Traumatic wounds

May mean anything from minor cuts to extensive tissue injuries which threaten life

The extent and nature of the force determine the nature and extent of the resultant injury

Pressure = force

area

Occur when forces exceed the failure limit of the tissue

Classification of wounds

Tidy

clean incision

uncontaminated

less than six hours old

caused by low energy trauma

Untidy

has a raged edge

is contaminated

more than twelve hours old

caused by high energy trauma

Principles of management

Priorities

Treat/prevent shock

History

Assess cause therefore probable pattern of tissue damage and probability of other damage

Assess likelihood of contamination/foreign bodies

Determine tetanus immunity status

Medical and medication history

Ensure perfusion

Check major blood vessels and local circulation

Possible arterial and venous shunting

Debridement

The most important single factor in management of a contaminated traumatic wound

Use of general or local anaesthesia

All devitalised and necrotic tissue must be excised

Small contaminated wounds may be debrided with repeated dressing of wet to dry gauze prior to closure

Irrigation

After debridement irrigate with large volumes of warm saline

Soap and water cleaning may be required to remove grease and dirt

A second look operation may be required 1 - 5 days later to check tissue viability

Subsequent irrigation may also be required

Hydrogen peroxide

Wound exploration

The wound must be fully explored

In contaminated wounds nerves and tendons may be repaired as a delayed primary closure when the wound is clean

Apparently minor wounds must be fully assessed as they may result in long term disability or disfigurement

Medications

Tetanus immunisation

Prophylactic antibiotics are used in heavily contaminated wounds and in immunocompromised patients

Dressings

Consider a porous dressing

Ensure wound stability

Maintain a moist environment

Limbs may be supported or elevated

Continued observations

Perfusion

Distal perfusion

Odour

Colour

Compartment syndrome in limb injuries, especially in the lower leg and crush or degloving injuries

Rate of healing

Wound closure

Primary intention

Secondary intention

Delayed primary healing

If in doubt leave wound open

Small untidy wounds may sometimes be tidied up by excision of 1 - 2 mm of raged edges

Do not use primary closure under tension

Wounds may be closed in layers

Repairs must be accurate to prevent deformity

Abrasions

Skin wounds caused by friction

Loss of epidermis and sometimes deeper structures

Exposed dermal nerve receptors are common

Often impregnated with foreign material

Consider soft tissue X ray if glass fragments are suspected

Thorough cleansing is needed

Use field local anaesthesia

General anaesthesia for larger wounds

Scrubbing may be required with a sponge or surgical brush

High pressure irrigation via a 25 G needle

Once healing has occurred it is almost impossible to remove trapped foreign material - tattooing

Use occlusive dressing

- keep moist

- increases rate of keratinocyte migration and epithelialisation

- reduces likelihood of infection

Bruises

Contusions result from direct blows

May also occur away from primary impact site

Capillary damage and increased capillary permeability - oedema and release of red cells into tissues

Consider medical causes

Consider pattern of bruises, possible NAI

Gentle mobilisation is probably optimal

Haematomas may lead to hypovolaemia, infection, skin necrosis, compartment syndrome, blood loss and myositis ossificans so may need to be evacuated.

Consider the space occupying lesion concept

Consider, elevation, application of ice, pressure dressings,

Local heat or ultrasound may increase reabsorption of blood residues

Shearing and degloving injuries

Skin and subcutaneous tissues are avulsed and devascularised eg. shearing between a moving vehicle tyre and the road

Look for pallor, loss of sensation, friction burns, tyre imprints, or abnormal skin mobility

Ischaemic skin needs to be excised and split grafted

Bullet wounds

The wound capacity of a missile is related to its energy on impact

KE = 1/2 mv²

Low velocity bullet

High velocity bullet

High velocity has ten times the energy of a low velocity

Low velocity bullet wounds

Damage is relatively slight unless important tissues are traversed

Bullets only damage tissues along their track

Debride entry and exit site and the track wound

Allow to heal by secondary intention or DPS

High velocity bullet wounds

Bullets produce temporary cavitation effects up to 30 times the size of the bullet tract

These effects cause widespread damage and can break bones, cause concussive effects on nerves and damage the endothelium of blood vessels

When a large amount of energy is released there is an explosive exit wound with tissue loss

Any factor retarding the forward rotational speed of the bullet will cause a more rapid release of energy

