Transcript Management of Soft Tissue Injuries

Management of Soft Tissue Injuries
By
A.M SALEHI
ORAL AND MAXILLOFACIAL SURGEON
INITIAL EXAMINATION
Primary Survey
Airway Maintenance with Cervical Spine Control
Breathing
Circulation Management
Disability
Exposure
Secondary Assessment
Face, Head, and Skull Injuries
Neck Injuries
Chest Injuries
Other Potentially Life-Threatening Injuries
Abdominal and Pelvic Trauma
Spine and Spinal Trauma
Extremities and Fractures
Wounds groups:
Clean
Contaminated
Initial Examination
Wound Contamination
Wound Débridement
The species of bacteria present are of less
concern in the development of an infection
than the total number of bacteria present
within the wound. The infectious
inoculum must exceed105 organisms/g
of tissue for gram-positive and gramnegative aerobic bacteria.
Crushing of tissue, the embedding of foreign
bodies or soil, and perforation into the oral cavity
with contamination of saliva markedly increase
the bacterial count and set the stage for infection.
Wounds caused by impact injuries are 100 times
more susceptible to infection than wounds
caused by shear forces.
Tetanus prophylaxis should be instituted with
contaminated wounds.
Prophylactic antibiotics are usually not
indicated in clean fresh lacerations of the skin.
The probability of contamination increases
rapidly and is directly related to the length of
time that has elapsed since the initial injury.
The contamination of the clean wound is
usually via Streptococcus and Staphylococcus
spp.
Antibiotics such as penicillin,
cephalosporin, and other drugs active
against gram-positive organisms are
the drugs of choice for soft tissue
injuries.
WOUND DEBRIDEMENT
Cleansing of the clean wound involves washing
the skin and removing foreign bodies from the
wound. Soap does not harm the skin surface,
because the thick cornified layer of epidermis
protects the underlying tissue surface, but soap
may enter the wound and cause cellular damage
and necrosis.
Balanced salt solution (e.g. lactated
ringer s solution,normal saline) is
appropriate for wound irrigation.
A rule regarding the application of antiseptic
is never to put anything in a wound that
could not be comfortably tolerated in
the conjunctival sac.
There are at least three mechanisms
whereby devitalized soft tissues potentiate
infection:
1. As a culture medium promoting
bacterial growth.
2. By inhibition of phagocytosis and
subsequent bacterial control by
leukocytes.
3. By the anaerobic environment limiting
leukocyte function.
ANATOMY OF THE SKIN
The skin is composed of the surface layer epidermis
and the underlying dermal layer. The epidermis is
stratified squamous epithelium with five layers (in
order from the surface to the dermal layer): the
stratum corneum, stratum lucidum, stratum
granulosum, stratum spinosum, and stratum
germinativum.
The epidermis sends projections into the dermis
and irregularities of the dermis interlock with the
epidermis; these are termed epidermal pegs and
dermal papillae, respectively.
The stratum lucidum is found only on the
palms of the hands and soles of the feet.
The stratum corneum, the outermost layer of
the epidermis, is formed of keratinized
flattened cells that are usually without
nuclei. The corneum layer is responsible for
the variable thicknesses of skin found on the
body.
The dermis is divided into two layers:
1.Superficial papillary layer
2.Deeper reticular layer
The papillary zone is a thin, finely textured
zone immediately beneath the epidermal
rete ridges
The papillary dermis and epidermis
together form a functional unit that
provides an important metabolic area for
retaining the normal integrity of the skin.
The reticular layer of the dermis is a thick dense
mass of collagenous and elastic connective tissue
fibers. Reticular fibers, which give the layer its
name, are young, finely formed collagen fibers
with a narrower diameter than that of mature
collagen.
Elastic and other collagen fibers in the papillary
dermal layer tend to be perpendicularly oriented
to the overlying epidermal layer, and the fibers in
the reticular layer are mainly oriented tangentially
to the epidermal layer.
The dermis also contains a small amount of
fat, numerous blood vessels, lymphatics,
nerves and sensory nerve endings, hair
follicles, sweat and sebaceous glands, and
smooth muscle.
The dermis is supported by subcutaneous
connective tissue that is thinner in the facial
region than in most of the body and is
nonexistent in the eyelids.
The muscles of facial expression are in the
subcutaneous layer and insert into the
reticular layer of the dermis.
LOCAL ANESTHESIA
1% lidocaine solution with 1 : 100,000 epinephrine
0.5% bupivacaine (Marcaine) solution with 1 : 200,000
epinephrine
Alternative local anesthetic for patients who report local
allergies is diphenhydramine.
