Basic Principles In The Management Of Soft Tissue


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Basic Principles In The Management Of Soft Tissue

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Basic Principles In The Management Of Soft Tissue

  1. 1. Basic Principles in the Management of Soft Tissue Injuries of the Face
  2. 2. Introduction <ul><li>Facial trauma is common </li></ul><ul><li>Susceptibility to injury comes with the position and anatomy of the face </li></ul><ul><li>Proper care and correct management ensure </li></ul><ul><ul><li>maintenance of function </li></ul></ul><ul><ul><li>good wound cosmesis </li></ul></ul><ul><ul><li>low infection rate. </li></ul></ul>
  3. 3. <ul><li>Frequency: </li></ul><ul><ul><li>exact incidence is unknown but very common </li></ul></ul><ul><ul><li>> 50% of facial traumas are secondary to motor vehicle accidents, others are from athletic and other recreational activities </li></ul></ul><ul><ul><li>Assault </li></ul></ul>Introduction
  4. 4. Biomechanics <ul><li>Facial soft tissue injuries are usually due to trauma from an external source rather than internal biomechanics </li></ul><ul><li>External forces leading to soft tissue injuries may include </li></ul><ul><ul><li>friction </li></ul></ul><ul><ul><li>Shear </li></ul></ul><ul><ul><li>Compression </li></ul></ul><ul><ul><li>Traction </li></ul></ul><ul><ul><li>(Repeated blows or pressure against the ear, as in boxing, wrestling, or rugby, can cause bleeding and result in cauliflower ear if left untreated) </li></ul></ul>
  5. 5. Initial Approach and Assessment <ul><li>History: </li></ul><ul><ul><li>The physician should obtain a thorough history from the patient or a family member, including any significant past medical history, whenever possible. </li></ul></ul><ul><ul><li>A thorough history and physical exam is essential for optimum management. </li></ul></ul><ul><ul><li>Knowing the onset and precise mechanism of injury is beneficial to the physician for providing optimum treatment. </li></ul></ul>
  6. 6. <ul><li>Physical: </li></ul><ul><ul><li>airway, breathing, and circulation </li></ul></ul><ul><ul><li>A careful examination starts with a symmetry survey, looking for any obvious deformities or deficits. </li></ul></ul><ul><ul><li>When approaching a patient with a laceration, the initial attention is focused on hemorrhage control. </li></ul></ul><ul><ul><ul><li>Most bleeding due to simple lacerations can be easily controlled with direct pressure </li></ul></ul></ul>Initial Approach and Assessment
  7. 7. <ul><li>Occasionally, when relatively large vessels are involved, special techniques are required </li></ul><ul><ul><li>Temporary placement of a tourniquet </li></ul></ul><ul><ul><li>Small-vessel ligation </li></ul></ul><ul><ul><li>placement of “figure of 8” sutures </li></ul></ul><ul><li>repair of larger, named arteries and veins may require consultation with, and operative repair by, another specialist. </li></ul>Initial Approach and Assessment
  8. 8. <ul><li>Once the patient is stabilized, attention can be focused on the management of the soft tissue injury/laceration </li></ul><ul><li>A complete examination of the laceration is necessary, making note of </li></ul><ul><ul><li>Location and depth </li></ul></ul><ul><ul><li>Gross contamination </li></ul></ul><ul><ul><li>Obvious foreign bodies </li></ul></ul><ul><ul><li>Associated injuries </li></ul></ul><ul><ul><li>Orientation of the laceration with regard to skin tension lines </li></ul></ul><ul><ul><ul><li>Lacerations that are perpendicular to these lines are subject to more static and dynamic tension and, therefore, develop more scarring </li></ul></ul></ul><ul><li>Roentgenograms of the injured site may be necessary to rule out an associated fracture or a retained radiopaque foreign body </li></ul><ul><li>Any open fracture or laceration associated with injury to specialized ducts or glands, or vessels or nerves requiring repair should be referred to the appropriate specialist </li></ul>Initial Approach and Assessment
  9. 9. DIFFERENTIALS <ul><li>Facial fractures </li></ul><ul><li>Facial soft tissue injures </li></ul><ul><li>Nasal fractures </li></ul>
  10. 10. Work up <ul><li>Imaging Studies: </li></ul><ul><ul><li>Any deformity or significant bony tenderness following a traumatic facial injury warrants the use of radiographic imaging to rule out facial fractures. </li></ul></ul><ul><ul><li>X-ray films can also be obtained to look for radiopaque foreign bodies. </li></ul></ul><ul><ul><li>If further evaluation is indicated, a CT scan or MRI is needed. </li></ul></ul>
