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Emergency
Medicine Atlas > Part 2. Specialty
Areas > Chapter 18. Wounds and Soft Tissue Injuries >
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Wound Cleaning and Irrigation
Associated Clinical Features
Wound cleaning and thorough
irrigation are the most important steps in wound care in terms of
reducing bacterial contamination and the subsequent risk for wound
infection. Although they are time-consuming, failure to go through these
procedures can result in infection or a cosmetically unacceptable scar.
Wound soaking (Fig. 18.1) is
commonly used to loosen debris and coagulated blood. While soaking can
assist in removing gross contaminants, it is not a substitute for
irrigation. Irrigation is the most effective way to cleanse a wound of
debris and contaminants as well as to reduce the bacteria count. Normal
saline is the irrigation fluid of choice. An acceptable alternative is
10%povidone-iodine (Betadine) solution. When diluted to a 1%
concentration (1 part per 10 parts saline), it can be safely applied to
wounds while retaining its bactericidal activity.
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Wound
Soaking Soaking is an
appropriate method for loosening debris and coagulated blood. While
freeing the physician to perform other duties, soaking should never
be used as a substitute for careful, thorough cleaning and
irrigation. (Courtesy of Matthew D. Sztajnkrycer, MD, PhD.)
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Emergency Department Treatment
and Disposition
Prior to wound cleansing and
irrigation, the patient is made comfortable and given adequate
anesthesia. It is prudent to have the patient lie supine so as to avoid
possible vagally mediated responses to pain or the sight of wound
manipulation. Gauze sponges soaked in 10%povidone-iodine solution diluted
1:10 to 1:20 may be used for cleansing the wound periphery. The sponges
can be used for gentle mechanical scrubbing of a grossly contaminated
wound. Cleansing continues until the area is visibly free from
contaminants. Hair can be cleansed like skin and need not be removed
unless it impedes the placement of sutures or staples. Removal of eyebrow
hair is discouraged because of its slow or absent regrowth.
High-pressure irrigation is more
effective than low-pressure irrigation in cleaning wounds. An 18- or
19-gauge intravenous catheter sheath or a commercially available splash
shield, either attached to a 20- or 30-mL syringe, will generate a
pressure stream of 5 to 8 psi (Figs. 18.2, 18.3). A typical bulb system's
pressure stream is only 0.5 to 1 psi. The higher-pressure systems have
been shown to decrease the risk of infection. Pulsatile irrigation
systems, which can generate pressures of 50 to 70 psi, are effective in
lowering bacteria counts and infection rates in large, grossly
contaminated wounds, but they may cause trauma to wound margins. They
offer no advantage for routine wounds cared for in the ED. Pulsatile
irrigation is reserved for mutilating injuries, such as those caused by a
lawn mower. Sustained high-pressure irrigation systems are associated
with an increased incidence of wound infection.
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High
Pressure Irrigation Devices The
ideal pressure for routine wound irrigation is 5–8 psi. This
can be easily achieved through the use of a 20 to 30 cc syringe
attached to an 18 or 19 gauge intravenous catheter sheath (top), or a
commercially available device with splash shield (bottom: Zerowet
Splashshield, Zerowet, Inc, Palos Verdes Peninsula, CA). (Courtesy of
Matthew D. Sztajnkrycer, MD, PhD.)
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Wound
Irrigation After adequate
anesthesia, an infected animal bite is opened and thoroughly
irrigated using a 30 cc syringe and commercial splash shield. Note
that even with the attached splash shield, there can be significant
splatter and potential for body fluid exposure. Universal precautions
should be followed at all times. (Courtesy of Matthew D.
Sztajnkrycer, MD, PhD.)
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It has been suggested that 500 to
1000 mL of irrigation fluid, or 60 mL/cm of wound length, should be used
for most uncomplicated wounds. Debris that cannot be irrigated from the
wound is either scrubbed or sharply debrided using iris scissors or a
scalpel with a number 15 blade. The tissue should appear pink and viable,
with a scant amount of fresh bleeding indicating good vascular supply.
Clinical Pearls
1. No matter how small the
wound, universal blood and body fluid precautions, including gloves and
face shield, should always be observed.
2. Antibiotics are no
substitute for thorough wound cleansing and irrigation.
3. Povidone-iodine combined
with an ionic detergent (Betadine scrub) is toxic to components of an
open wound and is not recommended for wound irrigation or cleansing.
4. Shaving the eyebrow for
wound repair is contraindicated, since hair in this area may not regrow.
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Wound Exploration
Associated Clinical Features
All wounds require a thorough
examination, including direct inspection and exploration. This can
determine the presence of foreign bodies as well as injuries to nerves,
tendons, blood vessels, joints, and other structures.
Emergency Department Treatment
and Disposition
The patient must be comfortable
for adequate wound exploration. Local or regional anesthesia is used, and
the area is thoroughly cleaned and irrigated. Assess nerve function prior
to anesthesia. The simplest way to control bleeding is by direct
pressure. Should this fail, gauze moistened with 1:10000 epinephrine or
tourniquets (Fig. 18.4) may be used for short periods. If epinephrine is
used, the gauze should not be applied for longer than 5 min, and its use
is contraindicated on fingers, toes, ears, the penis, and the nose tip.
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Finger
Ring Tourniquet The key to
proper wound exploration is adequate hemostasis and subsequent
exposure. The ring tourniquet is an effective means of hemostasis.
Removal after the procedure is important to prevent finger ischemia
and necrosis. Another effective method of hemostasis involves using a
Penrose drain tightened with hemostats. (Courtesy of Matthew D.
Sztajnkrycer, MD, PhD.)
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Adequate exposure of the wound can be achieved with
hemostats used to separate wound edges (Fig. 18.5). The hemostats are
applied to the superficial fascia, not the dermis, as that might injure
and further devitalize tissue. Small self-restraining devices, such as
Wheatlanders retractors, can further assist in exposure. If exposure is
still not adequate despite hemostasis and separation, the wound margins
may be slightly extended to allow better visualization. Extension is
performed by using a scalpel with a number 15 blade or fine iris
scissors. The wound is extended from one end, through the epidermis and
dermis only, to avoid further injury to underlying structures. Once the
superficial fascia has been exposed, it may be carefully and bluntly
dissected using forceps or scissors.
