Warnings and recommendations regarding wound care and wound healing process.
This article contains comprehensive information about common injuries and wound healing in daily life. After the biochemical building blocks of healing in the wound come together, fibroblasts begin to multiply and settle. The main task of fibroblasts is collagen synthesis. As the collagen content increases, the resistance of the wound site also increases. Sutures, 3-14 according to their localization. should be taken within days. However, the collagen content and tensile strength of the wound increase over the following weeks; Intra-wound collagen transformation continues indefinitely. This second stage of wound healing is called the "Fibroblastic stage" or "Collagen stage".
Ascorbic acid plays an important role in collagen formation. In the absence of vitamin C, proline cannot convert to hydroxyproline and thus collagen synthesis stops. If we recall the long-lasting wounds of sailors with scurvy in his work "Moby Dick", we know why today. While collagen resorption continues at the same rate in ascorbic acid deficiency, its synthesis stops and wound healing is halted as a result.
The longest phase of wound healing is the final phase. This 'maturation' or 'remodeling' phase can last for several years and is accompanied by an improvement in the appearance of the scar. During this time, progressive collagen replacement results in a soft and less noticeable scar. Maturation is important for the gradual healing of the wound.
Wounds with skin loss
Acute traumatic injuries such as severe burns, deep abrasions or avulsions that end with skin loss also go through the same stages of healing. In addition, wound closure requires two additional biological mechanisms. These are epithelial migration and wound contraction.
Epithelialization: As soon as the biochemical and cellular substrates required for healing are collected and bacterial contamination falls below 10 5 organisms/gram, epithelial proliferation begins and epithelial migration to the wound surface occurs. If the wound is a superficial burn or abrasion, the epithelium begins to spread rapidly from the sweat glands and hair follicles and covers the entire wound surface within 10-14 days. When all layers of the skin are lost, epithelial migration may occur only from the wound edges. Epithelialization is a very slow process and early closure of the wound is often not possible.
In addition, there is an epithelial migration that is not accompanied by dermal layers, and therefore it is more susceptible to trauma. The histology of the migrating epithelium is usually neoplastic. A malignant ulceration, namely Marjolin's ulcer, may occur over time on a chronic wound that does not close for years. Therefore, in the face of serious and widespread wounds, reconstructive surgeons have learned not to rely solely on epithelialization. Instead, they use grafts and flaps for wound closure.
Wound contraction: Open wounds tend to close with the effect of internal forces over time. The “granulation” of the wound means that the wound surface is filled with granulation tissue with a rough appearance formed by capillary and fibroblast proliferation. The formation of granulation tissue in an open wound corresponds to the fibroblastic phase of primary wound healing. After granulation, the wound lips are retracted to the edges; however, this shift cannot be explained by epithelialization alone.
The gradual reduction of the wound surface is called wound contraction and is a process that has not yet been fully elucidated. Today it is believed that this contraction is caused by myofibroblasts, a highly specialized type of fibroblast, acting like smooth muscle cells.
In the presence of heavy bacterial contamination, neither epithelial migration nor contraction can progress (10 5 organisms/gm). While the contraction can be slowed down by applying partial thickness skin grafts; With full-thickness skin grafts, contraction can be virtually stopped. Some synthetic membranes, such as Biobrane, can also inhibit wound contraction. Large wound defects, on the other hand, should not be allowed to heal spontaneously, as they are best treated with surgical closure.
The goal in wound healing is not to sterilize the wound !
When conducting a public opinion poll among physicians, questions are often related to the use of antiseptic solutions or antibiotics to prevent bacterial contamination or to maintain sterility . The disadvantage of overemphasizing sterility is that it may miss much more important factors in wound healing. Sterility is not an indispensable condition for the skin surface.In the absence of a traumatic injury, pathogenic and non-pathogenic bacteria coexist in healthy skin. Quantitative tissue biopsy studies have shown that the bacterial density on normal skin is 10 3 organisms/g. Most bacteria found on the skin surface live in epidermal recesses such as sweat glands, hair follicles, and other skin appendages. Thus, the skin creates an important barrier against infection.
Bacterial growth in the skin is dependent on several variables such as skin pH, dryness of the outer skin layers, and local secretions. Fatty acids produced in the sebaceous glands are very effective in preventing the proliferation of streptococci.