Damage may occur to other tissues

Treat tract like any other wound

Prognosis depends on extent of tissue destruction and amount of contamination

Bomb blast injuries

Often fatal or cause extensive tissue damage

Fragments, grit, stones, metal, masonry, glass travel at 2000 metres/sec

Shock waves with a pressure rise damage air filled structures, ear, lung, bowel

Indirect trauma as patients are thrown against objects

Head, neck, chest, liver and other abdominal injuries are common

Thorough dedridement and primary amputation are often required

Traumatic wounds

May mean anything from minor cuts to extensive tissue injuries which threaten life

The extent and nature of the force determine the nature and extent of the resultant injury

Pressure = force

area

Occur when forces exceed the failure limit of the tissue

Classification of wounds

Tidy

clean incision

uncontaminated

less than six hours old

caused by low energy trauma

Untidy

has a raged edge

is contaminated

more than twelve hours old

caused by high energy trauma

Principles of management

Priorities

Airway, breathing, circulation, haemorrhage, head injury, compound fractures, other fractures, other damage

Treat/prevent shock - poorly perfused hypoxic tissues will not heal

History

Assess cause therefore probable pattern of tissue damage and probability of other damage

Assess likelihood of contamination/foreign bodies

Determine tetanus immunity status

Medical and medication history

Ensure perfusion

Check major blood vessels and local circulation

Possible arterial and venous shunting

Debridement

The most important single factor in management of a contaminated traumatic wound

Use of general or local anaesthesia

All devitalised and necrotic tissue must be excised

* this removes heavily contaminated tissue

* improves the wounds ability to resist infection

* prevents systemic absorption of breakdown products eg. myoglobin (rhabdomyolysis)

Small contaminated wounds may be debrided with repeated dressing of wet to dry gauze prior to closure

Irrigation

After debridement irrigate with large volumes of warm saline

* removal of contaminants

* removal of free blood and haemotoma which are good bacterial growth mediums and act as sites for abcess formation

* wound scrubbing will cause oedema and reduce host defences

Soap and water cleaning may be required to remove grease and dirt - to prevent tattooing

A second look operation may be required 1 - 5 days later to check tissue viability

Subsequent irrigation may also be required

Hydrogen peroxide

* an oxygen donor

* may promote haemostasis by increasing local surface area

* seems to be good for new and older dirty wounds

Wound exploration

The wound must be fully explored

* determine the extent of the wound

* identify possible anaerobic areas and contamination

* discover and remove any foreign bodies

* allow debridement and cleaning

* identify damage to deep structures

In contaminated wounds nerves and tendons may be repaired as a delayed primary closure when the wound is clean

Apparently minor wounds must be fully assessed as they may result in long term disability or disfigurement

Medications

Tetanus immunisation

Prophylactic antibiotics are used in heavily contaminated wounds and in immunocompromised patients

Dressings

Consider a porous dressing - as serum and exudate are good bacterial growth mediums

Ensure wound stability

Maintain a moist environment

Limbs may be supported or elevated

Continued observations

Perfusion

Distal perfusion

Odour

Colour

Compartment syndrome in limb injuries, especially in the lower leg and crush or degloving injuries

Rate of healing

Wound closure

Primary intention

Secondary intention - eg low velocity gut shot wound

Delayed primary healing - may be sutured DPS or may need grafted when clean

If in doubt leave wound open

Small untidy wounds may sometimes be tidied up by excision of 1 - 2 mm of raged edges

Do not use primary closure under tension - as it is likely to break down

Wounds may be closed in layers - to avoid skin tension and avoid dead space

Repairs must be accurate to prevent deformity

Abrasions

Skin wounds caused by friction

Loss of epidermis and sometimes deeper structures

Exposed dermal nerve receptors are common

Often impregnated with foreign material

Consider soft tissue X ray if glass fragments are suspected

Thorough cleansing is needed

Use field local anaesthesia - round the wound as opposed to into the wound

General anaesthesia for larger wounds

Scrubbing may be required with a sponge or surgical brush

High pressure irrigation via a 25 G needle

Once healing has occurred it is almost impossible to remove trapped foreign material - tattooing

Use occlusive dressing

- keep moist

- increases rate of keratinocyte migration and epithelialisation

- reduces likelihood of infection - improved function of neutrophils and macrophages

