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					               Wound Management
• October 11, 2001
•   Gavin Greenfield and Bob Johnston
                 Objectives
• Wound Healing
• Wound Evaluation – History, Physical
  examination
• Wound Preparation
• Wound Closure
• Specific Wounds
  – face, scalp, eyebrow, eyelid, ear, lips,
    intraoral, puncture, fingertip and nail, foreign
    bodies, bites
            Wound Healing
• “the primary goal of wound care is not the
  technical repair of the wound; it is
  providing optimal conditions for the natural
  reparative processes of the wound to
  proceed”
  – Richard L. Lammers (Roberts and Hedges)
               Skin Anatomy
• Epidermis
  – keratinized squamous epithelium
  – avascular
• Dermis
  – dense, fibro-elastic tissue
  – highly vascular
  – cells of dermis mainly fibroblasts responsible for
    elaboration of collagen, elastin, ground substance
• Subcutaneous layer (superficial fascia)
  – connects dermis to underlying tissue
  – contains variable amounts of adipose tissue
                 Case 1
• 1st year medical student comes in with
  laceration to hand. You evaluate the
  wound and feel it is appropriate for primary
  closure. He asks you how the wound will
  go about healing itself? What do you tell
  him to appease his curious mind?
             Wound Healing
• Stages
  – hemostasis
  – inflammation
  – epithelialization
  – fibroplasia
  – contraction
  – scar maturation
            Wound Healing
• Inflammation
  – serves to remove bacteria, foreign debris, and
    devitalized tissue – a biologic debridement
  – if this stage is prolonged (from infection,
    foreign material, etc.) will get persistent
    inflammation and result in poor wound healing
            Wound Healing
• Epithelialization
  – in sutured wounds, surface of wound
    develops epithelial covering impermeable to
    water in 24-48 hours
  – eschar and surface debris impair this process
    by inhibiting the migration of the epithelial
    cells
            Wound Healing
• Fibroplasia
  – by fourth day fibroblasts begin synthesizing
    collagen, initiating scar formation
  – characterized clinically by pebbled red tissue
    in wound base
            Wound Healing
• Contraction
  – movement of skin edges toward center of
    defect, primarily in direction of underlying
    muscle
  – everting skin edges at time of repair accounts
    for the subsequent wound contraction
            Wound Healing
• Scar Maturation
  – amount of scar tissue influenced by physical
    forces acting across wound
  – strength of wound increases rapidly from day
    5-17, more slowly for additional 14 days, and
    further collagen remodeling / maturation for 2
    years
  – strength of scar tissue never quite reaches
    that of unwounded skin
                   Case 2
• Pt presents with two wounds – one is
  sharp, linear laceration on L hand from a
  clean knife. While riding her bike to
  hospital she falls on a pristine, flat, clean
  road and lands on dorsum of hand
  producing a jagged irregular laceration.
• Which of the two has higher chance of
  infection? Why?
                 Case 3
• Alcoholic, diabetic street person presents
  with laceration to R forearm. He thinks he
  did it about 24 hours ago but can’t
  remember mechanism. On examination
  small amount of soil type debris in wound.
• How will you manage this case?
