Treatment of injuries

Treatment includes wound care, local anesthesia, examination, surgical debridement and suturing. The tissues must be treated with the utmost care.

Toilet of the wound

Both the wound and the surrounding skin are washed. The subcutaneous tissues of the wound are quite delicate and should not be treated with irritants (e.g., concentrated iodine solutions, chlorhexidine, hydrogen peroxide) or rubbed roughly.

Removing hair from the edges of the wound is not important for its hygiene, but in the hairy area (head) it makes the wound more accessible for treatment. If necessary, it is better to cut the hair with scissors rather than shave it; the blade causes microtrauma to the skin, which can become a gateway for the penetration of microorganisms from the skin surface, which increases the risk of infection. Hair is cut before washing the wound so that any hair that gets into the wound is washed out. Eyebrows are never shaved, since the border of hair and skin is necessary for optimal matching of the edges of the wound.

Wound irrigation is not very painful, but local anesthesia is usually administered first, except in heavily contaminated wounds. In this situation, the wound is rinsed with running water and soap before anesthesia. Tap water is clean, does not contain typical wound pathogens, and is unlikely to increase the risk of infection when used in this way. The wound is then rinsed with a stream of liquid under pressure and sometimes scrubbed with a soft sponge; brushes and rough materials should be avoided. A stream sufficient for irrigation can be created with a 20- or 35-ml syringe with a 20-gauge needle or attached catheter. Sterile 0.9% sodium chloride solution is quite effective; special cleaning solutions are expensive and of questionable additional benefit. If the probability of microbial contamination is high (e.g. bites, old wounds, "organic debris" in the wound), a povidone-iodine solution can be added to a 0.9% sodium chloride solution in a ratio of 1:10. This concentration is effective and does not irritate tissue. The required volume varies. Irrigation continues until visible contaminants are removed, which usually requires 100 to 300 ml (larger wounds require a larger volume).

Treating the skin around the wound with povidone-iodine solution before suturing it reduces the contamination of the skin, but the solution should not be allowed to get into the wound.

Local anesthesia

Typically, local injection anesthesia is used, but in some cases, topical anesthesia may be effective.

Standard injection anesthetics include 0.5, 1, and 2% lidocaine and 0.25 and 0.5% bupivacaine, both amide anesthetics; the ester group includes procaine, tetracaine, and benzocaine. Lidocaine is the most commonly used. Bupivacaine has a slower onset of action (several minutes compared to the almost immediate action of lidocaine), but its duration of action is significantly longer (2-4 hours versus 30-60 minutes for lidocaine). The duration of action of both drugs is increased by adding epinephrine at a concentration of 1:100,000 as a vasoconstrictor. Since vasoconstrictors can weaken wound defenses, they are generally used only in well-perfused areas (e.g., face, scalp); To avoid tissue ischemia, they should not be used on the lower limbs and other distal parts of the body (eg, nose, ears, fingers, penis).

The maximum dose of lidocaine is 3 to 5 mg/kg (1% solution = 1 g/100 ml = 10 mg/ml), bupivacaine - 2.5 mg/kg. The addition of epinephrine increases the permissible dose of lidocaine to 7 mg/kg, and bupivacaine to 3.5 mg/kg.

Side effects of local anesthesia include allergic reactions: rash, sometimes anaphylaxis, and sympathomimetic effects of adrenaline (e.g., palpitations and tachycardia). True allergic reactions are rare, especially to the amide group of anesthetics; in most cases, patient complaints are due to fear or vagal reactions. Moreover, allergic reactions often occur to methylparaben, a preservative added to vials containing multiple doses of anesthetic. If the drug causing the allergy is known, it can be replaced by a drug of a different class (e.g., an ester instead of an amide). If the allergen is unknown, a test is performed by subcutaneously injecting 0.1 ml of preservative-free lidocaine (from a single-dose vial/ampoule); if there is no reaction after 30 minutes, the drug can be used.

Surface anesthesia does not involve injections and is completely painless, which is most convenient for children and adults who are afraid of pain. Usually, one of the two mixtures below is used. TAS consists of 0.5% tetracaine solution, epinephrine in a 1:2000 dilution, and 11.8% cocaine solution. LET consists of 2-4% lidocaine, epinephrine in a 1:2000 dilution, and 0.5-2% tetracaine solution. Gauze pads or balls the size of the wound are soaked in a few milliliters of the solution and placed in the wound for 30 minutes, which in most cases is enough for adequate anesthesia. Sometimes additional injection of anesthetic is necessary. Due to the presence of a vasoconstrictor, these solutions are used mainly on the face and scalp, avoiding their use in the area of the auricles, wings of the nose, and distal parts of the extremities. Very rare fatalities can result from cocaine absorption through mucous membranes, so they should not be used near the eyes and lips. LET is considered safer.

