++
Lacerations vary enormously in complexity and repairability. Very complex lacerations and those involving nerves or other structures should be referred to an expert.
++
Good approximation of wound edges minimises scar formation and healing time.
Pay special attention to debridement.
Avoid deep layers of suture material in a contaminated wound—consider drainage.
Inspect all wounds carefully for damage to major structures such as nerves and tendons and for foreign material:
Consider X-rays of wounds to look for foreign objects or fractures (compound fractures).
Trim jagged or crushed wound edges, especially on the face.
All wounds should be closed so that opposite layers line up.
Avoid leaving dead space.
Do not suture an ‘old’ wound (greater than 8 hours) if it is contaminated: leave 4 days before suturing (unless infected). You may need to excise a thin section off each edge to obtain a new healing surface.
Take care in poor healing areas, such as backs, necks, calves and knees, and in areas prone to hypertrophic scarring, such as over the sternum, chest or shoulder.
Use atraumatic tissue-handling techniques, with minimal handling of wound edges.
Everted edges heal better than inverted edges.
A suture is too tight when it blanches the skin between the thread—loosen it.
Avoid tension on the wound, especially in fingers, lower leg, foot or palm.
A finer scar and better result is obtained by using a large number of fine sutures rather than fewer thick sutures more widely spread.
Avoid haematoma.
Apply a firm pressure dressing when appropriate, especially with swollen skin flaps.
Consider appropriate immobilisation for wounds. Many wound failures are due to lack of immobilisation from a volar slab on the hand or a back slab on the leg.
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Monofilament nylon sutures are generally preferred for skin repair.
Use the smallest calibre compatible with required strains.
The synthetic, absorbable polyglycolic acid or polyglactin sutures (Dexon, Vicryl) are stronger than catgut of the same gauge, but are not as suitable as catgut on the face or subcuticularly.
++
Examples of good-quality instruments:
++
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The needle should be held about two-thirds of the way back from the tip; it can distort if held right near the back end (see FIG. 132.2). Tougher tissues may require grasping the needle at its centre.
++
++
Dead space should be eliminated to reduce tension on skin sutures. Use buried, absorbable sutures to approximate underlying tissue. This is done by starting suture insertion from the fat to pick up the fat/dermis interface so as to bury the knot (see FIG. 132.3).
++
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Eversion is achieved by making the ‘bite’ in the dermis wider than the bite in the epidermis (skin surface) and making the suture deeper than it is wide. Shown are:
++
++
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The mattress suture is the ideal way to evert a wound.
++
One should aim to use a minimum number of sutures to achieve closure without gaps but sufficient sutures to avoid tension. Place the sutures as close to the wound edge as is reasonably possible.
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Practice tips
Have the patient lie down for suturing and the parents of children sit down.
Avoid using antibiotic sprays and powders in simple wounds—resistant organisms can develop.
Consider tetanus and gas gangrene prophylaxis in contaminated and deep necrotic wounds.
Give a tetanus booster if the patient has not had one within 5 years for dirty wounds or within 10 years for clean wounds.
Give tetanus immunoglobulin if patient is not immunised and the wound is grossly contaminated.
Never send head-wound patients home before thoroughly washing their hair and carefully examining for other lacerations.
Any laceration in the cheek, mandible or lower eyelid may damage the facial nerve, parotid duct or lacrimal duct respectively.
When a patient falls onto glass it takes bone to halt its cutting path. Assume all structures between skin and bone are severed.
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SPECIAL TECHNIQUES FOR VARIOUS WOUNDS
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The three-point suture
++
In wounds with a triangular flap component, it is often difficult to place the apex of the flap accurately. The three-point suture is the best way to achieve this while minimising the chance of strangulation necrosis at the tip of the flap.
++
Pass the needle through the skin of the non-flap side of the wound.
Then pass it through the subcuticular layer of the flap tip at exactly the same level as the reception side.
Finally, pass the needle back through the reception side so that it emerges well back from the V flap (see FIG. 132.5).
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Triangular flap wounds on the lower leg
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Triangular flap wounds below the knee are a common injury and are often treated incorrectly. Similar wounds in the upper limb heal rapidly when sutured properly, but lower limb injury will not usually heal at first intention unless the apex of the flap is given special attention.
