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Soft tissue injuries are very seldom life threatening. You can occasionally have problems with life threatening hemorrhage. Those are usually easily controlled with pressure. In a trauma setting, if you have other injuries, those injuries are most certainly more important that the management of soft tissue injuries. In the trauma primary survey we worry about airway, circulation and then it’s in the definitive phase, the management of these injuries becomes important.
Wound healing. Primary intention, secondary intention and then a combination of the two - delayed primary closure or healing by third intention. Healing by primary intention occurs whenever we are able to anatomically re-approximate a wound. Most commonly that is a simple laceration. This is a lady who was involved in a motorcycle accident. She hit a cyclone fence. She has these lacerations about the mouth and she has no loss of tissue.
Wound dressings. Again, I don’t use a lot of wound dressings. I think if you decide to use wound dressings you have to decide what you are using them for. Number one would be protection of the wound and the tissues adjacent to the wound from trauma, from dirt. The absorption of serum that may leak out of the wound during that first 48 hours, and immobilization I think is important. Wounds that are properly immobilized - even soft tissue lacerations - are less painful.
General principles of wound management. I think very thorough irrigation and probably the key to even simple lacerations is very aggressive surgical debridement. You all probably manage simple skin lesions on a daily basis. In those cases you are not hesitant at all to sacrifice some normal skin so that you get a nice closure of the tissues. If you think of a simple laceration as a lesion, there’s no reason not to sacrifice the normal skin or some skin adjacent to the wound.
Cleansing is always a big question. The normal skin flora is approximately 10 to the 3rd organisms per gram. If the colonization increases much beyond 10 to the 5th we end up with a wound infection, so it’s important to at least cleanse a wound. What is the reason to cleanse a wound? You want to remove visible dirt. But you want to avoid some of these cytotoxic preparations. Betadine in wounds, there’s really no reason to use Betadine in a wound.
What are the techniques of wound closure? You are probably all familiar with skin staples. They certainly are very rapid and do accomplish the task. They are cheaper in many cases. If you are dealing with long operating room times, but they probably don’t do as good a job as suture material. On the scalp, there are people that can use adhesives and tie or braid the hair together to accomplish a scalp closure. I’ve tried it, I’ve not been able to do it. Skin closure tapes, or Steri-strips, if you’ve closed the deep layers can help you with alignment of skin. I don’t think it’s as good as the use of suture, but certainly is useful in some cases. Now the goal of all suturing techniques is the same. You want to precisely align anatomic layers, obliterate dead space and allow wound healing to occur.
In terms of absorbable sutures: whenever you are closing a wound you have to decide how long you want that suture to be present and provide support for the tissues and I tend to be a lumper and so I look at sutures and try to lump them together. Surgical gut sutures can be either plain or chromic. A chromic suture is just a tanning process that they put the suture through and increases the length of the time that they hang around. Plain sutures, 50% of tensile strength at one week. Chromic sutures, 50% tensile strength at two weeks. The polygalactic acid sutures, that would be Vicryl in the case of Ethicon, Dexon suture in the case of Davis and Geck, and Polysorb in the case of U.S. Surgical, three weeks 50% tensile strength. Then there’s a new group of longer acting sutures, the Polydioxanones the PDS in the case of Ethicon, Maxon in the case of Davis and Geck that maintain 50% of their tensile strength for 3 to 6 months. This just shows that graphically. Plain gut suture, seven days. Chromic gut suture, 14 days. Polygalactic acid, three weeks. Then the longer acting absorbable sutures.
One variation of the simple interrupted is the baseball stitch and you just begin with a simple interrupted suture and then continue approximating the tissues, tying the suture at the end of the laceration. It’s nice because it’s a little bit faster. You only tie the suture at each end of the wound. It provides even tension of the wound and that’s nice. It’s faster to remove because you don't have to cut all your knots. I think the only real indication is a straight line incision. And those occasionally occur on the face. I don’t think you are quite as precise as you are with simple interrupted.
This is another very useful suture that I use everywhere but the face, I think. This is a running subcuticular stitch, or intracuticular suture and I think you’ve all probably seen it. It’s a suture that passes in the dermis parallel to the surface of the skin. There’s many ways to begin and end this suture. The nice thing about the intradermal suture is that you can leave it in for two weeks, three weeks, and you don’t get those hatch marks. I routinely leave them in for two weeks.
