Wound - Knowledge (XXG)

1016:, a structure which serves as a barrier to the external environment. The preferred method of closure is to reattach/reapproximate the wound edges together, a process known as primary closure/healing by primary intention. Wounds that have not been closed within several hours of the initial injury or wounds that are concerning for infection will often be left open and treated with dressings for several days before being closed 3–5 days later, a process known as delayed primary closure. The exact duration of time from initial injury in which delayed primary closure is preferred over primary closure is not clearly defined. Wounds that cannot be closed primarily due to substantial tissue loss can be healed by secondary intention, a process in which the wound is allowed to fill-in over time through natural physiologic processes. When healing by secondary intention, granulation tissue grows in from the wound edges slowly over time to restore integrity of the skin. Healing by secondary intention can take up to months, requires daily wound care, and leaves an unfavorable scar, thus primary closure is always preferred when possible. As an alternative, wounds that cannot be closed primarily can be addressed with 525:– Also known as decubitus ulcers or bedsores, this type of wound is a result of chronic pressure to the skin over a prolonged period. While most individuals have intact sensation and motor function which allow for frequent positional change to prevent the formation of such ulcers, older individuals are particularly susceptible to this type of chronic injury due to impaired neurosensory responses. Pressure ulcers can occur in as little as two hours of immobility in a bedridden patient or person who is otherwise unconscious/sedated (surgery, syncope, etc.). In the United States, pressure ulcers are graded using the National Pressure Injury Advisory Panel (NPIAP) system. In this system, ulcers are graded on wound depth with stage 1 being the least severe (erythema, intact skin) and stage 4 being full thickness damage through subcutaneous tissue down to muscle, tendon, or bone. Any ulcer that cannot be assessed due to overlying 1044:. Suture is the most frequently used for closure. There are many types of suture, but broadly they can be categorized as absorbable vs non-absorbable and synthetic vs natural. Absorbable sutures have the added benefit of not requiring removal and are often preferred in children for this reason. Staples are less time-consuming and more cost effective than suture but have a risk of worse scarring if left in place for too long. Adhesive glue and sutures have comparable cosmetic outcomes for minor lacerations <5 cm in adults and children. The use of adhesive glue involves considerably less time for the doctor and less pain for the person. The wound opens at a slightly higher rate but there is less redness. The risk for infections (1.1%) is the same for both. Adhesive glue should not be used in areas of high tension or repetitive movements, such as joints or the posterior trunk. 1118:(NPWT): A unique type of dressing which consists of a foam dressing surrounded with an airtight film and then connected to power-assisted vacuum suction, creating a negative pressure environment over the wound. This negative pressure environment is thought to promote formation of granulation tissue and decrease inflammatory fluid. NPWT has the added benefit of requiring less frequent dressing changes, a process that is often painful for patients. Since its implementation, NPWT has been implemented broadly for chronic non-healing wounds but can also be applied to acute wounds that cannot be closed primarily due to swelling or concern for infection. This type of dressing is typically applied in the operating room but can be done at bedside with appropriate analgesia. 878:. Proper cleansing of a wound is critical to prevent infection and promote re-epithelialization. Further efforts should be made to eliminate/limit any contributing factors to the wound (e.g. diabetes, pressure, etc.) and optimize the wound's healing ability (i.e. optimize nutritional status). The end goal of wound management is closure of the wound which can be achieved by primary closure, delayed primary closure, or healing by secondary intention, each of which is discussed below. Pain control is a mainstay of wound management, as wound evaluation, wound cleansing, and dressing changes can be a painful process. 1176:. Wounds on the body were believed to correlate with wounds to the soul and vice versa; wounds were seen as an outward sign of an inward illness. Thus, a man who was wounded physically in a serious way was said to be hindered not only physically but spiritually as well. If the soul was wounded, that wound may also eventually become physically manifest, revealing the true state of the soul. Wounds were also seen as writing on the "tablet" of the body. Wounds acquired in war, for example, told the story of a soldier in a form which all could see and understand, and the wounds of a 927:, or slough. Debridement is a critical aspect of wound care because devitalized tissue, particularly necrotic tissue, serves as nutrients for bacteria thereby promoting infection. Additionally, devitalized tissue creates a physical barrier over a wound which limits the effectiveness of any applied topical compounds and prevents re-epithelialization. Lastly, devitalized tissue, especially eschar, prevents accurate assessment of underlying tissue, making appropriate assessment of a wound impossible without adequate debridement. Debridement can be achieved in several ways: 487:– Wound healing impairment in the setting of diabetes is multifactorial. Hyperglycemia, neuropathy, microvascular complications, impaired immune and inflammatory responses, and psychological factors have all been implicated in the formation and propagation of diabetic wounds. Feet are the most common location of diabetic wounds, although any type of wound can be negatively impacted by diabetes. It has been estimated that up to 25% of patients with diabetes mellitus will be affected by non-healing wounds in their lifetime. 52: 1157: 395: 995:) to the wound bed. These larvae release proteolytic enzymes which dissolve necrotic tissue before then ingesting the now debrided tissue. Biologic debridement has the added benefit of being bactericidal since larvae will ingest bacteria as well as devitalized tissue. Despite the safety and effectiveness of this method, its applications are often limited due to patient's negative feelings towards larvae which are commonly associated with poor hygiene and perishable food. 1005: 1193: 356: 332: 368: 419: 383: 407: 344: 859: 584: 109:), and wound sterility, among other factors. Treatment strategies for wounds will vary based on the classification of the wound, therefore it is essential that wounds be thoroughly evaluated by a healthcare professional for proper management. In normal physiology, all wounds will undergo a series of steps collectively known as the 792:, but is limited in diagnostic capabilities. CT is another quickly implemented option which generally provides more diagnostic information compared to ultrasound, however it is less cost-effective and exposes patients to radiation. MRI offers the greatest image resolution and can provide diagnostic information on presence of 753:, or needle biopsy. Surface swabs are most commonly used due to low cost, ease of use, and minimal pain to patient. Although swab cultures have been shown to reliably identify the organisms causing an infection, swabs are only able to identify bacteria on the surface of a wound and can occasionally be contaminated by normal 1127:

Ideally, wound dressings should be changed daily to promote a clean environment and allow for daily evaluation of wound progression. Highly exudative wounds and infected wounds should be monitored closely and may require more frequent dressing changes. Negative pressure wound dressings can be changed

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The goal of wound care is to promote an environment that allows a wound to heal as quickly as possible, with emphasis on restoring both form and function of the wounded area. Although optimal treatment strategies vary greatly depending on the specific cause, size, and age of a particular wound, there