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Wound
Exploration Once hemostasis
has been obtained, in this case through the use of an inflated blood
pressure cuff, the wound can be exposed and properly explored.
Exploration reveals the two severed ends of an extensor tendon.
(Courtesy of Matthew D. Sztajnkrycer, MD, PhD.)
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Clinical Pearls
1. Scalp lacerations should be
explored digitally to palpate for depressed skull fractures.
2. After functional testing,
all wounds over tendons should be explored to determine tendon integrity.
This examination should include visualization of the tendon through its
range of motion, with particular attention to limb position at the time
of injury. In the neutral hand position, a tendon laceration may be
remote from the wound site.
3. Never probe a wound blindly
or blindly attempt to control bleeding with hemostats.
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Wound Foreign Bodies
Associated Clinical Features
Every foreign body has the
potential to act as a nidus for infection and to impair wound healing.
The majority of wound debris may be removed through meticulous, copious
irrigation. However, direct visualization and removal with instruments
may be required. Objects can either be inert (nonreactive) or organic
(reactive). Examples of inert objects include bullets, needles, and metal
objects. While these may cause chronic pain, they do not provoke an
inflammatory response. Organic materials—such as wood, bone, stone,
rubber, and soil—may cause infection and must be completely
removed. The most common objects retained in hand wounds are, in
decreasing order of frequency, wood splinters, glass fragments, metallic
objects, and needles. Plain radiographs may be used to identify tooth
fragments, metals, and most glass (Fig. 18.6). Ultrasound may play a
minor role in wound foreign body identification, although it is not
routinely practical. Direct inspection is the preferred method.
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Radiodensity
of Common Foreign Bodies The
plain radiograph demonstrates the radiodensity of common foreign
bodies. Counterclockwise from top left: pebbles, paper clip fragment,
wood splinter, hollow needle, lightbulb glass, dark ("beer
bottle") glass, transparent glass, and automobile windshield
glass. Note that, although faint, the wood splinter is visible on the
plain radiograph. Ruler markings are in centimeters. (Courtesy of
Matthew D. Sztajnkrycer, MD, PhD.)
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Differential Diagnosis
Apparent foreign bodies in wounds
may represent open fractures, blood or fibrin coagulum, or neurovascular
structures.
Emergency Department Treatment
and Disposition
Patient reliability in
determining the presence of a foreign body is inaccurate in approximately
half of all cases. Certain clinical situations should raise the suspicion
of retained foreign bodies. These include lacerations caused by broken
glass, perioral injuries in association with traumatic loss of dentition,
and injuries to the hands and feet with needles, nails, or splinters.
Prior to anesthesia, one may elicit a foreign-body sensation by gently
running gloved fingers over the wound. After adequate hemostasis and
anesthesia have been implemented, gentle probing of the wound with a
hemostat will generate a distinct "grating" sensation in the
presence of some foreign bodies. However, aggressive probing is
discouraged. Good hemostasis cannot be overemphasized. Even small amounts
of blood can impair exploration.
Suspicion of a retained foreign
body mandates local wound exploration and the consideration of
radiographic (Fig. 18.7) or ultrasound evaluation. Nearly 80% of objects
can be identified on plain radiographs. More specifically, 95% of glass
fragments greater than 2 mm in size can be identified through the use of
plain radiographs; fragments as small as 0.5 mm can be identified in 50
to 60% of cases. Nonradiodense objects, including wood, chicken bones,
and some plastics, may still be identified as filling defects or outlined
by air drawn into the wound at the time of injury.
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Radiodensity
of Common Foreign Bodies in Tissues The paper clip, dark glass, and wood splinter (top to
bottom) described above were inserted into chicken legs and
radiographs taken. The wooden splinter is no longer clearly visible
within the soft tissue of the chicken. For purposes of foreign-body
localization, a minimum of two radiographic views at 90 degrees to
one another are obtained and the site of the foreign body entry
clearly marked. (Courtesy of Matthew D. Sztajnkrycer, MD, PhD.)
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The decision to remove inert
objects is based upon location and potential for subsequent tissue damage
and functional limitation. Inert objects need not be removed and will
frequently be encapsulated within soft tissue, causing no sequelae. While
biologically inert, glass foreign bodies are frequently symptomatic and
all but the smallest fragments should be removed. All organic objects
have to be removed. Localization and retrieval of identified foreign
bodies can be complicated, and time-consuming; consultation may be
required.
Clinical Pearls
1. A thorough history of wound
mechanism can alert the treating health care worker to the potential for
a retained foreign body.
2. An alert patient often may
be able to report a foreign-body sensation in the wound. This
"feeling" should prompt thorough wound exploration and
consideration of radiographs or ultrasound.
3. In attempting to locate an
object with radiographs, the laceration is marked and two views of the
area, at 90 degrees to one another, are obtained for proper spatial
orientation. A paper clip taped to the wound edge is often used.
4. Missed retained foreign
bodies are a very common source of litigation in emergency medicine.
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Traumatic Wounds
Associated Clinical Features
Traumatic surface wounds are
usually caused by one of three mechanisms: shearing, tension, or
compression. Such a division helps to guide management decisions, predict
the chance of infection, and determine the extent of eventual scar
formation.
Shearing Injuries
These are caused by sharp
objects, such as glass shards or knives; they generate a simple division
of tissues (Figs. 18.8, 18.9). They are low-energy injuries, with minimal
tissue destruction. The majority of uncomplicated shearing injuries
(i.e., those not involving a neurovascular or other anatomically
important structure) can be repaired primarily in the ED. They have a low
incidence of wound infection; scar formation is usually minimal and
cosmetically acceptable.
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Linear
Laceration A large but
uncomplicated linear leg laceration is demonstrated. Given the depth
and gaping nature of the wound, it can be closed using a layered
closure to remove surface tension at the wound edges and promote a
more cosmetically acceptable outcome. (Courtesy of Alan B. Storrow,
MD.)
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Linear
Laceration A long linear
laceration involving the forehead and scalp, with exposed galea. The
wound is explored and palpated for evidence of a depressed or open
linear skull fracture. Closure of large galeal lacerations is
recommended to prevent spread of infection. Large frontal galeal
lacerations are also repaired to prevent a cosmetic deformity of the
frontalis muscle. (Courtesy of Kevin J. Knoop, MD, MS.)
