see also: [[leg ulcers|Leg ulcers → venous insufficiency]], [[Animal Bites]] see: [Wound care incredibly simple: treatment of vascular ulcers](x-devonthink-item://4A0A6619-A8AE-4C2A-95DD-D3D26DECF493?page=136), [Diabetic foot ulcers](x-devonthink-item://4A0A6619-A8AE-4C2A-95DD-D3D26DECF493?page=142) notes from [Dunn - wound management and suturing](x-devonthink-item://F24C0B8D-19CB-495D-BAE5-80C95953B02F) ## Factors affecting wound healing **systemic factors** - nutritional - protein malnutrition - vitamin Def (vitamin C, zinc) - systemic diseases - diabetes - organ failure (heart, renal, liver, resp) - malignancy - drugs (cytotoxins, *steroids*), anticoagulants - peripheral vascular disease / chronic venous insufficiency - fragile skin/poor skin integrity - smoking **Local factors** - regional vascularity (eg pre-tibial laceration) - foreign body - wound infection - movement - dependence - radiation - local temperature (warmer temps promote fibroblastic proliferation) - trauma - gravity-dependent areas - regional vascular differences **surgical factors** - haematoma formation - suture tension - extent of wound edge apposition ## management comments - no benefit of sterile gloves - trim hair to 1-2 mm above skin rather than shaved -- shaving damages hair follicles and ↑ risk of infection - don't remove eyebrows and eyelashes - skin prep - 70% alcohol/2% chlorhex better than 10% povidone iodie - lower surgical site infection rate (9.5% to 16.1% - don't use near eyes; use saline for wounds near eye - debridement then irrigation - irrigation - copious irrigation important in contaminated wounds, need pressure ## Special wound types ### pretibial lacerations see: [Cameron - pretibial laceration](x-devonthink-item://7BE8CB4E-98EA-4C7B-B185-F64551B519A8?page=18&start=4607&length=20&search=PRETIBIAL%20LACERATION) - often flap wounds - cover with saline soaked gauze as soon as possible to prevent flap drying and shrinking in size - flaps > 6 hours old less likely to survive; primary repair not advised if > 12 hours old - clean wound, debride, remove fat - close with tissue adhesive tapes avoiding tension on tissue - dress and firm bandaging - refer to plastics if: - significant tissue loss - contaiminated wounds - large haematoma - \> 12 hours old - follow up plastics clinic most wounds at risk of breakdown ### pretibial haematoma - early drainage required to prevent overlying tissue necrosis - USS may help determining if collection is fluid vs clotted requiring I&D ### flap wounds - at risk of avascular necrosis -- especially distal flaps, may require skin graft. - use 3-point suture "corner stitch" ![[Pasted image 20240807163422.png]] ### Ear wounds - Risk of developing [Perichondritis of the Pinna](x-devonthink-item://2883438F-E514-4F37-99C0-AA00305BB164) if cartilage involved; may need cipro if infected - Cartilage needs to be cleaned and closed with absorbable suture prior to closing skin ## wound closure delay see: [Robert Hedges - Delayed Primary or Secondary Closure](x-devonthink-item://31ACDC98-D2CC-48C5-BE69-E9B37E53FA8C?page=752) **contraindications to primary wound closure** - delay in cleansing/closure - \> 6 hours - \> 24 hours on face - bites - human or animal - infected wounds - unable to oppose wounds without excessive tension *delayed primary closure technique:* - initial debridement - dress with fine-mesh gauze and sterile dressing - delayed closure at 48-96 hours ## suture techniques - *vertical mattress* - better wound support than simple sutures - useful for preventing wound inversion on wounds of posterior neck or those on concave surfaces - improves haemostasis - superior wound edge eversion - drawbacks: more scarring, may cause wound edge necrosis or over eversion if suture pulled too tight - *horizontal mattress* - good for distributing wound tension across larger wounds - good for repairing wounds with fragile wound edges - temporary suture to hold wound edges together while other sutures are placed - risks impairing dermal blood supply *staples*: - ↑ infection in contaminated wounds - low rate of reactivity in clean wounds - good for wounds on scalp or other non-cosmetic areas - linear wounds with sharp edges not requiring deep sutures ## post-wound repair care - dressing -- apply at least 12 hours absorb bleeding generally for first 48 hours **indications for antibiotic ppx** - underlying bone/tendon or joint involvement - penetrating wounds - contaminated wounds with delayed cleaning - IM penicillin 1.2g as single dose or oral fluclox Tetanus immunisation suggestions: | vaccination status | toxoid | immunoglobulin | | ------------------- | ---------------------------------------- | ------------------------------------- | | unknown or <3 doses | yes | clean wound - no<br>dirty wound - YES | | ≥ 3 doses | clean - if >10 years<br>dirty - >5 years | no for clean or dirty wounds | ## Dressings > RCH has a good [guide to dressings](https://www.rch.org.au/clinicalguide/guideline_index/Wound_dressings_acute_traumatic_wounds/) including pros/cons of each, as well as [burns dressings](https://www.rch.org.au/clinicalguide/guideline_index/Burns_post_acute_care_and_dressings/). ***Other wound dressing resources:*** - [Wound Dressings Chart](x-devonthink-item://48CAE54B-8EF6-4427-A3D2-32496D392914) - [Wound Care incredibly visual - dressings](x-devonthink-item://4A0A6619-A8AE-4C2A-95DD-D3D26DECF493?page=174) - [RHH wound management - bear](bear://x-callback-url/open-note?id=83833207-2B4B-456A-9F32-0C7A33ADE5FA-17510-000008EC83DA7655) ### Scalp turban dressing Can watch [video](https://www.stemlynsblog.org/turban-technique-scalp-bandage/) from st emlyns; essentially: 1. tie an end of a 2cm and a 6cm bandage together 2. The smaller bandage wraps horizontally (circumferentially) around head and the 6cm one goes on top of head 3. The 2cm dressing always goes OVER the larger bandage folds to stop it from slipping; the larger one zig-zags across top of head, being supported by the pressure from the smaller bandage wraps keeping it on