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or arterial/venous insufficiency. However, it is important to note that any acute wound has the potential to become a chronic wound if any of the normal stages of wound healing are interrupted. Chronic wounds are most commonly a result of disruption of the inflammatory phase of wound healing, however

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formation, typically lasts 12 months but can continue as long as 2 years after the initial injury. Acute wounds can further be classified as either open or closed. An open wound is any injury whereby the integrity of the skin has been disrupted and the underlying tissue is exposed. A closed wound, on

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has been implicated as a complementary therapy in wound healing; however, there is no high quality research supporting its use as an evidence based clinical intervention. More than 400 species of plants are identified as potentially useful for wound healing. Only three randomized controlled trials,

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Wound sterility, or degree of contamination of a wound, is a critical consideration when evaluating a wound. In the United States, the CDC's Surgical Wound Classification System is most commonly used for classification of a wound's sterility, specifically within a surgical setting. According to this

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appropriately. The goals of a wound dressing are to act as a barrier to the outside environment, facilitate wound healing, promote hemostasis, and act as a form of mechanical debridement during dressing changes. The ideal wound dressing maintains a moist environment to optimize wound healing but is

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Class 3 – contaminated wound: an open, accidental wound resulting from trauma outside of a sterile setting is automatically considered a contaminated wound. Additionally, any surgical wound where there is a major break in sterile technique or obvious contamination from the gastrointestinal tract is

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Wounds can be broadly classified as either acute or chronic based on time from initial injury and progression through normal stages of wound healing. Both wound types can further be categorized by cause of injury, wound severity/depth, and sterility of the wound bed. Several classification systems

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Proper cleansing of a wound is critical in preventing infection and promoting healing of any wound. Irrigation is defined as constant flow of a solution over the surface of a wound. The goal of irrigation is not only to remove debris and potential contaminants from a wound, but also to assist in

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There is moderate evidence that honey is more effective than antiseptic followed by gauze for healing wounds infected after surgical operations. There is a lack of quality evidence relating to the use of honey on other types of wounds, such as minor acute wounds, mixed acute and chronic wounds,

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Mechanical debridement: Achieved through use of mechanical force to remove devitalized tissue (e.g. wet-to-dry dressing, pressurized wound irrigation, pulse-lavage); however, this process will remove both healthy and non-healthy tissue and is therefore considered a non-selective debridement

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for diagnosing wound infections due to being both more accurate and precise than swabs, however it is more invasive, more painful, and less cost effective than swabs and therefore is not the first choice for collecting wound cultures. Needle aspiration can only be implemented in wounds with

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can be classified as either open or closed, depending on whether the integrity of the overlying skin has been disrupted or preserved, respectively. Several classification systems have been developed to further characterize soft tissue injuries in the setting of an underlying fracture:

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is not preferred since these solutions are toxic to tissue and inhibit wound healing. The exact volume of irrigation used will vary depending on the appearance of the wound, although some sources have reported 50–100 mL of irrigation per 1 cm of wound length as a guideline.

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Wound presentation will vary greatly based on a number of factors, each of which is important to consider in order to establish a proper diagnosis and treatment plan. In addition to collecting a thorough history, the following factors should be considered when evaluating any wound:

159:, lasts from minutes to hours after initial injury. This stage is followed by the inflammatory phase which typically lasts 1 to 3 days. Proliferation is the third stage of wound healing and lasts from a few days up to a month. The fourth and final phase of wound healing, remodeling/ 1082:. When the inner colloid layer comes in contact with liquid, it becomes a gel allowing the dressing to maintain a moist environment while simultaneously absorbing exudate. Hydrocolloids cause minimal pain on removal but are at increased risk of skin maceration and bacterial growth. 475:

errors in any phase can result in a chronic wound. The exact duration of time which distinguishes a chronic wound from an acute wound is not clearly defined, although many clinicians agree that wounds which have not progressed for over three months are considered chronic wounds.

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Films: Films are made of translucent polyurethane which is adherent to skin and semi-occlusive, allowing them to retain within the dressing but also allow for exchange of gases such as oxygen and carbon dioxide. The translucent nature of this dressing makes monitoring wounds

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Hydrofibers: A derivative of hydrocolloid dressings, hydrofibers are able to absorb up to 25 times their weight in fluid, making them the most absorbent dressing. They are much like alginate dressings in their absorptive capacity and tendency to form a gel upon contact with

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Foams: A flexible material with a hydrophobic outer layer that shields liquid from the outside environment, while having a highly absorptive inner layer which is ideal for highly exuding wounds. Foams should not be used in dryer wounds that require exudate to stay

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is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying disease processes such as

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process, which include hemostasis, inflammation, proliferation, and tissue remodeling. Age, tissue oxygenation, stress, underlying medical conditions, and certain medications are just a few of the many factors known to affect the rate of wound healing.

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Alginates: Derived from seaweed, alginates can absorb up to 15–20 times their weight in liquid and are ideal for highly exudative wounds. Like hydrocolloids, alginates form a gel when they come in contact with fluid, making removal relatively

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A thorough wound evaluation, particularly evaluation of wound depth and removal of necrotic tissue, should be performed only by a licensed healthcare professional in order to avoid damage to nearby structures, infection, or worsening pain.

493:– Impaired blood outflow (venous) or inflow (arterial) can both impair wound healing, thereby causing chronic wounds. Much like diabetes, venous/arterial insufficiency most commonly result in chronic wounds of the lower extremities. In 1096:

material with soothing properties which is useful in treating burn wounds, dry chronic wounds, and pressure ulcers. Like hydrocolloids, hydrogels are capable of retaining excess moisture leading to skin maceration and bacterial

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are applied topically to digest devitalized tissue. Depending on the agent, this process can be either selective or non-selective. Examples include trypsin, streptokinase-streptodornase combination, subtilisin, papain, and

833:(ABI/TBI): These tests can be used to assess blood supply to the lower extremities and their results may affect management of lower extremity wounds such as venous/arterial ulcers, diabetic foot ulcers, or pressure ulcers. 646:

Wound depth: The depth of a wound is often not apparent on visual inspection alone. Proper evaluation of wound depth includes use of a probe to measure wound depth and evaluate for undermining of wound edges or

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Medicated dressings: Many dressings come impregnated with medication, typically antimicrobial agents or debriding chemicals. Silver, iodine, growth hormones, enzymes, and antibacterial agents are most common.

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Critical wounds – Including large burns that have been split. These wounds can cause serious hydroelectrolytic and metabolic alterations including fluid loss, electrolyte imbalances, and increased catabolism.