Inspection

The wound is examined to its full depth in order to detect foreign bodies and identify possible damage to the tendons. Foreign material is best identified by a characteristic tapping sound during careful palpation of the wound with the tip of a blunt forceps. Deep wounds near large arteries should be examined by a surgeon in an operating room.

Surgical treatment of the wound

During surgical treatment, dead and obviously non-viable tissues are removed with a scalpel and scissors, as well as contaminants that are tightly adhered to the wound (e.g. grease, paint). When treating a wound of a complex shape, it is not necessary to transform it into a linear one. The edges of macerated and lacerated wounds are excised, usually 1-2 mm is sufficient. Undermined wound edges are sometimes treated so that they become perpendicular.

Sewing

The need to suture a wound depends on its location, time since the injury, cause, degree of contamination and risk factors in the patient. Most wounds can be sutured immediately (primary suture). This applies to clean wounds within 6-8 hours after the injury (up to 18-24 hours on the face and scalp) without signs of infection.

Other wounds can be sutured after several days (primary delayed suturing). This applies to wounds older than 6-8 hours, especially with initial signs of inflammation, as well as wounds of any age with significant contamination, especially organic matter. The possibility of using primary delayed suturing is reduced in patients with a high risk of impaired healing. Upon admission, anesthesia, examination, surgical treatment are performed as with any other wounds (maybe a little more thoroughly), and then the wound is loosely tamponed with wet wipes. Dressings are changed at least once a day and after 3-5 days the possibility of its suturing is determined. If there are no signs of infection, the wound is sutured using the standard technique. Closure with guiding sutures at the very beginning is ineffective and unacceptable due to the almost inevitable adhesion of the wound edges.

Some types of wounds should not be sutured. These include cat bites, any bites to the hands and feet, stab wounds, and gunshot wounds.

Materials and methods

Traditionally, sutures were used to correct traumatic wounds, but metal staples, adhesive tapes, and liquid tissue adhesives are now also used for some wounds. Regardless of the material chosen, wound management remains the same. However, a typical mistake is to inspect wounds during treatment without debridement, due to the planned non-invasive wound closure (adhesive tapes), which does not require local anesthesia.

Staples are easy and quick to apply, there is a minimum of foreign material in the skin, and the risk of infection is lower than with suturing. However, they are suitable mainly for straight, even incisions with perpendicular edges in areas of slight skin tension and do not have great cosmetic potential. Successful use of staples usually requires the participation of two people. One uses tweezers to match and turn out the edges of the wound, and the other surgeon works with a stapler. A common mistake is incorrect turning out of the edges of the wound.

Tissue adhesives used in the United States contain octyl cyanoacrylate. It sets within a minute; is strong, nontoxic, and waterproof. It has antibacterial properties. However, the adhesive should not be injected into the wound. Infectious complications are unlikely, and good cosmetic results are achieved in most cases. Tissue adhesive is good for simple, routine wounds; it is not suitable for wounds under tension. In wounds requiring debridement, subcutaneous suturing, or examination under local anesthesia, the advantages of reduced pain and reduced procedure time are minimized. As with staples, two people are required: one to align the wound edges, the other to apply the adhesive. For the strongest possible wound bond, three to four layers of adhesive are needed. The adhesive is spontaneously rejected within a week. Accidentally applied excess adhesive is removed with any Vaseline-based ointment or, in areas away from the eyes and open wounds, with acetone.

Adhesive tapes are probably the quickest way to join wound edges with a very low risk of infection. They can be used in the same clinical situations as tissue adhesives, with the same limitations. An additional difficulty with adhesive tapes is their use in areas with mobile skin (e.g., the back of the hand) due to the tendency of the wound edges to fold inward. Adhesive tapes are especially useful for wounds on an extremity immobilized by a plaster cast (which prevents removal of a conventional suture). The skin should be dried before using the tape. Most physicians use tincture of benzoic acid to enhance the adhesive effect. Adhesive tapes can be removed by the patient himself.