For delivery of a local anesthetic, the following
guidelines are recommended:
• Use a needle that is small (25 gauge or smaller).
• Insert the needle into the wound margin, as
opposed to piercing the intact skin.
• Pass the needle through subcutaneous tissue.
• Inject slowly.
• Insert the needle no more than two thirds of its
length to prevent complications associated with
needle breakage.
Toxic reactions to local anesthetics are
more common than allergic reactions
and are usually caused by accidental
intravascular injection or administration
of large quantities of the drug.
Patients at the extremes of age are
particularly at risk.
The initial signs and symptoms of toxicity
caused by local anesthetics are mediated
primarily by the central nervous system.
Initially, the patient may experience slurred
speech, shivering, muscular twitching in the
face and distal extremities, flushing of the
skin, dizziness, tinnitus, and disorientation.
Further elevations of local anesthetic
blood levels produce seizure activity
and later cardiac and respiratory
depression, which can lead to death.
The lack of understanding about
maximum dosages has led to fatalities
in children.
Vasoconstrictors can limit plasma levels of
local anesthetics by decreasing the rate of
absorption, which reduces the risk of toxic
reactions. Additional benefits of
vasoconstrictors include increased duration
of action of local anesthesia and assisting
with hemostasis at the surgical field.
However, the use of vasoconstrictive drugs should
be avoided or kept to a minimum in patients
receiving certain medications such as beta blockers,
monoamine oxidase (MAO) inhibitors, and tricyclic
antidepressants, or in patients with conditions such
as hyperthyroidism, elevated blood pressure
(systolic blood pressure greater than 200 mm Hg,
diastolic blood pressure greater than 115 mm Hg),
and recent cerebrovascular accident or myocardial
infarction.
SUTURE MATERIAL
To understand the interaction of suture materials
with biologic tissue, an appreciation of the
wound-healing process is important.
Wound-healing process
Wound healing can be divided into three phases.
During the initial lag phase (up to day 5), there is
no gain in wound strength and the wound is
dependent on sutures and epidermal cellular
adhesion to maintain closure. During the
fibroblastic phase (days 5 to 15), a rapid increase
in wound strength occurs. The maturation phase
(day 14 and beyond) is characterized by further
connective tissue remodeling.
By the end of the second week, when most
skin sutures are removed, only 3% to 7% of
the final tensile strength has been achieved.
By the end of the third week, 20% of the
tensile strength is attained and, at the end of
the first month, 50% is present.
Wounds never regain more than 80% of the
strength of intact skin.
Suture material:
Absorbable or nonabsorbable
Coated or uncoated
Natural or synthetic
Multifilament (braided)or monofilament
Synthetic, nonabsorbable sutures
include:
Dacron (Mersilene, Polydek, Tevdek,
Ethibond, and Tycron)
Nylon (Ethilon and Dermalon),
Polypropylene (Prolene and Surgilene).
Natural, nonabsorbable sutures include:
Silk
Cotton
Metals such as stainless steel, tantalum, and
titanium
Natural absorbable sutures
Natural absorbable sutures are made of
catgut and plain and chromic collagen.
Synthetic absorbable sutures:
Polyglycolic acid (Dexon)
Polyglactic acid (Vicryl)
Polydioxanone (PDS)
Sutures that undergo degradation rapidly
and lose their tensile strength within 60
days are termed absorbable.
Those that maintain their tensile strength
for longer than 60 days are termed
nonabsorbable.
WOUND CLOSURE
With repair of facial wounds, the following
guidelines should be followed:
1. The injured tissue should be handled
gently and minimally débrided to ensure an
adequately clean bed.
2. Complete hemostasis must be obtained.
3. Incisions should be placed to follow
tension lines and the natural folds of the
skin.
4. The skin margins must be relaxed without
tension.
5. Fine sutures should be used and removed
as early as possible.
6. The wound edges should be everted.
7. Dead space must be obliterated.
8. The tissue should be closed in layers.
9. The scar tissue must be allowed to mature
before revision procedures.
Wound closure should follow examination,
débridement, and preparation of the wound
margins.
Key landmarks, such as the eyebrows, mucosal
margins of the lip and nose, eyelids, and other
anatomic structures, must be aligned and
repaired properly.
Wounds in the facial region should be repaired in
layers to provide anatomic alignment and prevent dead
Space.
All deep lacerations must be inspected carefully. Divided
muscles should be reapproximated.