        Wound Evaluation – History
  American College of Emergency Physicians: Clinical policy for the initial approach to patients
    presenting with penetrating extremity trauma. Ann Emerg Med Vol 33 No. 5 May 1999


• identify all extrinsic and intrinsic factors that
  jeopardize healing and promote infection
   – mechanism of injury
   – time of injury
   – environment in which wound occurred
        • potential contaminants, foreign bodies
   – species of animal if bite
   – pt’s medical problems / immune status
• tetanus immunization status
• handedness / vocation
     Wound Evaluation - History
• Risk Factors for wound infection (Singer et al. Risk
  factors for infection in patients with traumatic lacerations. Academic Emergency Medicine. July 1,
  2001; 8(7): 716-20)

   – older age
   – diabetes
   – laceration width
   – presence of foreign body
    Wound Evaluation – History
      (mechanism of injury)
• Type of force causing wound
• Acute traumatic wounds caused by one or
  combination of 3 forces
  – shear
  – compressive
  – tensile
    Wound Evaluation – History
      (mechanism of injury)
• Shear Forces
  – produced by sharp objects that cut through
    the skin
  – amount of energy required to cut skin with
    sharp object is low therefore little energy
    directed to surrounding tissue with minimal
    cell damage
  – results in lower risk of infection and problems
    with wound healing because remaining tissue
    is not devitalized
     Wound Evaluation – History
       (mechanism of injury)
• Compressive and Tensile Forces
  – compressive forces produced when blunt object
    impacts the skin at right angles (wounds tend to be
    stellate or complex with ragged/shredded edges)
  – tensile forces produced when a blunt object impacts
    skin at oblique angles (wounds tend to be triangular
    or produce a flap)
  – compared to shear forces much more energy
    deposited with high amounts applied to area around
    wound
  – results in devitalization of surrounding tissue with
    higher incidence of wound infection
    Wound Evaluation – History
      (mechanism of injury)
• Shear vs. Compressive / Tensile Forces
  – Infection
     • with compressive / tensile forces the critical
       number of bacteria needed to produce infection is
       much lower (~100,000 organisms per gram of
       tissue)
     • with shear forces the number of bacteria needed to
       produce infection is much higher ~ 10,000,000
       organisms per gram of tissue
 Wound Evaluation – History (time
           of injury)
• “golden period” refers to time after injury that
  wound can be safely closed without increased
  risk of infection
   – delay in wound cleaning is most important variable
   – contrary to popular belief not a fixed number of hours
   – “there is little change in wound infection rates in most
     areas of the body for up to 19 hours after a variety of
     traumatic injuries, and infection rates of simple
     wounds involving the head are essentially unaffected
     by the interval between injury and repair”
      • Berk et al. Evaluation of the “golden period” for wound
        repair: 204 cases from a third world emergency department.
        Ann Emerg Med 17:496, 1988
 Wound Evaluation – History (time
           of injury)
• accelerated growth phase of bacteria
  starts at 3 hours post wound
           Timing of Closure
• primary, delayed primary, secondary
  – decision to close a laceration is multifactorial
  – base decision on wound history, physical
    examination, host factors
• Revisit Case 3
      Wound Evaluation – Physical
            Examination
• Examine for:
  – amount of tissue destruction
  – degree of contamination
  – damage to underlying structures
• Wounds may be classified into 6 categories
  –   lacerations
  –   abrasions
  –   crush wounds
  –   avulsion wounds
  –   puncture wounds
  –   combination wounds
   Wound Evaluation – Physical
         Examination
• Lacerations
  – if caused by shear force little tissue damage
    at wound edge and margins are sharp and
    wound appears “tidy”
  – if caused by compressive or tensile forces,
    more force is required to produce the
    laceration and therefore more tissue trauma;
    often appear jagged, contused
   Wound Evaluation – Physical
         Examination
• Abrasions
  – results from forces applied in opposite
    directions (e.g. skin grinding against road
    surface)
   Wound Evaluation – Physical
         Examination
• Crush Wounds
  – caused by impact of an object against tissue,
    especially over a bony surface, which
    compresses the tissue
  – at higher risk for subsequent compartment
    syndrome
   Wound Evaluation – Physical
         Examination
• Avulsions
  – wounds in which a portion of tissue is
    completely separated from its base and is
    either lost or left with a narrow base of
    attachment
   Wound Evaluation – Physical
         Examination
• Puncture Wounds
  – wounds with a small opening and whose
    depth cannot be visualized


• Combination Wounds
    Wound Evaluation – Physical
          Examination
• Amount of tissue destruction / devitalized
  tissue
   Wound Evaluation – Physical
         Examination
• Degree of Contamination
  – bacteria and foreign material
  – primary determinants of wound infection are
    the amount of bacteria and dead tissue
    remaining in wound
  – the presence of undetected reactive foreign
    bodies in sutured wounds almost guarantees
    infection
   Wound Evaluation – Physical
         Examination
• Underlying Structures
  – nerves, vessels, tendons, bones, joints
   Wound Evaluation – Physical
         Examination
• Wound Location
  – has considerable importance in the risk of
    infection
  – high endogenous bacterial counts in hairy
    scalp, forehead, axilla, groin, foreskin of
    penis, vagina, mouth, nails
  – wounds in areas of high vascularity more
    easily resist infection (scalp, face)’
     Delayed Primary Closure
• wound preparation (debridement,
  cleansing, etc.), dress with saline soaked
  fine mesh gauze, follow up in 72-96 hours
  for debridement, repeat cleansing and
  closure if no evidence of infection
          Skin Preparation
• prevents transfer of bacteria into wound
  from instruments, suture needles, gloved
  fingers
• use whatever (no research suggest one
  better than another)
• important to distinguish between skin
  preparation and wound cleansing
        Wound Cleansing (not skin
             preparation)
• Soaking
  – of little value and may actually increase
    bacterial counts (Lammers, Fourre, Callaham et al. Effect of poviodine-iodine and
     saline soaking on bacterial counts in acute, traumatic contaminated wounds. Ann Emerg Med 19: 709,
     1990)
     Wound Cleansing (not skin
          preparation)
• Mechanical Scrubbing
  – gentle scrubbing may be useful in wounds
    older than 3-4 hours (a glycoprotein matrix
    enters wound and may protect it from further
    attempts to lower bacterial counts with
    irrigation)
• Debridement of devitalized tissue
  paramount to reducing risk of infection
• Scalpel excision of wound margins can be
  used in grossly contaminated wounds
         Wound Cleansing (not skin
              preparation)
• Irrigation
    – Equipment?
