Editors

EeroHirvensalo

ErkkiTukiainen

Treatment of Traumatic Wounds and Wound Infections

When treating traumatic wounds, it is essential to detect any muscle, nerve, tendon or vascular injuries. The timing of treating any associated injuries depends on the main injury.
- Vascular injuries threatening circulation in a limb must be treated immediately.
- Nerve, tendon and muscle injuries should be treated within a few days or as considered appropriate by the surgeon but within no more than 3 weeks. For the examination of tendons in patients with hand injuries, see Examining the Integrity of Tendons in Palmar Hand Injury.
- If, for example, an incisional wound in a finger was sustained in the evening and the flexor tendon was severed, the wound should be cleansed immediately, the skin closed atraumatically with 5-0 suture and the patient referred to a hand surgical unit for the following morning.
So-called road rash (where dirt is rubbed into abraded skin and cannot be removed by light rinsing) should be treated soon to avoid foreign bodies remaining as permanent pigmentation in the skin as epithelium grows over the dirt. If there is extensive contamination, revision should be done in an operating room and under general anaesthesia, as necessary.
Patients with extensive bite Bite Wounds, contusion or bullet wounds should be referred to a surgical unit.
For wounds in children, see also Wounds and Abrasions in Children.
Tetanus prophylaxis should be provided, as necessary; see Tetanus.

Whether the wound can be closed depends on the risk of infection and the anatomic location. The risk of wound infection depends on the delay in treatment, patient-specific factors increasing infection risk, as well as contamination and location of the wound.
- Very dirty wounds and bites should be cleaned and without hesitation usually left open until delayed wound closure.
The timing of wound closure varies from case to case.
- Clean wounds in areas with a good blood supply, such as the face or the head, can usually be closed as late as 24 hours after injury.
- Clean wounds on the trunk and limbs should be closed within 12 hours.
- In delayed wound closure, the cleaned wound is, as a rule, left open, and antimicrobial prophylaxis of 3-5 days is started. The wound should be checked after 1-3 days, and once it has been confirmed that no infection has developed or that any infection has been successfully treated, it can be closed. If there are no signs of an inflammatory reaction, the wound is in an area with good circulation and the patient's general health is good, the wound can be directly closed also after the 12-hour limit, after a thorough cleansing and possibly revision.

Check the function of nerves, muscles and tendons before anaesthetizing the wound.
Wash and anaesthetize the wound. Then cleanse and inspect it more closely.
Before suturing, trim the edges so that the wound can heal.
- If the wound edges are dry or dirty, debride them to expose a healthy tissue surface.
- Remove lacerated skin flaps that are too small to heal.
When closing the wound, avoid using sutures that are too thick. The following thicknesses are used most commonly:
- for the face and neck 5-0 (or 6-0)
- for the hands 5-0
- for other sites 4-0 or 3-0.
Tight sutures and cavities remaining in the wound should be avoided. Deep sutures or retention sutures can be placed in the tissue, as necessary.

Splinters, thorns from hedges, grains of sand and pieces of shattered windshields are likely to remain in the tissue. Sharp shards of glass rarely remain there.
Foreign bodies should be removed immediately if this can be done easily; otherwise, the patient should be referred to a facility where the diagnosis can be confirmed and the foreign body removed in an operating room.
- Imaging should be considered case by case.

Antimicrobial prophylaxis is necessary if the wound is very dirty, a bite wound (see Bite Wounds) or a deep puncture wound
- A clean, traumatic wound in a healthy patient does not usually require antimicrobial prophylaxis.
The first choice for antimicrobial prophylaxis of dirty wounds is 500 mg amoxicillin/clavulanate 3 times daily for 3-5 days.

An infection is often detected when removing sutures.
- The signs may include malodour, dehiscence, erythema around the wound, more extensive oedema, tissue fluid beginning to drain from the wound and elevated body temperature.
If there is an infected wound associated with foreign material (such as a hip or knee prosthesis), always contact the unit where the surgery was performed; they will decide on further examinations and on the need for antimicrobial therapy.
Antimicrobial therapy must always cover Staph. aureus (floxacillin, cephalexin, clindamycin or cefuroxime, for example).
- Medication for intestinal or gynaecological surgical wound infections should also cover anaerobic bacteria (metronidazole).

Remove skin sutures and open the wound.
- Take a bacterial culture sample from the wound bed.
- If there is a purulent cavity in the wound, place a rubber strip or drainage dressing to allow pus to drain.
Place a non-stick dressing on the open wound, and cover the wound loosely. The dressing should be changed and wound cleansed and inspected daily at first.
If a wound that opens when sutures are removed is not clearly infected, renewed debridement and closure can be considered.

An acute postoperative haematoma that causes pain or tightness of tissues should be treated in the unit that performed the surgery. If the wound has bled externally, check clinical signs of haemorrhage and, as necessary, haemoglobin concentration.
A haematoma in a limited area after a contusion can be drained by puncture. A large haematoma in the area of the lower leg or thigh, for example, can cause necrosis of the skin and subcutaneous tissue through pressure effect. Emergency surgical care and treatment of the haematoma and bleeding is in these cases warranted before any tissue damage occurs.
Drain the collected fluid by puncture, under ultrasound guidance, as necessary.
- 18G (blood) needle and 20-60-ml syringe
- Bacterial culture of the aspirated fluid, if there are any signs of infection
If signs of infection are found and the seroma or haematoma cannot be completely drained by puncture, opening the wound and surgical drainage of the focus should be considered.
A sterile seroma cavity that repeatedly fills with fluid should be drained by puncture and it can be treated by injecting glucocorticoid into the cavity; this reduces the formation of fluid. Persistent recurring seromas that remain large may require surgical treatment.