511:; therefore, any disease of the immune system has the potential to impair the inflammatory phase of wound healing, thereby leading to a chronic wound. Patients suffering from diseases such as 788:(MRI) can all be used to assess for identifying fluid collections, necrotic tissue, or inflammation. Ultrasound is portable, low cost, quickly implemented, and does not expose patients to 543:

Class 1 – clean wound: a wound that is not infected and without signs of inflammation. This type of wound is typically closed. By definition, this type of wound excludes any wounds of the

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which is readily accessible in the emergency department, although recent studies have shown no difference in emergency department infection rates when comparing normal saline to potable

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or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a "through-and-through."

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solution, but studies have again shown no difference in infection rates when compared to normal saline. Irrigation with antiseptic solutions, such as non-diluted povidone iodine,

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Bahramsoltani R, Farzaei MH, Rahimi R (September 2014). "Medicinal plants and their natural components as future drugs for the treatment of burn wounds: an integrative review".

1237: 124: 394: 639:. Presence of a dark red wound bed which bleeds easily on contact or excess granulation tissue (i.e. hypergranulation tissue) may indicate the presence of an 569:. Class 4 wounds are usually found in old traumatic wounds which were not adequately treated and will show evidence of devitalized tissue or gross purulence. 558:

Class 2 – clean-contaminated wound: a wound with a low level of contamination. May involve entry into the respiratory, genital, alimentary, or urinary tract.

800:. Like ultrasound, MRI does not expose patients to radiation, however it is the slowest and most difficult to implement of the all of these imaging methods. 123:

have been developed to describe wounds and guide their management. Some notable classification systems include the CDC's Surgical Wound Classification, the

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AO Classification – adapted from the Tscherne classification, provides separate grading system for skin, muscles/tendons, and neurovascular structures.

1452:"Using the Red Cross wound classification to predict treatment needs in children with conflict-related limb injuries: a retrospective database study" 2671:

Bazaliński, Dariusz; Przybek-Mita, Joanna; Pytlak, Kamila; Kardyś, Daria; Bazaliński, Adrian; Kucharzewski, Marek; Więch, Paweł (30 October 2023).

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are universal principles of wound management that apply to all wounds. After a thorough evaluation is performed, all wounds should be properly

666:). Removing this tissue is critical for properly evaluating both the depth of a wound and quality of the wound bed, and promotes wound healing. 1936: 1232: 448: 355: 132: 2775:"Is the use of specific time cut-off or 'golden period' for primary closure of acute traumatic wounds evidence based? A systematic review" 497:, blood pooling impedes oxygen exchange and creates a chronic pro-inflammatory environment which both promote formation of venous ulcers. 2125:"Impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine" 931:

Autolytic debridement: The most conservative type of debridement whereby the body's own natural defenses break down necrotic tissue via

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levels may be useful in evaluating nutrition status in patients with chronic wounds or at risk for developing chronic wounds. Elevated

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Mecott GA, González-Cantú I, Dorsey-Treviño EG, Matta-Yee-Chig D, Saucedo-Cárdenas O, Montes de Oca-Luna R, et al. (April 2020).

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Wound edges: May provide clues to cause of specific wounds, such as gently sloping edges of venous ulcers or rolled edges of certain

793: 662:: Wounds may be covered with a layer of dead tissue which may appear cream/yellow in color (slough) or as a black, hardened tissue ( 1688:

Rae L, Fidler P, Gibran N (October 2016). "The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation".

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classification system, four different classes of wound exist, each with their own postoperative risk of surgical site infection:

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Surgical debridement: Also known as sharp debridement, this is a process in which devitalized tissue is removed through use of

101:. Wounds can vary greatly in their appearance depending on wound location, injury mechanism, depth of injury, timing of onset ( 501:, on the other hand, causes wounds due to poor blood inflow and typically affects the most distal extremities (fingers, toes). 3640: 808: 624:. Acute wounds will be located in areas consistent with the mechanism of injury (e.g. diagonal chest wall bruising from 609:

Size of wound: Should be accurately measured at time of initial presentation and regularly remeasured until wound resolution.

1068:: Composed of woven or non-woven cotton, rayon, and polyester, gauze is highly absorbent, but removal can be uncomfortable. 3507: 2895: 1725:"Efficacy and Safety of Pirfenidone in Patients with Second-Degree Burns: A Proof-of-Concept Randomized Controlled Trial" 1172:, the body and the soul were believed to be intimately connected, based on several theories put forth by the philosopher 3966: 676:

Surrounding skin: Appearance of the surrounding skin can provide clues to underlying disease processes, such as redness/

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Additional diagnostic tests may be needed during wound evaluation based on the cause, appearance, and age of a wound.

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In humans and mice it has been shown that estrogen might positively affect the speed and quality of wound healing.

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the other hand, is any injury in which underlying tissue has been damaged but the overlying skin is still intact.

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less frequently, every 2–3 days. Wound progression over time can be monitored with transparent sheet tracings or

702:: Classic signs of infection are redness, warmth, swelling, odor, and pain out of proportion to wound appearance. 498: 3578: 1061:

or bacterial growth. Several wound dressing options are available, each tailored to different kinds of wounds:

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Any wound which is arrested or delayed during any of the normal stages of wound healing is considered to be a

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visual inspection of a wound and hydrate the wound. Irrigation is typically achieved with either a bulb or

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where the extremity is pulled off rather than cut off. When used in reference to skin avulsions, the term '

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Nicks, Bret A.; Ayello, Elizabeth A.; Woo, Kevin; Nitzki-George, Diane; Sibbald, R. Gary (December 2010).

871: 548: 210:(the epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough surface such as 31: 519:

have been found to have larger wounds and prolonged time to heal when compared to the general population.

451:– Classifies open fractures based on wound size, extent of soft tissue loss, and degree of contamination. 1242: 1075: 971: 853: 816: 776:

is useful to assess for an underlying fracture which may not be apparent on physical examination alone.

228:– injuries in which a body structure is forcibly detached from its normal point of insertion; a type of 3782: 2443:"Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations" 2312:

Yam, Mun; Loh, Yean; Tan, Chu; Khadijah Adam, Siti; Abdul Manan, Nizar; Basir, Rusliza (24 July 2018).

1156: 1028:. There are several methods that can be implemented to achieve primary closure of a wound, including 820: 815:(CRP) can confirm presence of an infection but alone are not diagnostic. Routine bloodwork such as a 758: 512: 418: 406: 343: 3951: 3894: 3563: 2963:

Farion K, Osmond MH, Hartling L, Russell K, Klassen T, Crumley E, Wiebe N (2002). Farion KJ (ed.).

