Wound Closure Classification

The Wound Closure Classification calculator is a tool that helps classify what type of wound closure is needed in open wounds after traumatic injuries.
Clean wounds with minimal tissue loss, e.g. surgical wounds, clean lacerations 0
Significant tissue loss precluding tension-free approximation of edges, devitalized edges, ulcerations, or abscess cavities 1
Grossly contaminated wounds with or without significant tissue loss 2


Measured Factor
Type of wound closure
Measured Factor Disease
  • Contamination of the wound with possible significant tissue loss
  • Delayed primary closure
Measured Factor Detail
Wound management starts with assessment and classification. The Wound Closure Classification calculator helps physicians assess the type of open wound present and classify it in order to determine the best course of treatment or tyoe of wound closure needed. The calculator classifies the type of wound depending on the wound's etiology and pattern of injury, morphology, contamination, and complexity. Based on this information, the wound is classified as primary, secondary or tertiary. Primary wounds can be closed within 6-8 hours of the trauma. Secondary wounds do not need surgical closure, but need daily dressing changes. Tertiary wounds are the most serious and need to be observed for 3-7 days before surgically closing it or performing skin grafting.
Body System
Multiple body systems
Measured Factor High Impact
  • Irrigation and debridement
  • Careful observation for 3-7 days before surgical closure
  • Skin grafting
  • Delayed primary closure

Result Interpretation

Ranges Ranges
  • Critical High: Tertiary wound closure classification | Contaminated wounds with or without significant tissue loss.
  • Normal: Primary wound closure classification | Clean wounds with minimal tissue loss
  • Normal Adult Male: Primary wound closure classification | Clean wounds with minimal tissue loss
  • Normal Adult Female: Primary wound closure classification | Clean wounds with minimal tissue loss
  • Normal Geriatric Male: Primary wound closure classification | Clean wounds with minimal tissue loss
  • Normal Geriatric Female: Primary wound closure classification | Clean wounds with minimal tissue loss
Result High Conditions
  • Contamination of the wound with possible significant tissue loss
  • Delayed primary closure
Test Limitations
Based on various review articles published, the wound closure classification calculator has limited application in abdominal and orthopedic wounds. These multiple studies have compared primary versus tertiary wound closure of contaminated abdominal wounds and open orthopedic wounds and found no significant difference in reduction of surgical site infections. A retrospective review of 84 patients with open tibia fractures treated within 72 hours after injury showed that delayed coverage was not necessary if healthy soft tissue can be used. Similarly, a meta analysis of 8 randomized control trials comparing primary versus tertiary skin closure in contaminated abdominal incisions showed no statistical significance in reduction of surigical site infections when using tertiary closure.
References: 2, 3


