it’s only a flesh wound

Monday, May 27, 2013

Hockey trainers make a living closing nicks and cuts, getting the blood to stop, so that the player can get back onto the ice without missing a shift. They do their job well in the public eye and the television camera loves the close up. What the spectator doesn’t appreciate is the wound care that happens in the locker room after the game. While a jagged scar may be a badge of honor, most people don’t appreciate seeing that scar every morning when they look in the mirror.

Repairing a laceration weds science and art to allow for a good looking scar while minimizing the risk of infection, preventing a wound from falling apart. Let’s begin with the first rule. The purpose of wound repair is to maintain function and prevent infection. The second rule is that a good looking scar cannot occur if the first rule is not followed. And the third rule is that there will always be a scar.

Regardless of the word used, whether it is cut, laceration or wound, they all describe a situation where the integrity of the skin has been compromised and the potential for infection is introduced. As well, critical structures beneath the skin are at risk for injury, and depending upon location can include tendons, arteries, nerves, and ducts. Repairing a laceration is all about balancing form and function. While a good cosmetic result is a nicety, a normally functioning body is a necessity.

The steps of repair have not changed since Louis Pasteur described germ theory as the cause of infection. Perhaps Dr. Harvey Cushing, the father of modern neurosurgery, said it best:  “Certainly, infections cannot be attributed to the intervention of the devil but must be laid at the surgeon’s door.”

Wounds need to be cleaned and explored before they can be repaired and the purpose of the repair needs to be remembered each time a patient presents with a laceration. Since all wounds will heal eventually over time, that purpose is to give a good looking scar.

  • Step 1. Know how the wound happened. A clean wound by a kitchen knife is approached differently than a burst wound in happens on a muddy football field.
  • Step 2. Examine the patient and understand anatomy. Know what structures lay beneath the skin and are at risk for damage. Know your patient. Those with diabetes or peripheral vascular disease may have a harder time healing wound and infection rates may increase.
  • Step 3. Anesthetize the wound so that it can be explored to its full depth and cleaned thoroughly.
  • Step 4. Take a deep breath. If all is well beneath the surface, the rest of the job is all about cosmetics. The wound will heal if it is clean, but even if washed out well, the risk of closing the skin and locking in a potential infection may be too high. Think animal bites and humans. It may be that wound repair stops here.
  • Step 5. If all is well, it’s time to close the wound. Whether it is steristrips, skin glue, staples or thread, the idea is to bring the edges of the skin together with as little tension as possible to minimize the scarring that will always occur.  Depending on the location and situation, one type of closure will be preferable to another. Skin glue can’t be used when hair is involved. Eyebrows are out, since shaving them is not an option; there is no guarantee that they well regrow. Steristrips don’t work well when the laceration is 90 degrees to the crease lines and are placed under stress when the body moves. Suture gives the most control and the size and type of thread used depends upon body location and sewer’s preference. Before the skin is closed, it is important to remember that, if needed, deep layers may need to be sewn together to decrease the amount of work that the stitches that hold the edges of the skin together need to do. The less tension on the skin, the better the scar.
  • Step 6. Keep the wound clean and take the stitches out as soon as feasible, again depending upon the location and situation. The face has great blood supply and heals quickly. Stitches are often removed in 4-5 days to prevent the stitches themselves from scarring causing the appearance of crosshatching or railroad tracks. Wounds across a joint take longer to heal since the skin is always moving.

The mechanics of wound repair are not difficult. Make certain that everything works and then wash the crap out of the wound to prevent infection. The art of wound repair is what takes practice and expertise. With enough experience, good cosmetic results are routine regardless if it is the family doctor, emergency physician or plastic surgeon holding the needle driver.

Watch the trainers on the bench. The tools that they use are saline (salt water) and gauze pads for cleaning and skin glue or steristrips to close the skin. Anything more needs to happen in the locker room or the ER. Their goal is a temporary fix to get the player back on the ice. The end game remains the same A good looking scar may yet happen but at a different place and at a different time.

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