1165: 1053: 1041: 959: 613: 3443:"Transcriptional profiling of lung cell populations in idiopathic pulmonary arterial hypertension" 3956: 3862: 3772: 3675: 3462: 3420: 2941: 2542: 1754: 1141:

pressure ulcers, Fournier's gangrene, venous leg ulcers, diabetic foot ulcers and Leishmaniasis.

812: 636: 504: 253: 203: 98: 72: 2314:"General Pathways of Pain Sensation and the Major Neurotransmitters Involved in Pain Regulation" 2773:

Jaman, Josip; Martić, Krešimir; Rasic, Nivez; Markulin, Helena; Haberle, Sara (December 2021).

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Kellam J (2018). "Fracture classification". In Buckley RE, Moran CG, Apivatthakakul T (eds.).

1901: 1852: 1803: 1746: 1705: 1642: 1617: 1568: 1510: 1483: 1432: 1383: 1327: 1286: 1144: 1004: 975: 908: 892: 629: 544: 467: 225: 173: 106: 94: 64: 1636: 745:: If there is concern for infection, a wound can be more carefully evaluated for presence of 470:. Most commonly, these are wounds which develop due to an underlying disease process such as 3930: 3838: 3777: 3757: 3725: 3720: 3470: 3454: 3404: 3367: 3326: 3310: 3269: 3261: 3220: 3204: 3155: 3077: 3059: 2984: 2976: 2925: 2859: 2843: 2802: 2786: 2702: 2684: 2643: 2627: 2554: 2507: 2470: 2454: 2400: 2384: 2343: 2325: 2284: 2268: 2227: 2219: 2144: 2136: 2027: 2017: 1976: 1968: 1924: 1891: 1883: 1842: 1834: 1793: 1785: 1736: 1697: 1607: 1599: 1558: 1548: 1473: 1463: 1422: 1414: 1373: 1365: 713: 259: 211: 148: 102: 3730: 3710: 3680: 1169: 1058: 1037: 1033: 1029: 1025: 900: 863: 717: 685: 648: 196:. Lacerations and incisions may appear linear (regular) or stellate (irregular). The term 77: 3082: 3047: 2707: 2672: 151:

is any wound which results from direct trauma and progresses through the four stages of

3475: 3442: 3331: 3298: 3274: 3249: 3225: 3192: 2989: 2964: 2864: 2831: 2807: 2774: 2648: 2615: 2475: 2442: 2405: 2372: 2348: 2313: 2289: 2256: 2232: 2208:"Surgical Wound Classification and Surgical Site Infections in the Orthopaedic Patient" 2207: 2149: 2124: 2032: 2005: 1981: 1956: 1896: 1871: 1847: 1822: 1798: 1773: 1741: 1724: 1612: 1587: 1563: 1536: 1478: 1451: 1427: 1402: 1378: 1353: 1021: 986: 617: 592: 552: 522: 239: 2558: 2212:

Journal of the American Academy of Orthopaedic Surgeons. Global Research & Reviews

1192: 3945: 3884: 3715: 3700: 3193:"Digital Photography and Transparency-Based Methods for Measuring Wound Surface Area" 1758: 1017: 904: 849: 804: 797: 434: 152: 136: 110: 3572: 3568: 3424: 2945: 2616:"Wound debridement products and techniques: clinical examples and literature review" 2371:

Li, Shuxin; Renick, Paul; Senkowsky, Jon; Nair, Ashwin; Tang, Liping (1 June 2021).

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AO Principles of Fracture Management: Vol. 1: Principles, Vol. 2: Specific fractures

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Hannover Fracture scale – Used in open fractures as an extremity salvage assessment.

3925: 3871: 3853: 3762: 3705: 3265: 2673:"Larval Wound Therapy: Possibilities and Potential Limitations—A Literature Review" 2614:

Nowak, Marcela; Mehrholz, Dorota; Barańska-Rybak, Wioletta; Nowicki, Roman (2022).

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Onyekwelu I, Yakkanti R, Protzer L, Pinkston CM, Tucker C, Seligson D (June 2017).

1065: 989:, biological debridement is done through controlled application of sterile larvae ( 923:

is defined as removal of devitalized or dead tissue, particularly necrotic tissue,

830: 716:, or inflammatory, each of which can provide clues to the cause of a wound. Proper 621: 508: 445:– Used to describe external appearance of wounds in both open and closed fractures. 321: 283: 193: 1662: 970:, or surgical scissors. Surgical debridement can be done in a hospital bed, in an 324:– caused by a great or extreme amount of force applied over a long period of time. 3583: 3441:

Saygin D, Tabib T, Bittar HE, Valenzi E, Sembrat J, Chan SY, et al. (1984).

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Jull AB, Cullum N, Dumville JC, Westby MJ, Deshpande S, Walker N (March 2015).

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Britto, Errol J.; Nezwek, Trevor A.; Popowicz, Patrycja; Robins, Marc (2024).

2980: 2887: 2847: 2458: 2140: 1887: 1838: 1701: 1603: 1535:

Raziyeva K, Kim Y, Zharkinbekov Z, Kassymbek K, Jimi S, Saparov A (May 2021).

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This article is about wounds in humans and other animals. For other uses, see

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Chhabra, Shruti; Chhabra, Naveen; Kaur, Avneet; Gupta, Niti (December 2017).

2798: 2698: 2639: 2519: 2466: 2396: 2339: 2280: 2272: 2022: 1823:"Classifications In Brief: The Tscherne Classification of Soft Tissue Injury" 1418: 1052:

After a wound is irrigated, debrided, and, if possible, closed, it should be

3889: 3880: 3822: 3767: 3589: 2790: 2631: 2388: 932: 896: 789: 699: 640: 625: 566: 313: 298: 256:– caused by an object such as a knife entering and coming out from the skin. 233: 215: 3484: 3416: 3381: 3340: 3283: 3234: 3177: 3118: 3091: 3025: 2998: 2937: 2913: 2873: 2816: 2752: 2716: 2657: 2593: 2566: 2527: 2499: 2484: 2414: 2357: 2298: 2241: 2185: 2158: 2102: 2068: 2041: 2004:

Burgess JL, Wyant WA, Abdo Abujamra B, Kirsner RS, Jozic I (October 2021).

1990: 1972: 1905: 1856: 1807: 1750: 1709: 1621: 1572: 1514: 1487: 1450:

van Gennip L, Haverkamp FJ, Muhrbeck M, Wladis A, Tan EC (September 2020).

