Wound Management

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Wound Management

• October 11, 2001
• Gavin Greenfield and Bob Johnston

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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

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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)

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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

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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?

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Wound Healing

• Stages
• hemostasis
• inflammation
• epithelialization
• fibroplasia
• contraction
• scar maturation

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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

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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

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Wound Healing

• Fibroplasia
• by fourth day fibroblasts begin synthesizing
  collagen, initiating scar formation
• characterized clinically by pebbled red tissue in
  wound base

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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

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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

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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?

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Case 3

• Alcoholic, diabetic street person presents with
  laceration to R forearm. He thinks he did it
  about 24 hours ago but cant remember mechanism.
  On examination small amount of soil type debris
  in wound.
• How will you manage this case?

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Wound Evaluation HistoryAmerican 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
• pts medical problems / immune status
• tetanus immunization status
• handedness / vocation

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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

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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

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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

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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

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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

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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 17496, 1988

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Wound Evaluation History (time of injury)

• accelerated growth phase of bacteria starts at 3
  hours post wound

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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

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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

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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

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Wound Evaluation Physical Examination

• Abrasions
• results from forces applied in opposite
  directions (e.g. skin grinding against road
  surface)

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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

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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

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Wound Evaluation Physical Examination

• Puncture Wounds
• wounds with a small opening and whose depth
  cannot be visualized
• Combination Wounds

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Wound Evaluation Physical Examination

• Amount of tissue destruction / devitalized tissue

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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

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Wound Evaluation Physical Examination

• Underlying Structures
• nerves, vessels, tendons, bones, joints

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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)

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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

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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

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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)

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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

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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 19704-708)
• 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

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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 24, 1995

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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 13396, 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

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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

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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)

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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

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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

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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 130808, 1997

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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

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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

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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 594-99
• Quinn et al. A randomized trial comparing
  octylcyanoacrylate tissue adhesive and sutures in
  the management of laceration. JAMA
  19972771527-1530
• 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 199832645-649
• Maw et al. A prospective comparison of
  octylcyanoacrylate tissue adhesive and suture for
  the closure of head and neck incisions. J
  Otolaryngol 19972626-30
• may be useful for wounds under higher skin
  tension
• Saxena Octylcyanoacrylate tissue adhesive in the
  repair of pediatric extremity lacerations. Am
  Surg 1999 May65(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

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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

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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

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Specific Wounds Face

• high vascularity therefore low incidence of
  infection
• debride minimally to preserve normal facial
  contours
• be more aggressive with layered closure

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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

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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?

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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

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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

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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

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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

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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

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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

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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

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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

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Specific Wounds - Lips

• Through and through lacerations
• 3 layer closure 1st mucosal layer with
  rapidly absorbable suture 2nd orbicularis
  oris 3rd skin

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Specific Wounds IntraoralArmstrong.
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 (lt2cm) 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)

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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

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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

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Specific Wounds Finger tip and nail injuries

• Tip injuries with exposed bone
• if bony protuberance lt 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

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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

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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 9209, 1991.
  Meek et al. Subungual hematomas is simple
  trephining enough? J Accid Emerg Med 15269,
  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

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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?

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Specific Wounds Puncture WoundsReference 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

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Specific Wounds Puncture Wounds

• Microbiology
• partly dependent on environmental location
• Staph aureus, beta-hemolytic streptococci (GAS),
  gram negatives
• pseudomonas common with wounds through shoes

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Specific Wounds Puncture Wounds

• Evaluation
• routine wound evaluation as previously discussed
• have low threshold for x-rays, especially re
  presence of foreign body

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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

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Specific Wounds Puncture Wounds

• Antibiotics
• no prospective, randomized trials
• consider wound and host factors

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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

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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 pts if they think something in there
• all wounds require deliberate and careful
  exploration

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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)

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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

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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

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Case 6

• 25 year old female piano player presents with 8
  cm curvilinear laceration to dorsum of dominant
  hand from a dog bite.

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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

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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

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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

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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 199423)
• 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)

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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

97
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

98
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

99
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

100
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