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

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

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

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

5. 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?

6. 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

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

8. 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.

9. 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.

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

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

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

13. 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

14. 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

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

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

17. 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.

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

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

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

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

22. Questions

23. 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