Wound Healing — MCQs
Delayed wound healing is seen in all except-
First cell to migrate into a wound due to chemotaxis to start the process of wound healing is -
Which of the following protein molecules is responsible for cell-to-cell adhesion?
Which of the following statements is true about Marjolin's ulcer?
Which of the following statements about keloids is MOST true?
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
A Young Male complained of intermittent pain, swelling and discharge at the base of spine. He also had episodes of fever and repeated abscesses that had burst spontaneously. By occupation, he is a jeep driver. Physical examination showed pilonidal sinus. Which flap-based procedure is used for pilonidal sinus surgery?
What type of graft or dressing is used to cover the post-burn wound shown in the image?
The best skin graft for an open wound is
What is the ideal angle for Z-plasty?
Wound Healing Indian Medical PG Practice Questions and MCQs
Question 1: Delayed wound healing is seen in all except-
- A. Hypertension (Correct Answer)
- B. Malignancy
- C. Infection
- D. Diabetes
Explanation: ***Hypertension*** - While **severe or uncontrolled hypertension** with microvascular complications may theoretically affect tissue perfusion, hypertension **alone is not classically listed** among the primary independent causes of delayed wound healing in standard surgical teaching. - Unlike the other options, hypertension is **not a direct metabolic or local tissue factor** that impairs the wound healing cascade. - The major recognized factors causing delayed wound healing are infection, metabolic disorders (diabetes, malnutrition), malignancy, and immunosuppression—hypertension does not fall into these classical categories. *Diabetes* - **Hyperglycemia** impairs neutrophil function, reduces collagen synthesis, and causes **microvascular disease** that reduces oxygen and nutrient delivery to wounds. - **Diabetic neuropathy** prevents early wound detection, and peripheral vascular disease further compromises healing. - Diabetes is one of the **most important systemic causes** of chronic non-healing wounds. *Infection* - **Bacterial colonization** prolongs the inflammatory phase and prevents progression to proliferation and remodeling. - Pathogens produce **proteases and toxins** that destroy granulation tissue, consume oxygen, and create a hostile wound environment. - Infection is a **local factor** that directly impairs all phases of wound healing. *Malignancy* - **Cancer-associated cachexia** and malnutrition deprive the body of resources needed for tissue repair. - Tumors can **directly invade** wound sites, and cancer treatments (chemotherapy, radiation) impair cellular proliferation and angiogenesis. - Malignancy creates a **systemic catabolic state** unfavorable for healing.
Question 2: First cell to migrate into a wound due to chemotaxis to start the process of wound healing is -
- A. Lymphocyte
- B. Macrophage
- C. Platelet
- D. Neutrophil (Correct Answer)
Explanation: ***Neutrophil*** - Neutrophils are the **first responders** in the wound healing process, rapidly migrating to the site due to **chemotactic signals** [1,2]. - Their primary role includes **phagocytosing pathogens** and debris, facilitating the subsequent healing phases. *Lymphocyte* - Lymphocytes typically arrive later in the healing process and are mainly involved in **immune response** rather than initial wound healing. - They play a significant role in **adaptive immunity** but do not participate in the **early inflammatory phase**. *Platelet* - While platelets aggregate at the wound site and are crucial for **clot formation**, they do not migrate into the wound through chemotaxis like neutrophils [1]. - Their primary function is to initiate the **hemostatic response** rather than directly phagocytosing debris. *Macrophage* - Macrophages are important for **later stages** of wound healing, clearing debris and coordinating tissue repair, but they arrive after neutrophils. - They are involved in the **remodeling phase** and are not the first cells to respond to the wound. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 188-189. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Migration in the tissues toward a chemotactic stimulus, pp. 86-87. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Inflammation and Repair, pp. 87-89.
Question 3: Which of the following protein molecules is responsible for cell-to-cell adhesion?