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Proximally based flap
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A fall through a gap in floorboards will produce a proximally based flap; a heavy object (such as the tailboard of a trailer) striking the shin will result in a distally based flap.
++
Often the apex of the flap is crushed and poorly vascularised; it will not survive to heal after suture.
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Treatment methods (under infiltration with LA)
++
Preferred method: to attempt to salvage the distal flap, scrape away the subcutaneous tissue on the flap and use it as a full-thickness graft.
An alternative is to excise the apex of the flap, loosely suture the remaining flap and place a small split-thickness graft on the raw area (see FIG. 132.6).
++
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For both methods apply a suitable dressing and strap firmly with a crepe bandage. The patient should rest with the leg elevated for 3 days.
++
See FIGURE 132.7. This flap, which is quite avascular, has a poorer prognosis. The same methods as for the proximally based flap can be used. Trimming the flap and using it as a full thickness graft has a good chance of repair in a younger person but a poor chance in elderly people.
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While small lacerations of the buccal mucosa of the lip can be left safely, more extensive cuts require careful repair. Local anaesthetic infiltration may be adequate, although a mental nerve block is ideal for larger lacerations of the lower lip.
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For wounds that cross the vermilion border, meticulous alignment is essential. It may be advisable to pre-mark the vermilion border with gentian violet or a marker pen. It is desirable to have an assistant.
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Close the deeper muscular layer of the wound using 4/0 CCG. The first suture should carefully appose the mucosal area of the lip, followed by one or two sutures in the remaining layer.
Next, insert a 6/0 monofilament nylon suture to bring both ends of the vermilion border together. The slightest step is unacceptable (see FIG. 132.8). This is the key to the procedure.
Close the inner buccal mucosa with interrupted 4/0 plain catgut sutures.
The outer skin of the lip (above and below the vermilion border) is closed with interrupted nylon sutures.
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Apply a moisturising lotion (or petroleum jelly) along the lines of the wound.
Remove nylon sutures in 3–4 days (in a young person) or 5–6 days (in an older person).
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Repair of lacerated eyelid
++
Preserve as much tissue as possible.
Do not shave the eyebrow.
Do not invert hair-bearing skin into the wound.
Ensure precise alignment of wound margins.
Tie suture knots away from the eyeball. If necessary, leave suture ends long and tape the strands away from the eye.
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Place an intermarginal suture behind the eyelashes if the margin is involved.
Repair conjunctiva and tarsus with 6/0 catgut.
Then repair skin and muscle (orbicularis oculi) with 6/0 nylon (see FIG. 132.9).
++
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Repair of tongue wound
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Wherever possible, it is best to avoid repairs to tongue wounds because these heal rapidly. However, large flap wounds to the tongue on the dorsum or the lateral border may require suturing. The best method is to use buried catgut sutures.
++
Get patient to suck ice for a few minutes, then infiltrate with 1% lignocaine and leave for 5–10 minutes.
Use 4/0 or 3/0 catgut sutures to suture the flap to its bed, and bury the sutures (see FIG. 132.10).
++
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It should not be necessary to use surface sutures. If it is, 4/0 silk sutures will suffice.
++
Instruct the patient to rinse the mouth regularly with salt water until healing is satisfactory.
++
In this emergency situation, instruct the patient to place the severed finger directly into a fluid-tight sterile container, such as a plastic bag or sterile specimen jar. Then place this ‘unit’ in a bag containing iced water with crushed ice.
++
Note: Never place the amputated finger directly in ice or in fluid such as saline. Fluid makes the tissue soggy, rendering microsurgical repair difficult.
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Care of the finger stump
++
Apply a simple, sterile, loose, non-sticky dressing and keep the hand elevated.
++
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Human bites and clenched fist injuries
++
Human bites and clenched fist injuries can present a serious problem of infection. Beta-lactamase-producing anaerobic organisms in the oral cavity (e.g. Vincent’s) can penetrate the damaged tissue and form a deep-seated infection. Streptococcus species, staphylococcal organisms and Eikenella corrodens are common pathogens. Complications of the infected wounds include cellulitis, wound abscess and lymphangitis. A Cochrane review of antibiotic prophylaxis concluded that it reduces the risk of infection.2
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Principles of treatment
++
Clean and debride the wound carefully (e.g. aqueous antiseptic solution or hydrogen peroxide).