        • 35 cc syringe with 18 G needle produces about 7-8 psi
    – Solution?
        • NS or 1% poviodine-iodine solution (ie. diluted Betadine) (Dire and Walsh: A comparison
          of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990; 19:704-708)
               – infection rate in poviodine arm was lower than saline arm but not statistically
                 significant (4.3% vs 6.9%)
        • Hydrogen peroxide kills fibroblasts and occludes microvasculature,
          chlorhexadine toxic to tissue defenses, detergents contained in scrub
          solutions cause tissue damage in wounds
    – How much? (all expert opinion – no clinical trials)
        • minimum of 100-300 cc with continued irrigation until all visible particles
          removed
        • 50-100 cc per cm of wound length
        • if irrigation alone is ineffective in removing contaminants from a wound, the
          wound should be lightly scrubbed
 Prophylactic Antibiotics - Topical
• Ointments
  – reduce formation of crust which could inhibit
    epithelialization
  – prevent dressing from adhering to wound
  – routine use encourages pt inspection of
    wound
  – one randomized, double blind clinical trial
    demonstrated reduced infection rate
    • Dire et al. Prospective evaluation of topical antibiotics for preventing
      infections in uncomplicated soft-tissue wounds repaired in the ED. Acad
      Emerg Med 2:4, 1995
 Prophylactic Antibiotics - Systemic
• no role for routine antibiotic use for most
  wounds (Cumming et al. Antibiotics to prevent infection of simple wounds: A
   meta-analysis of randomized studies. Am J Emerg Med 13:396, 1995)

• specific wounds: contaminated with debris,
  feces, saliva; punctures, bites, extensive
  tissue destruction, wounds in avascular
  areas, oral lacerations, wounds involving
  joint spaces, tendons, or bones; presence
  of impaired host defenses
     Wound Closure - Sutures
• Classification: nonabsorbable vs
  absorbable
• Size (according to diameter): 6-0 face, 5-
  0,4-0 trunk and extremities, 3-0 scalp, sole
  of foot
       Wound Closure – Sutures -
           Nonabsorbable
• Natural or Synthetic / Monofilament or Multifilament
   – natural incite tissue reactivity (therefore increase risk of infection,
     synthetic less so)
   – monofilament have less pliability and knot security than
     multifilament but multifilament increase risk of wound infection
• Natural multifilament - silk
   – easiest to handle but poses greatest risk of infection because of
     tissue reactivity (it is both a natural suture and multifilament)
• Synthetic monofilament – nylon (Ethilon), polypropylene
  (Prolene), polybutester (Novafil)
• Synthetic multifilament – nylon, polyester (Mersilene)
      Wound Closure – Sutures -
            Absorbable
• Natural (collagen) or Synthetic (polymers)
• Natural – plain gut and chromic gut
  – plain gut loses tensile strength the quickest (half life
    5-7 days); produces marked tissue reactivity;
    generally used only for oral mucosal closures
    (because heal so quickly)
  – chromic gut absorbed less rapidly than plain gut but
    faster than synthetics (half life 10-14 days); less
    tissue reactivity than plain gut because of chromic
    coating; useful in situations where suture removal
    may be difficult
      Wound Closure – Sutures -
            Absorbable
• Synthetic Multifilament – polyglycolic acid
  (Dexon), polyglactin 910 (Vicryl)
  – most commonly used in emerg for sq layers
• Synthetic Monofilament - polyglyconate (Maxon),
  polydioxanone (PDS II)

• Remember – presence of any suture material in
  a wound increases risk of infection;
  subcutaneous sutures have highest risk
        Wound Closure - Staples
• lower tissue reactivity than even the least
  reactive suture material
• get less accurate closure with higher