I just want to go through a few specific examples. This is minor soft tissue laceration, a scalping-type laceration that occurred on this young lady’s forehead. The critical thing here is the very precise alignment of the eyebrow, and then good surgical debridement of the wound margins. This is just closure at the time of injury and what you see here is we have done a pretty good job of aligning that eyebrow. Fairly aggressive at debridement so we’ve got nice healthy tissues.
I said that I thought very aggressive surgical debridement was very important, there are a few exceptions and one of them is the eyebrow. This is a very unique, hair-bearing structure and if you very aggressively debride eyebrow it’s very difficult to restore. This is a lady with a very minor laceration. It’s kind of a stellate laceration but it’s very ragged. Anyplace else you’d want to very aggressively excise that but since we were dealing with eyebrow.
Lacerations to the vermilion or special situations, the most important thing is the alignment of that vermilion border. That first example was a good example where I didn’t get the vermilion lined up very well and the result was less than optimal. Through and through lacerations. The principle is, if you have a wound infection, you want that infection to drain intraorally so you very loosely approximate the mucosal surface, do a layered repair, close the muscles.
Now, evulsion of tissues. I think this is an area where you can get into trouble. Sometimes it’s possible to close these wounds as long as you don’t distort normal anatomy. Again, if you distort the normal anatomy it’s difficult to reconstruct secondarily. A lot of times when you have soft tissue evulsion you need grafts or flaps or something a little more elaborate to accomplish a good repair. This is just an example of a dog bite wound at the commissure with some evulsion of tissue. In the lip, you can lose up to one-third of the lip and get away with it. And we don’t distort the commissure here.
Dog bites, another special consideration. Certainly on the face where we want a good aesthetic result it’s important to get a good primary closure after very aggressive surgical debridement and very copious irrigation. On other sites we like to leave those open. There are a number of facial lacerations that we term "complex facial lacerations" and those include some specialized structures: the lacrimal system. You can have a disruption in the lacrimal system. It’s nice to identify it if you can repair it over a Silastic stent. You like to do that primarily. In reality, if you close those lacerations even with disruption of the lacrimal drainage system, only about 25% of those patients will develop tearing or epiphora. And those that do can be handled with a secondary procedure. But if possible, it’s nice to identify them early. The parotid ducts are a different story.
Another special consideration is foreign body within the superficial epidermis and dermis. Road rash. This is actually a blast injury and we have a lot of imbedded foreign body. If you don’t get that out at the time of the initial injury, that’s going to become a tattoo and it’s going to become impossible or nearly impossible to clean out as a secondary procedure. How do you take care of these? Well, scrub brushes certainly have their place. Sometimes just a scalpel blade.
Scar revisions. So many times we see patients who are initially not very happy with the result of a traumatic injury. I see them all the time and I think the most important thing to do is remember that wound healing occurs over a period of 12 to 18 months. Ninety-five plus percent of the patients that I see at two weeks.
I wanted to cover fingertip injuries real quickly. Fingertip injuries account for 3 to 4% of all emergency room visits. There are some simple fingertip injuries that are important. Subungual hematomas. I think the principle is if they are less than 30% of the surface area of the nail you can simply decompress the nail and the nail bed. If they are greater than 30% of the surface area, that signifies that there is fairly significant injury to the nail bed and that the nail plate needs to be removed and the laceration or injury repaired. This just shows a simple method for decompressing subungual hematoma. You probably all have your favorite methods.
Splinting: it’s important to splint these injuries. It helps maintain the nail fold, maintains the position of the repaired nail bed and protects and supports the fingertip. There are many ways to do that. We sometimes take the nail plate off, clean it up and suture that back on. I don’t care to do that anymore. The foil that comes in some of your suture materials works very nicely as a nonadherent material that you can place in that nail fold and support the tip, or we can use some nonadherent dressing materials. This just shows the use of a nail plate that’s sutured on, helping to support that nail bed.
Avulsed parts, especially on kids under four, you can put back on as composite grafts. This is not a case where you could replant this fingertip but on a child, just take a needle, pass it through the distal fingertip and about 40 to 50% of these fingertips will survive as composite grafts. So I think in conclusion, with nail bed injuries, you have to be very aggressive with lacerations of the nail bed. Be very conservative with avulsions.