The sutures are optimal for complex wounds of irregular shape, with skin defects, with tension of edges and when subcutaneous sutures are required.

Because sutures can serve as a gateway for infection and represent a significant amount of foreign material under the skin, they are the most likely to become infected. Sutures are generally classified as monofilament, braided, and non-absorbable. Their characteristics and uses vary; typically, absorbable sutures are used for subcutaneous sutures and non-absorbable sutures are used to join the edges of a skin wound. Braided sutures are considered to have a slightly higher risk of infection than monofilament, but they are softer, easier to tie, and hold a knot more securely.

Aftercare of injuries

Tetanus prophylaxis should be given as indicated. The usefulness of antibiotic ointments is not always clear, but they probably do no harm, and some clinicians consider them helpful; in any case, they should not be used with tissue adhesive or adhesive tape. Systemic antibiotic prophylaxis is not indicated except for some bite wounds, wounds involving tendons, bones, joints, and possibly oral wounds and heavily contaminated wounds. If antibiotics are necessary, they should be given as soon as possible, preferably parenterally for the first dose. Excessive mobility of the injured area interferes with healing. Wounds of the hand and fingers are immobilized with cotton-gauze dressings. Patients with wounds to the lower extremities (except for minor injuries) should be kept in bed for several days; crutches may be used.

The wound should be clean and dry; after 48 hours the dressing is removed and the wound is examined. A small clean wound can be examined by a reliable patient himself, but if the patient cannot be trusted and the wound is severe, the examination should be performed by a doctor.

Infection complicates the course of 2-5% of wounds; the first manifestation is often persistent increasing pain, the first signs are redness and swelling. Systemic administration of antibiotics effective against skin microflora is started; usually cephalexin is used at a dose of 500 mg orally 4 times a day (penicillin antibiotics 500 mg orally 4 times a day for oral infection). Infection that develops after 5-7 days gives reason to think about an abandoned foreign body.

After 48 hours, a well-healing wound can be carefully cleaned of any remaining wound discharge with water or half-diluted hydrogen peroxide and left open (with wounds on the face, this can be done earlier and more often; they are treated without a bandage from the very beginning).

Short-term moistening of the wound under the shower is safe, but prolonged wetting should be avoided. Suture material, excluding tissue glue, is removed within a time frame depending on the location. On the face, sutures are removed on the 3rd-5th day to prevent the formation of visible traces of sutures and injections; some doctors prefer to reduce the wound on the face with strips of adhesive tape, which are usually kept on for several days longer. Sutures and staples on the trunk and upper limbs are removed on the 7th-10th day. Sutures on the extensor surfaces of the elbow joint, knee joint and areas located below should remain for up to 10-12 days.

Abrasions are skin lesions that do not penetrate the epidermis. Examination, debridement, and treatment of abrasions are similar to wounds. Abrasions are more difficult to anesthetize. However, large amounts of dirt, small stones, or glass fragments are particularly problematic, and are not uncommon. Regional anesthesia or intravenous sedation may be required for treatment. After thorough debridement, an antibiotic ointment (e.g., bacitracin) and a nonadhesive gauze dressing may be applied. Other commercially available dressings may be used that aim to prevent the wound from drying out (as this slows reepithelialization) without sticking to the wound.

Musculoskeletal injuries include fractures, dislocations of joints, sprains and damage to ligaments, muscles and tendons. Injuries can be open (in combination with a skin wound) or closed. Some injuries can cause rapid blood loss, sometimes internal. Fat embolism is a life-threatening but preventable complication of fractures of long tubular bones. Bone fractures can cause damage to nerves, including the spinal cord.

Complications that can threaten limb viability or permanent limb dysfunction are rare in limb injuries. The most serious threats to limbs are injuries that disrupt blood supply, primarily direct trauma to arteries and sometimes veins. Closed injuries may cause ischemia due to rupture of an artery, as may occur with posterior knee dislocations, hip dislocations, and supracondylar humeral fractures with displacement. Some injuries may cause compartment syndrome (increased tissue pressure within the fascial space with impaired blood supply and tissue perfusion). Penetrating injuries can severely damage peripheral nerves. Blunt, closed trauma may result in neurapraxia (bruising of a peripheral nerve) or axonotmesis (crushing of a nerve), a more severe form of injury. Dislocation (complete separation of the articular surfaces of the bones that form the joint) may be accompanied by vascular and neurological disorders, especially if the restoration of anatomical relationships (reposition of bone fragments or elimination of dislocation) is delayed. Open injuries may cause infection. Closed and uncomplicated fractures, partial ligament injuries, sprains and tendon ruptures are much less likely to lead to serious complications.

