundamental requirement for the success of mandisk sutures. Rosenberg reports a complete healing rate of 96% for stable knee sutures versus 33% for an unstable knee. The Crusader must be reconstructed with an intra-articular plasty.

Layers

The layers of granulation tissue are separated:

on superficial leukocyte-necrotic;
the layer of granulation tissue itself;
fibrous deep layer.

Over time, the growth of capillaries and cells declines, and the number of fibers increases. Granulation tissue begins to turn first into fibrous, and then into scar tissue.

wound healing

Healing by primary and secondary intention

Wound healing can occur by primary or secondary intention, depending on their nature.

Healing under the scab

Pathologies of granulation

Importance of granulation tissue

So, summing up, we highlight the main roles played by granulation tissue:

Replacement of wound defects. Granulation - plastic material that fills the wound.
Protection of the wound from foreign bodies, penetration of organisms, toxins. This is achieved due to the large number of leukocytes, macrophages, as well as a dense structure.
Rejection and sequestration of necrotic tissue. The process is facilitated by the presence of macrophages, leukocytes, as well as proteolytic enzymes that secrete cellular elements.
In the normal course of healing, epithelialization begins simultaneously with granulation. Granulation tissue is transformed into coarse fibrous tissue, then a scar is formed.

In response to injury to body tissues, a complex mechanism is launched to restore the previous functioning and integrity of organ systems. This process is called tissue regeneration. There are three stages in the development of this mechanism. Their duration is individual for each person and directly depends on his age and the state of the immune system.

The prognosis of the healing time of a particular injury is also made on the basis of observations of the nature of the injury and depends on its severity. All types of wounds are divided into two types according to the depth of damage:

Simple - the integrity of the skin, adipose tissue, as well as the structure of adjacent muscles is violated.
Complex wounds are characterized by damage to internal organs, large veins and arteries, and bone fractures.

The stages of regeneration are the same for any damage, regardless of its origin and type.

Shulepin Ivan Vladimirovich, traumatologist-orthopedist, highest qualification category

The total work experience is more than 25 years. In 1994 he graduated from the Moscow Institute of Medical and Social Rehabilitology, in 1997 he completed residency in the specialty "Traumatology and Orthopedics" at the Central Research Institute of Traumatology and Orthopedics named after I.I. N.N. Prifova.

All systems of human organs have the ability to restore the structure. However, the rate of their regeneration is different. In case of damage, the skin is especially quickly restored. Reparative changes in other systems take much longer.

Interesting fact! Until recently, scientists were sure that nerve endings do not have the ability to recover. But modern research has proven that the CNS produces new neurons, albeit extremely slowly.

The following phases of reparative regeneration of damaged tissues are distinguished:

Inflammatory stage;
granulation stage;
Stage of scar formation;

Each of these phases has pronounced external manifestations, gradually replacing each other as the wound heals.

Features of the course of the stage of inflammation

Immediately after the violation of the integrity of the tissues, a complex enzymatic mechanism is launched, leading to blood clotting and cessation of bleeding. There are two stages in this process:

Primary hemostasis It is characterized by a sharp narrowing of the vessels in the damaged area and mechanical clogging of the torn capillary walls by platelet aggregates, which form a kind of plug. The average time for this phase is 3 minutes.
Secondary hemostasis proceeds with the participation of the fibrin protein, which forms blood clots and thickens the blood. As a result of its formation, the blood will change its consistency, becoming curdled, and lose its fluidity. The process of fibrin clot formation takes 10-12 minutes.

Depending on the depth of the damage and the nature of the bleeding, I put stitches on the wound or are limited to a bandage. If the injured area was not infected with pathogenic microflora, after the bleeding stops, gradual tissue regeneration begins.

External manifestations of the stage of inflammation:

Puffiness. It arises as a result of increased release of plasma of destroyed cells into the intercellular space.
Local rise in temperature. Injury to tissues leads to a sharp violation of blood circulation, which leads to a change in the temperature balance.
Redness of the damaged area. This phenomenon is also explained by changes in microcirculation and an increase in the permeability of capillary walls.

Usually the phase of inflammation proceeds within 5-7 days.

All sutures are removed after it is completed, if there are no purulent discharges and there are clear signs of healing of the injured area. Gradually, the formation of new tissues begins, and the recovery process flows into the granulation stage.

Characteristics of the granulation stage

The inflammatory reaction characteristic of the damaged area is replaced by the processes of wound cleansing and exfoliation of dead cells. At the same time, granulation tissue is formed. Its formation begins at the periphery of the wound, and only then does the neoplasm reach the center of the injured area.