Give prophylactic penicillin if a severe or deep bite.
Avoid suturing if possible.
Tetanus toxoid (although minimum risk).
Consider rare possibility of HIV and hepatitis B or C infections.
For high-risk wounds, give procaine penicillin 1.5 g IM statim and/or amoxycillin/clavulanate 875/125 mg bd for 5 days.3
If established infection in a deep wound, take a swab and give metronidazole 400 mg (o) bd for 14 days plus either cefotaxime 1 g IV 8 hourly or ceftriaxone 1 g IV daily for 14 days.
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Dog bites typically have poor healing and carry a risk of infection with anaerobic organisms, including tetanus, staphylococci and streptococci. Puncture and crush wounds are more prone to infection than laceration. Up to 25% of dog bite wounds become infected, with the first signs appearing in about 24 hours.4
++
Principles of treatment (see FIG. 132.11):
++
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Clean and debride the wound with aqueous antiseptic, allowing it to soak for 10–20 minutes.
Aim for open healing—avoid suturing if possible (except in ‘privileged’ sites with an excellent blood supply such as the face and scalp).
Apply non-adherent, absorbent dressings (paraffin gauze and Melolin) to absorb the discharge from the wound.
Tetanus prophylaxis: immunoglobulin or tetanus toxoid.
A 2008 Cochrane review found no evidence supporting prophylactic antibiotics for dog or cat bites.2 Small wounds presenting within 8 hours that do not involve joints or tendons do not require antibiotics.
However, for a severe or deep bite, give prophylactic penicillin: 1.5 million units procaine penicillin IM statim, then orally for 5–10 days. An alternative is amoxycillin/clavulanate for 5–7 days. Use this antibiotic for 7–10 days for an established infection (depending on swab).4
Inform the patient that slow healing and scarring are likely.
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Rabid or possibly rabid dog (or other animal)
++
Not currently applicable in Australia (see CHAPTER 15).
++
Wash the site immediately with detergent or saline (preferable) or hydrogen peroxide or soap (if no other option).
Do not suture.
If rabid:
Uncertain: capture and observe animal, consider vaccination.
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Cat bites have the greatest potential for suppurative infection, with Pasteurella multocida being the most common organism. The same principles apply as for the management of human or dog bites. For deep or delayed wounds, use amoxycillin + clavulanate for prophylaxis for 5 days. For infection, swab the wound but start with metronidazole + doxycycline or ciprofloxacin.3 It is important to clean a deep and penetrating wound. Another problem is cat-scratch disease, presumably caused by a Gram-negative bacterium, Bartonella henselae.
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Clinical features of cat-scratch disease
++
An infected ulcer or papule pustule at bite site (30–50% of cases) after 3 days or so5
1–3 weeks later: fever, headache, malaise, regional lymphadenopathy (may suppurate)
Intradermal skin test positive
Benign, self-limiting course usually not requiring antibiotic treatment
Sometimes severe symptoms for weeks, especially in immunocompromised
For lymphadenopathy unresolved after 1 month, or significant morbidity, treat with erythromycin or roxithromycin for 10 days3
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Water-related wound infections3
++
These complex infections may require expert advice.
++
Wounds from coral cuts are at risk of serious infection with Vibrio organisms (marine pathogens) or Streptococcus pyogenes. Such wounds require cleaning with antiseptics, debridement, dressing and antibiotic cover with doxycycline 100 mg bd or cephalexin 500 mg bd for 7 days.
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Fish tank/swimming pool granuloma
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Due to Mycobacterium marinum, which causes a localised papular or nodular skin lesion, usually in people who clean aquaria or swimming pools. Diagnosis is by biopsy and culture (acid-fast bacilli).
++
Treatment: single lesion excision (may suffice). May need antibiotic therapy e.g. clarithromycin (o) bd for 3–4 months plus rifampicin for severe or unresponsive infection. Seek expert advice.
+++
Aeromonas species wound infections
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From fresh or brackish water or mud exposure to open wounds. Treat with ciprofloxacin for 14 days.3
+++
Shewanella putrefaciens
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From salt or brackish water, particularly legs with vascular compromise. Causes severe cellulitis with necrosis, even sepsis. Treat with ciprofloxacin or meropenem/imipenem.