1436: 1387: 1331: 1290: 823:(CBC) are not typically required but may be useful in select circumstances. 1928: 1078:: Consist of an outer, water-impermeable layer and an inner layer made of 612:

Wound location: Very useful consideration in many chronic wounds, such as

3848: 3748: 2330: 1774:"Burns: Pathophysiology of Systemic Complications and Current Management" 1553: 1085: 936: 746: 677: 670: 484: 471: 279: 247: 219: 17: 3191:

Bhedi, Amul; Saxena, Atul K.; Gadani, Ravi; Patel, Ritesh (April 2013).

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Fernandez, R.; Griffiths, R. (23 January 2008). Fernandez, Ritin (ed.).

1957:"Differentiating Lower Extremity Wounds: Arterial, Venous, Neurotrophic" 858: 583: 565:

Class 4 – dirty/infected: a wound with evidence of an existing clinical

3692: 1079: 967: 963: 888: 781: 763: 693: 689: 652: 302: 3532: 3466: 2929: 3799: 3740: 3661: 3544: 3314: 1177: 1132:, each of which produce reliable measurements of wound surface area. 947: 924: 750: 663: 659: 526: 263: 3372: 3355: 2580:

Manna, Biagio; Nahirniak, Phillip; Morrison, Christopher A. (2024).

2543:"Antiseptics, iodine, povidone iodine and traumatic wound cleansing" 939:. This method requires a moist environment and intact immune system. 176:

or incised wounds – caused by a clean, sharp-edged object such as a

3458: 2965:"Tissue adhesives for traumatic lacerations in children and adults" 2255:

Grey, Joseph E; Enoch, Stuart; Harding, Keith G (4 February 2006).

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The end goal of wound care is to re-establish the integrity of the

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is an important consideration in wound management, particularly in

27:

Acute injury from laceration, puncture, blunt force, or compression

3622:– EWMA works to promote the advancement of education and research. 3594: 3299:"A rapid evidence assessment of recent therapeutic touch research" 1173: 1155: 1003: 857: 773: 724:

care where analgesia is often necessary prior to dressing changes.

582: 516: 374: 297:

Hematomas that originate from internal blood vessel pathology are

287: 181: 177: 3876: 3046:

Bhoyar, Surbhi D; Malhotra, Karan; Madke, Bhushan (April 2023).

1872:"In brief: Gustilo-Anderson classification. [corrected]" 1013: 721: 705: 291: 243: 207: 206:(grazes) – superficial wounds in which the topmost layer of the 160: 3629: 1821:

Ibrahim DA, Swenson A, Sassoon A, Fernando ND (February 2017).

1772:

Nielson CB, Duethman NC, Howard JM, Moncure M, Wood JG (2017).

635:

Wound bed: A healthy wound bed will appear pink due to healthy

400:

Fresh incisional wound on the fingertip of the left ring finger

312:

Hematomas that originate from an external source of trauma are

1187: 891:

and needle/catheter. The preferred solution for irrigation is

3613: 3608: 2123:

Avishai E, Yeghiazaryan K, Golubnitschaja O (March 2017).

692:, or eczematous changes due to a chronic irritation (e.g. 978:

depending on the particular wound, risk of bleeding, and

946:

Enzymatic debridement: A process of debridement in which

3144:"Negative pressure wound therapy in orthopaedic surgery" 361:

An infected puncture wound to the bottom of the forefoot

3148:

Orthopaedics & Traumatology: Surgery & Research

2055:

Robles-Tenorio A, Lev-Tov H, Ocampo-Candiani J (2023).

1586:

Chhabra S, Chhabra N, Kaur A, Gupta N (December 2017).

1204: 3619: 2832:"Wound Healing Concepts in Clinical Practice of OMFS" 1588:"Wound Healing Concepts in Clinical Practice of OMFS" 3522: 1148:

however, have been done for the treatment of burns.

899:. Irrigation can also be achieved with a diluted 1% 3908: 3831: 3798: 3739: 3691: 3668: 3526: 3113:. Treasure Island, Florida: StatPearls Publishing. 3020:. Treasure Island, Florida: StatPearls Publishing. 2747:. Treasure Island, Florida: StatPearls Publishing. 2588:. Treasure Island, Florida: StatPearls Publishing. 2541:Khan, Muhammad N.; Naqvi, Abul H. (November 2006). 1238:

International Red Cross Wound Classification System

1057:also capable of absorbing excess fluid as to avoid 63: 44: 3498:Desiree May Oh, MD, Tania J. Phillips, MD (2006). 844:Emergency bleeding control § Wound management 309:. The different classifications are based on size. 3360:Journal of Pharmacy & Pharmaceutical Sciences 507:– The immune system plays a critical role in the 3297:Garrett, Bernie; Riou, Marliss (20 March 2021). 1160:Medieval treatment of wound with lance grittings 3150:. 2016 Instructional Course Lectures (SoFCOT). 2180:. Treasure Island (FL): StatPearls Publishing. 2097:. Treasure Island (FL): StatPearls Publishing. 2063:. Treasure Island (FL): StatPearls Publishing. 1537:"Immunology of Acute and Chronic Wound Healing" 1509:. Treasure Island (FL): StatPearls Publishing. 1326:. Treasure Island (FL): StatPearls Publishing. 1285:. Treasure Island (FL): StatPearls Publishing. 59:Hand abrasion resulting from a bicycle accident 591:(x-ray) is used to ensure there are no hidden 200:is commonly misused in reference to incisions. 3641: 3614:Association for the Advancement of Wound Care 2888:"Absorbable sutures in pediatric lacerations" 1313: 1311: 1309: 1307: 155:along an expected timeline. The first stage, 8: 3048:"Dressing materials: A comprehensive review" 1354:"Wounds - from physiology to wound dressing" 1272: 1270: 1268: 1266: 1264: 1262: 1260: 1258: 192:– irregular tear-like wounds caused by some 125:International Red Cross Wound Classification 3254:The Cochrane Database of Systematic Reviews 3105:Zaver, Vasudev; Kankanalu, Pradeep (2024). 2969:The Cochrane Database of Systematic Reviews 2504:The Cochrane Database of Systematic Reviews 2447:International Journal of Emergency Medicine 2318:International Journal of Molecular Sciences 1277:Nagle SM, Stevens KA, Wilbraham SC (2023). 3648: 3634: 3626: 3523: 3052:Journal of Cutaneous and Aesthetic Surgery 1876:Clinical Orthopaedics and Related Research 1827:Clinical Orthopaedics and Related Research 50: 41: 3474: 3436: 3434: 3371: 3330: 3273: 3250:"Honey as a topical treatment for wounds" 3224: 3159: 3081: 3063: 2988: 2863: 2836:Journal of Maxillofacial and Oral Surgery 2806: 2706: 2688: 2647: 2474: 2404: 2347: 2329: 2288: 2231: 2148: 2031: 2021: 1980: 1895: 1846: 1797: 1740: 1611: 1592:Journal of Maxillofacial and Oral Surgery 1562: 1552: 1501:Wallace HA, Basehore BM, Zito PM (2023). 1477: 1467: 1426: 1377: 282:(or blood tumor) – caused by damage to a 2089:Zemaitis MR, Boll JM, Dreyer MA (2023). 2907: 2905: 2620:Advances in Dermatology and Allergology 1635:American Academy of Pediatrics (2011). 1254: 757:. Deep tissue biopsy is considered the 327: 2898:from the original on 26 December 2008. 985:Biological debridement: Also known as 236:' is also sometimes used as a synonym. 3620:European Wound Management Association 3137: 3135: 2952:from the original on 5 November 2013. 2734: 2732: 2730: 2728: 2726: 2436: 2434: 2432: 2430: 2428: 2426: 2424: 1950: 1948: 1233:European Wound Management Association 242:– caused by an object puncturing the 7: 3510:from the original on 7 January 2013. 2914:"Minor incised traumatic laceration" 2912:Cals JW, de Bont EG (October 2012). 1961:Seminars in Interventional Radiology 1870:Kim PH, Leopold SS (November 2012). 1641:. Jones & Bartlett. p. 39. 1352:Kujath P, Michelsen A (March 2008). 388:An incision: a small cut in a finger 97:, venous/arterial insufficiency, or 3397:Archives of Dermatological Research 2739:Labib, Amir; Winters, Ryan (2024). 1778:Journal of Burn Care & Research 1669:. U.S. National Library of Medicine 2373:"Diagnostics for Wound Infections" 1923:. Stuttgart: Georg Thieme Verlag. 1742:10.1097/01.ASW.0000655484.95155.f7 1456:World Journal of Emergency Surgery 1358:Deutsches Ärzteblatt International 25: 3356:"Phyto-extracts in wound healing" 3107:"Negative Pressure Wound Therapy" 1729:Advances in Skin & Wound Care 1403:"Factors affecting wound healing" 1401:Guo S, Dipietro LA (March 2010). 3500:"Sex Hormones and Wound Healing" 2006:"Diabetic Wound-Healing Science" 1667:MedlinePlus Medical Encyclopedia 1191: 562:considered a contaminated wound. 417: 405: 393: 381: 366: 354: 342: 330: 1180:told the story of their faith. 1116:Negative-pressure wound therapy 749:via surface swabs, deep tissue 479:Common causes of chronic wounds 449:Gustilo-Anderson classification 316:, also commonly called bruises. 133:Gustilo-Anderson classification 3609:US based wound healing society 3266:10.1002/14651858.CD005083.pub4 3142:Robert, N. (1 February 2017). 2512:10.1002/14651858.CD003861.pub2 2224:10.5435/JAAOSGlobal-D-17-00022 809:erythrocyte sedimentation rate 373:A puncture wound from playing 1: 2559:10.1016/S0965-206X(06)64002-3 2091:"Peripheral Arterial Disease" 1318:Herman TF, Bordoni B (2023). 595:in this patient's knee wound. 491:Venous/Arterial insufficiency 250:, nail, knife or sharp tooth. 2677:Journal of Clinical Medicine 1790:10.1097/BCR.0000000000000355 1123:Maintenance and surveillance 495:chronic venous insufficiency 139:soft tissue grading system. 3857: 3154:(1, Supplement): S99–S103. 2547:Journal of Tissue Viability 2500:"Water for wound cleansing" 2172:Zaidi SR, Sharma S (2023). 