Restorative processes are actively going on in the young tissue, primarily the growth of new capillaries. They reach the wound surface, and then, forming loops, return deep into the tissue. The damaged surface becomes grainy, bright red. Due to its appearance, the tissue was called granulation tissue.

The appearance of the granulation cover may vary depending on the location of the injury. On the skin and mucous membranes, it looks like a soft-grained, red area, the surface of which is often covered with plaque. In the thickness of the internal organs, granulation tissue is easily recognizable by its rich color and larger structure.

The newly formed tissue is very delicate, with a careless touch, bleeding can be easily caused due to the large number of capillaries that form.

Interesting! There are no nerve endings in the thickness of the granulation formation, so touching it does not cause pain.

The granulation tissue lining the wound consists of six distinct layers:

Leukocyte-necrotic layer. Formed from sloughing cells. Covers the wound for a long time until the scar is completely formed.
layer of blood vessels and capillaries. If wound healing is delayed, thick collagen fibers are formed in this layer, which are parallel to the surface of the damaged area.
Layer of vertical vessels. The capillaries of this layer are surrounded by amorphous tissue. Fibroblasts are actively synthesized in it - cells that form connective tissue fibers.
maturation layer. It develops cells that form the basis of the surface layers. Here, the fibroblasts formed in the deep layers take their final shape.
The layer of horizontal fibroblasts increases as the wound heals. Consists of young fibroblasts and a large number of collagen fibers.
The fibrous layer is a barrier that protects the internal environment of the body from external factors. It has pronounced bactericidal properties, blocks the effects of pathogens.

The main role in the formation of granulation formation belongs to fibroblasts - cells involved in the synthesis of collagen. With sufficient accumulation, the granulation stage passes into a new phase - the formation of a scar.

Stages of wound healing. Visual picture. Daily photo report for two weeks

Scar formation stage

The longest phase of the wound healing process.

It takes about a year to form a dense scar.

Initially, it retains a rich red color, but then acquires a skin color. This is due to a decrease in the number of blood vessels in the connective tissue after the completion of the wound granulation stage.

Interesting! The density of scar tissue is very high. It makes up more than 80% of the density of healthy skin.

However, the newly formed tissue does not have the ability to stretch. Formed on the skin in the area of the joints, it can interfere with the normal flexion of the limbs, leading to limited mobility of the individual.

The duration of each phase of healing depends on many factors. The age of the patient has the greatest influence. Observations have shown that the stage of formation of the cicatricial phase passes much faster in children of the prepubertal period.

Infection of the wound leads to an increase in the healing time. Weak immunity, disease patients also have a negative impact on the regeneration process.

Importance of the granulation phase for tissue repair

The granulation stage of new tissue formation is a complex process in which several groups of cells take part. It consists of:

Plasma cells are cells that synthesize antibodies, which, in turn, are responsible for the body's immune response.
Histiocytes. They perform a protective function, inactivating foreign objects that enter the newly formed tissue layer.
Fibroblasts responsible for secreting the collagen precursor protein.
Leukocytes - protect the body from any pathogenic agents.
Mast cells are one of the components of the formed connective tissue.

The entire cycle of maturation of granulation tissue takes 20-30 days.

It should be remembered that this is a temporary formation that will be replaced by dense scar tissue. Most of it is made up of newly formed capillaries. Over time, the thin walls of the vessels are covered with new cells, which continue to divide, forming a dense layer that tightens the site of damage.

Treatment of injured areas in the granulation phase

Granulation tissue has a delicate, loose structure. It is easy to damage it by touching carelessly or carelessly changing the bandage. When treating a wound, you should be as careful as possible.

It is not allowed to wipe the surface of the damaged area with cotton pads, swabs.

Only irrigation of the wound with warm bactericidal solutions is permissible. There are several types of treatment for injured tissue:

Physiotherapy;
medication;
Treatment at home;

When choosing a method of treatment, it is necessary to take into account the nature of the wound, as well as the characteristics of its healing.

Physiotherapy treatment method

Of the specific ways to accelerate regeneration, one should single out the method ultraviolet irradiation. When it is used, the surface of the damaged area is cleansed of pathogenic microflora, and the regeneration processes are significantly accelerated. This method will be especially relevant for slowly forming, sluggishly granulating tissue. Indications for the use of radiation:

wound infection;
Profuse purulent discharge;
Weakened immunity and, as a result, a violation of the mechanisms of reparation;

However, other methods of treatment are used to speed up the healing of the injury. Most often resort to medical methods wound surface treatment.

