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Special Wounds |
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Abrasions Skin abrasions are usually a result of a fall onto the ground. Ensure all ingrained dirt is removed, to prevent a resulting skin tattoo. Loose particles can be scrubbed away, but ingrained tissue may require removal with a scalpel blade. Such areas will heal spontaneously, dress with chloramphenicol ointment.
Airgun pellets Penetrating injuries from airgun pellets can often involve the head and neck region. Assess the depth of penetration of the pellet. Superficially lying pellets can be palpated in the subcutaneous tissue, lying several centimetres from the entry wound. These can often be removed under local anaesthesia. Deeply-embedded pellets are not readily palpable, and can be seen on radiographs to deviated on contact with bone. These may require a GA for removal.
Bites— Human and Dog inflicted bites
Burns Need specialist referral.
Ears Drain haematomas to avoid ‘cauliflower’ ear. This can be achieved by aspiration with a needle or by a small incision under LA. This then should be packed with ribbon gauze soaked in Iodoform paste and a pressure bandage applied to prevent recurrence. Follow up within 3 days. Some patients who have sustained trauma to the pinna may complain of deafness in the affected ear, secondary to perforation of the tympanic membrane. Prescribe a broad-spectrum antibiotic and refer to ENT for auroscopy.
Eyelid, pinna, eyebrow and vermillion Require precise matching and assessment of nerve function. Accurate repair of these wounds is most important, not only for cosmetic result but also to avoid the complication of an entropion or ectropion developing secondary to scar contraction on the lower lid, or uneven contact with the upper eyelid on blinking. Do not shave they eyebrow when suturing this area.
Facial Nerve Injuries CN VII emerges from the base of the skull through the stylomastoid foramen, giving off the posterior Auricular nerve. It then runs into the parotid gland and gives off its five main branches - 1. Temporal branch 2. Zygomatic branches 3. Buccal branch 4. Mandibular branch 5. Cervical branch Damage to any of the branches should be suspected with any deep facial wounds and the muscle function around the eyes, lips and cheeks should be tested in the conscious patient. Nerve repair requires the use of a microscope and this is the treatment of choice, and should be carried out without delay.
Gunshot wounds Can cause massive tissue loss and may need microvascular techniques for reconstruction. Look for and remove all foreign bodies. Fragments of glass, wood, road grit and gun projectiles can often be identified using radiographs. Copious irrigation can be used to flush out multiple small fragments. ¨ Low velocity handgun bullets damage only the tissue they touch and thus inflict wounds that can be managed by conventional surgical methods. ¨ High velocity wounds from rifle bullets or explosive blast fragments produce very small entrance wounds hiding extremely severe wounds with extensive necrotic tissue contaminated with clostidial spores, other bacteria, clothing and debris. There is a danger of gas gangrene. ¨ High velocity wounds have a mortality 4 –5 times higher than low velocity wounds and require specialised attention.
Stab wounds Stab wounds should be treated with suspicion as there may be extensive damage beneath an apparently trivial wound. The wound may need to be explored, especially if in the neck. Radiographs are indicated.
Septum Drain haematoma to prevent perforation/ collapse.
Tissue Loss Nasal tip, pinna and lip commonest areas. Skin graft or local flap repair is more likely to succeed that stitching severed part back on.
Vermillion border When repairing lacerations of the vermillion border tack the mucosa/ skin borders accurately together before proceeding to muscle repair. Inaccurate repair of a laceration of the vermillion border can lead to an ugly step defect and the need for scar revision. |