But an injury dramatically changes that balance. Even minimal trauma, such as shaving the night before elective surgery, can increase bacterial levels 10 times or more. Burns destroy the keratin layer, which prevents bacterial invasion. A laceration exposes deep layers of tissue. Crushing blows, on the other hand, cause more cell damage. Problems increase when treatment is delayed. When the wound is contaminated with soil, the bacterial count increases.
None of the antiseptic solutions are effective enough to change other factors other than removing visible dirt. A solution cannot destroy bacteria, reverse cell death, or alleviate the adverse effects of delayed treatment.
In fact, some of the commonly used cleaning solutions make the healing environment worse. For example, solutions containing alcohol or hydrogen are also fatal to healthy cells; Solutions containing strong detergents are nothing more than a physiological soap. Solutions containing a high concentration of pigment paint the wound and prevent the difference between living and non-living tissues.
Shaving the wound is another popular ritual when treating a wound. However, exaggerating this results in patients who present to the emergency department with a small laceration in the scalp, leaving the emergency room with balding areas. Basically, although the hair is not dirtier than the skin; it is neither sterile nor unusually contaminated. However, hair is a protein and acts like a foreign body if the wound gets inside the lips. Therefore, it is not necessary to shave the hair and hair around the wound if care is taken not to let the hair into the wound.
So what about a satisfactory wound preparation? First, draw physiological saline into a 50 cc syringe and pressurize the wound. Thus, by acting like a macrophage, you remove clots, necrotic tissues, foreign bodies and some of the bacteria from the wound. This crucial step dilutes the bacteria already present and removes dead tissue from the healing area, reducing the risk of infection and increasing the likelihood of uncomplicated healing. Do not hesitate to apply local anesthesia before doing this procedure; you do not spread the infection; you might even do a pretty good job of resting the nerve endings.
Do not put any substance in the wound that could further damage the cells. Avoid all alcohol and detergent-containing solutions. A simple and balanced salt solution is perfectly suitable both as a preparation and as an irrigant. You don't need a stronger one. If you have povidone iodine (Batticon, Betadine) on hand, use the solution, not the detergent, and then wash with physiological saline. But don't be fooled into thinking that this practice reduces the risk of infection. After cleaning the wound, you can now act like a myofibroblast and bring the wound lips closer together.
It is useful to dwell on the measurement of infection in wounds. Biopsy culture allows for numerical determination of bacterial density. Studies have shown that the risk of infection is high if the wound is sutured when quantitative cultures have values greater than 10 5 organisms/gm. At values below this figure, infection rarely occurs unless technical errors such as tight closure and insufficient debridement are made. Streptococci are excluded from this rule; Even small amounts of these are dangerous.
If you frequently encounter badly contaminated wounds due to your job, you may prefer to delay closure and ask your microbiology laboratory, if available, to support you with biopsy culture technology. Secondary closure is best completed after the inflammatory phase of wound healing has reduced the bacterial density to a safe level.
Wound care priorities
The most appropriate order of care in acute soft tissue injuries should be as follows
Inspection: Quickly look at the wound immediately after the patient arrives. You will need to decide whether the bleeding is under control and whether the size of the wound is beyond your current capabilities. Remember to look beyond the most visible wound and check for signs of other serious wounds.
For a complex wound, you may decide to share responsibility with a consultant. Otherwise, you may be temporarily deprived of your authorization due to similar or more difficult problems. In such a case, the appropriate solutions are; seek help and take action later, or if the injury is minor, ask the patient and family to wait. In the last two cases, you need to convince the patient and their relatives that nothing will be lost by delaying the treatment for an hour or two. In the meantime, have the patient wait in a comfortable place. Before starting the treatment, determine the characteristics of the wound, take the patient's history, including past medical history, allergies, treatments and vaccinations.
Anesthesia : Local anesthesia must be applied before any intervention on the wound. Even if the dirt inside the wound is visible, infiltrate the surface first; then apply irrigation and debridement. It is not true that the needle you have made will spread the contamination. Injection directly into the wound, not from the adjacent skin, does not increase the risk of infection and is less painful.
Adequate irrigation and debridement can only be achieved if the wound is well anesthetized. If you prepare the wound without giving an anesthetic, your chances of success will decrease. Remember that the toxic limit of xylocaine (Lidocaine) is 7mg/kg/hour. This is 70 kg. This corresponds to 50 ml of 1% Xylocaine per hour for a person weighing in, 1 ml of 1% solution contains 10 mg of drug.