The use of drugs at the granulation stage

Properly selected medication promotes faster epithelialization of the wound. As a rule, with hypergranulation, doctors recommend using gel forms of drugs. Whereas with excessively rapid drying of the surface of the damaged area, ointments are used.

The main drugs used at the granulation stage:

One of the most popular drugs prescribed at this stage is Solcoseryl. Granulation of sutures, healing of damaged areas after burns and other injuries of the skin are accompanied by the appearance of unaesthetic scars. Solcoseryl contributes to the formation of a more homogeneous connective tissue, which looks much more natural.

Home treatment of a wound in the granulation phase

It is worth resorting to folk methods of treating injuries only with minor damage to the skin (minor cuts on the fingers, first-degree burns, slight frostbite).

St. John's wort oil has long been the most well-known agent that promotes cell regeneration.

To prepare the oil, 300 ml of sunflower oil are mixed with 30-50 grams of dried St. John's wort. The resulting mixture is boiled in a water bath for no more than 30 minutes.

Cooled St. John's wort oil is soaked in gauze bandages and applied to the damaged area.

Options for further development of the granulation stage

If the first and second stages of wound healing passed without complications, then gradually the damaged area is completely covered with dense scar tissue and the regeneration process is successfully completed.

However, sometimes the mechanisms of tissue repair fail. For example, there is necrosis of areas adjacent to the wound.

This condition is extremely dangerous for the patient and requires immediate surgical intervention.

A necrectomy is an operation to remove dead tissue.

If the wound is infected with pathogenic microflora, the healing process can be delayed for a long time. Antibiotics are used to restore normal tissue regeneration.

The granulation stage of healing of the damaged area is a complex adaptive mechanism aimed at the speedy separation of the internal environment of the body from adverse external influences. It provides the formation of new layers of tissue to replace the damaged ones. Thanks to the granulation stage, the trophism of the injured area is restored and other, deeper tissues are protected.

The wound healing system of our body. The most important stage of granulation.

A wound means an injury in which the skin, muscles, tendons, internal organs, bones are damaged. Usually, healing occurs in several stages, but not everyone knows what wound granulation is.

The wound healing process includes the stages of inflammation, granulation and epithelialization. In addition, healing can be with primary and secondary intention, as well as under the scab. It depends on how complex the damage is and how all the phases go, how quickly the victim will be cured.

Stages of wound healing

When healing, any wound goes through several stages:

Inflammation. The body first reacts to a wound by producing substances that clot the blood. Blood clots form that clog blood vessels. They prevent the development of severe bleeding. Further, cellular reactions occur, leading to an inflammatory process, a new tissue begins to grow - granulation, which is impossible without the participation of fibroblasts. In cases where the treatment of a wound requires suturing, they are removed after a week, but if there is tension under the suture, this can lead to a divergence of the edges of the wound. This happens because a scar has formed on the edges of the wound, and not granulation. The inflammatory stage lasts an average of 5-7 days.
Granulation wounds. With a favorable course of the healing process, a week after the injury, the stage of wound granulation begins. During the month, the damaged area continues to be filled with maturing granulation tissue, which includes inflammatory cells, connective tissue, and newly formed vessels. Successful granulation is not possible without cytokines and sufficient oxygen. Toward the end of this phase, new epithelial cells grow on the granulation tissue, and the edges of the wound are connected by a bright red scar.

Granulation tissue has a different appearance depending on the stage of its development. Normal tissue initially looks like soft-grained tissue, covered with a cloudy, gray-greenish coating, juicy, rich in thin-walled vessels, which bleeds easily. In later periods, the tissue becomes paler, denser, the granularity disappears, turning into a whitish dense scar.

The granulation tissue consists of six layers that gradually merge into each other:

superficial leukocyte-necrotic layer
superficial layer of vascular loops
layer of vertical vessels
maturing layer
layer of horizontal fibroblasts
fibrous layer

epithelialization. This stage of healing begins immediately after granulation is completed. This phase lasts for almost a year. The epithelium and connective tissue completely fills the damage space. The scar becomes brighter, because the vessels in it become much smaller than initially. As a result, the healed wound is covered with a scar, the strength of which is approximately 85% compared to healthy skin.

All these stages of wound healing are purely individual, their duration depends on many factors, including the general condition of the patient and the care of the injury.

The role of the granulation stage

Leukocytes will play not the last role in wound granulation.

