Surgery Overview

GENERAL INFORMATION   Consider all factors that can affect wound healing in a particular patient (host factors, wound characteristics, external factors). Bite wounds will be contaminated and should be left open or closed only with drainage. Minor wounds discovered within 6-8 hours of onset should be treated with lavage, debridement and primary closure. Penetrating wounds should not be closed without surgical exploration. Healthy granulation tissue is extremely resistant to infection. To avoid the pain, and therefore patient manipulation of excessively tight sutures, keep skin sutures loose. To prevent “dog ears”, place sutures close together on the concave side of the defect and further apart on the convex side.

Replace or salvage of weight-bearing pads.  Partly or completely replace a pad by removing P3 and P2 from digit two or five and transposing the pad and skin to the injured area (phalangeal fillet technique).

MOST COMMON COMPLICATIONS AND DIFFICULTY
 

• Improper wound preparation prior to closure, with resulting abscessation.
• Necrotic tissue development in wounds closed too early.
• Seroma formation and infection are the most common complications of lacerations and wounds. Be sure to provide proper drainage of potentially infected wounds.

"EXPERTS' ADVICE"
 

• Do not use through-and-through drains in most scenarios. Drains should have an exit site only.
• Manage severely traumatized or contaminated wounds with open wound management prior to closure, even if they are recently acquired.
• With large defects, consider using walking sutures to avoid placing tension on the skin edges.

Thorough cleaning of the wound is essential prior to closure. “Dilution is the solution to pollution.” Use of sterile isotonic crytalloid solution will reduce bacterial load and has the advantage of not overhydrating the tissue. For grossly contaminated wounds, layered or en bloc debridement of devitalized tissue may be required prior to closure. Monofilament suture is generally chosen for closure of contaminated wounds.