So a 5 kg baby can safely take 3.5 ml. early signs of toxicity; excitation and subsequent convulsion, then depression, arrest, and even death. The use of sedation before local anesthesia increases the margin of error.
Antiseptic solution: Many physicians are concerned about which prep solution to use. However, this issue is the least important among the issues that affect the success of wound treatment. Never use agents that damage living tissue. Prep solutions containing alcohol, peroxide, or strong detergents do more harm than good. They kill bacteria, but they also kill fibroblast and epithelial cells.
Solutions containing high concentrations of pigments change the appearance of the wound and make it difficult to determine tissue vitality. Do not completely ignore the use of solutions. You can clean the area around the wound with these solutions. Patients will expect this from you. For the next and most important step, irrigation, the most appropriate solution to use is a simple, balanced salt solution.
Irrigation and debridement: All wounds benefit from washing, except for very small and superficial wounds. This is the main step in preparing a wound for closure. This physiological wash solution dilutes the bacterial concentration present. It also displaces dirt particles and most importantly enables the identification of partially broken oil particles and other inanimate tissues. If these are not debrided, they form food for existing microorganisms. Use a 50 cc syringe and 25 gauge needle to provide optimal irrigation force.
Decision – To close or not to close: In the case of a long time after injury or heavily contaminated crushing injuries, it is best to delay closure for three to five days. During this time, the inflammatory phase of healing reaches its maximum.
One of the most important surgical lessons learned from past wars is that a wound that has been treated in less than ideal conditions can be temporarily left open for greater benefit. Immediate suturing creates a higher risk of infection. Perhaps the only exception to this general rule is facial injuries. Prompt suturing of a facial laceration is not a problem when effective irrigation and debridement is ensured, as blood supply to the head and neck area is good.
Tetanus prophylaxis: Even minor minor wounds can cause tetanus. In this regard, it is very important to question previous tetanus prophylaxis. It is important to know the differences between a previous tetanus vaccine and full prophylaxis, which requires three injections. If in doubt, first passively immunize your patient using a human antibody preparation.
Antibiotics: Antibiotics should be used on wounds where serious contamination is likely. This includes all animal and human bites. Antibiotics may also benefit patients whose treatment is significantly delayed. Wounds that are completely covered or contaminated with soil, especially crush and rupture injuries where blood supply is compromised; are injuries that are open to infection and therefore benefit from antibiotics. Antibiotics can shift the balance towards recovery, but they are not a substitute for appropriate debridement and sensible surgical decision.
Instructions to patients: Never assume that your patient is listening to everything you say. A patient who has been accidentally injured will often be thinking about the causes of the accident rather than heeding your instructions. Be willing to repeat what you say. Speak in clear and simple language. But most importantly, write down important post-treatment instructions on a piece of paper. This can then be used by the patient.
Medicines for acute injuries
Unfortunately, there is a common misconception that narcotics, sedatives, and nearly all medications are unsafe for traumatic injury victims. This principle certainly applies to patients presenting with multiple system injuries. However, it is not true for those who come with regional injury. Do not ignore pharmacological support for such patients. Observe for signs of intracranial trauma; if not, have your patient benefit from pain relievers and sedatives.
If the patient has an acute injury, administer all medications intravenously. Intramuscular injections are less effective and unnecessary suffering for the patient. With an intravenous catheter, it is possible to add other drugs as needed. The entire pharmacological approach is not covered in this book. It is said that simple remedies will likely suffice. For many patients, barbiturates are an ideal sedative. Of course, before giving anything to your patient, you should definitely inquire about their allergies and previous drug intolerances. Also, wait a certain amount of time for the sedative to take effect before administering a local anesthetic. Local anesthetic will be more effective in a patient who has achieved adequate sedation.
A sedative such as nembutal is just a sedative, not an analgesic. If the patient is in pain, or you expect it to be, a medication, preferably a narcotic, should be prescribed to control the pain. Both Morphine and Demerol are suitable for this. Use whichever drug you know better. However, if the patient has developed nausea or an adverse reaction to the medicine you are using, use the other one.
In addition to a sedative or analgesic, patients may also benefit from a short-acting relaxant such as Diazepam, which is best given just before the local anesthetic is administered.
Administer lower doses to people you think have a marked sensitivity to sedatives or narcotics. In contrast, be prepared to administer higher doses to those who develop drug tolerance. Of course, do not forget to inquire about previous sensitivity or tolerance. Do not try to prescribe a single medicine that will serve all purposes. Some physicians simply prescribe Diazepam before going any further.