  11. 11. TREATMENT <ul><li>Acute Phase: </li></ul><ul><ul><li>Possible Complications: </li></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><ul><ul><li>Hematoma </li></ul></ul></ul><ul><ul><ul><li>Flap necrosis </li></ul></ul></ul><ul><ul><ul><li>Nasal septum necrosis </li></ul></ul></ul><ul><ul><ul><li>Retained foreign bodies </li></ul></ul></ul><ul><ul><ul><li>Cauliflower ear </li></ul></ul></ul><ul><ul><ul><li>Poor cosmesis </li></ul></ul></ul><ul><ul><ul><li>Loss of function </li></ul></ul></ul>
  12. 12. <ul><li>Surgical Intervention: </li></ul><ul><ul><li>Anesthesia </li></ul></ul><ul><ul><li>Adequate anesthesia must be administered for proper wound examination and exploration. </li></ul></ul><ul><ul><ul><li>Lidocaine 1% with and without epinephrine is used commonly </li></ul></ul></ul><ul><ul><ul><li>Toxic doses are 7 mg/kg and 5 mg/kg, respectively </li></ul></ul></ul>TREATMENT
  13. 13. <ul><li>For a complicated wound or if prolonged anesthesia is needed: </li></ul><ul><ul><li>bupivacaine 0.25-0.5% provides approximately 6 hours of pain control. </li></ul></ul><ul><ul><li>Toxic doses of bupivacaine are 2 mg/kg without epinephrine and 3 mg/kg with epinephrine. </li></ul></ul>TREATMENT
  14. 14. <ul><li>Overadministration of anesthetic </li></ul><ul><ul><li>more likely to occur in the presence of a large laceration in a child </li></ul></ul><ul><ul><li>Mild lidocaine toxicity is expressed as an acute change that may include slurred speech, drowsiness, confusion, nausea, vomiting, ataxia, twitching, tinnitus, and vertigo. Complications of higher levels of toxicity include psychosis, seizures, respiratory depression, and death. </li></ul></ul><ul><li>Topical anesthetic combinations such as lidocaine, epinephrine, and tetracaine are an appealing approach in injuries of the face. Application on the mucosal barrier must be avoided to prevent systemic toxicity. </li></ul>TREATMENT
  15. 15. <ul><li>Regional nerve blocks </li></ul><ul><ul><li>Four types of regional nerve blocks </li></ul></ul><ul><ul><ul><li>Supratrochlear </li></ul></ul></ul><ul><ul><ul><li>Supraorbital </li></ul></ul></ul><ul><ul><ul><li>Infraorbital </li></ul></ul></ul><ul><ul><ul><li>Mental </li></ul></ul></ul><ul><ul><li>associated with injuries on the face. </li></ul></ul><ul><ul><li>save time </li></ul></ul><ul><ul><li>decrease the risk of systemic toxicity </li></ul></ul><ul><ul><li>involve less volume-related tissue distortion </li></ul></ul>TREATMENT
  16. 16. <ul><li>Wound decontamination </li></ul><ul><ul><li>Removing pyogenic bacteria and devitalized tissue is paramount to creating a clean wound. </li></ul></ul><ul><ul><li>Irrigation is the mainstay procedure for accomplishing this goal. </li></ul></ul><ul><ul><ul><li>18- or 19-gauge catheter with a 60-mL syringe provides the needed pressure for adequate wound cleaning. </li></ul></ul></ul><ul><ul><ul><li>A standard guideline for volume of irrigation is 60 mL/cm of wound length. Low-pressure irrigation with a bulb syringe or plastic bottle is inadequate. </li></ul></ul></ul><ul><ul><ul><ul><li>Normal saline </li></ul></ul></ul></ul><ul><ul><ul><ul><li>tap water </li></ul></ul></ul></ul><ul><ul><ul><li>Avoid chlorhexidine, hydrogen peroxide, benzalkonium chloride, and products containing detergent because of tissue toxicity. </li></ul></ul></ul>TREATMENT
  17. 17. <ul><li>Wound decontamination </li></ul><ul><ul><li>Wounds may be scrubbed to remove gross contamination. </li></ul></ul><ul><ul><ul><li>Take care in scrubbing wounds; activity that is too vigorous increases tissue damage and infection rates. </li></ul></ul></ul><ul><ul><li>Devitalized tissue is extremely pyogenic and can be removed easily with a No. 15 blade or iris scissors. </li></ul></ul><ul><ul><li>Preserve healthy tissue, if possible. </li></ul></ul><ul><ul><li>After adequate cleansing, drape the wound in sterile fashion. Also, prepare the skin around the wound in sterile fashion. </li></ul></ul><ul><ul><ul><li>Povidone-iodine solution may be used for this </li></ul></ul></ul><ul><ul><ul><li>toxic to tissue at its standard strength </li></ul></ul></ul><ul><ul><ul><li>1% solution of povidone and iodine </li></ul></ul></ul>TREATMENT