- A. Laminin
- B. Fibronectin
- C. Collagen
- D. Cadherin (Correct Answer)
Explanation: ***Cadherin*** - **Cadherins** are transmembrane proteins that mediate **direct cell-to-cell adhesion** in a calcium-dependent manner - They form **adherens junctions** and **desmosomes**, which are essential for maintaining tissue integrity - Cadherins on adjacent cells bind to each other (**homophilic binding**), creating strong cell-cell connections - Critical for **embryonic development**, tissue architecture, and **epithelial barrier function** *Fibronectin* - **Fibronectin** is an extracellular matrix glycoprotein that mediates **cell-to-ECM adhesion**, not direct cell-to-cell adhesion - It binds to **integrins** on the cell surface, facilitating cell attachment to the extracellular matrix - Important for cell migration, wound healing, and embryonic development - Does not directly connect cells to each other *Collagen* - **Collagen** is the most abundant structural protein providing **tensile strength** to connective tissues - Primarily functions as **extracellular scaffolding**, not as an adhesion molecule - Provides mechanical support but does not mediate cell-cell adhesion *Laminin* - **Laminins** are major components of the **basal lamina** (basement membrane) - Mediate **cell-to-basal lamina adhesion** through integrin receptors - Important for cell differentiation, migration, and tissue organization - Function in cell-to-ECM adhesion, not cell-to-cell adhesion
Question 4: Which of the following statements is true about Marjolin's ulcer?
- A. Squamous cell carcinoma develops
- B. Slow growing lesion
- C. Develops in long standing scar
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - Marjolin's ulcer is a **malignant transformation** that occurs in chronic wounds and scars, which tend to be **long-standing**. - It most commonly leads to the development of **squamous cell carcinoma (SCC)**, and these lesions are generally **slow-growing**. *Squamous cell carcinoma develops* - This statement is true; the most common histological type of malignancy arising in a Marjolin's ulcer is **squamous cell carcinoma (SCC)**. - Less frequently, **basal cell carcinoma** or other sarcomas can also arise, but **SCC** is the predominant form. - The SCC arising in Marjolin's ulcer tends to be **more aggressive** than conventional SCC, with higher rates of **local invasion** and **metastasis**. *Slow growing lesion* - This statement is true; Marjolin's ulcer lesions typically exhibit a **slow growth rate** over an extended period. - This characteristic often contributes to delayed diagnosis, as patients may initially dismiss the changes as non-malignant wound complications. - The latency period can range from **years to decades** after the initial injury. *Develops in long standing scar* - This statement is true; Marjolin's ulcer is defined by its development in areas of **chronic inflammation**, such as **burn scars**, **pressure sores**, **venous stasis ulcers**, and other non-healing wounds. - The latency period for malignant transformation in such scars can range from years to decades, indicating a **long-standing** nature. - **Burn scars** are the most common site, accounting for the majority of cases.
Question 5: Which of the following statements about keloids is MOST true?
- A. Keloids may extend beyond the original wound. (Correct Answer)
- B. Extended excision is often not the treatment of choice.
- C. It contains growth factors.
- D. None of the options.
Explanation: ***Keloids may extend beyond the original wound.*** - Keloids are characterized by their **overgrowth** beyond the boundaries of the original injury. - This distinguishes them from **hypertrophic scars**, which remain confined to the wound edges. *Extended excision is often not the treatment of choice.* - **Excision alone** is usually insufficient for keloids and can even be counterproductive, as the recurring wound often leads to a larger keloid. - While excision can be part of a treatment plan, it is typically combined with supplementary therapies like **steroid injections** or **radiation therapy** to prevent recurrence. *It contains growth factors.* - While keloids involve abnormal fibroblast activity and deposition of **extracellular matrix**, the statement that it "contains growth factors" is too vague and not a defining characteristic that differentiates it from a range of other tissues or conditions. - Many tissues and healing processes involve growth factors, so this statement alone does not provide a specific or most true characteristic of keloids. *None of the options.* - This option is incorrect because the statement that **keloids may extend beyond the original wound** is a hallmark characteristic of keloids and is definitively true.
Question 6: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 7: A Young Male complained of intermittent pain, swelling and discharge at the base of spine. He also had episodes of fever and repeated abscesses that had burst spontaneously. By occupation, he is a jeep driver. Physical examination showed pilonidal sinus. Which flap-based procedure is used for pilonidal sinus surgery?