  chance of malapposition of wound edges
  and development of scar
• generally reserved for sites where scar is
  less of an issue (hairy scalp)
  –   Kanegaye et al. Comparison of skin stapling devices and standard sutures for pediatric scalp
      laceration: A randomized study of cost and time benefits. J Pediatr 130:808, 1997
       Wound Closure - Tapes
• useful for flat, dry, nonmobile surfaces where
  wounds fit together with no tension –ie
  superficial, straight laceration under little tension
• more resistant to infection than sutured wounds
• adherence of tapes improved with use of
  benzoin to skin surface
• recommend not getting wet but…
• should stay in place as long as equivalent suture
  and will spontaneously detach as underlying
  epithelium exfoliates
     Wound Closure – Tissue
  Adhesives (2-octylcyanoacrylate)
• closes wounds by forming an adhesive layer on top of
  intact epithelium, which holds edges together
• cause inflammatory reaction within wounds
• Useful
   – edges less than 5 mm apart, clean, sharp edges, clean
     nonmobile areas, laceration less than 5 cm in length
• Not useful
   – wounds near eye, on mucous membranes or mucosal surfaces,
     wet wounds or those exposed to body fluids, or in areas with
     dense hair, wounds under significant tension
    Wound Closure – Tissue
 Adhesives (2-octylcyanoacrylate)
• Literature
  – in selected lacerations produces cosmetic
    appearance that is comparable with standard suture
    closure
     • Singer et al. Prospective, randomized, controlled trial of tissue adhesive (2-
       octylcyanoacrylate) vs. standard wound closure techniques for laceration repair. Acad
       Emerg Med 1998; 5:94-99
     • Quinn et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and
       sutures in the management of laceration. JAMA 1997;277:1527-1530
     • Quinn et al. Tissue adhesive versus suture wound repair at 1 year: Randomized clinical
       trial correlating early, 3 month, and 1 year cosmetic outcome. Ann Emerg Med
       1998;32:645-649
     • Maw et al. A prospective comparison of octylcyanoacrylate tissue adhesive and suture
       for the closure of head and neck incisions. J Otolaryngol 1997;26:26-30
  – may be useful for wounds under higher skin tension
     • Saxena Octylcyanoacrylate tissue adhesive in the repair of pediatric extremity
       lacerations. Am Surg 1999 May;65(5):470-2
     • in above study they looked at 32 children with high skin tension lacerations (hand, feet,
       over joints). Following closure splints were applied to restrict movement
    Wound Closure – Tissue
 Adhesives (2-octylcyanoacrylate)
• Application
  – hold wound edges together with tissue
    forceps (???), lightly wipe applicator tip over
    area starting at least 5 mm from edge of
    wound in direction of long axis of wound
    (some authors support perpendicular
    application), 3-4 thin layers, hold wound
    edges together for 60 s post application
  – avoid ointments and dressings
    Wound Closure – Tissue
 Adhesives (2-octylcyanoacrylate)
• Tips
  – avoid latex gloves – use vinyl gloves
  – avoid plastic instruments (ie. tissue forceps)
  – if enters wound needs to be wet sponged
    immediately
  – use antibiotic ointment for removal of
    hardened Dermabond in wound
     Specific Wounds – Face
• high vascularity therefore low incidence of
  infection
• debride minimally to preserve normal
  facial contours
• be more aggressive with layered closure
  Specific Wounds - Forehead
• unrepaired muscle layers more likely to
  produce scars
• be liberal with deeper sutures in wounds
  under tension
• reapproximate skin tension lines and
  hairline precisely
                Case 7
• 8 month old boy presents with 2 days
  progressive lethargy with weakness L side
  of body. 1 month ago was bitten on scalp
  by dog. What has happened and how?