However, Diazepam is not a sedative or analgesic. Diazepam is an excellent relaxant given after a Barbiturate and a narcotic analgesic. Finally, you need to know the appropriate antidote for the oversedated or narcotized patient: If you think you have administered too much barbiturate, give supplemental oxygen and no more medication. You can delay wound care until the patient is more stable.
If you think an overdose of the narcotic has been given, give 0.4 mg immediately and then Naloxone as needed. Note that naloxone is very short-lived. Do not send the patient home with just one dose. Also remember that Naloxone reverses all narcotic effects such as analgesia and respiratory depression. Your goal should be to give the patient the right treatment, as well as to make them feel well taken care of in your office or in the emergency room. Intravenous medications can be used to calm the patient.
How to Stop Bleeding
The source of bleeding and how to stop it is a problem for all physicians. Even the most experienced surgeons are concerned about intraoperative bleeding and spend a lot of time training to control these bleedings.
Where is it bleeding from?
Whether in elective incisions or traumatic lesions, bleeding occurs from three sites:
Subdermal plexus: The subdermal plexus, which is a network rich in vascular structures located at the border of the dermis and subcutaneous adipose tissue, is the most common source of hemorrhages. If you doubt this source, consider the fact that skin blood flow increases hundreds of times under favorable environmental conditions, such as when someone enters a sauna in cold weather. The same vascular network also expands in response to trauma. The important thing here is to learn how epinephrine limits dermal blood flow.
Superficial veins: When you review your anatomy information, you will remember that the venous system is generally more superficial than the arterial network. Large veins run just under the skin in the head and neck and extremities. In the hand, the veins are located on the back of the hand so that they can be displaced according to the position of the hand. During lacerations or elective incisions (although veins can be seen and preserved in elective incisions), the integrity of these veins may be compromised.
Superficial arterial branches: You may encounter a superficial arterial branch, most often on the face and scalp. Arterial bleeding is light red and pulsatile.
How to prevent bleeding:
The accepted principle in medical practice is that prevention is better than correction.
- Investigate bleeding disorder in history: Remember to ask the patient if they have had previous bleeding problems. Sometimes the patient forgets to tell you or doesn't know anything about it. If in doubt, postpone surgery and run coagulation tests. If the injury is acute, you can tell if there is a problem as you begin to heal. In such a case, consult a hematologist.
- Position of the patient: If you are working in the face area, raise the patient's head 30 degrees. If you work by hand, do not let the hand hang. In other areas, choose the most suitable position for both the comfort of the patient and your work. Low venous pressure at the incision site will help you.
- Know the anatomy: When repairing a laceration, or drawing an elective incision, consider important points about the patient's local anatomy. Check if the superficial veins are dilated. If you are palpating an artery and are not in a position to locate and ligate the artery, avoid surgery. If you still feel uncomfortable, maybe you shouldn't do this procedure.
- Use epinephrine: The best way to control dermal bleeding is to use a local anesthetic containing dilute epinephrine. Even a concentration as low as 1:500,000 will provide sufficient shrinkage of the subdermal plexus if you wait long enough (which is usually 6-7 minutes). Infiltration of local anesthetic with epinephrine before putting on your gloves will give you sufficient time.
How to stop bleeding:
a) Incision: From one end of the incision to the other, do not let go of your blade until it has completely cut through the dermis. Once the dermis is retracted, blood flow often stops immediately. If you stop before completing the incision and try to clamp a bleeding vessel, the bleeding will increase and you will not be successful.
b) Surgical field of view: If you can see what you are doing, you will bleed less. Use huk or retractor for this purpose. Always see what you are clamping. If you cannot identify the source of the bleeding, press the bleeding site for a while and then try again.
c) Help: A nurse or other helper can show you the bleeding site or hold the vein with a moskito clamp.
d) Binding by sewing:Ligation sutures are used by surgeons to tie off bleeding vessels at the bottom of deep cavities as well as to control superficial bleeding. In cases where you are trying to ligate a bleeding vein and no one is available to assist you, clamp the vein, tie it off and loosen the clamp without loosening the ligature. Your connection may be unbind, then try again. If unsuccessful, then use an absorbable suture material with a needle. Hold the bleeding focus with a clamp and thread your needle through the base of the clamp and knot on one side of the clamp. Then knot it once on the other side. Loosen the clamp and check for bleeding. If the bleeding has stopped, it's OK. If you are unsuccessful again, pass the needle in the same way and reconnect. Do not cut the suture ends until the bleeding has stopped. When clamping a vessel, hold only the vessel; Be careful not to damage structures such as nerves adjacent to the vessel.