When muscle is severed, layered closure is essential;
otherwise, the muscle will retract, with a hematoma
filling the gap and eventually organizing to form a
depressed scar.
Deep layers should be approximated with 3-0 or
4-0 absorbable sutures and the skin should be
repaired with 5-0 or 6-0 suture.
Skin sutures are placed in an interrupted fashion
or as a continuous subcuticular pull-out suture.
Interrupted sutures should be of 5-0 or 6-0
strength, and nylon, polypropylene (Prolene), and
polydioxanone (PDS) suture materials are
indicated, but occasionally 6-0 chromic gut suture
may be used.
Sutures should be placed close to the wound
margin and close enough to each other to
relieve all wound margin tension.
Excessive numbers of sutures are
unnecessary. The needle should enter the
tissue at a 90-degree angle to the skin
surface, approximately 2 mm from the
wound margin.
In lacerations without extensive tissue loss,
meticulous attention should be paid to hair
and eyebrow alignment, wrinkle continuity,
and orientation of muscle movements
to produce unobtrusive scars and restore
normal anatomic function.
Skin sutures in the face should be
removed 4 to 6 days after placement.
Sutures in thin-skinned areas, such as
the eyelid, should be removed 3 to 5
days following placement.Alternate
sutures can be removed beginning
at day 4 and the wound should be
supported by adhesive strips.
Suture marks are usually caused by three factors:
(1) skin sutures left in place longer than 7 days,
resulting in the epithelialization of the suture
track
(2) tissue necrosis from sutures that were tied
too tightly or became tight from tissue edema
(3) the use of reactive sutures in the skin
Interrupted skin sutures should not be used in
patients who are subject to hypertrophic scars.
The continuous subcuticular suture is good
for approximation of the skin margins and
can be left in place for 3 to 4 weeks,
without the formation of suture tracks.
Polypropylene or nylon synthetic
monofilament materials of 4-0 strength are
used for the subcutaneous suture.
Other options
• SURGICAL TAPE
• Cyanoacrylate (Histoacryl)
• Fibrin tissue adhesives
CLASSIFICATION AND MANAGEMENT
OF SOFT TISSUE WOUNDS
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CONTUSIONS
ABRASIONS
LACERATIONS
AVULSION INJURIES
Avulsion
• Underminig and primary closure
• Skin graft
partial thickness
full thickness
• Flaps
local
distant
free
Local flaps
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Rotational Flap
Transpositional Flap
Interpolated Flap
Single-Pedicle Advancement Flap
Bipedicle Advancement Flap
V-Y Advancement Flap
Rotational Flap
Double-rotation (O-Z) flaps
Interpolated flap.
The V-Y plasty, or island advancement
flap
A bilobed transpositional flap
The classic rhomboid transpositional
flap (Limberg flap)
Advancement flap
bilateral advancement flap
Distant flaps
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Pectoralis
Trapezius
Latissimus dorsi
Deltopectoral
And ….
Free flaps
ANIMAL BITES
• Although infections resulting from animal
bites are polymicrobial, Pasteurella spp. (P.
multocida) are most frequently cultured from
dog bite wounds, followed by S. aureus.
• Infections that occur with Pasteurella species
are most likely to be seen within 24 hours after
the incident whereas, after 24 hours, wounds
are more likely to contain Staphylococcus or
Streptococcus species
Animal bite management
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Radiographic evaluation
Debridement and irrigation
Primary wound closure or not
Antibiotic therapy
Postexposure rabies prophylaxis
• Puncture types of wounds should not be
closed primarily because it is difficult to clean
and prepare the wound adequately.
• Bite wounds with extensive crush injury and
wounds requiring a considerable amount of
débridement are best treated with delayed
primary closure.
INJURIES TO STRUCTURES REQUIRING
SPECIAL TREATMENT
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LIP
EAR
NOSE
EYEBROW
EYELID
ORAL MUCOSA AND TONGUE
SALIVARY GLANDS AND DUCTS
LACRIMAL APPARATUS
SCALP
Lip
• Mucocutaneous line (gray or white line)
• Orbicularis oris muscle
Lip
• In avulsive injuries to the lips, 25% of the
upper lip and up to 25% of the lower lip can
be lost without resultant functional or
aesthetic defects.
Reconstructive flaps used in avulsive lip injuries. A, The
Abbe flap. B, The Abbe-Estlander flap. C, The Karapandzic flap.
Ear
• The external ear consist of the pinna, external
auditory meatus, and tympanic membrane.
The pinna consists of a thin central area of
relatively avascular cartilage that depends on
the thin overlying layer of skin for its blood
supply.