      Specific Wounds - Scalp
• 5 layers
• can bleed +++
• shaving increases risk of infection; clip hair or
  use ointment to mat it down
• check for disruption of galea and repair if
  present (either single or layered closure)
• subaponeurotic (subgaleal) loose connective
  tissue contains emissary veins that
  communicate with intra-cranial venous sinuses
   – subgaleal hematomas can become infected and
     infection can be transmitted intra-cranially via
     emissary veins
   Specific Wounds - Eyebrow
• minimal if any debridement; if needed
  angle scalpel parallel to direction of hair
  shafts to minimize damage to hair follicles
  and resulting alopecia
• never shave eyebrows
• use edges to serve as landmarks for
  reapproximation
    Specific Wounds - Eyelids
• Layers (out to in): skin, subcutaneous
  tissue, muscle (orbicularis oculi and
  levator palpebrae in upper eyelid),
  supporting tissue (forward continuation of
  sub-galeal aponeurotic layer of scalp),
  tarsal plate (dense fibroelastic plate),
  conjunctiva
• with any eyelid laceration ensure no
  penetrating globe injury
    Specific Wounds - Eyelids
• When to repair
  – superficial; use 6-0 or 7-0 nonabsorbable synthetic,
    small bites
• When to refer
  – lacerations involving inner surface of lid
  – lacerations involving lid margins (imperfect closure
    results in ectropion or entropion)
  – lacerations involving lacrimal duct (clue is laceration
    of lower lid medial to punctum)
  – lacerations associated with ptosis (levator injury)
  – lacerations extending into tarsal plate
      Specific Wounds - Ears
• Anatomy
  – auricle (pinna) – modified horn shaped structure
    composed of elastic cartilage covered by skin –
    converges onto the external auditory meatus (canal)
  – earlobe
• with blunt forces ensure no ruptured TM
• examine closely for subchondral hematoma
  – absolutely have to avoid persistent hematoma
  – need perfect hemostasis to prevent formation of
    hematoma
  – if present consider plastics or ENT referral
      Specific Wounds - Ears
• gaping through and through lacerations
  require 3 layer closure
  – 1st – one or two sutures will approximate
    cartilage edges, include anterior and posterior
    perichondrium in suture
  – 2nd – approximate posterior skin
  – 3rd – anterior surface of ear using landmarks
    joined point to point
• all repaired ears should be enclosed with
  compression dressing
        Specific Wounds - Nose
• Anatomy
   – separated into two halves by the septum (cartilaginous structure)
   – tip formed by two C-shaped alar cartilages covered directly by
     skin
• Exposed cartilage increases risk of infection and
  therefore needs to be covered
• Nasal trauma can result in septal hematoma
   – can lead to permanent thickening of the septum with subsequent
     airway obstruction
   – pressure from a septal hematoma may cause necrosis and
     subsequent erosion / rupture of septum
   – aspirate with 18G needle or horizontal incision at base; nasal
     packing following drainage will prevent reaccumulation
       Specific Wounds - Lips
• Anatomy
  – skin, vermilion border, vermilion, oral mucosa
  – obicularis oris
• Always inspect intraoral and mucosal lip wounds
  for foreign bodies – esp. teeth and teeth
  fragments
• Lacerations through vermilion border
  – use traction to the lips place first stitch at vermilion
    border – need perfect alignment
  – then repair obicularis oris
  – then repair skin and remainder of lip
      Specific Wounds - Lips
• Through and through lacerations
  – 3 layer closure – 1st – mucosal layer with
    rapidly absorbable suture – 2nd – orbicularis
    oris – 3rd – skin
        Specific Wounds – Intraoral
 Armstrong. Lacerations of the Mouth. Emergency Medicine Clinics of North America
                              Vol 18, No 3 August 2000

• Irrigation as per normal
• lacerations of buccal mucosa and gingiva heal
  without repair of wound edges not widely
  separated
• Small (<2cm) intraoral lacerations need not be
  repaired
• Close bigger lacerations and lacerations with
  flaps that fall between chewing surfaces with
  absorbable sutures (plain gut, chromic gut or
  synthetic absorbables)
 Specific Wounds – Finger tip and
           nail injuries
• Anatomy
  – eponychium, lunula, nail root, nail,