a) Pressure : Time and pressure can help you to stop the bleeding, albeit limited. For example; Pressure is sufficient for dermal hemorrhages that occur at the places where we pass stitches during skin closure. If you need to apply prolonged pressure to stop bleeding in a wound that is ready to close, stop, re-explore the area, and re-suture. Otherwise, you may experience a hematoma later.
b) Pressure closure: As we have emphasized in the dressing section, dressing materials are not designed for bleeding control. If you have to apply a pressure dressing to control bleeding, go back and try the basic methods one more time.
c) Topical agents: Thrombin, Gelfoam and many other topical agents are produced to stop bleeding. Although some of these are used in special surgical procedures, they are not as reliable as pressure dressing as a rule.
d) Drains: Drains are used to drain fluid from inside the wound. However, drains are rarely helpful in preventing hematoma. Blood is a dense liquid; Fluids such as urine, bile, CSF, lymph and pus can be removed more easily with a drain.
A good dressing should be able to fulfill one or more of the functions listed below.
Koruma:The dressing protects the wound from additional trauma, pain-inducing temperature changes and the prying eyes of others. A simple bandage protects against unwanted questions caused by an exposed sutured wound and stains on clothes. In addition, dressing closure provides a suitable environment for optimum wound healing. When circulation is impaired, an unhealed wound cannot maintain its own moisture and the resulting dryness causes increased tissue loss. On the other hand, the wound surface can generate a large amount of exudative leakage, which leads to an unnecessary metabolic loss. Although some physicians believe that dressings protect the wound from bacterial contamination, a sutured wound is actually not easily contaminated after a few hours of treatment. After the inflammatory phase of wound healing begins,
Absorption: The dressing can absorb the exudative leakage that occurs at the wound surface. This reduces the possibility of bacterial proliferation and subsequent wound infection. The moist dressing acts like a wick, drawing fluid from the wound. Thus, it prevents exudate from staying in the wound and crusting.
Remember, neither the wound surface nor the skin is sterile. Bacteria are inevitably present on these surfaces. If we allow bacterial growth, of course, the bill will be heavy. Delayed wound healing due to the developing infection and ending the event with a significant scar is an undesirable outcome.
Pressure: A good dressing should be able to apply reasonable pressure to prevent edema in the wound. However, excessive pressure, which may cause ischemia, should also be avoided.
Immobilization: A good dressing should also provide immobilization in the healing area. A constantly moving wound cannot heal as quickly or as well as a stationary wound. Effective immobilization is essential for neovascularization of skin grafts.
Characteristics of a good dressing
It should always be considered that the dressing is suitable for the patient's living conditions. The choice of dressing may differ from that of an inpatient who is seen in the emergency room and will return to work soon. An uncomfortable and dysfunctional dressing will reduce the patient's compliance. Therefore, the outer layer of dressings should be clean, smooth and tidy.
The first layer of dressing should not adhere to the wound surface. For this purpose, prefer lightly lubricated gauze with liquid permeability. The gaps of the gauze are wide enough to allow the passage of liquid. Telfa, Saran and other impermeable materials are not suitable as they cause maceration.
The second layer should have the property of absorbing the fluids leaking from the wound. While folded gauze or pads are sufficient for small wounds, larger wounds require a large number of flaf gas with high absorption property. Cotton is a building block traditionally used in gauze. However, synthetic materials with a high degree of absorption have also been produced. Wrapping around the extremity with soft gas dressings after flasks both increases the absorption capacity and stabilizes the first layer of the dressing. However, these soft materials loosen very quickly and may not provide adequate pressure and stability of the dressing.
Controlled pressure with non-elastic bandages is best initially. Elastic bandage is useless in this type of dressing. Because increased pressure can cause ischemia. The durability of the dressing increases if this layer of the dressing is supported by adhesive tapes. The purpose here is to provide pressure. It does not create strangulation or ischemia. Applying the gauze in a raised way and supporting it with adhesive tapes helps fix the extremity significantly. For further immobilization, an additional splint is needed. However, it is necessary to be careful when using the splint. If you do not use enough cotton, you will cause compression and ischemia. Dressing should be done skillfully and should be aesthetic.
open wound care
Dressings applied to abrasions, burns or open wounds should also fulfill the functions of protection, absorption, compression and immobilization as in closed wounds. However, the dressing of such wounds requires care. Partial thickness damage such as superficial burns and abrasions should be cleaned of all foreign objects and covered with a protective but non-adhesive layer such as Bactigras. While this layer is being removed, the new proliferative epithelium should never be damaged, the second layer should have absorbent properties. While the dressing is renewed, the upper layer is replaced without removing the first layer. The first layer separates on its own when the wound heals.