Ear
• The ear has a good blood supply and can
maintain large portions of tissue on very small
pedicles.
• Conservative débridement and manipulation
should be used to maintain as much tissue as
possible.
NOSE
• The nose is the most prominent structure on
the face and is commonly traumatized.
• Many injuries result in fractures to the bony
structure, with or without soft tissue
involvement.
NOSE
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Lacerations
Septal hematoma
Nasal bone fx
Nasal bleeding
EYEBROW
• The muscular layer should be closed with fine
absorbable sutures to prevent spreading of
the tissue and scar formation.
• Special care should also be taken to avoid
tight constricting sutures in the area, because
hair follicles are sensitive to decreases in
blood flow
• If nonvital tissue must be removed, incisions
should be made parallel to the hair follicles to
injure as few as possible.
• The wound should be inspected and
underlying fractures of the frontal sinus or
supraorbital rim repaired before closure.
EYELID
• In the treatment of injuries to the eyelid, it is
important to restore not only the appearance
of the individual but also, and more
importantly, the vital function of the structure.
• The major function of the eyelid is to protect
the globe and prevent drying of the cornea
and adjacent tissue.
• Eyelids aid in removal of tears through the
canalicular system.
EYELID
• Lacerations of the eyelids can be divided into
two categories, wounds that involve the lid
margin and those that do not.
• Lacerations should be closed in layers,
restoring the integrity and orientation of the
skin, muscle, tarsal, and conjunctival layers.
EYELID
• Lacerations of the upper eyelid must be explored
to identify damage to the levator muscle.
• At the point at which the levator attaches to the
superior portion of the tarsus, an upper lid fold is
normally created.
• If the fold is violated,it should be restored by
repair of the muscle-tarsus junction and suture of
the subcutaneous layer to the deep structures.
EYELID
• Marginal lacerations must be repaired
carefully and accurately to prevent functional
and cosmetic defects.
• The most common identifiable structures are
the lash line, meibomian gland orifices, and
gray line.
EYELID
• Avulsive injuries to the eyelids are treated
with fullthickness skin grafts from the
postauricular region or the other upper eyelid.
• With avulsive injuries of the lid margins,
carefully placed pedicled tissue will usually be
maintained because of the excellent blood
supply in the region.
EYELID
• Full-thickness eyelid avulsions of less than
25% of the lid length can be approximated
primarily as a simple laceration.
• Larger defects require grafts or flaps, such as
an Abbe-type rotational flap from the
unaffected eyelid.
ORAL MUCOSA AND TONGUE
• Lacerations of the oral mucosa and tongue should
be inspected, especially for pieces of teeth or
restorations,and débrided as for other wounds.
• The wounds should be thoroughly irrigated with
normal saline and sutured loosely.
• Mucosal wounds should be sutured with 3-0 or 40 chromic gut suture.
• Deep lacerations should be closed in layers, with
chromic gut sutures in the muscle layers to
prevent formation of a hematoma.
ORAL MUCOSA AND TONGUE
• The tongue has a rich blood supply and
injuries to the tongue or the floor of the
mouth may cause serious hemorrhage that
could threatens the airway.
• The tongue should be closed in layers, with 40 Vicryl (dyed) sutures in the superficial layers.
SALIVARY GLANDS AND DUCTS
• The facial nerve exits the stylomastoid
foramen, where it divides into five branches
within the substance of the parotid gland.
• The temporal and zygomatic branches run
over the zygomatic arch, the buccal branch
courses over the superficial aspect of the
masseter muscle along with the parotid duct.
SALIVARY GLANDS AND DUCTS
• The mandibular branch crosses superficially to
the facial vessels at the angle of the mandible,
and the cervical branch runs down the neck.
• The parotid duct exits the gland anteriorly,
runs along the superficial portion of the
masseter muscle, and penetrates the
buccinator to enter the oral cavity opposite
the upper second molar.
SALIVARY GLANDS AND DUCTS
• Treatment of a parotid duct injury depends on
the site of the injury.
• If the injury is anterior to the masseter and
the distal portion of the duct cannot be
located, the duct may be drained directly into
the mouth.
• If the injury is over the masseter muscle, the
distal and proximal portions may be
connected using a stent.
SALIVARY GLANDS AND DUCTS
• If the injury is within the parotid gland,
treatment should include closure of the
parotid capsule and application of a pressure
dressing.
• Lacerations involving the parotid duct
frequently damage the buccal branch of the
facial nerve because of close approximation of
the two structures.
Lacerations to the parotid duct frequently damage the
buccal branch of the facial nerve because of the close
approximation of the two structures.