337:An open wound (an avulsion) 135:of open fractures, and the 3983: 3788:Retroperitoneal hemorrhage 3161:10.1016/j.otsr.2016.04.018 2741:"Complex Wound Management" 1663:"Cuts and puncture wounds" 1469:10.1186/s13017-020-00333-0 1407:Journal of Dental Research 1008:A surgeon placing a suture 847: 841: 803:Laboratory studies: Serum 786:magnetic resonance imaging 688:due to uncontrolled wound 529:is considered unstageable. 29: 3866: 3409:10.1007/s00403-014-1474-6 3354:Ghosh PK, Gaba A (2013). 3209:10.1007/s12262-012-0422-y 3197:Indian Journal of Surgery 2981:10.1002/14651858.CD003326 2848:10.1007/s12663-016-0880-z 2459:10.1007/s12245-010-0217-5 2141:10.1007/s13167-017-0081-y 1888:10.1007/s11999-012-2376-6 1839:10.1007/s11999-016-4980-3 1702:10.1016/j.ccc.2016.06.001 1604:10.1007/s12663-016-0880-z 1370:10.3238/arztebl.2008.0239 658:Necrotic tissue, slough, 499:Peripheral artery disease 58: 49: 3065:10.4103/JCAS.JCAS_163_22 2779:Croatian Medical Journal 2273:10.1136/bmj.332.7536.285 2023:10.3390/medicina57101072 1955:Star A (December 2018). 1419:10.1177/0022034509359125 2791:10.3325/cmj.2021.62.614 2632:10.5114/ada.2022.117572 2389:10.1089/wound.2019.1103 950:such as proteinases or 443:Tscherne classification 349:A laceration to the leg 129:Tscherne classification 2377:Advances in Wound Care 1973:10.1055/s-0038-1676362 1638:First Aid for Families 1503:"Wound Healing Phases" 1320:"Wound Classification" 1161: 1024:, typically done by a 1009: 866: 862:Wound, sewn with four 596: 32:Wound (disambiguation) 3895:Occupational injuries 3447:Pulmonary Circulation 1929:10.1055/b-0038-160815 1690:Critical Care Clinics 1243:Wound bed preparation 1159: 1007: 861: 854:Wound bed preparation 817:basic metabolic panel 794:soft tissue infection 766:or fluid collections. 643:or non-healing wound. 586: 290:to collect under the 3900:Traumatic amputation 2331:10.3390/ijms19082164 1554:10.3390/biom11050700 1136:Alternative medicine 982:requirements. 960:surgical instruments 827:Ankle-brachial index 821:complete blood count 614:diabetic foot ulcers 600:Physical examination 513:rheumatoid arthritis 509:inflammatory process 286:that in turn causes 184:, or glass splinter. 3967:Medical emergencies 2690:10.3390/jcm12216862 2582:"Wound Debridement" 1022:flap reconstruction 937:proteolytic enzymes 782:computed tomography 696:to wound dressing). 505:Immunologic disease 99:immunologic disease 3863:Penetrating trauma 3783:Grey Turner's sign 3773:Subungual hematoma 2257:"Wound assessment" 2057:"Venous Leg Ulcer" 1279:"Wound Assessment" 1203:. You can help by 1162: 1010: 867: 831:toe-brachial index 813:C-reactive protein 637:granulation tissue 597: 254:Penetration wounds 73:Emergency medicine 3939: 3938: 3604: 3603: 3014:"Wound Dressings" 2930:10.1136/bmj.e6824 2267:(7536): 285–288. 1938:978-3-13-242309-1 1882:(11): 3270–3274. 1221: 1220: 1145:Therapeutic touch 972:outpatient clinic 909:hydrogen peroxide 694:allergic reaction 485:Diabetes mellitus 472:diabetes mellitus 95:diabetes mellitus 86: 85: 39:Medical condition 16:(Redirected from 3974: 3931:Abdominal trauma 3839:Ballistic trauma 3726:Friction blister 3721:Fracture blister 3650: 3643: 3636: 3627: 3524: 3512: 3511: 3495: 3489: 3488: 3478: 3438: 3429: 3428: 3392: 3386: 3385: 3375: 3351: 3345: 3344: 3334: 3315:10.1002/nop2.841 3309:(5): 2318–2330. 3294: 3288: 3287: 3277: 3245: 3239: 3238: 3228: 3188: 3182: 3181: 3163: 3139: 3130: 3129: 3127: 3125: 3102: 3096: 3095: 3085: 3067: 3043: 3037: 3036: 3034: 3032: 3009: 3003: 3002: 2992: 2960: 2954: 2953: 2909: 2900: 2899: 2884: 2878: 2877: 2867: 2827: 2821: 2820: 2810: 2770: 2764: 2763: 2761: 2759: 2736: 2721: 2720: 2710: 2692: 2668: 2662: 2661: 2651: 2611: 2605: 2604: 2602: 2600: 2577: 2571: 2570: 2538: 2532: 2531: 2495: 2489: 2488: 2478: 2438: 2419: 2418: 2408: 2368: 2362: 2361: 2351: 2333: 2309: 2303: 2302: 2292: 2252: 2246: 2245: 2235: 2203: 2197: 2196: 2194: 2192: 2174:"Pressure Ulcer" 2169: 2163: 2162: 2152: 2129:The EPMA Journal 2120: 2114: 2113: 2111: 2109: 2086: 2080: 2079: 2077: 2075: 2052: 2046: 2045: 2035: 2025: 2001: 1995: 1994: 1984: 1952: 1943: 1942: 1916: 1910: 1909: 1899: 1867: 1861: 1860: 1850: 1818: 1812: 1811: 1801: 1784:(1): e469–e481. 1769: 1763: 1762: 1744: 1720: 1714: 1713: 1685: 1679: 1678: 1676: 1674: 1659: 1653: 1652: 1632: 1626: 1625: 1615: 1583: 1577: 1576: 1566: 1556: 1532: 1526: 1525: 1523: 1521: 1498: 1492: 1491: 1481: 1471: 1447: 1441: 1440: 1430: 1398: 1392: 1391: 1381: 1349: 1343: 1342: 1340: 1338: 1315: 1302: 1301: 1299: 1297: 1274: 1216: 1213: 1195: 1188: 1166:Classical Period 992:Lucilia sericata 421: 412:Abrasion on knee 409: 397: 385: 370: 358: 346: 334: 191: 190: 54: 42: 21: 3982: 3981: 3977: 3976: 3975: 3973: 3972: 3971: 3942: 3941: 3940: 3935: 3904: 3827: 3794: 3735: 3731:Sucking blister 3711:Delayed blister 3687: 3664: 3654: 3605: 3600: 3599: 3535: 3521: 3516: 3515: 3497: 3496: 3492: 3440: 3439: 3432: 3394: 3393: 3389: 3373:10.18433/j3831v 3353: 3352: 3348: 3296: 3295: 3291: 3260:(3): CD005083. 3247: 3246: 3242: 3190: 3189: 3185: 3141: 3140: 3133: 3123: 3121: 3104: 3103: 3099: 3045: 3044: 3040: 3030: 3028: 3011: 3010: 3006: 2975:(3): CD003326. 2962: 2961: 2957: 2911: 2910: 2903: 2886: 2885: 2881: 2829: 2828: 2824: 2772: 2771: 2767: 2757: 2755: 2738: 2737: 2724: 2670: 2669: 2665: 2613: 2612: 2608: 2598: 2596: 2579: 2578: 2574: 2540: 2539: 2535: 2506:(1): CD003861. 