Wound Management Year 4 Aim of Talk Basic introduction to wound management. Wound healing. Assessment. Wounds in special areas and tetanus prophylaxis.

Aims of lecture Types of wounds Approach to wound management Special wounds

Aim To provide the most favourable conditions to promote healing & return of normal function To restore physical integrity & function without infection or deformity

“Minor injuries” incorrectly managed Long term complications Principle “Minor injuries” incorrectly managed Long term complications

Wound history What (and who) caused it? When did it occur? Was there a crush component? Where did it occur? Any chance of foreign body? PMH? Tetanus status?

Tetanus Prophylaxis Change in immunisation programme in 1960s Immunisations given at 2,3 & 4 months old, pre-school and end of school – immunised for life Immunoglobulin required for puncture wounds, contaminated wounds Obtain IgG from BTS

Wound Types Superficial, blunt tangential force Abrasion Contusion Laceration Incision Superficial, blunt tangential force Blunt, subcutaneous blood Blunt, full thickness Sharp, full thickness

Approach to Wounds Clean or contaminated ? ?Foreign body ? Damage to deep structures - explore Should I close it – if so how? Have I the skills to proceed? Questions you need to ask yourself In picture, possible extensor injury.

Dirty Wounds ? > 6hrs Contain Bites (human, cat etc) organic material foreign material Bites (human, cat etc) Dead / devitalised tissue Point of Slide. Picture actually shows grossly contaminated amputation.

Dirty Wounds “ The solution to pollution is DILUTION ” Irrigate +++ Point of Slide. Picture shows shotgun wound.

Glass / Metal - X-ray Wood / Plastic - USS Foreign Bodies Patient can’t straighten thumb

Explore Patient can’t straighten thumb. Extensor pollicus longus divided

v Wound Closure Primary Closure (wound closed) Clean wound No tissue loss Delayed primary closure Secondary Closure (heals by secondary intention) Dirty wound Tissue loss v Delayed primary closure – close in 24-48hrs – usually because too swollen initially or concern about infection Secondary closure – closure by secondary intention – heals from bottom up – problems of time it takes, pain during it and dressing changes, if wound on back or buttocks need someone to change it for you, larger scar. Secondary closure not really appropriate if expose vital structures (eg nerves, bones) or if mobile area like joint as scar tissue would potentially restrict movement

Pros & Cons Method of Closure Steristrips Tissue Adhesive Sutures Staples Pros & Cons Steristrips – painless, less strenght, not good in mobile areas, need to stay dry Glue – painless, only dry for 24hrs, don’t get glue in wound, not near eye Sutures – painful, need removed Staples – visually less tolerated, need staple remover

Suturing Local anaesthetic Wound toilet & explore Choose suture and technique Arrange FU Face & Hands – 5 days Scalp – 7 days Trunk and limbs- 10 -14 days

Special Wounds Point of Slide. Picture shows posture in flexor tendon injuries. Assessment of tendon function.

Special wounds Lips Accurate repair of vermilion border Face Careful suturing 5/0 or 6/0 for 5 days Point of Slide. Face wounds. Parotid duct, facial nerve.

Pre-tibial laceration Do not suture Remove haematoma Wound toilet Replace flap without tension Steristrip and Mepitel Rest and Elevation

Point of Slide. ‘Fight bite’ explain infection prone, intra-articular injuries.

“Fight Bite” Infection Fracture Foreign Body Hepatitis B cover Secondary closure Antibiotic cover Point of Slide. ‘Fight bite’ explain infection prone, intra-articular injuries.

Close the wound ? Point of Slide. Animated slide ask question and then show answer.

Questions

Summary Take a good history Describe wounds correctly Clean and explore all wounds Consider infection and immunisation Decide whether to close or not Consider options for closure