Study Validation 1
This review article assessed the infection rate in the nonstoma wound in patients that had stoma closures and to identify factors that affect this rate. Results were based on the records of 95 patients that underwent ileostomy or colostomy closure at a Toronto hospital between 1988 and 1993. Patient charts were studied for information about patient and technical factors associated with wound infection. Diagnosis of incisional infection was made based on criteria outlined by the Centers for Disease Control and Prevention (CDC) for nosocomial infections. Overall, the rate of infection was 29% and primary wound closure was associated with an increase in wound infection rate of 41%, while the infection rate for delayed primary or secondary wound closure was 15%. Infection rate was unaffected by patient age, but patients with multiple diagnoses and certain underlying disease states showed a higher rate of infection. In conclusion, the best way to reduce infections in nonstoma abdominal incisions appeared to be using delayed primary closure or secondary closure.
References: 4
Study Validation 2
This retrospective study evaluated the safety, efficacy and outcomes of esophageal stenting in patients with esophageal leaks, fistulae, and perforations (L/F/P) and identified factors associated with successful wound closure. Data was collected from a pool of patients at the Indiana University Hospital endoscopic database between 2003 and 2012. All necessary data was abstracted from patient’s medical records, including demographics, size and location of the L/F/P, indications for stent placement, stent characteristics, time from diagnosis to stent placement, short term effects and long-term effects among others. The type, length, number and degree of coverage (partial or fully covered) of each stent was decided by the attending endoscopist. Descriptive statistics consisting of means, standard deviations, medians and ranges were used for analyzing the data. A total of 54 patients were included in the study, 29 patients with stents for esophageal leaks, 15 with stents for esophageal fistulae, and 10 patients with stents for esophageal perforations. Primary closure was performed and successful in 40 patients (74%), while secondary closure was performed and successful in 5 patients (83%). After a short term follow up of <3 months, 27 patients (50%) were asymptomatic, while 22 patients (41%) had technical adverse events. Successful primary closure was associated with shorter time between diagnosis and initial stent insertion (p=0.003) and smaller luminal opening size (p=0.002). In conclusion, researchers found that temporary stents are safe and effective for treating esophageal L/F/P.
References: 5
Study Additional 1
This retrospective review evaluated comorbidities, risk factors for infections, wound classification and wound outcomes in patients with abdominal surgery. The review was based on patients that had undergone abdominal reconstruction by the same single surgeon. Patients were defined as high risk if they had infections or contamination at the time of surgery or needed a skin flap for skin closure while also having one or more comorbidities like diabetes, hypoxemia or a history of wound infection among others. Wound coverage was done using negative-pressure wound therapy and antibiotics were given to all patients. Wounds were assessed at the time of dressing removal, 2 weeks, and 4 weeks after surgery. Primary outcome measured was infection of the skin or the subcutaneous tissue, as defined by the Centers for Disease Control and Prevention. A total of 30 patients were identified in whom negative pressure was used for an average of 5.6 days. None of the patients developed ischemia, necrosis or wound infections. Wound complication rate was 3% and χ(2) analysis showed a statistically significant decrease in the infection rate with negative pressure wound therapy (p<0.05). In conclusion, negative pressure wound therapy in closed, high risk surgical wounds decreased the rate of wound infection.
References: 6
Study Additional 2
A cross-sectional, quantitative study was conducted among wound experts in order to examine the content validity of a set of three negative pressure wound therapy (NPWT) algorithms and to enhance the understanding of previously identified wound terminology issues. This study consisted of a paper/pencil survey on the NPWT algorithms, a demographic questionnaire and a request to identify the definition of 5 commonly used terms; acute wound, chronic wound, and primary, secondary, and tertiary intention healing. To present and analyze the data, a Likert scale (Range 1-4) was used and space was provided for comments. A total of 114 wound care experts participated and the majority were registered nurses (72%) practicing in the US (94%). Results showed that the content validity of the NPWT components was strong with a mean rating of 3.76 and a standard deviation of 0.56. There was some consensus on wound definitions, but important disparities in mutual understanding of what classified as acute and chronic were observed. Additionally, surgical closure definitions of primary, secondary and tertiary intention were not clearly or correctly understood by a significant number of participants. In conclusion, the study demonstrated additional research is needed to test whether the NPWT algorithms do indeed facilitate safe patient care.
References: 7


David Leaper, MD, ChM, FRCS, FACS, and FLS is an Emeritus Professor of Clinical Sciences and Surgery at the University of Huddersfield and the University of Newcastle, respectively. He graduated from Leeds Medical School in 1970 and trained in general surgery. In addition, Dr. Leaper also completed the Fellowship in Surgery of the Royal Colleges of Edinburgh, England and Glasgow. His research interests include surgical site infection, sepsis, critical care and wound healing.


  1. Kumar S, Leaper DJ. Classification and management of acute wounds. Surgery (Oxford). 2005 Feb 1;23(2):47–51.
  2. Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open fractures: a prospective study. J Trauma. 1983;23(1):25-30.
  3. Bhangu A, Singh P, Lundy J, Bowley DM. Systematic Review and Meta-analysis of Randomized Clinical Trials Comparing Primary vs. Delayed Primary Skin Closure in Contaminated and Dirty Abdominal Incisions. JAMA Surg.2013;148(8):779-786
  4. Hackam DJ, Rotstein OD. Stoma closure and wound infection: an evaluation of risk factors. Can J Surg. 1995 Apr;38(2):144-8.
  5. El Hajj II, Imperiale TF, Rex DK, Ballard D, Kesler KA, Birdas TJ, et al. Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes. Gastrointest Endosc. 2014 Apr;79(4):589-98.
  6. Vargo D. Negative pressure wound therapy in the prevention of wound infection in high risk abdominal wound closures. Am J Surg. 2012 Dec;204(6):1021-3; discussion 1023-4.
  7. Beitz JM, van Rijswijk L. Content validation of algorithms to guide negative pressure wound therapy in adults with acute or chronic wounds:a cross-sectional study. Ostomy Wound Manage. 2012 Sep;58(9):32-40.

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