    hyponychium, germinal matrix, nail bed
    (matrix)
  – finger tip injuries are defined as occurring
    distal to the insertion of the flexor and
    extensor tendons at the level of the lunula
  – classified as Zone I, II, III
 Specific Wounds – Finger tip and
           nail injuries
• Tip injuries with skin and pulp tissue loss only
  (no exposed bone)
   – if less than 1 square cm can treat conservatively with
     serial dressing changes alone (wound heals by
     secondary intention)
   – if severed skin tip available can use as full thickness
     graft; amputated tissue is debrided, de-fatted, then
     sutured in place
   – if greater than 1 square cm can consider using split or
     full thickness graft from distant site vs conservative
     management
 Specific Wounds – Finger tip and
           nail injuries
• Tip injuries with exposed bone
  – if bony protuberance < 0.5 cm and soft tissue defect
    less than 1 square cm trim back bone with rongeuer
    and consider leaving wound open to heal by
    secondary intention with serial dressing changes
  – if wound dorsal obliquely angulated can treat with
    bone shortening followed by primary closure of wound
    using adjacent volar tissue
  – amputations in a transverse or volar obliquely
    angulated often require referral for sophisticated flaps
 Specific Wounds – Finger tip and
           nail injuries
• Nail Growth
  – germinal matrix produces bulk of nail plate
  – sterile matrix produces a layer of cells that is
    added to the under surface of the growing nail
  – if nail bed injury results in scarring of sterile
    matrix will get a poorly adherent nail with
    ridging – cosmetically not appealing
  – takes 4 months for a new nail to reach
    hyponychium
  Specific Wounds – Finger tip and
            nail injuries
• Injuries to nail and surrounding structures
   – nail bed injured when force directed to dorsum of nail crushing
     nail bed against underlying tuft of distal phalanx
• Subungual hematoma
   – tradition deems that if occupies more than 50% of nail bed area,
     remove nail and repair associated nail bed laceration
   – Two prospective studies found simple trephination produced
     good results (Seaberg et al. Treatment of subungual hematomas with nail trephination: A prospective study: Am J
       Emerg Med 9:209, 1991.   Meek et al. Subungual hematomas: is simple trephining enough? J Accid Emerg Med 15:269, 1998)

   – Roberts and Hedges suggest that if nail adherent do not
     routinely remove nail to search for bed laceration
   – remove nail and fix bed lacerations if nail partly avulsed or loose,
     or if there are deep lacerations that involve the nailbed
   – replace avulsed nail after bed repair and suture in place
                 Case 4
• 16 year old healthy male playing tennis
  steps on a nail that punctures bottom of
  shoe and punctures sole of foot.
• How will you approach and manage this
  pt?
    Specific Wounds – Puncture
              Wounds
                Reference: Up To Date 2000

• usually due to nails
• deeper the penetration, higher the
  incidence of infection
• wounds in area of MTP joints penetrate
  deeper because this is weight bearing
  area
• increased risk of infection with wounds to
  forefoot or shoe wearing at time of
  puncture
    Specific Wounds – Puncture
              Wounds
• Microbiology
  – partly dependent on environmental location
  – Staph aureus, beta-hemolytic streptococci
    (GAS), gram negatives
  – pseudomonas common with wounds through
    shoes
    Specific Wounds – Puncture
              Wounds
• Evaluation
  – routine wound evaluation as previously
    discussed
  – have low threshold for x-rays, especially re
    presence of foreign body
    Specific Wounds – Puncture
              Wounds
• Initial Management
  – no prospective trials in literature
  – Tetanus
  – foreign body removal
  – surface scrubbing
  – questionable role for irrigation
  – probably no role for coring, probing
  – rest, foot elevation
    Specific Wounds – Puncture
              Wounds
• Antibiotics
  – no prospective, randomized trials
  – consider wound and host factors
                 Case 5
• Pt working in lumbar yard and walks by
  piece of wound – catches leg on it and
  ends up puncturing lower leg with piece of
  wood. He feels “something is in there”.