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Puncture wounds are typically due to sharp,
elongated objects that pierce the skin and penetrate into deeper tissues
(Fig. 18.10). Such wounds have a higher potential for infection,
foreign-body retention, or underlying structure injury.
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Puncture
Wound A puncture wound to the
foot with a contaminated garden instrument. Tetanus status must be
carefully addressed in such an injury. A radiograph of the foot
demonstrated no associated bony injuries. (Courtesy of Matthew D.
Sztajnkrycer, MD, PhD.)
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Tension or Partial Avulsion
Injuries
These occur when objects strike
the skin at a sharp angle, commonly generating a triangular flap (Fig.
18.11). A flap of this type results in vascular disruption to the two
sides of the wound and thus is at risk for further compromise, ischemia,
and necrosis. The energy required to generate such an injury is greater
than that needed for shearing injuries; the result is greater tissue
destruction and an increased potential for ischemia (Fig. 18.12). These
two factors place the partial avulsion injury at increased risk for wound
infection and scar formation. Care must be taken during examination and
repair to preserve the remaining vascular supply to the flap; otherwise
the flap may become ischemic. In addition, distal-based partial avulsion
injuries are at an even greater risk for vascular compromise.
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Partial
Avulsion Injury This patient
has sustained a typical partial avulsion laceration from a fall onto
the edge of a staircase. Note the triangular "flap" in the
upper left quadrant of the wound. Closure of partial avulsion
injuries must be particularly meticulous to reduce any further
compromise of the flap tip's vascular supply. (Courtesy of Alan B.
Storrow, MD.)
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Degloving
Avulsion-Type Injury The
patient sustained a complex degloving injury after her lower
extremity became tangled in a rope while she was water-skiing.
(Courtesy of Alan B. Storrow, MD.)
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Crush or Compression Injuries
These occur when a blunt object
strikes tissue at a right angle, imparting a high degree of kinetic
energy. This force results in significant underlying tissue destruction
of the skin and underlying supportive fascial layers. Crush injuries are
typically ragged, with irregular wound edges and a complex laceration
pattern (Fig. 18.13). Despite meticulous wound care and careful primary
closure, the resulting scars may be cosmetically poor.
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Crush
(Compression) Injury A fall
from a bicycle has resulted in a complex stellate laceration,
characterized by ragged, irregular wound edges. The potentially high
forces involved in producing a crush wound may be sufficient to cause
deeper damage. Computed tomography of the head unfortunately
demonstrated a left frontal hemorrhagic contusion. (Courtesy of
Matthew D. Sztajnkrycer, MD, PhD.)
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Differential Diagnosis
The differential for a traumatic
wound includes other mechanisms of laceration: avulsion, partial or
complete amputation, abrasion, hematoma, or contusion.
Emergency Department Treatment
and Disposition
All patients with traumatic
wounds, regardless of mechanism, should have their tetanus immunization
status addressed (Table 18.1). The physical examination is directed to
functional and neurovascular status. To obtain optimal wound healing,
adequate hemostasis, thorough irrigation, removal of devitalized and
contaminated tissues, and appropriate closure tension must be achieved.
All wounds must be thoroughly inspected for the presence of foreign
bodies and underlying injuries. Plain radiographs are appropriate to help
rule out open fractures and may be useful in the identification of
certain foreign bodies. If open fractures are suspected or confirmed,
intravenous antibiotics are administered and an orthopedic surgeon is
consulted. Repair of traumatic wounds depends on the depth, complexity,
and location of the wound. Deep wounds are closed in layers or by using a
vertical mattress technique to remove dead space and take tension off the
wound. Superficial wounds may be repaired with staples, simple
interrupted sutures, or running sutures. In certain circumstances,
Steri-Strips or adhesive glues may be warranted.
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Table 18.1 Recommendations for
Tetanus Prophylaxis
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Clean, Minor
Wounds
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All Other
Woundsa
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Tetanus
Immunization Status
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Td
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TIG
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Td
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TIG
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Unknown or
< 3 doses
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Yes
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No
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Yes
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Yes
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> 3
Doses
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Last
dose < 5 years
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No
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No
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No
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No
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Last
dose 5–10 years
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No
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No
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Yes
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No
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Last
dose > 10 years
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Yes
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No
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Yes
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No
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Key: Td, tetanus-diphtheria toxoid; TIG, tetanus
immune globulin (250 U).
a Defined as contaminated wounds, puncture wounds,
avulsion injuries, burns, crush injuries.
Source: Adapted from Hollander JE, Singer AJ: State of
the art: laceration management. Ann Emerg Med 1999;
34:356–367.
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Clinical Pearls
1. Shearing injury is the most
common wound mechanism seen in the ED.
2. The vascular supply to the
flap is tenuous and improper closure may further compromise the tissue,
especially at the tip. A repair using a corner stitch will help minimize
further ischemia.
3. Crush injuries have an
increased susceptibility to infection. Thorough cleansing, copious
irrigation, and judicious debridement are required.
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Ear Lacerations
Associated Clinical Features
The ear is composed of a poorly
vascularized cartilaginous skeleton covered by tightly adherent skin.
There is little subcutaneous tissue, and an injury to the ear that
results in hematoma formation can cause pressure necrosis of the
cartilage, infection, loss of shape and stability, and a poor cosmetic
outcome. The goal of repair in ear lacerations is complete coverage of
exposed cartilage (Fig. 18.14) and evacuation or prevention of hematoma.
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Ear
Laceration This patient has
presented after sustaining an uncomplicated, linear laceration to the
pinna. Closure must cover all exposed cartilage. (Courtesy of Alan B.
Storrow, MD.)
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Differential Diagnosis
In addition to simple lacerations
of the ear, trauma to the ear may include abrasions, partial avulsions,
soft tissue swelling, and perichondral hematomas.
Emergency Department Treatment
and Disposition
Prior to laceration repair, the
area is examined for signs of acute hematoma formation or other
associated traumatic injuries. Hemotympanum or Battle's sign suggests the
presence of a more serious closed head injury, especially basilar skull
fracture. Blunt trauma may result in barotrauma to the eardrum, including
perforation. Examination can be facilitated by local anesthesia infiltration
or, in the case of larger or more complex lacerations, a field block.