So, wound granulation is a complex process in which the following types of cells take part:

leukocytes;
mast cells;
plasmacytes;
histiocytes;
fibroblasts.

A special role is played by fibroblasts, which produce the supply of collagen after the granulation reaches the edges of the wound. VARIATIONS nalichii obshipnyh gematom, DURING bolshom ckoplenii ekccydata or nekpotizatsii tkani in oblacti pacpolozheniya pany At Process pepemescheniya fibpoblactov to kpayam povpezhdeniya zamedlyaetcya chto yvelichivaet On Time, neobhodimoe for zazhivleniya.

Important! The most pronounced activity of fibroblasts is observed on the 6th day after the formation of the lesion. And the granulation process itself continues for a month.

Granulations are a temporary tissue, which, after performing its function, undergoes regression and is replaced by a scaly tissue. The morphological basis of granulation is the glomeruli of newly formed cells. The tissue growing in the process of healing of injuries envelops these vessels, increasing in volume. Outwardly, granulation looks like a delicate fabric of pink color.

The granulations formed during the healing process also perform a sanitary function, separating non-viable tissues. Similar ischemic areas of the tissue, as the wound heals, independently regress by lysing. When treating a wound surgically, non-viable tissues are removed mechanically.

Wound care at the initial stage of healing

The optimal solution for the speedy recovery of damaged tissue is the regular use of dressings. Disinfection here is carried out with solutions of potassium permanganate and hydrogen peroxide. These substances are applied in a warm form on a gauze swab. Next, a careful impregnation of the wound is performed, in which touching the damage with the hands is excluded - this can lead to the development of infections.

Treatment of injured areas in the granulation phase

Granulation tissue has a delicate, loose structure. It is easy to damage it by touching carelessly or carelessly changing the bandage. When treating a wound, you should be as careful as possible.

It is not allowed to wipe the surface of the damaged area with cotton pads, swabs.

Only irrigation of the wound with warm bactericidal solutions is permissible.

There are several types of treatment for injured tissue:

Physiotherapy;
medication;
Treatment at home;

When choosing a method of treatment, it is necessary to take into account the nature of the wound, as well as the characteristics of its healing.

Physiotherapy treatment method

Of the specific ways to accelerate regeneration, the method of ultraviolet irradiation should be distinguished. When it is used, the surface of the damaged area is cleansed of pathogenic microflora, and the regeneration processes are significantly accelerated. This method will be especially relevant for slowly forming, sluggishly granulating tissue.

Indications for the use of radiation:

wound infection;
Profuse purulent discharge;
Weakened immunity and, as a result, a violation of the mechanisms of reparation;

However, other methods of treatment are used to speed up the healing of the injury. Most often resort to medical methods of treating the surface of the wound.

The use of drugs at the granulation stage

Main drugs used in the granulation stage

Home treatment of a wound in the granulation phase

In the presence of a simple injury, in which only the superficial extreme layers of the epithelium are affected, alternative methods of treatment can be resorted to for recovery. A good solution here is the imposition of gauze bandages soaked in St. John's wort oil.

The presented method contributes to the early completion of the granulation phase and active tissue renewal. To prepare the above remedy, it is enough to take about 300 ml of refined vegetable oil and about 30-40 grams of dried St. John's wort. After mixing the ingredients, the composition should be boiled over low heat for about an hour. The cooled mass must be filtered through gauze. Then it can be used to apply bandages.

It is also possible to heal wounds at the granulation stage with the help of pine resin. The latter is taken in its pure form, rinsed with water and, if necessary, softened by gentle heating. After such preparation, the substance is applied to the damaged tissue area and fixed with a bandage.

Options for further development of the granulation stage

However, sometimes the mechanisms of tissue repair fail. For example, there is necrotization of areas adjacent to the wound.

This condition is extremely dangerous for the patient and requires immediate surgical intervention.

A necrectomy is an operation to remove dead tissue. If the wound is infected with pathogenic microflora, the healing process can be delayed for a long time. Antibiotics are used to restore normal tissue regeneration .

Surgical intervention

With a delay in the processes of granulation, the formation of deep wound passages is possible, in which an accumulation of purulent streaks is observed. In such cases, it is difficult to clean the wound due to the use of ointments and gels. The elimination of unpleasant complications most often occurs through surgical intervention. In this case, the specialist performs an incision, removes purulent accumulations, disinfects the wound, and then applies counter-openings.