  18. 18. <ul><li>Wound exploration </li></ul><ul><ul><li>After adequate anesthesia and wound cleansing, explore the wound. </li></ul></ul><ul><ul><ul><li>Adequate lighting, hemostasis, and a cooperative patient are of paramount importance </li></ul></ul></ul><ul><ul><li>Plain films can identify radiopaque foreign bodies (eg, glass, metal, gravel). Studies have shown that on a 2-view radiograph, glass of at least 2 mm and gravel of at least 1 mm can be visualized. </li></ul></ul><ul><ul><li>Exploration with forceps can help identify some foreign bodies through a characteristic &quot;clink&quot; sound generated when contact is made. </li></ul></ul>TREATMENT
  19. 19. <ul><li>Wound exploration </li></ul><ul><ul><li>The advisability of removal of objects depends on the </li></ul></ul><ul><ul><ul><li>expertise of the provider </li></ul></ul></ul><ul><ul><ul><li>proximity to vital structures. </li></ul></ul></ul><ul><ul><li>Hemostasis may be aided by the use of anesthetics containing epinephrine. The risk of ischemia of wound edges on the face is low. </li></ul></ul><ul><ul><li>A figure-eight stitch is also valuable for controlling deep bleeding, but the clinician must take care to not ligate a nerve. </li></ul></ul>TREATMENT
  20. 20. <ul><li>Wound closure </li></ul><ul><ul><li>The need to create an aesthetic wound </li></ul></ul><ul><ul><li>Most lacerations are approximated with excellent cosmetic results using simple sutures </li></ul></ul><ul><ul><li>Observe lines of expression </li></ul></ul><ul><ul><li>Wounds on the face may be closed up to 24 hours after injury in nonimmunocompromised patients </li></ul></ul><ul><ul><li>The wound edge (1-2 mm) may be removed safely to rid the wound of devitalized tissue. </li></ul></ul><ul><ul><li>A perpendicular wound edge creates a much smoother and less noticeable scar </li></ul></ul>TREATMENT
  21. 21. <ul><li>Wound closure </li></ul><ul><ul><li>skin sutures are placed under minimal to no tension. </li></ul></ul><ul><ul><li>If tension exists, the wound margins can be approximated by undermining the surrounding wound edges or by placing subcutaneous stitches. </li></ul></ul><ul><ul><li>use the least amount of subcutaneous sutures necessary because subcutaneous materials increase the risk of wound infection. </li></ul></ul><ul><ul><li>For deep wounds under tension, </li></ul></ul><ul><ul><ul><li>approximate with a 5-0 intradermal absorbable monofilament suture. Then, close the overlying skin with a 6-0 suture. </li></ul></ul></ul><ul><ul><li>Simple interrupted sutures work well for facial repair. </li></ul></ul>TREATMENT
  22. 22. <ul><li>Delayed primary closure </li></ul><ul><ul><ul><li>may be used for lacerations that cannot be closed initially </li></ul></ul></ul><ul><ul><ul><li>gross contamination </li></ul></ul></ul><ul><ul><ul><li>violation of joints </li></ul></ul></ul><ul><ul><ul><li>retained foreign bodies </li></ul></ul></ul><ul><ul><ul><li>host immune status </li></ul></ul></ul><ul><ul><ul><li>inability to adequately cleanse the wound </li></ul></ul></ul><ul><ul><ul><li>delayed presentation. </li></ul></ul></ul>TREATMENT
  23. 23. <ul><li>Delayed primary closure </li></ul><ul><ul><li>The wound is irrigated and debrided as usual, then moist gauze is applied and covered by a protective dressing. Antibiotics </li></ul></ul><ul><ul><li>On day 4, the dressing is removed and the wound is irrigated and sutured. </li></ul></ul><ul><ul><li>The cosmesis achieved with delayed primary closure is equivalent to that of primary closure. </li></ul></ul>TREATMENT
  24. 24. <ul><li>Wound edge eversion </li></ul><ul><ul><li>Improved cosmesis </li></ul></ul><ul><ul><li>After the initial repair, the edges flatten and become flush with the surrounding skin </li></ul></ul><ul><ul><li>If the edges were not everted initially, then the wound appears concave and has poor cosmesis. </li></ul></ul><ul><li>Shaving </li></ul><ul><ul><li>increases the risk of infection </li></ul></ul><ul><ul><li>do not shave around wounds to be closed </li></ul></ul><ul><ul><li>hair can be clipped or parted with bacitracin or petroleum jelly to provide a clear view </li></ul></ul><ul><ul><li>Surrounding hair can also be prepared with povidone-iodine solution. </li></ul></ul>TREATMENT
  25. 25. <ul><li>Skin-closure tape </li></ul><ul><ul><li>works well in nonmobile areas that have good wound edge approximation without tension. </li></ul></ul><ul><ul><li>Forceps are used to attach the tape to one side of the wound and then to pull the wound edges together for a good fit. The remaining part of the tape is then attached to the opposite side of the wound. </li></ul></ul><ul><ul><li>advantage of skin tape is the lack of need for anesthesia and removal of sutures. </li></ul></ul><ul><li>Staple closure is not suited for the face. </li></ul>TREATMENT