Simple lacerations through the
earlobe or involving the helix but that do not expose cartilage can be
repaired with interrupted 6-0 nonabsorbable monofilament sutures. Simple
lacerations that involve the cartilage are primarily repaired by ensuring
complete coverage of the exposed cartilage by careful apposition of
overlying skin. The skin generally provides sufficient support that no
sutures are required for the cartilage itself. If the wound is irregular
and cartilage debridement is required to avoid undue wound tension, the
debridement is kept to a minimum. No more than 5 mm of cartilage can be
removed or the cartilaginous skeleton may be deformed.
A perichondral hematoma must be drained
within 72 h to prevent potential pressure necrosis and development of a
"cauliflower" ear (see Figs. 1.26 and 1.27). Drainage is
accomplished through a small incision directly over the hematoma and
expression of coagulum. Ear wounds are best dressed with a mastoid
pressure dressing either primarily or after later hematoma drainage. Such
a dressing reduces the chances for future hematoma formation and its
complications.
Ear sutures are removed in 3 to 5
days in children, 4 to 5 days in adults.
Clinical Pearls
1. Epinephrine-containing
anesthetic agents are not to be used for ear lacerations.
2. Hematomas are rechecked in
24 h to evaluate for reaccumulation.
3. If cartilage has been
exposed or a hematoma drained, antistaphylococcal antibiotic coverage is
recommended.
4. Complex lacerations and
hematomas of the ear are best cared for in conjunction with a consultant.
(Fig. 18.15)
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Ear
Laceration After being
assaulted with a glass bottle, a patient presents to the emergency
department with a complex ear laceration, involving the tragus and
peri-auricular area. Care must be taken to evaluate important
structures in the area, including the parotid duct and seventh
cranial nerve. (Courtesy of Matthew D. Sztajnkrycer, MD, PhD.)
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Lip Lacerations
Associated Clinical Features
Lip lacerations may result in
significant cosmetic defects if not properly repaired. The lip has two
significant anatomic landmarks: the mucosal border, which divides
intraoral and external portions of the lip, and the vermilion border,
which separates the mucosa of the lip from the skin of the face. Another
important anatomic structure of the lip is the underlying orbicularis
oris muscle. Meticulous alignment of the vermilion border and its
associated "white line" is the cornerstone of cosmetic repair.
Lip anatomy may be distorted by the kinetic energy of the impact as well
as the resultant edema surrounding the wound. Lacerations of the lip's
vermilion border may be partial- or full-thickness, compromising the
orbicularis oris.
Differential Diagnosis
Lacerations to the lip may not
involve the vermilion border but may be limited to the mucosa or the
intraoral portion. Facial lacerations in close proximity to the vermilion
border may mimic a laceration that crosses the border. Other
injuries—including abrasions, hematomas, and soft-tissue
swelling—may initially mimic a vermilion border laceration.
Emergency Department Treatment
and Disposition
Given the high bacterial content
of the oral cavity, lip lacerations will not remain clean during the
repair. The goal of irrigation is to remove gross contaminants such as
tooth fragments or dirt. If tooth fractures are noted, the wound must be
explored for fragments. A radiograph may also prove useful for
foreign-body evaluation. Anesthesia for laceration repair is best
performed using either an infraorbital (upper lip) or mental (lower lip)
nerve block. Local infiltration may further distort tissues and obscure
the alignment of the vermilion border.
If the vermilion border is
violated by a superficial laceration, then the first suture, typically
6-0 in size, is placed at the vermilion border to reestablish anatomic
relationships (see Fig. 6.13). Once alignment is judged adequate, simple
interrupted sutures are used for completion. If the laceration extends
within the oral cavity, absorbable 5-0 sutures are used to close the
intraoral component.
With deep or "through and
through" lacerations involving the orbicularis oris (Fig. 18.16),
the muscle layers are initially approximated with deep, usually 5-0,
absorbable sutures. Once the muscle is approximated, the first skin
suture is again placed at the level of the vermilion border and the
repair is completed as described above.
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Complex
Vermilion Border Laceration
After being assaulted, this patient sustained a large laceration
through the vermilion border and the orbicularis oris muscle.
Examination of the wound demonstrated an underlying fracture of the
alveolar ridge with subluxation of the number 10 tooth. (Courtesy of
Matthew D. Sztajnkrycer, MD, PhD.)
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Sutures are removed in 3 to 5
days in children, 4 to 5 days in adults. The patient is advised to eat
soft foods, not to apply excessive force to the suture line, and to rinse
after eating to prevent the accumulation of food particles.
Clinical Pearls
1. Misalignment of the
vermilion border by as little as 1 mm may result in a cosmetically
noticeable defect. Any repair of vermilion border lacerations should
begin with alignment and suturing of this structure.
2. Regional anesthesia rather
than local infiltration is optimal for repair, as it causes less
distortion of the anatomic structures.
3. A marking pen may be used to
identify landmarks prior to placing the sutures, as suturing itself
causes some tissue edema, bleeding, and distortion.
4. Any patient with a lip
laceration requires a thorough inspection of the oral cavity for
associated trauma, including dental fractures, oral lacerations, and
mandibular injuries.
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Tendon Lacerations
Associated Clinical Features
Tendon injuries are often
associated with lacerations to the hand or wrist. These injuries should
be suspected either by the anatomic location of the laceration or when
patients report an inability to flex or extend a digit or digits. A
thorough neurovascular examination is critical to evaluate for associated
injuries. Accurate assessment of motor function is necessary in any hand
injury, although partial tendon injuries, including near complete (90%)
tendon lacerations, may still result in normal mechanical function.
Testing for strength might show diminished tendon function (Fig. 18.17),
although function may be difficult to evaluate in the setting of an
acute, painful injury. Any wound suspected of harboring a tendon
laceration must be carefully explored in spite of normal testing.
