The treatment of an open wound begins with obtaining a clear history.
Patient History Must:
- Determine the lacerating instrument
- The position of the arm and hand during the laceration
- The direction and depth of the laceration
The exam will confirm the injured tissue and the history will provide the direction the wound should be extended during surgical exploration.
The cleaning of the wound, repair of muscle, artery and tendon is done with the use of a microscope. The improved magnification allows for accurate approximation of the injured tissue.
Tetanus shot is updated if it has been longer than 10 years. For a dirty wound, the tetanus must be no longer than five years current. This avoids the danger of acquiring gas gangrene, a deadly infection from the organism, clostridium perfringens.
For one week after the repair, oral antibiotics covering skin flora are used to avoid the risk of infection.
If the wound is a farm injury or dirty, penicillin is also used to cover clostridium perfringens.
When the wound was caused by a dog bite, the use of antibiotics covering animal flora like pasturella multicida, pseudomonas, staphylococcus and streptococcus must be used.
Human bites, as in a clenched fist injury, also require antibiotics covering eikenella corrodens like augmentin.
The treatment of an amputation starts immediately after the amputation is sustained. The amputated part must be immediately wrapped in saline moistened gauze and placed in ice slush. Ice slush is made by crushing ice in a zip lock plastic bag and put in a cooler. The amputated part can then be transported to ROC for replantation.
Upon arriving at ROCâ€™s emergency facility, the patient is prepared for surgery while the amputated part is taken to the operating room, cleaned and dissected out under a microscope to prepare for replantation.
Replantation is typically successful with amputations beginning at the base of the nail and more proximal amputations towards the shoulder.
Successful replantations are related to the size of the arteries and veins which become too small to repair if it is beyond the nail base.
Steps of Replantation
- First, the bone is fixed
- Second, the tendons are repaired
- Third, the nerve(s).
- Whether the arteries or veins are fixed next is surgeonsâ€™ choice. Fixing veins first can prevent excessive bleeding. While fixing the arteries first can allow easier visualization of the veins
The results of replantations performed from the level of the forearm to the shoulder are more functional if:
- Patients is younger than 15 years of age, beacuase of better nerve regrowth potential
- Amputation is a clean cut
- The part is brought for replantation immediately
Partial amputations with the skin still attached should be left attached since valuable blood supply may be provided by the retained tissue.
With avulsion type amputations, which is a pulling injury, or a severe crush injury, the likelihood of a successful replantation is significantly less.
Special splints are applied after surgery to avoid certain movements that might damage a repair performed. The injured extremity must be elevated to at least heart level to avoid swelling of the limb. Limb swelling causes moderate pain, cuts off the blood supply and delays wound healing if allowed to occur.
Regardless of the type of amputation, it is advisable to bring in the amputated part immediately for the surgeon to examine.
The surgeon can assess the likelihood of replantation success or may use the tissue from the amputated limb as donor tissue to treat the wound base where the amputation occurred.