Chapter 9- Management of wounds and soft tissues

Question 1

What are the types of soft tissue injury

Answer 1

• Puncture (from within or without)
• Incised: clean cut edges with little or no surrounding tissue damage
• Crushed: Skin edges often ragged and contused, severe devitalisation of soft tissue. Myoglobin released if muscle has been crushed
• Degloved: Skin and subcutaneous fat layer is sheared off or separated from its deeper layers, losing its blood supply. Closed degloving, where the skin is left in place is often mistaken for an area of bruising

Question 2

When can a wound be treated definitively at that time

Answer 2

Wounds seen within 6 hours of the injury

Question 3

How should a wound presenting more than 6 hours after injury be treated

Answer 3

• potentially infected (devitalised tissue)

- Delayed closure with repeated wound debridement is recommended

Question 4

Phases of wound healing

Answer 4

• Haematoma formation
• Inflammatory response
• Capillary ingrowth
• Granulation tissue
• Fibrous tissue
• Superficial epithelialisation

Question 5

Favourable factors affecting wound healing

Answer 5

• minimal gap around wound edges
• Good blood supply to the area
• Absence of local infection
• Age- children heal faster than adults

Question 6

unfavourable factors affecting wound healing

Answer 6

• Large, untidy wounds with lots of devitalised or necrotic tissue
• Poor blood supply to the area (Diabetes, RA, smoking, PVD, venous status
• Presence of local infection
• Poor or debilitated general condition (eg malnutrition/ chronic infection

Question 7

What is healing by secondary intention

Answer 7

• Excess of granulation and fibrous tissue
• Broad, sensitive, raised or puckered scar
• Scar results in adhesions to underlying tendons or contractures around the joints

Question 8

Torrential bleeding from a larger artery which does not stop with local pressure can be controlled with application of temporary tourniquet proximal to the artery, how should this be done to avoid ischaemia and necrosis?

Answer 8

• Inflate the tourniquet for 60 minutes, let it down for 5 minutes during which time pressure is applied to the wound, but not occluding the artery
• Then inflate tourniquet again
• Repeat every hour

Question 9

How should protruding objects be treated

Answer 9

-Should be left in situ and removed in hospital with resus/ theatre facilities available, which will enable one to gain control of sudden, major arterial bleeding

Question 10

Prevention of pressure sores

Answer 10

• Identify patients at risk
• If at all possible, sit out of bed for part of the day
• Must be recumbent then turn onto sides, back at 2 hourly intervals if sensory impaired or 4 hrly intervals for normal, sensate skin
• Position limbs to avoid pressure over bony prominences or protect these with sheepskin, pillows, water-filled bags
• Check pressure points twice daily- sacrum, trochanters, heels, elbows- rub with spirits to harden skin
• Position so that areas threatening to develop pressure sore (redness) do not take any pressure

Question 11

Treatment of pressure wound

Answer 11

• Prevent further pressure
• Apply clean, sterile dressing to prevent contamination by faecal or other organisms
• areas of slough should be removed either chemically or surgically
• Clean areas can be dressed with appropriate agent to the formation of granulation tissue ? eg granuflex
• Deep pressure sores with exposed bone will need skin cover by grafts or flaps