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Flexor
Tendon Laceration The patient
presented to the ED after sustaining a laceration to his third and
fourth digits (A). The injury was associated with an inability to
flex these two digits. Wound exploration revealed the distal segment
of the transected flexor tendon apparatus (B). (Courtesy of Matthew
D. Sztajnkrycer, MD, PhD.)
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Differential Diagnosis
In addition to tendon
lacerations, trauma may generate partial tendon lacerations, trauma to
the tendon sheath, or bony injuries including avulsion fractures. In
cases of remote injury, the differential diagnosis also includes bony
injury, tenosynovitis, and arthritis.
Emergency Department Treatment
and Disposition
Prior to wound examination, a
thorough examination of the extremity is performed to assess
neurovascular and motor function. All individual flexor and extensor
tendons are assessed, including deep and superficial flexor digitorum
tendons. Abnormal resting posture of the involved extremity can indicate
tendon injury. Tendons are taken through a full range of motion,
including re-creation of limb position at the time of injury, in order to
detect injuries along the length of the tendon. Adequate tendon
exploration requires excellent hemostasis, which can be achieved through
direct pressure or the brief use of a blood pressure cuff or other
tourniquet.
Initial wound care should include
irrigation, exploration for foreign bodies, debridement, antibiotics, and
tetanus prophylaxis if indicated.
Partial tendon lacerations are
treated conservatively, with splinting in neutral position and
appropriate follow-up. Extensor tendon lacerations (Fig. 18.18) can be
repaired primarily in the ED under limited conditions and in consultation
with a specialist. Flexor tendon lacerations require consultation (Fig.
18.19).
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Extensor
Tendon Laceration Note the
laceration over the third metacarpal head. Inability to extend the
long finger is strong clinical evidence of complete disruption of the
extensor tendon. (Courtesy of Kevin J. Knoop, MD, MS.)
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Flexor
Tendon Laceration This patient
with a palmar laceration is unable to flex his index finger secondary
to complete disruption of the flexor tendon. (Courtesy of Daniel L.
Savitt, MD.)
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Clinical Pearls
1. Tendon function may remain
unaffected despite a near complete tendon laceration.
2. All wounds with potential
tendon lacerations are carefully explored through a full range of motion
in order to detect lacerations along the course of the tendon.
3. Flexor tendon lacerations
are immediately referred to a hand specialist.
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Bite Wounds
Associated Clinical Features
Bites account for approximately
6% of all ED patients with traumatic wounds. Dog bites predominate (Fig.
18.20), at 60 to 80%, with cat bites accounting for another 5 to 15%. The
frequency of human bites varies by institution but has been reported to
range from 3.6 to 23%. Bite injuries are most likely to occur in children
between age 5 and 14. The microbiology of bite wounds is frequently
polymicrobial, but clinically relevant bacterial species include Pasteurella
(P. multocida, P. canis, P. dagmatis), Streptococcus,
Staphylococcus, Moraxella, and Enterococcus. The microbiology
of human bites is more complex than that of cat and dog bites. Eikenella
corrodens has been recovered from nearly 30% of all human bites,
including 25% of all clenched-fist injuries. All mammalian bites are at
risk for infection by anaerobic organisms such as Fusobacterium,
Bacteroides, Porphyromonas, Prevotella, and Peptostreptococcus;
human bites demonstrate the greatest risk of anaerobic infection.
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Dog
Bite An 8-year-old girl
presented to the ED after being attacked by several dogs. She
sustained multiple shearing lacerations to her chest and back.
(Courtesy of Matthew D. Sztajnkrycer, MD, PhD.)
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A number of risk factors are predictive of bite
wound complications and influence wound management strategies. Three
quarters of these wounds in adults occur on the extremities, but the
majority of wounds in children occur on the face and head. The hand is at
highest risk for developing infection (30%), while the most resistant
anatomic location is the face (1.4 to 5.8%).
Wounds caused by fangs,
especially cat fangs that penetrate deeply into tissues, are associated
with a high risk of infection. Large open wounds caused by shearing, as
seen in the bites of dogs or larger animals (Fig. 18.21), are less likely
to become infected. Superficial lacerations with minimal tissue
disruption are associated with a low risk of infection regardless of
species.
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Cougar
Bite This patient has
sustained large wounds as a result of a cougar attack. In contrast to
the small penetrating injuries seen with house cat and small dog
bites, the weight and force of large animals often results in
shearing injuries. (Courtesy of Alan B. Storrow, MD.)
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Emergency Department Treatment
and Disposition
The management of bite wounds
depends on location, wound type, severity, and signs of infection. Contusions
and superficial abrasions may be treated with thorough cleansing, while
larger wounds that violate the epidermis and dermis require standard
wound care protocols. All devitalized tissue must be thoroughly debrided
to reduce the possibility of wound infection. Copious pressure irrigation
after debridement is recommended. Radiographs are obtained to exclude
bony injury or retained dentition. Appropriate cultures can be obtained
in purulent wounds, although the polymicrobial results usually do not
affect management.
Closure of dog bites is not
recommended for wounds more than 8 to 12 h old, puncture wounds, hand
lacerations, or high-risk wounds. Because of the excellent blood supply,
bite wounds on the face may be considered for closure after 8 to 12 h. Cat
bites and scratch wounds are best left open and treated with thorough
irrigation and debridement. Large, easily irrigated human bites less than
12 h old on the trunk or a proximal extremity may be sutured with a
single layer of nonabsorbable suture material. Facial bites without
evidence of infection and less than 12 h old may likewise be closed.
Other human bites should generally be left open and considered for
delayed primary closure. Clenched-fist injuries are left open and managed
in consultation with a hand specialist.
For established infections caused
by cat and dog bites, empiric antibiotic therapy is started with
broad-spectrum antibiotics such as ampicillin-sulbactam, cefoxitin, or
ceftriaxone, alternatively, ciprofloxacin and clindamycin can be used. In
children, trimethoprim-sulfamethoxazole may be substituted for
ciprofloxacin. Infection by P. multocida classically starts within
24 h of the bite, is marked by prominent pain and swelling, and is
associated with a serosanguineous gray exudate. The antibiotic of choice
for Pasteurella is penicillin; doxycycline is an alternative.
Antibiotics are used for nearly all bite wounds, although the efficacy of
this approach has not been substantiated. Amoxicillin-clavulanate or
dicloxacillin plus penicillin are suggested regimens to cover typical
skin flora and Pasteurella species.
Clinical Pearls
1. Fang puncture wounds may be
carefully widened using a number 15 scalpel blade to improve irrigation.