Wet / moist dressing
A wet-moist dressing and perhaps one of the newer hydrocolloid dressings is always preferable to a dry dressing. Any dressing is slightly moistened when opening; because it causes pain when removing dry dressing. Another advantage of wet-moist or hydrocolloid dressings is that they provide a moist environment that promotes epithelial migration and granulation tissue formation.
Wound care in burns
As the title suggests, in this section we will discuss what exactly minor burns are. Mild burns may be underestimated by surgeons. We surgeons can say that "mild burns are someone else's problem, not our concern" or "mild burns do not require a specialist or a burn center". But this may not always be true.
- It is usually less than 5% of the body area.
- Partial thickness injuries.
- Burns that do not involve the face, hands, feet, or genitals.
In this section, we have considered only the treatment of mild burns. The basic principles described here can also be applied to larger burns; however, it is recommended that patients with major burns be sent to a specialist or a burn center.
Type of wound
Mild burns are like partial thickness abrasions. They are superficial and do not cross the skin in full. But remember, a partial-thickness burn today may be full-thickness tomorrow, or its depth may be misdiagnosed initially. So be on the lookout for greater damage.
Initial treatment in burn injuries
In the beginning, as with all wounds, gently clean the wound surface. A general cleaning with materials such as physiological serum, Betadine, Batticon, Sulfamylon reduces the risk of infection of these wounds. Leave small, unexploded and uninfected bullae intact to protect the wound surface. If the blisters have ruptured, debride the epithelial layer to avoid bacterial contamination. Then cover it with an oily gauze cloth and cover it with an absorbent material. Change the top dressing every 24-48 hours.
Topical antibacterials such as Povidone, Mafenide or Silver Sulfadiazine are not very necessary. They have limited benefit in patients with extensive burns and risk of sepsis. Topical antibacterials inhibit wound healing. Systemic antibacterials are also not necessary for minor superficial burns if wound care is started immediately.
monitoring through the bullae
Do not send your patient with mild burns out of follow-up and home without giving advice. You will need to re-examine frequently. A partial thickness burn may be a misdiagnosis or the damage may progress. If your diagnosis is correct, minor burns will heal in 10-12 days. If the burn extends into the dermis, healing is delayed and sometimes hypertrophic scarring may occur. Deep dermal burns heal better with skin grafts. Consult a plastic surgeon if you think there is no successful healing.
Bite injuries account for 1% of patients presenting to the emergency department, and approximately 2 million bite injuries occur annually in the United States. Dog bites account for 80-90% of all bite wounds, followed by cat bites. The rate of this is 5-15%. human bites account for less than 5%. Although most bites result in minor injuries, they can result in great morbidity.
Often times the teleporter recognizes the dog and often provokes the dog. It is more common in children. Young dogs and female dogs are more prone to bite. While most bites occur on the extremities, they are more common on the head and neck, especially in young children. Fatal dog bites happen with large dogs and death can occur, often from bleeding from large neck veins. Dog bites are infected by 2-20%. This is one of the lowest rates of mammal bites. Hand bites increase the risk of infection, tenosynovitis, and septic arthritis. Among the microorganisms found in the oral cavity of dogs are Pasteurella multocida, Staf. aureus, Staf. intermedius, Alpha-hemolytic streptococcus, Eikenella corrodens, and Capnocytophaga canimorsus.
Abrasions caused by cat bites and scratches are more likely to become infected than dog bites. This is because cats' teeth are small and pointed, so they can easily penetrate the joint and periosteum. Cat's oral flora is similar to that of dogs, and the most common microorganism produced from cat bites is Pasteurella. (50-70%).
Most human bites happen during a fight, and medical attention is often delayed. The bite wound when punching is a classic example of this. The patient punches someone in the mouth, punctures the female metacarpophalangeal joint of the other person, causing microorganisms to pass into the joint. Human bites can lead to serious infections. The human oral cavity is highly contaminated, with Streptococcus viridans, Staf. aureus, Eikenella, Haemophilus influenza and oral anaerobic bacteria may be the cause of infection.