SALIVARY GLANDS AND DUCTS
• Facial nerve injuries distal to the parotid gland
and medial to the lateral canthus of the eye rarely
result in severe disfigurement.
• A rich anastomotic network of the branches of
the nerve allows frequent return of function in
this area. Repair of the forehead and mandibular
branches should be considered because cross
innervation in these areas is less predictable.
The parotid duct is typically found along the plane from the
tragus of the ear to the middle of the upper lip.
SALIVARY GLANDS AND DUCTS
• Repair of a lacerated submandibular duct is
usually unnecessary because a fistula into the
mouth usually develops and allows the duct to
drain.
• Scarring with obstruction of the duct may
eventually require reestablishment of the duct
opening.
SALIVARY GLANDS AND DUCTS
• Chronic obstruction or inflammation is usually
best treated with removal of the
submandibular gland.
LACRIMAL APPARATUS
• Tears produced by the lacrimal gland drain
across the surface of the cornea to the medial
portion of the eye, where they enter the
puncta of the upper and lower lid margins and
proceed to the canaliculi in the nasolacrimal
apparatus.
• The tears then drain into the inferior meatus
of the nose.
LACRIMAL APPARATUS
• Any lacerations of the medial third of the lower lid
should immediately raise the suspicion of injury to the
inferior canaliculus. Establishing hemostasis of the
laceration is mandatory for finding the injury.
• The canaliculus is a fairly large white-walled tube and
may be located by placing a lacrimal duct probe
through the punctum and into the wound. The
canaliculus begins at the punctum and proceeds
perpendicular to the eyelid margin for approximately 2
mm and then turns medially and proceeds to the
nasolacrimal apparatus.
Anatomy of the nasolacrimal system
SCALP
• The scalp and forehead are portions of the
same highly vascularized anatomic unit
responsible for protection of the skull.
• They consist of five layers, which can best be
remembered by the mnemonic SCALP.
• In order, from the skin to the cranial bone,the
layers are skin (S), subcutaneous tissue (C),
aponeurosis layer (A), loose subepicranial
space (L), and pericranial layer (P).
The layers of the scalp can be remembered by the mnemonic
SCALP: Skin, Connective tissue, Aponeurotic layer, Loose
connective tissue, and Periosteal or Pericranial layer.
SCALP
• The subcutaneous layer has many large
vessels that anastomose freely. Because this
layer is so inelastic, the blood vessels
minimally contract when severed and tend to
bleed easily. Thus, large amounts of blood can
quickly be lost.
SCALP
• The pericranium is very vascular and can be
easily stripped from the cranium.
• The pericranium will accept a free graft readily
because of its excellent vascularity.
• The outer table of the skull will not accept a
free graft, so the pericranium is therefore
extremely important in any avulsive injury to
the scalp.
SCALP
• Avulsed scalp flaps are replaced if the tissue is
not badly damaged, and most survive.
• Free graft survival depends on the presence of
the pericranium over the skull.
• Closure is easy if the scalp defect is less than
2.5 cm wide. If larger defects are encountered,
flaps should be used.
SCALP
• If the pericranial tissue is intact and the
cranium has not been fractured, defects in the
scalp that cannot closed primarily should be
covered with a split-thickness skin graft.
• After stabilization and healing of the defect,
the area can be reconstructed by various
advancement or rotational flaps to bring
similar tissue into the defect, with or without
atraumatic tissue expansion
SCALP
• Tissue expansion is an alternative for the
closure of wound defects because it provides
donor tissue of the same color, texture, and
thickness, with minimal scar formation and
minor donor site morbidity.
• Tissue expansion involves developing donor
tissue without depriving the donor site of
tissue.
Double tissue expander application for
reconstruction of a scalp burn
SCALP
• If the pericranium has been lost, the exposed
cortical cranial bone will not support a skin
graft. When bone is exposed in large avulsive
injuries of the scalp, primary closure with flap
procedures is indicated.
• The flap procedures used with scalp defects
include advancement flaps, transpositional
flaps, rotation-advancement flaps,and
microvascular free scalp flaps.
Hair Apposition Technique
• After standard cleaning and débridement, hair
on both sides of a laceration is apposed with a
single twist. It is then held into position with
tissue adhesives. Severely contaminated
wounds, actively bleeding wounds, and
patients with hair strands shorter than 3 cm
may not be suitable for this technique.
SCALP
• In conclusion, in small superficial scalp
wounds in the appropriate clinical situation,
the HAT technique may be desirable.