2497: 2496: 2492: 2440: 2439: 2422: 2370: 2369: 2365: 2311: 2310: 2306: 2254: 2253: 2249: 2205: 2204: 2200: 2190: 2188: 2171: 2170: 2166: 2122: 2121: 2117: 2107: 2105: 2088: 2087: 2083: 2073: 2071: 2054: 2053: 2049: 2003: 2002: 1998: 1954: 1953: 1946: 1939: 1918: 1917: 1913: 1869: 1868: 1864: 1820: 1819: 1815: 1771: 1770: 1766: 1722: 1721: 1717: 1687: 1686: 1682: 1672: 1670: 1661: 1660: 1656: 1649: 1634: 1633: 1629: 1585: 1584: 1580: 1534: 1533: 1529: 1519: 1517: 1500: 1499: 1495: 1449: 1448: 1444: 1400: 1399: 1395: 1364:(13): 239–248. 1351: 1350: 1346: 1336: 1334: 1317: 1316: 1305: 1295: 1293: 1276: 1275: 1256: 1251: 1229: 1217: 1211: 1208: 1201:needs expansion 1186: 1170:Medieval Period 1154: 1138: 1125: 1059:skin maceration 1050: 1042:surgical strips 1026:plastic surgeon 1002: 918: 901:povidone iodine 884: 856: 846: 840: 735: 618:pressure ulcers 602: 581: 576: 536: 534:Wound sterility 481: 464: 432: 425: 422: 413: 410: 401: 398: 389: 386: 377: 371: 362: 359: 350: 347: 338: 335: 276: 240:Puncture wounds 188: 187: 170: 145: 120: 82: 78:Plastic surgery 40: 35: 28: 23: 22: 15: 12: 11: 5: 3980: 3978: 3970: 3969: 3964: 3959: 3954: 3944: 3943: 3937: 3936: 3934: 3933: 3928: 3923: 3918: 3912: 3910: 3906: 3905: 3903: 3902: 3897: 3892: 3887: 3874: 3869: 3860: 3851: 3846: 3841: 3835: 3833: 3829: 3828: 3826: 3825: 3820: 3815: 3810: 3804: 3802: 3796: 3795: 3793: 3792: 3791: 3790: 3785: 3780: 3775: 3770: 3765: 3760: 3745: 3743: 3737: 3736: 3734: 3733: 3728: 3723: 3718: 3713: 3708: 3703: 3697: 3695: 3689: 3688: 3686: 3685: 3684: 3683: 3672: 3670: 3666: 3665: 3655: 3653: 3652: 3645: 3638: 3630: 3624: 3623: 3617: 3611: 3602: 3601: 3598: 3597: 3586: 3575: 3556: 3536: 3531: 3530: 3528: 3527:Classification 3520: 3519:External links 3517: 3514: 3513: 3490: 3459:10.2307/462158 3430: 3403:(7): 601–617. 3387: 3366:(5): 760–820. 3346: 3289: 3240: 3203:(2): 111–114. 3183: 3131: 3097: 3038: 3004: 2955: 2901: 2879: 2842:(4): 403–423. 2822: 2785:(6): 614–622. 2765: 2722: 2663: 2626:(3): 479–490. 2606: 2572: 2533: 2490: 2453:(4): 399–407. 2420: 2383:(6): 317–327. 2363: 2304: 2247: 2198: 2164: 2115: 2081: 2047: 1996: 1967:(5): 399–405. 1944: 1937: 1911: 1862: 1833:(2): 560–564. 1813: 1764: 1715: 1696:(4): 491–505. 1680: 1654: 1648:978-0763755522 1647: 1627: 1598:(4): 403–423. 1578: 1527: 1493: 1442: 1413:(3): 219–229. 1393: 1344: 1303: 1253: 1252: 1250: 1247: 1246: 1245: 1240: 1235: 1228: 1225: 1219: 1218: 1198: 1196: 1185: 1182: 1153: 1150: 1137: 1134: 1124: 1121: 1120: 1119: 1113: 1110: 1106: 1102: 1098: 1083: 1073: 1069: 1049: 1046: 1001: 998: 997: 996: 987:larval therapy 983: 976:operating room 956: 944: 940: 917: 914: 883: 880: 842:Main article: 839: 836: 835: 834: 824: 801: 798:bone infection 767: 734: 731: 726: 725: 708:: Pain can be 703: 697: 674: 667: 656: 644: 633: 610: 601: 598: 593:bone fractures 580: 577: 575: 572: 571: 570: 563: 559: 556: 535: 532: 531: 530: 523:Pressure ulcer 520: 502: 488: 480: 477: 463: 462:Chronic wounds 460: 459: 458: 455: 452: 446: 431: 428: 427: 426: 423: 416: 414: 411: 404: 402: 399: 392: 390: 387: 380: 378: 372: 365: 363: 360: 353: 351: 348: 341: 339: 336: 329: 326: 325: 319: 318: 317: 310: 275: 272: 271: 270: 267: 262:– caused by a 260:Gunshot wounds 257: 251: 237: 223: 201: 185: 169: 166: 144: 141: 119: 118:Classification 116: 84: 83: 81: 80: 75: 69: 67: 61: 60: 56: 55: 47: 46: 38: 26: 24: 14: 13: 10: 9: 6: 4: 3: 2: 3979: 3968: 3965: 3963: 3960: 3958: 3955: 3953: 3950: 3949: 3947: 3932: 3929: 3927: 3924: 3922: 3919: 3917: 3914: 3913: 3911: 3907: 3901: 3898: 3896: 3893: 3891: 3888: 3886: 3885:Chemical burn 3882: 3878: 3875: 3873: 3870: 3868: 3864: 3861: 3859: 3856:/superficial/ 3855: 3852: 3850: 3847: 3845: 3842: 3840: 3837: 3836: 3834: 3830: 3824: 3821: 3819: 3816: 3814: 3811: 3809: 3806: 3805: 3803: 3801: 3797: 3789: 3786: 3784: 3781: 3779: 3778:Cullen's sign 3776: 3774: 3771: 3769: 3766: 3764: 3761: 3759: 3758:Battle's sign 3756: 3755: 3754: 3750: 3747: 3746: 3744: 3742: 3738: 3732: 3729: 3727: 3724: 3722: 3719: 3717: 3716:Edema blister 3714: 3712: 3709: 3707: 3704: 3702: 3701:Blood blister 3699: 3698: 3696: 3694: 3690: 3682: 3679: 3678: 3677: 3674: 3673: 3671: 3667: 3663: 3659: 3651: 3646: 3644: 3639: 3637: 3632: 3631: 3628: 3621: 3618: 3615: 3612: 3610: 3607: 3606: 3596: 3592: 3591: 3587: 3585: 3581: 3580: 3576: 3574: 3570: 3566: 3565: 3561: 3557: 3555: 3551: 3547: 3546: 3542: 3538: 3537: 3534: 3529: 3525: 3518: 3509: 3505: 3501: 3494: 3491: 3486: 3482: 3477: 3472: 3468: 3464: 3460: 3456: 3453:(1): 154–61. 3452: 3448: 3444: 3437: 3435: 3431: 3426: 3422: 3418: 3414: 3410: 3406: 3402: 3398: 3391: 3388: 3383: 3379: 3374: 3369: 3365: 3361: 3357: 3350: 3347: 3342: 3338: 3333: 3328: 3324: 3320: 3316: 3312: 3308: 3304: 3300: 3293: 3290: 3285: 3281: 3276: 3271: 3267: 3263: 3259: 3255: 3251: 3244: 3241: 3236: 3232: 3227: 3222: 3218: 3214: 3210: 3206: 3202: 3198: 3194: 3187: 3184: 3179: 3175: 3171: 3167: 3162: 3157: 3153: 3149: 3145: 3138: 3136: 3132: 3120: 3116: 3112: 3108: 3101: 3098: 3093: 3089: 3084: 3079: 3075: 3071: 3066: 3061: 3057: 3053: 3049: 3042: 3039: 3027: 3023: 3019: 3015: 3008: 3005: 3000: 2996: 2991: 2986: 2982: 2978: 2974: 2970: 2966: 2959: 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