The incised wound is left open to close by secondary intention.
2. All patients with bite
wounds from susceptible animals are assessed for rabies exposure as well
as tetanus status.
3. Given cosmetic concerns and
low infection risk, dog bites to the face can be sutured even after 8 to
12 h.
4. Although rare, a potentially
fatal cause of dog-bite infection is Capnocytophaga canimorsus
(CDC group DF-2), a gram-negative rod. Patients with this infection are
often immunocompromised or asplenic and may present with sepsis and
disseminated intravascular coagulation. The recommended antibiotic for
treatment is amoxicillin-clavulanate.
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Fishhook Injuries
Associated Clinical Features
Because of their design and
nature, accidental impalement with fishhooks poses problems with removal.
Often, the hook cannot be removed by the patient because of the barbs.
Several different methods have been described to remove fishhooks (Fig.
18.22).
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Fishhook
Removal Hooks with small barbs
that are only superficially embedded may be carefully backed out
through the original puncture site (A and B). This may require a
small incision, made in line with the concavity of the curve of the
hook. The push-through technique is useful for hooks with large barbs
or those more deeply embedded. The hook is pushed out through the
skin, the barb removed, and the remainder of the hook subsequently
removed through the original penetration site (C, D, and E). The traction
(string) technique provides an alternative for removing hooks with
small barbs. While pressing down on the shaft of the hook, traction
is applied with 0 silk or umbilical tape. A swift yank of the cord in
the direction opposite the barb will dislodge the hook (F). Care is
taken to warn bystanders of the potential for the fishhook to fly
across the room.
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Emergency Department Treatment
and Disposition
The wound is thoroughly cleaned
and irrigated. Tetanus status is determined. After adequate anesthesia
has been obtained, several different removal methods may be employed
depending upon the location and type of hook.
Superficially embedded hooks or
hooks with small barbs may be removed in a retrograde fashion, by backing
the hook out through the original site of penetration. A small incision
is frequently required in line with the concavity of the fishhook. A
technique utilizing string has also been described. The string should
have good tensile strength, such as 0-silk or umbilical tape. The string is
looped around the curved portion of the hook and then carefully and
gently pulled in a direction parallel to and away from the shaft of hook.
At the same time, the shaft and eyelet are depressed against the skin and
slightly rotated to disengage the barbs. The string is then sharply
pulled, releasing the hook. This technique has the advantage of not
requiring anesthesia.
The most common and successful
removal technique is the "push-through and cut" technique. This
is recommended for deeply embedded hooks or hooks with large barbs. Basic
skin preparation and local wound infiltration are performed in the
standard manner. The hook shaft is manipulated with a hemostat in order
to push the hook and barbs through the dermis (Fig. 18.23). The end of
the hook and barb is removed with wire cutters and the shaft is backed
out through the wound.
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Fishhook
Injury and Removal A patient
presented to the ED with a fishhook embedded in his finger. The
push-through technique was used to remove the hook. Use of a ring
cutter proved unsuccessful; a bolt cutter was eventually required to
remove the distal portion of this large hook. (Courtesy of Alan B.
Storrow, MD.)
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Clinical Pearls
1. Thorough irrigation and
debridement of devitalized tissue is necessary after removal of the
fishhook.
2. Hooks embedded in
cartilaginous structures, such as the ear or nose, are best managed with
the push-through methods.
3. Hooks that penetrate joint
spaces are removed with the push-through technique, as fine barbs may
break off with the retrograde technique. These wounds should be managed
in consultation with an orthopedic surgeon.
4. Fishhooks that penetrate the
globe of the eye are left in place and emergent ophthalmologic
consultation obtained. The patient is placed in the semirecumbent
position to decrease intraocular pressure and the globe is protected with
an eye shield. Pressure patches are contraindicated, as they may extrude
intraocular contents.
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Simple Wound Closures
Associated Clinical Features
The majority of wounds seen in
the ED are uncomplicated lacerations generated from shearing or flap
injuries and are readily amenable to primary wound closure. Each wound
will have different technical factors that influence the repair. The
cornerstones of wound closure are layer matching, wound edge eversion,
and prevention of excessive wound edge tension.
In repairing any laceration, it
is important to suture individual layers to their counterparts (e.g.,
superficial fascia to superficial fascia). Failure to do so may result in
improper healing and poor cosmetic results. Wound edge eversion is
equally important in the initial repair, as scars have a tendency to
contract over time. Everted wounds flatten with scar maturation, while
noneverted wounds contract into linear pits, with resultant poor cosmetic
results (Figs. 18.24, 18.25).
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Wound
Edge Eversion Eversion of
wound edges is critical for optimal wound healing. For proper
eversion, the needle point should enter the epidermis at a 90-degree
angle, generating a square or bottle-shaped suture configuration
18.24A. This results in a slight rise of the skin edges above the
skin plane 18.25A. Such eversion will flatten at the level of the
skin plane during healing. Entry at a shallower angle 18.24B often
leads to wound edge inversion, eventual contraction of the wound
edges below the skin plane, and subsequent scar formation 18.25B.
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The repair of any wound will
place a degree of tension upon the wound. Excessive wound tension by the
sutures may result in impaired capillary blood flow to the healing wound,
with possible necrosis and a cosmetically unacceptable scar. The first
suture throw is critical in determining the amount of tension on the
wound. When brought together, wound edges should just touch and be
slightly everted, as wound edges tend to become slightly edematous after
repair.
Emergency Department Treatment
and Disposition
All laceration repairs should
begin with a thorough evaluation. Tetanus status is addressed. Different
wound closure techniques include simple interrupted sutures, staples,
running sutures, dermal sutures, tissue adhesives, and tape (Steri-Strips).
Suture material, size, and duration before removal are determined by the
anatomic site of the wound (Table 18.2). Use of deep, absorbable sutures
may be necessary to reduce wound tension before superficial repair (Fig.
18.26).