- A. Circular flap
- B. Rhomboid flap (Correct Answer)
- C. Rotational flap
- D. Free flap
Explanation: ***Rhomboid flap*** - The **Limberg flap** (also called rhomboid flap) is the most commonly used and well-established flap-based technique for **pilonidal sinus surgery** - It involves excising the sinus in a rhomboid shape and then rotating an adjacent flap of skin and subcutaneous tissue to cover the defect, leading to **faster healing and lower recurrence rates** - This technique effectively **obliterates the natal cleft**, which helps prevent future pilonidal disease by eliminating the deep sulcus where hair and debris can collect - The specific geometric design provides excellent tissue coverage with minimal tension *Circular flap* - Circular flaps are generally **not used for pilonidal sinus surgery** because they can lead to tension at the wound edges and do not effectively flatten the natal cleft - Simple excision with primary closure techniques are associated with **higher recurrence rates** (up to 40%) and wound complications compared to flap-based techniques *Rotational flap* - This is a **generic term** encompassing various flap designs that rotate tissue to cover defects - While the rhomboid flap is technically a type of rotational flap, this option is **too non-specific** as an answer - The question asks for the specific flap-based procedure used, making "Rhomboid flap" the more precise and appropriate answer - Other rotational techniques (Karydakis flap, V-Y advancement) have different geometries and applications *Free flap* - **Free flaps** involve microsurgical transfer of tissue from a distant site with its own vascular pedicle, requiring microvascular anastomosis - This is **overly complex and unnecessary** for pilonidal sinus reconstruction - Reserved for large, complex defects in highly specialized reconstructive cases, not for routine management of **pilonidal disease**
Question 8: What type of graft or dressing is used to cover the post-burn wound shown in the image?
- A. Split thickness skin graft (Correct Answer)
- B. Full thickness skin graft
- C. VAC dressing
- D. Normal saline dressing
Explanation: ***Split thickness skin graft*** - The image shows a **meshed pattern** on the skin graft, which is characteristic of a **split-thickness skin graft** that has been expanded to cover a larger area. - This type of graft consists of the epidermis and a portion of the dermis, making it more flexible and able to **"take" more reliably** on various wound beds, commonly used for burn wounds. *Full thickness skin graft* - A **full-thickness skin graft** includes the entire epidermis and dermis and typically does not have a meshed appearance. - They are used for smaller defects where cosmesis is a priority, but have a **lower take rate** than split-thickness grafts, making them less suitable for large burn wounds. *VAC dressing* - A **VAC (Vacuum-Assisted Closure) dressing** is a system that applies negative pressure to a wound to promote healing and is not a skin graft itself. - It involves a foam or gauze dressing sealed with an adhesive film, connected to a vacuum pump, which is not what is depicted in the image. *Normal saline dressing* - A **normal saline dressing** is a simple wet-to-dry or wet-to-wet dressing for wound care, involving gauze soaked in normal saline. - This is a basic wound management technique and does not involve grafting or have the characteristic meshed appearance seen in the image.
Question 9: The best skin graft for an open wound is
- A. Isograft
- B. Autograft (Correct Answer)
- C. Allograft
- D. Homograft
Explanation: ***Autograft*** - An autograft is tissue transferred from one site to another **within the same individual**, ensuring 100% genetic match and no immune rejection. - This makes it the ideal choice for **permanent coverage of open wounds** as it will be vascularized and incorporated into the host tissue without risk of rejection. *Isograft* - An isograft is tissue transferred between **genetically identical individuals** (e.g., identical twins). - While genetically identical, this option is generally not available for the vast majority of patients with open wounds. *Allograft* - An allograft (also known as a homograft) is tissue transferred between **genetically different individuals of the same species**. - Allografts carry a significant risk of **immune rejection** and are typically used as temporary covers for large burns or wounds, while awaiting autografting. *Homograft* - Homograft is another term for **allograft**, referring to tissue transplanted between genetically non-identical individuals of the same species. - Like allografts, homografts are primarily used for **temporary wound coverage** due to the high risk of immune rejection.
Question 10: What is the ideal angle for Z-plasty?
- A. 90°
- B. 45°
- C. 60° (Correct Answer)
- D. 75°
Explanation: ***60°*** - An angle of **60°** is considered ideal for Z-plasty because it provides the best balance between **lengthening the scar** and maintaining **tissue viability**. - This angle typically results in a **75% gain in length** along the central limb of the Z-plasty, while ensuring the flaps have a broad enough base for adequate blood supply. *90°* - While a **90°** angle would provide the most lengthening (around 100%), it creates very **thin, narrow flap tips** that are highly susceptible to **ischemia and necrosis** due to compromised blood supply. - This angle is generally avoided in Z-plasty due to the high risk of **flap complications**. *45°* - A **45°** angle results in less lengthening (approximately 50% gain) compared to a 60° angle, which may not be sufficient for significant release of scar contractures. - While it offers excellent flap viability due to wider bases, the **suboptimal lengthening** makes it less efficient for many Z-plasty applications. *75°* - An angle of **75°** would yield greater lengthening than 60°, but it also compromises flap viability making the flap susceptible to **necrosis**. - The benefits of increased length are often outweighed by the increased **risk of complications** when using this angle.
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