Bruises

Contusions result from direct blows

May also occur away from primary impact site eg. peri-orbital from nasal injury

Capillary damage and increased capillary permeability - oedema and release of red cells into tissues

Consider medical causes

Consider pattern of bruises, possible NAI

Gentle mobilisation is probably optimal

Haematomas may lead to hypovolaemia, infection, skin necrosis, compartment syndrome, blood loss and myositis ossificans so may need to be evacuated. (ossification of muscle tissue)

Consider the space occupying lesion concept

Consider, elevation, application of ice, pressure dressings,

Local heat or ultrasound may increase reabsorption of blood residues

Shearing and degloving injuries

Skin and subcutaneous tissues are avulsed and devascularised eg. shearing between a moving vehicle tyre and the road

Look for pallor, loss of sensation, friction burns, tyre imprints, or abnormal skin mobility

Ischaemic skin needs to be excised and split grafted

Bullet wounds

The wound capacity of a missile is related to its energy on impact

KE = 1/2 mv²

Low velocity bullet - 200 metres/sec

High velocity bullet - 650 metres/sec

High velocity has ten times the energy of a low velocity

Low velocity bullet wounds

Damage is relatively slight unless important tissues are traversed

Bullets only damage tissues along their track

Debride entry and exit site and the track wound

Allow to heal by secondary intention or DPS

High velocity bullet wounds

Bullets produce temporary cavitation effects up to 30 times the size of the bullet tract

These effects cause widespread damage and can break bones, cause concussive effects on nerves and damage the endothelium of blood vessels

When a large amount of energy is released there is an explosive exit wound with tissue loss

Any factor retarding the forward rotational speed of the bullet will cause a more rapid release of energy

Damage may occur to other tissues

Treat tract like any other wound - open and pack for secondary healing

Prognosis depends on extent of tissue destruction and amount of contamination

Bomb blast injuries

Often fatal or cause extensive tissue damage

Fragments, grit, stones, metal, masonry, glass travel at 2000 metres/sec

Shock waves with a pressure rise damage air filled structures, ear, lung, bowel

Indirect trauma as patients are thrown against objects

Head, neck, chest, liver and other abdominal injuries are common

Thorough dedridement and primary amputation are often required

The handout below is a condenced version for introductions

Traumatic wounds

Classification of wounds

Tidy

* clean incision * uncontaminated

* less than six hours old * caused by low energy trauma

Untidy

* has a raged edge * is contaminated

* more than twelve hours old * caused by high energy trauma

Continued observations

Perfusion

Distal perfusion

Odour

Colour

Compartment syndrome in limb injuries, especially in the lower leg and crush or degloving injuries

Rate of healing

Wound closure

Primary intention

Secondary intention

Delayed primary healing

If in doubt leave wound open

Small untidy wounds may sometimes be tidied up by excision of 1 - 2 mm of raged edges

Do not use primary closure under tension

Wounds may be closed in layers

Repairs must be accurate to prevent deformity

Abrasions

Skin wounds caused by friction

Loss of epidermis and sometimes deeper structures

Exposed dermal nerve receptors are common

Often impregnated with foreign material

Consider soft tissue X ray if glass fragments are suspected

Thorough cleansing is needed

Use field local anaesthesia

General anaesthesia for larger wounds

Scrubbing may be required with a sponge or surgical brush

High pressure irrigation via a 25 G needle

Once healing has occurred it is almost impossible to remove trapped foreign material - tattooing

Use occlusive dressing

- keep moist

- increases rate of keratinocyte migration and epithelialisation

- reduces likelihood of infection

Bruises

Contusions result from direct blows

May also occur away from primary impact site

Capillary damage and increased capillary permeability - oedema and release of red cells into tissues

Consider medical causes

Consider pattern of bruises, possible NAI

Gentle mobilisation is probably optimal

Haematomas may lead to hypovolaemia, infection, skin necrosis, compartment syndrome, blood loss and myositis ossificans so may need to be evacuated.

Consider the space occupying lesion concept

Consider, elevation, application of ice, pressure dressings,

Local heat or ultrasound may increase reabsorption of blood residues

Shearing and degloving injuries

Skin and subcutaneous tissues are avulsed and devascularised eg. shearing between a moving vehicle tyre and the road

Look for pallor, loss of sensation, friction burns, tyre imprints, or abnormal skin mobility

Ischaemic skin needs to be excised and split grafted