  26. 26. <ul><li>Abrasions or avulsions </li></ul><ul><ul><li>These types of wounds are commonly dirty and require careful debridement and irrigation to prevent traumatic tattooing. </li></ul></ul><ul><ul><li>Radiographs are valuable in determining the presence of deeply embedded glass and gravel. </li></ul></ul><ul><ul><li>Full-thickness avulsions are closed primarily with 6-0 nonabsorbable sutures. </li></ul></ul><ul><ul><li>Gauze impregnated with petroleum jelly is then applied for protection during epithelialization. </li></ul></ul><ul><ul><li>In 7-8 days, the gauze may be removed and the patient should be evaluated for further repair by a plastic surgeon </li></ul></ul>TREATMENT
  27. 27. <ul><li>  MEDICATION </li></ul><ul><ul><li>goals of pharmacotherapy </li></ul></ul><ul><ul><ul><li>eradicate the infection when present </li></ul></ul></ul><ul><ul><ul><li>to reduce morbidity </li></ul></ul></ul><ul><ul><ul><li>to prevent complications </li></ul></ul></ul>TREATMENT
  28. 28. <ul><li>Tetanus toxoid </li></ul><ul><ul><li>Immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. </li></ul></ul><ul><ul><li>Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen–containing product. Administer dT 0.5 mL IM to patients >7 y who have not been immunized within 5 y. </li></ul></ul>TREATMENT
  29. 29. <ul><li>Tetanus toxoid </li></ul><ul><ul><li>Adult Dose Primary immunization: 0.5 mL IM; give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection Booster dose: 0.5 mL q10y </li></ul></ul><ul><ul><li>Pediatric Dose Administer as in adults </li></ul></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>Documented hypersensitivity; history of any type of neurological symptoms or signs following administration </li></ul></ul></ul><ul><ul><ul><li>elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis </li></ul></ul></ul>TREATMENT
  30. 30. <ul><li>Immunoglobulins </li></ul><ul><ul><li>Used for passive immunization </li></ul></ul><ul><ul><li>Consists of administration of immunoglobulin pooled from serum of immunized subjects. </li></ul></ul><ul><ul><li>Induces passive immunization in any person with a wound that might be contaminated with tetanus spores. </li></ul></ul>TREATMENT
  31. 31. <ul><li>Immunoglobulins </li></ul><ul><ul><li>Adult Dose Prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid lesion </li></ul></ul><ul><ul><li>Pediatric Dose Prophylaxis: 250 U IM in opposite extremity to tetanus toxoid </li></ul></ul><ul><ul><li>Contraindications </li></ul></ul><ul><ul><ul><li>do not administer within 3 mo of live virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live virus vaccination </li></ul></ul></ul>TREATMENT
  32. 32. <ul><li>Antibiotics </li></ul><ul><ul><li>Not recommended as part of routine, uncomplicated wound care </li></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>large intraoral wounds </li></ul></ul></ul><ul><ul><ul><li>Human bites or abrasions caused by human teeth </li></ul></ul></ul><ul><ul><ul><li>Puncture wounds (eg, nails, cat bites) </li></ul></ul></ul><ul><ul><ul><li>wounds with signs of infection </li></ul></ul></ul><ul><ul><ul><li>grossly contaminated wounds </li></ul></ul></ul><ul><ul><ul><li>wounds with retained foreign bodies </li></ul></ul></ul>TREATMENT
  33. 33. <ul><li>Antibiotics </li></ul><ul><ul><li>Penicillin G benzathine </li></ul></ul><ul><ul><li>Dicloxacillin </li></ul></ul><ul><ul><li>Amoxicillin and clavulanate (Augmentin) </li></ul></ul><ul><ul><li>Cephalexin </li></ul></ul><ul><ul><li>Penicillin VK </li></ul></ul><ul><ul><li>Clindamycin </li></ul></ul>TREATMENT
  34. 34. <ul><li>Aftercare and follow-up procedures are as follows: </li></ul><ul><ul><li>The wound should be rechecked after 2-3 days for signs of infection. </li></ul></ul><ul><ul><li>An antibacterial ointment should be applied for the first 2 days after repair. </li></ul></ul><ul><ul><li>A dressing may be applied for up to 3 days after repair. </li></ul></ul><ul><ul><li>Showering can begin 12-24 hours after repair. </li></ul></ul><ul><ul><li>Facial sutures are usually removed after 3-5 days. </li></ul></ul>TREATMENT
  35. 35. <ul><li> </li></ul>
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