Treatment of hemorrhagic shock is performed. Injured arteries, except for small arterial branches in an area with good collateral circulation, are repaired surgically. Severe nerve injuries are also treated surgically; initial treatment of neurapraxia and axonotmesis usually consists of observation, supportive measures, and sometimes physical therapy.

Identifying the most commonly missed damages

Symptom	Inspection result	Damage
Shoulder pain	Limitation of passive external rotation during elbow flexion	Posterior shoulder dislocation
	Inability to actively abduct the shoulder joint to 90° and maintain the arm in this position with moderate resistance	Rotator Cuff Tear
	Pain on palpation in the sternoclavicular joint area	Sternoclavicular joint injury
Pain or swelling in the wrist area	Pain on palpation in the projection of the "anatomical snuffbox" (limited by the styloid process of the radius, the tendon of the long extensor of the thumb, the tendons of the short extensor and the long muscle that abducts the thumb)	Scaphoid fracture
	Pain in the lunate fossa (base of the third metacarpal bone) and pain with axial load on the third finger	Lunate fracture
Hip pain	Lower limb in external rotation, pain with passive rotation of the joint, limitation of active flexion of the hip joint	Medial femoral fracture
Knee pain in children or adolescents	Pain with passive rotation of the hip with the knee flexed	Hip joint injuries (slipped epiphysiolysis, Legg-Calve-Perthes disease
Knee pain or swelling in the joint area	Insufficiency of active extension in the knee joint	Quadriceps injury, patella fractures

Most injuries, especially those that are markedly unstable, are immediately immobilized with splints (immobilization with nonrigid and noncircumferential devices) to prevent further soft-tissue injury to unstable fractures and to reduce pain. In patients with long bone fractures, splinting may prevent fat embolism. Pain is usually treated with opioid analgesics. Definitive treatment often includes reduction, which usually requires analgesia or sedation. Closed reduction (without skin incision) is performed when possible; otherwise, open reduction (with skin incision) is performed. Closed reduction of fractures is usually followed by casting; some dislocations may require only a splint or sling. Open reduction usually involves the use of a variety of hardware (eg, pins, screws, plates, external fixators).

Local treatment

For patients with soft tissue injuries, with or without musculoskeletal injuries, treatment that includes rest, ice, compression, and elevation is most appropriate. Rest prevents further injury and may speed healing. Ice in a plastic bag wrapped in a towel, applied periodically for 15 to 20 minutes at a time, as often as possible, during the first 24 to 48 hours after injury to reduce swelling and pain. Compression with a splint or elastic bandage or Jones compression bandage (several elastic bandages separated by cloth) helps reduce swelling and pain. Elevating the injured limb above the level of the heart for 2 days after injury allows gravity to assist in the drainage of edema fluid, which also reduces swelling. After 48 hours, intermittent application of heat (eg, heating pads) for 15 to 20 minutes at a time may reduce pain and speed healing.

Immobilization

Immobilization facilitates healing by preventing further injury, except in cases of very rapidly healing injuries. Joints proximal and distal to the injury should be immobilized.

A plaster cast is usually used. Sometimes, in rare cases, swelling under the cast can cause compartment syndrome. If significant swelling is suspected, the cast is cut along its entire length in the middle and on the side (bivalve). Patients with plaster casts should be given written instructions for plaster casts (e.g., keep the cast dry, never put foreign objects under the cast, seek medical attention if there is an unpleasant odor from under the cast or if the body temperature rises, which may be signs of infection). Hygiene rules must be followed. Plaster casts must be dry.

Splints can be used to immobilize some stable injuries. A splint allows the patient to apply ice, move more, and is not associated with a risk of compartment syndrome.

Immobilization with bed rest, which is sometimes necessary for fractures (e.g., some pelvic fractures), can cause problems (e.g., deep vein thrombosis, UTI). Immobilization of an individual joint can also cause problems (e.g., contractures, muscle atrophy). Early mobilization is useful whenever possible, in some cases even in the first days. This approach minimizes the likelihood of contractures and muscle atrophy, and therefore accelerates functional recovery.