Important points in anamnesis; whether there is a delay in treatment, tetanus vaccine status and the possibility of rabies transmission. Immunocompromised patients require intensive treatment as they carry a higher risk of serious infection. In the physical examination, it is necessary to pay attention to the degree of crushing and fragmentation; because these wounds are more prone to infection. If the injury also involves the tendon and nerve, it is necessary to refer the patient for a possible surgical intervention. Joint penetration is another indication for referral. If bone or joint damage is suspected, a direct radiograph should be taken.
Foreign bodies seen in the film may be tooth fragments; they must be removed. All bite wounds should be thoroughly washed and cleaned and inanimate tissue debrided. Most dog bites can be safely closed if less than 8 hours have passed. Cat and human bites should be left open due to higher infection rates. Hole-shaped bites should also not be closed. Human bites on the face and cosmetically important areas can be closed after a good debridement. The closure technique is the same as for other lacerations. After the wounds are closed, they should be followed carefully for infection.
The use of prophylactic antibiotics is controversial. It is not necessarily used for uninfected, fresh dog bites. Prophylactic antibiotic treatment is usually started in cat and human bites. The drug of first choice in all these wounds is Amoxicillin/Clavulonic acid. In patients with penicillin allergy, the options are doxycycline (contraindicated in children and pregnant women) and ciprofloxacin. Empirical treatment with these drugs can be started in established infections; Culture is taken and treatment is continued according to the result.
Fingertip injuries are quite common. Although it is not life-threatening, it causes high morbidity and loss of work power. Fingertip injuries can occur in the form of crushing or cutting with sharp objects. The aim of the treatment is to preserve the length of the finger as much as possible and to provide healing as soon as possible with the least scarring. In crush injuries, if there is no suspicion of bone injury, plain radiographs should be taken.
Soft tissue loss at the fingertip
Fingertip avulsion injuries can be complete or partial. If part of the fingertip is still attached to the finger and appears lively, it should be sewn in place. In this way, excellent results can be achieved. If the fingertip is completely avulsed, we have several treatment options. If the tissue defect at the fingertip is less than 1 cm 2 , good results can be obtained by leaving the wound to secondary healing. The finger should be cleaned and covered with vaseline gauze (such as Bactigras) and the dressing changed daily. In this way, full recovery is usually achieved within 4-6 weeks.
As a second option, the broken piece can be sewn into place. However, this option is not suitable for crush injuries. In children, broken pieces that are stitched back into place as composite grafts often suffer; however, it is not as successful in adults. It is used as a skin graft after the subcutaneous fat layer of the ruptured part is thoroughly cleaned.
The finger should be immobilized and protected. In larger injuries where the bone is exposed or the broken piece is not suitable, the wound needs to be closed somehow. For this, if the bone is not exposed, skin graft taken from the wrist, lateral palm or the inner surface of the upper arm; if the bone is exposed, local or distant flaps can be used. These cases should usually be referred to a Plastic Surgeon.
nail bed injuries
Subungual hematoma can be seen in crush injuries. The hematoma can be drained by puncturing the nail with electric cautery or scalpel over the hematoma. Often there is a fracture underneath, but the nail acts as a splint.
In nail avulsion injuries in which the nail bed is also damaged, the nail is removed and the underlying lacerations are sutured with a thin, absorbable suture such as 6-0 chrome catgut. The nail bed should be protected by returning it to the nail place or with a non-adherent piece of vaseline gauze placed on the nail bed. The new nail grows on the nail bed within a few months. If there is no separation in the nail bed, if the nail is still adhered to its place and still acts as a splint, there is no need for repair.
Nail matrix injuries can cause deformity when the nail grows back. More severe deformities may require reconstruction with partial thickness nail matrix grafts or toenail matrix transfer. If only small remnants of the germinal matrix remain, they should be completely removed to prevent regrowth of uneven nail fragments.
Felon (colloquially known as dolama) is the name given to the infection of the finger pulp. They are very painful because the fibrous partitions in the pulp keep the abscess in a closed space. In this case, incision and drainage are indicated. The incision should be made where the sensitivity is maximum, but avoid making it on the tactile surface if possible. Fibrous compartments should be divided to completely drain the abscess, and antibiotic therapy should be started. Paronychia is an inflammation of the nail fold.