• Manage
    Soft Tissue Foreign Bodies
• foreign bodies promote infection, prolong
  inflammatory phase of healing and result in poor
  wound healing
• infections resulting from foreign bodies are
  typically resistant to antibiotics
• every wound has a potential foreign body
• listen to pt’s if they think “something in there”
• all wounds require deliberate and careful
  exploration
   Soft Tissue Foreign Bodies
• Radio-opaque
  – metal, aluminum, bone, teeth, glass, certain plastics,
    gravel, sand
  – obtain x-rays with underpenetrated “soft-tissue
    technique”
• Radio-lucent
  – organic material like wood, thorns, cactus spines,
    some fish bones, most plastics
  – sometimes indirect evidence of presence (radiolucent
    filling defect when object is less dense than
    surrounding tissue)
   Soft Tissue Foreign Bodies
• if wound caused by radio-opaque material
  and no foreign body found on exploration
  or plain films – end search; otherwise:
• CT
• Ultrasound
• MRI
   Soft Tissue Foreign Bodies
• Not all need to be removed
• Indications for foreign body removal
  – Potential for inflammation or infection
  – Toxicity
  – Functional and cosmetic problems
  – Potential for later injury
                 Case 6
• 25 year old female piano player presents
  with 8 cm curvilinear laceration to dorsum
  of dominant hand from a dog bite.
      Specific Wounds - Bites
• Epidemiology
  – 60-90% dog bites, cats 1-15%, rodents 1-7%,
    other species less than 2%
• Dog Bites
  – jaws can exert +++force but teeth not sharp
  – results in relatively superficial crush injuries
  – face and scalp most common site in children
  – incidence of infection 5-10%
  – infection rate on face 1-5%
     Specific Wounds - Bites
• Cat Bites
  – typical bite is a puncture wound
  – possess long, slender, pointed teeth
  – overall infection rate about 14% (80%
    according to 2001 Sanford Guide); 28-80% in
    NEJM article
          Specific Wounds - Bites
• Microbiology of dog and cat bites (Talan et al. Bacteriologic
  Analysis of Infected Dog and Cat Bites. NEJM January 14, 1999)

   – almost always polymicrobial
   – aerobes, anaerobes
   – Pasteurella canis most common isolate in dog bites
   – Pasteurella multocida most common isolate in cat
     bites
   – authors suggest that if antibiotics prescribed a beta
     lactam antibiotic combined with a beta lactamase
     inhibitor would be appropriate choice for prophylaxis
          Specific Wounds - Bites
• Dog Bite Management (Cummings. Antibiotics to prevent
  infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann
  Emerg Med 1994;23)

   – face, scalp, trunk – solid support for primary
     closure
   – ?distal extremities – look at wound and
     patient factors; can probably primarily suture
     all dog bite wounds
   – prophylactic antibiotics only in high risk
     wounds (hands, wound / patient factors)
     Specific Wounds – Bites
• Cat Bite Management
  – puncture wounds should be left open
  – primary closure on face and scalp only
  – consider delayed primary closure in other
    locations
  – consider prophylactic antibiotics in all cases
Specific Wounds – Human Bites
• Epidemiology
  – 60-75% hands and upper extremities
• Microbiology
  – polymicrobial
  – mixed gram positive, gram negative, aerobic,
    anaerobic
  – eikenella corrodens
  – Hepatitis B
• Complications of human bites most commonly
  occur in hand wounds
Specific Wounds – Human Bites
• Management
  – routine wound evaluation and care
  – non-hand wounds can be closed primarily
  – hand wounds need to be left open to heal by
    secondary intention or delayed primary
    closure
  – routine prophylactic antibiotics in hand
    wounds only
                 Objectives
• Wound Healing
• Wound Evaluation – History, Physical
  examination
• Wound Preparation
• Wound Closure
• Specific Wounds
  – face, scalp, eyebrow, eyelid, ear, lips,
    intraoral, puncture, fingertip and nail, foreign
    bodies, bites
           Take Home Points
• Evaluate wound and patient factors when
  determining closure, risk of infection, antibiotics,
  etc.; infection is enemy
• Lacerations caused by compressive/tensile
  forces result in more complications than
  lacerations caused by knife cut (shear forces)
• “golden period” is not fixed and dependent on
  many variables
• V-Y plasty for fingertip amputations
• re bites: routine antibiotics for all cat bites and
  dog and human bites to hand

				
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