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Table 18.2 Suture Materials,
Size, and Duration by Anatomic Site
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Anatomic
Site
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Skin
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Deep
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Duration
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Scalp
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5-0, 4-0
Monofilament
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4-0
Absorbable
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6–8
days
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Ear
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6-0
Monofilament
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N/A
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4–5
days
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Eyelid
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7-0, 6-0
Monofilament
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N/A
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4–5
days
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Eyebrow
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6-0, 5-0
Monofilament
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5-0
Absorbable
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4–5
days
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Nose
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6-0
Monofilament
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5-0
Absorbable
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4–5
days
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Lip
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6-0
Monofilament
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5-0
Absorbable
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4–5
days
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Oral
mucosa
|
N/Aa
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5-0
Absorbable
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N/A
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Face/forehead
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6-0
Monofilament
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5-0
Absorbable
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4–5
days
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Chest/abdomen
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5-0, 4-0
Monofilament
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3-0
Absorbable
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8–10
days
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Back
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5-0, 4-0
Monofilament
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3-0
Absorbable
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12–14
days
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Arm/leg
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5-0, 4-0
Monofilament
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4-0
Absorbable
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8–10
days
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Hand
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5-0
Monofilament
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5-0
Absorbable
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8–10
daysb
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Extensor
tendon
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4-0
Monofilament
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N/A
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N/A
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Foot/sole
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4-0, 3-0
Monofilament
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4-0
Absorbable
|
12–14
days
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a Not applicable.
b Add 2 to 3 days for joint extensor surfaces.
Source: Adapted from Trott AT: Wounds and
Lacerations: Emergency Care and Closure, 2d ed. St. Louis, MO:
Mosby–Year Book, 1997.
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Deep
Sutures Judicious placement of
deep sutures allows approximation of the dermis, reduces tension on
the wound edges, and may facilitate final superficial closure. The
needle is driven from deep within the wound to a superficial level
(A). On the opposite side of the wound, the needle is driven from
superficial to deep (B). By having the leading and trailing suture
come out on the deep side and on the same side of the
superficial cross suture (B). The resultant knot is buried within the
wound (C).
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Simple Interrupted Closures
This closure involves single
nonabsorbable sutures, each independently tied (Figs. 18.27, 18.28). They
can provide excellent wound edge approximation and are the most common
type of wound closure used in the ED.
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Simple
Interrupted Wound Closure An
uncomplicated linear laceration generated by a sharp object. For
anesthesia and hemostasis, the wound edges are infiltrated with
lidocaine containing epinephrine. The wound is subsequently closed
with simple interrupted sutures. Attention is paid to obtaining a
degree of wound edge eversion (Courtesy of Alan B. Storrow, MD.)
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Staples
Studies have demonstrated that
staples, a rapid means of closing linear wounds, engender less
inflammatory response, resist infection more effectively, and generate
greater wound tensile strength than sutures. Staples are best utilized in
repairing linear, sharp lacerations of the scalp, trunk, and extremities
(Fig. 18.29). Staples are not used on the face, over joints, or on the
hands or feet.
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Staple
Closure Meticulous care must
be taken when using staples to properly approximate and evert wound
edges. This can be facilitated through the use of forceps during
staple closure.
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Running Closure
This rapid closure technique
involves taking several bites along the length of a wound without tying
individual knots. Knots are tied only at the beginning and end. This
method is most useful for superficial linear lacerations greater than 5
cm in length. Particular care must be taken to achieve equal wound
tensions with each bite. Proper wound eversion may be difficult.
Dermal Closures
Also known as the subcuticular
closure, this technique involves the use of absorbable sutures placed in
the superficial fascia and dermis, with the knot buried in the wound. The
dermal closure may be achieved using either simple interrupted or running
techniques. When properly performed, it provides excellent cosmetic
results and avoids the need for suture removal.
Wound Adhesives
Cyanoacrylate adhesives have
advantages in wound closure because of speed of closure, reported low
infection rate, lack of repeat visit for suture removal, and no
anesthesia requirement. Wounds closed using adhesives are at increased
risk of immediate dehiscence, but no difference in tensile strength has
been reported at 7 days. The wound edges must be approximated during
application; thus two operators may be required for optimal closure.
Proper application requires considerable practice in technique.
Clinical Pearls
1. In order to obtain proper wound
edge eversion, the point of the needle should generally enter the
epidermis and dermis at a 90-degree angle before it is brought around
through the tissue.
2. The bites on both sides of a
wound should be equidistant for both optimum wound healing and cosmetic
outcome.
3. In gaping wounds, surface
tension may be reduced with the use of deep sutures. The minimum number
of such sutures is used because they may act as a foreign body and a
potential nidus for infection. Deep sutures also stimulate a greater
healing response and may therefore generate a larger final scar.
4. Use of cyanoacrylate wound
adhesives does not obviate the need for good wound care, including
thorough irrigation and exploration. Local or regional anesthesia may
still be required.
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Complex Wound Closures
Associated Clinical Features
Although the majority of
lacerations can be managed by using simple wound closure techniques,
certain lacerations require more advanced techniques. These include the
horizontal and vertical mattress stitch and the corner stitch.
Emergency Department Treatment
and Disposition
The vertical mattress suture
is a useful technique for generating wound edge eversion, particularly in
deep wounds (Fig. 18.30). The suture is performed by first taking a large
tissue bite through the fascial layer approximately 1 to 1.5 cm from the
wound edge and crossing equidistant to the other wound edge. The needle
is then reversed and a second small bite through the epidermal-dermal
junction 1 to 2 mm from the wound edge is taken. This suture has several
additional advantages. It acts as both a deep and superficial closure,
thereby reducing wound tension. It is particularly useful in areas of
marked skin laxity, such as the dorsum of the hand.
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Vertical
Mattress Suture The suture is
placed by first taking a large deep bite of tissue approximately 1 cm
away from the wound edge and exiting at the same location on the
other side of the wound. A second small superficial bite is then
performed in the reverse direction (A). When the bites are complete
(B), tying results in nice apposition of the wound edges (C). This
technique is especially useful in areas of lax skin, such as the
elbow or dorsum of the hand.
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The horizontal mattress suture may also be
used to optimize wound edge eversion (Fig. 18.31). With this suture, the
needle is introduced through the skin in the standard manner for a simple
interrupted stitch. Rather than tie the knot at this point, a second bite
is taken approximately 5 mm from the first. The knot is subsequently tied
on the side of the initial bite. As well as causing wound edge eversion,
this technique is particularly useful in areas under significant tension,
such as the knee.