In the early period, antibiotic therapy, aspiration and immobilization are sufficient for the patient who presents with pain and cellulitis. If there is fluctuation, if there is pus under the nail, drainage should be applied. Often the nail may need to be pulled. For this, the nail is released from its bed with a thin hemostat, scissors or an elevator and separated from the eponchial fold. Care should be taken not to injure the nail bed. More serious infections involve the tendon sheath or the deep palmar spaces. When you encounter signs of deep hand infections, always consult an experienced surgeon.
Scars and Keloids
All wounds on the skin heal with scar formation. This is so, regardless of who and how well the wound is closed. Scarring is an inevitable consequence of deep wounds that require stitches. Proper treatment cannot prevent scarring, but it can make it less visible. There are several factors that affect the severity of a scar. Some parts of the body, such as the shoulder, knee, and presternal region, are notorious for bad scar formation.
These regions are areas of movement and tension. In general, the less tension there is in the wound, the less the scar will expand over time. If the tissue loss is excessive and the wound has to be closed tight, the scar will be evident here. If the surrounding tissues are crushed and the injury involves a large area, a bad scar remains. These are situations that the doctor and the patient cannot control.
There are also situations that the doctor can control. Devitalized tissues should be debrided to prevent infection and reduce scar tissue. Foreign objects such as soil and glass should be removed as they will cause infection. In deep wounds, closing the wound in several layers will eliminate the formation of dead space and reduce the tension in the wound lips. The choice of suture affects the final form of the scar.
In general, the thinnest suture that can hold the wound lips together should be selected and the suture material that causes the least inflammatory reaction should be selected. Absorbable sutures cause more inflammation than non-absorbable sutures. Monofilament sutures are the least inflammatory sutures. Removal of stitches prevents scars from remaining that can be seen more clearly than the scar itself.
Keloids and hypertrophic scars
Although they look alike, hypertrophic scar and keloid are not the same thing. They are almost identical histologically due to excessive collagen formation. However, a hypertrophic scar remains within the boundaries of the wound, while a keloid protrudes beyond the boundaries of the scar. Hypertrophic scarring is common in children and light-skinned people. It is red, raised from the skin and itchy. In this scar, there is an imbalance between collagen synthesis and degradation. New collagen is formed in all healing wounds; some of it is destroyed. In immature wounds and hypertrophic scars, more collagen synthesis occurs than is destroyed.
In most of the cases, this condition is temporary and disappears in 1 year or more without the need for treatment. Steroid injections are helpful in controlling itching, but may cause the scar to become larger. Sealing with silicone gel can be effective; however, it should be used for at least 12 hours a day.
Keloid is caused by uncontrolled collagen proliferation. It is common in Africans and Asians, but can be seen in all races. Some people are very prone to keloid formation, and even minor scratches can develop keloids. Although the best way to reduce the risk of keloid formation is to perform wound care in the most perfect way, keloid can still develop in sensitive people. If a keloid is beginning to form, it can often be suppressed with an injection of 10-40 mg of triamcinolone every 6 weeks into the wound.
Treatment of scars
Don't promise your patient a perfect or worse, an invisible scar. Make cautious assessments, knowing that the course or nature of the wound is a low probability of an invisible scar. Some doctors never talk about bad news at the time of injury. Plastic surgeons prefer to prepare the patient and their family for a visible scar. If the anticipated scar seems unacceptable to the patient, recommend treatment by a plastic surgeon at a later date. But never mention that the plastic surgeon will “wipe” the scar, because this is impossible.
To revise a scar is to make a new less visible scar after removing the old one, by redirecting it, reducing the level difference, or redoing it under more favorable conditions. However, the new wound must be closed and all healing phases, namely inflammation, repair and regeneration, must be experienced again. In this regard, the decision to revise an old wound can be thought of as a temporary step back. However, scar revision provides an opportunity to alter the course of the scar, or at least to close the defect in more controlled conditions than at the time of the initial injury. It is best to make the decision to do or not to scar revision be made by an experienced plastic surgeon six to twelve months after the injury in order to reduce the procedure.
Prepared by the American Plastic Surgery Education Foundation, the educational arm of the American Society of Plastic Surgery. For his support and contributions in the preparation of this booklet, Gazi University Faculty of Medicine, Head of Plastic and Reconstructive Surgery Department Prof. Dr. M. Cemalettin ÇELEBİ and Dr. Yavuz BAŞTERZİ, Assist. Assoc. Dr. Sühan AYHAN and Prof. Dr. We would like to thank Kenan ATABAY.