Finally

So we figured it out, wound granulation - what is it? As practice shows, one of the determining conditions for accelerating the healing process is differentiated treatment. The correct selection of medications is also important. All this contributes to the speedy granulation of the damaged area and the formation of a new, healthy tissue.

Depending on the nature of the injury, the degree of development of the microflora, and the characteristics of the impaired immune response, three classical types of wound healing are considered:

Healing by primary intention,

Healing by secondary intention,

Healing under the scab.

Healing by primary intention (sanatio per primam intentionem) is the most economical and functionally beneficial, it occurs in a shorter time with the formation of a thin, relatively strong scar.

Surgical wounds heal by primary intention when the edges of the wound come into contact with each other (connected with sutures). The amount of necrotic tissue in the wound is small, the inflammation is not pronounced.

After the phenomena of inflammation subside and the wound is cleansed of non-viable cells in the regeneration phase, connective tissue adhesions are formed between the walls of the wound channel due to collagen formed by fibroblasts and germinating vessels. At the same time, there is an increase in the epithelium from the edges of the wound, which serves as a barrier to the penetration of microbes.

Incidental, superficial wounds of small size with dehiscence up to 1 cm can also heal by primary intention without suturing. This is due to the convergence of the edges under the influence of edema of the surrounding tissues, and in the future they are held by the resulting “primary fibrin adhesion”.

Thus, with this method of healing, there is no cavity between the edges and walls of the wound, and the resulting tissue serves only to fix and strengthen the fused surfaces.

Only non-infected wounds heal by primary intention: aseptic surgical or accidental wounds with minor infection, if microorganisms die within the first hours after injury.

The development of an infectious complication in the wound is facilitated by the presence of a substrate for the vital activity of microbial agents. These may be a hematoma, an abundance of necrotic tissue, the presence of a foreign body. Hematoma, in addition to a nutrient medium for microorganisms, is also a factor ensuring the absence of tight contact between the wound walls. A foreign body present in a wound can serve as a source of infection and cause a rejection reaction, accompanied by severe, long-term inflammation and necrosis of surrounding tissues.

For healing by primary intention, the absence of factors that violate the general condition of the patient and adversely affect the course of the wound process is necessary.

Thus, in order for the wound to heal by primary intention, the following conditions must be met:

No infection in the wound

Tight contact of the edges of the wound,

Absence of hematomas and foreign bodies in the wound,

The absence of necrotic tissue in the wound,

Satisfactory general condition of the patient (absence of common adverse factors).

Healing by primary intention takes place in the shortest possible time, practically does not lead to the development of complications and causes less functional changes. This is the best type of wound healing, which must always be strived for, and therefore, the necessary conditions for this must be observed.

Healing by secondary intention (sanatio per secundam intentionem) - healing through suppuration, through the development of granulation tissue. In this case, healing occurs after a pronounced inflammatory process, as a result of which the wound is cleared of necrosis.

Conditions for healing by secondary intention:

Significant microbial contamination of the wound,

Significant defect in the skin

The presence of foreign bodies in the wound, hematoma,

The presence of necrotic tissue

Unfavorable condition of the patient's body.

With secondary intention, there are also three phases of healing, each of which has certain differences.

Features of the inflammation phase

In the first period, the phenomena of inflammation are much more pronounced and the cleansing of the wound takes much longer. Phagocytosis and lysis of cells devitalized as a result of trauma or the action of microorganisms causes a significant concentration of toxins in the surrounding tissues, increasing inflammation and worsening microcirculation. A wound with an infection that has developed in it is characterized not only by the presence of a large number of microbes in it, but also by their invasion into the tissues surrounding the wound. At the border of penetration of microorganisms, a pronounced leukocyte shaft is formed. It helps to separate healthy tissues from infected ones. Gradually, demarcation, lysis, sequestration and rejection of non-viable tissues occur. The wound is gradually cleared. As the areas of necrosis melt and the decay products are absorbed, the intoxication of the whole organism increases. This is evidenced by all the common manifestations characteristic of the development of wound infection. The duration of the first phase of healing depends on the amount of damage, the characteristics of the microflora, the state of the body and its resistance. As a result, at the end of the first phase, after lysis and rejection of necrotic tissues, a wound cavity is formed and the second phase begins - the regeneration phase, the peculiarity of which is the emergence and development of granulation tissue.

The structure and functions of granulation tissue

During healing by secondary intention in the second phase of the wound process, the resulting cavity is filled with granulation tissue.

Granulation tissue (granulum - grain) is a special type of connective tissue that is formed only during wound healing by the type of secondary tension, which contributes to the rapid closure of the wound defect. Normally, without damage, there is no granulation tissue in the body.