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Horizontal
Mattress Suture Useful in
achieving wound edge eversion, the horizontal mattress suture begins
with a standard suture throw. A second bite is taken approximately
half a centimeter from the first exit (A) and brought through at the
original starting edge, half a centimeter from the original entry
point (B and C).
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Many wounds result in the generation of jagged
irregular wound margins, with triangular corners or small flaps. These
wounds have tenuous vascular supplies, and improper suturing may further
compromise the viability of the tissue. A common technique for securing
the triangular corner of a wound without further compromising the small
capillary beds is the corner stitch (Figs. 18.32, 18.33, 18.34).
The technique is effectively a half-buried mattress suture, where the
needle is initially introduced through the skin in the noncorner area of
the wound. The needle is brought out through the dermis and then passed
horizontally through the dermis of the triangular portion of the wound.
It is then brought through the dermis on the other portion of the wound
and out through the opposite noncorner area, where the knot is tied. Once
the corner is secured, simple sutures are used to repair the rest of the
wound, with care taken to place the sutures far enough from the tip to
optimize circulation.
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Corner
Stitch Flaps generated by
partial avulsion injuries must be repaired with care to avoid
compromising the tenuous blood supply of the flap. A corner stitch is
an excellent technique that can solve many tricky wound problems.
(Courtesy of Matthew D. Sztajnkrycer, MD, PhD.)
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Corner
Stitch The corner stitch is
performed through the use of a half-buried horizontal mattress
suture. The suture begins percutaneously away from the corner of the
wound. The suture needle is then brought horizontally through the
corner at the level of the dermis and back out through the epidermis
at the opposite noncorner portion of the wound (A). This technique
avoids placing suture material near the apex of the flap (B).
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Corner
Stitch for Stellate Wounds The
corner stitch may also be used to close stellate lacerations, as
described in Fig. 18.33.
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Clinical Pearls
1. Utilization of a mattress
suture can aid in wound edge eversion, dead space removal, and tension
reduction.
2. A single corner stitch may
be used to close several corners of a stellate wound. The corner stitch
is one of the most useful techniques in the ED management of complex
wounds.
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Wound Care Complications
Associated Clinical Features
Despite appropriate and
meticulous care, all wounds are subject to three main complications:
infection, dehiscence, and hypertrophic scar formation. Nearly all wounds
evaluated in the ED have occurred under nonsterile conditions and should
be considered contaminated. Disruption of the epidermis allows a portal
of entry for skin flora, while contaminants may harbor microorganisms.
Bacterial concentrations vary depending upon the anatomic location; the
highest epidermal bacterial concentrations are found on the scalp,
axillae, mouth, feet, nail folds, and perineum. A key factor in
determining bacterial concentration in the wound is time elapsed until
presentation. Wounds should therefore be thoroughly cleaned and irrigated
in a timely manner following presentation. Wound infection is suggested
by pain, warmth, erythema, edema, and purulent drainage from the wound
site (Fig. 18.35).
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Postoperative
Wound Infection The patient
presented to the ED with increasing pain and redness at the site of
his staple closure. The area was erythematous, tender, and warm and
had scant purulent drainage around some of the staples. (Courtesy of
Matthew D. Sztajnkrycer, MD, PhD.)
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Wound healing occurs via a structured process of
epithelialization, neovascularization, collagen synthesis, wound
contraction, and remodeling. New collagen fibril synthesis occurs by day
2, and peak synthesis occurs by day 5 to 7. Damaged collagen is
subsequently degraded by proteolytic enzymes and replaced with the newly
synthesized collagen. A nadir in wound strength occurs between days 7 and
10; during this weakest point, which frequently coincides with suture
removal, the wound is at risk for dehiscence (Fig. 18.36) or breakdown.
Factors that may contribute to wound dehiscence by impairing wound
healing include infection, drugs (especially corticosteroids), foreign
bodies, advanced age, poor nutritional status, diabetes mellitus, and
peripheral vascular disease.
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Wound
Dehiscence After suture
removal, the patient returned to the ED. The wound had dehisced but
had a clean base of granulation tissue. The wound was allowed to
close by secondary intention. (Courtesy of Alan B. Storrow, MD.)
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At the opposite extreme to wound dehiscence, wound
healing may occur in an exaggerated manner, resulting in hypertrophic
scars and keloid formation (Fig. 18.37). Hypertrophic scars are the
result of excessive collagen deposition within the borders of the
original wound, generating excessive scar bulk. These wounds occur at
areas of increased tissue stress. Keloids represent inappropriate
scarring that extends beyond the boundaries of the original wound. While
keloids are most commonly described in the African-American population,
they may occur in any darkly pigmented skin areas.
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Keloid The degree of excessive scar bulk extending
beyond the original wound margins may be dramatic and cosmetically
significant. (Courtesy of Thea James, MD.)
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Emergency Department Treatment
and Disposition
Sutures and staples represent
foreign bodies within the wound and generate varying degrees of
inflammatory reaction. Local wound infections are treated with suture
removal and thorough irrigation and drainage as well as possible
radiographic and visual exploration of the wound for missed foreign
bodies. A 7-day course of a first-generation cephalosporin or
antistaphylococcal penicillin is appropriate for most infections. For
animal bites, other antibiotics may be more appropriate. More advanced
wound infections, including those with evidence of lymphangitic streaking
and systemic toxicity, should be managed with parenteral antibiotics.
Wound dehiscence is treated
conservatively by treating the underlying causes and allowing healing via
secondary intention. Dehiscence of wounds in cosmetically sensitive areas
is best managed in conjunction with a consultant.
Hypertrophic scars and keloids
are managed in conjunction with a consultant. Treatment modalities
include corticosteroids, compressive dressings, surgical excision, and
radiation therapy.
Clinical Pearls
1. All accidental wounds are
considered contaminated and treated as such. Thorough irrigation and
cleansing is of paramount importance in preventing wound infection.
2. Expedient ED wound care is
important, since bacterial contamination increases over time.
3. The tensile strength of the
wound reaches its nadir between 7 to 10 days.
4. All patients with wounds in
areas of increased tissue stress and a history of hypertrophic scarring
are treated with splinting and physical therapy to minimize the risk of
excessive scarring.
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