Mechanisms- Shear
- Tension
- Distributed impact over bony prominence
- => Devitilised tissue
- Compression
- Hard/focused impact over bony prominence
Considerations
- Diabetes
- Microvascular insufficiency delays healing
- Drugs
- Steroids, Aspirin
- OCP (mechanism unknown)
- Region
Initial exploration
- Document well! cf Medico-legal
- Length / Breadth
- Depth
- NV status
- Tendon injury
- Make sure you move the distal structure over the full range, to check for damage initially hidden
Xrays
- FB
- Bony injusry
- Pneuomo/haemo peritoneum/thorax
- Air track
- Air trapped in tissue reveals depth of wound
- => Can tell if joint cavity penetrated
- May need to use a marker to identify site
Lignocaine
- Use 1%
- Max:
- 3-4 mg/kg plain
- 7 mg/kg with 1:100,000 adrenaline
- i.e. Max approx. 20 ml typically
- Infiltrate from WITHIN wound, not through skin
Closure
- Pressure with WET gauze to control haemorrhage
- Use antiseptics BEFORE irrigation
- 50 ml syringe + green needle + one hand provides appropriate pressure for cleaning
- Staples interfere with CT - e.g. Head injury
- Don't put glue in wound - Overlay after approximation
- Suture
- Absorbable (vicryl) for tissue under skin
- Non-absorbable (ethilon, prolene) for skin
- Sizes:
- 5, 4, 3, 2, 1, 0, 00 (2-0), 000 (3-0) .... (11-0)
- 4-0 - 6-0 usual for skin
- Plain forceps are ONLY for FB removal (crush tissue)
- Scalpel to debride if necessary
- Pretty much always simple interrupted:
- 1 cm between sutures, 0.5 cm on face
- 3-4 mm from wound edge
- Can use a layer of simple interrupted in fat layer underneath to close in layers
- Don't strangulate tissue with know - Leave room for oedema
Timing
- Within 6-8 hrs => Primary closure
- Or within 24 hrs on face (better blood supply, cleaner)
- >8 hrs wait
- Inadine dressing (povidone-iodine)
- Prophylactic Abx
- >4 days => Secondary closure
- Infection would be there by this stage
- May have to freshen edges with gauze/scalpel to encourage healing
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