FORMATION OF GRANULATION TISSUE

A clear boundary of the transition from the first phase to the second is usually not observed. Vascular growth plays an important role in the formation of granulations. At the same time, the newly formed capillaries, under the pressure of the blood entering them, acquire a direction from the depth to the surface and, not finding the opposite wall of the wound (as a result of the first phase, a wound cavity was formed), make a sharp bend and return back to the bottom or wall of the wound, from which they originally grew. . capillary loops are formed. In the area of these loops, shaped elements migrate from the capillaries, fibroblasts are formed, giving rise to connective tissue. Thus, the wound is filled with small granules of connective tissue, at the base of which are loops of capillaries.

Islets of granulation tissue appear in the still not completely cleansed wound, against the background of areas of necrosis as early as 2-3 days. On the 5th day, the growth of granulation tissue becomes very noticeable.

Granulation tissue can form in the wound without infection. This occurs when the diastasis between the edges of the wound exceeds 1 cm and the capillaries growing from one wall of the wound also do not reach the other and form loops.

The development of granulation tissue is the fundamental difference between healing by secondary intention and healing by primary intention.

Granulations are delicate, bright pink, fine-grained, shiny formations that can grow rapidly and bleed profusely with minor damage. Granulations develop from the walls and bottom of the wound, tending to quickly fill the entire wound defect.

STRUCTURE OF GRANULATION TISSUE

In the structure of granulation tissue, 6 layers are distinguished, each of which carries its own specific functional load.

Superficial leukocyte-necrotic layer. Consists of leukocytes, detritus and exfoliating cells. It exists during the entire period of wound healing.

layer of vascular loops. Contains, in addition to vessels, polyblasts. With a long course of the wound process, collagen fibers can form in this layer, which are located parallel to the surface of the wound.

layer of vertical vessels. It is built from perivascular elements and amorphous interstitial substance. Fibroblasts are formed from the cells of this layer. This layer is most pronounced in the early period of wound healing.

The maturing layer is essentially the deeper part of the previous layer. Here, perivascular fibroblasts take a horizontal position and move away from the vessels, collagen and argyrophilic fibers develop between them. This layer, characterized by polymorphism of cell formations, remains the same in thickness throughout the wound healing process.

Layer of horizontal fibroblasts. Direct continuation of the previous layer. It consists of more monomorphic cellular elements, is rich in collagen fibers and gradually thickens.

fibrous layer. Reflects the process of maturation of granulations.

THE SIGNIFICANCE OF GRANULATION TISSUE

The role of all granulation tissue is as follows:

Wound defect replacement: is the main plastic material that quickly fills the wound defect;

Protection of the wound from the penetration of microorganisms and the ingress of foreign bodies: it is achieved by the content of a large number of leukocytes and macrophages in it and the dense structure of the outer layer;

Sequestration and rejection of necrotic tissues, which is facilitated by the activity of leukocytes, macrophages and the release of proteolytic enzymes by cellular elements.

With the normal course of healing processes, epithelialization begins simultaneously with the development of granulations. Through reproduction and migration, epithelial cells "crawl" from the edges of the wound towards the center, gradually covering the granulation tissue. Fibrous tissue produced in the lower layers lines the bottom and walls of the wound, as if pulling it together (wound contraction).

As a result, the wound cavity is reduced, and the surface is epithelialized.

The granulation tissue that filled the wound cavity is gradually transformed into a mature coarse fibrous connective tissue - a scar is formed.

Under the influence of any adverse factors affecting the healing process (deterioration of blood supply, oxygenation, decompensation of the function of various organs and systems, re-development of the purulent process, etc.), the growth and development of granulations and epithelialization fade. Granulations become pathological. Clinically, this appears as a lack of wound contraction and a change in the appearance of the granulation tissue. The wound becomes dull, pale, sometimes cyanotic, loses turgor, becomes covered with a coating of fibrin and pus.

Also, tuberous granulations protruding beyond the wound are considered pathological - hypertrophic granulations (hypergranulations). They, hanging over the edges of the wound, prevent epithelialization. Usually they are cut or cauterized with a concentrated solution of silver nitrate or potassium permanganate and continue to heal the wound, stimulating epithelialization.

Wound healing under the scab occurs with minor injuries such as superficial skin abrasions, epidermal damage, abrasions, burns, etc. The healing process begins with coagulation of the outflow of blood, lymph and tissue fluid on the surface of the injury, which dry up with the formation of a scab.