Management of soft tissue injury

1. Management of soft tissue
injury in ER at UHC
Dr MOHAMMAD TAZDIDUL ISLAM
Medical officer
Upazilla Health Complex, Singair

2. Introduction
Soft tissue injury comprises injury to the –
1. Skin and subcutaneous tissue
2. Muscle, tendon, ligament
3. Neuro-vascular structures
4. Internal organs
Modes of injury :
- Road traffic accidents
- Physical assault
- Sport injury
- Accidental falls and cuts

3. Types
• 2 types :
1. Closed soft tissue injury
- Contusion
- Hematoma
- Crush injury
2. Open soft tissue injury
- Abrasion
- Laceration
- Penetrating wound
- Degloving wound
- Incised wound
- Incised looking wound

4. Closed soft tissue injury
• Contusion :
- Also known as bruises
- Produced due to bleeding from small
blood vessels
- Caused by blunt trauma

5. Cont’d...
• Hematoma :
- Collection of blood beneath the skin
- Produced due to larger blood vessels
damage
- Caused by blunt trauma

6. Cont’d...
• Crush injury :
- Traumatic compression of tissue
against the underlying bone
- Caused by blunt crushing force

7. Cont’d...
• Common features :
- Pain
- Swelling
- Discolouration of skin
• Common management : RICE therapy
- Rest
- Ice (to reduce pain and swelling)
- Compression (to inhibit hematoma formation)
- Elevation (to prevent pulling of blood)

8. Cont’d...
• Antibiotics - usually not required
• Surgical intervention - may be necessary in case of abscess formation
• Counselling - 3 to 6 weeks may be required for resolution of bruise or
hematoma

9. Open soft tissue injury
• Abrasion :
- Damage to the superficial layer of the
skin
- Caused by frictional force

10. Cont’d...
• Laceration :
- Damage to the skin as well as deeper
structures
- Caused by blunt trauma

11. Cont’d...
• Degloving wound :
- Extensive loss of skin and underlying
tissue
- Caused by frictional force

12. Cont’d...
• Incised wound :
- Straight, regular margin
- Caused by sharp cutting instrument
• Incised looking wound :
- Irregular, rigged margin
- Caused by sudden severe blunt force
against bony prominence which leads
to splitting

13. Cont’d...
• Common features :
- Pain
- Bleeding
- Associated skin and underlying tissue damage
• Common management :
1. Toileting – Standard is to use Normal saline, Hexiscrub solutions
Alternative is to use tap water and soap
2. Wound debridement – Removal of dead and devitalized tissue

14. Cont’d...
3. Haemostasis -
elevation > pressure > packing > cauterization, suturing
4. Repair -
Relatively clean wound, less tissue damage – primary intention healing
Dirty wound, more tissue damage – secondary intention healing
Suture materials used :
Scalp, Thin skin – Silk/Prolene
Face, thick skin, tendon – Prolene
Muscle – Vicryl
Vessels, mucosal surface - Catgut

15. Cont’d...
5. Bandage application –
Not too loose > to withstand primary or reactionary haemorrhage
Not too tight > to prevent vascular impairment
6. Appropriate antibiotics –
Abrasion – Topical antibiotic
Incised or incised looking wound – Oral antibiotic
Laceration, degloving wound – Oral/ i.v. Antibiotic
7. Appropriate analgesic

16. Cont’d...
• Application of local anaesthetic – should be checked and re-checked that the
local anaesthetic drug is not instilled in vessel
• Use of Povisep/Hexisol – should be avoided in the cut surface of the wound. Can
be used to disinfect skin surface after repair
• Prioritise vascularity over cosmesis – inappropriate distance between sutures >
pressure necrosis
• Tetanus prophylaxis – most important in case of women in the child bearing age

17. Cont’d...
• When not to repair –
1. Inadequate facility
2. Soft tissue injury over a suspected fracture
3. Associated internal injury
4. Comparatively dirty wound
5. Bite wounds – human bites, animal bites

18. Medico legal facts
• Description of injury & weapon :
1. Number of wound
2. Sites of wound (ex: right forearm in flexor /extensor surface)
3. Nature of wound (ex: laceration, incised, abrasion, swelling)
4. Size of wound (length, width, depth)
Abrasion , bruise, hematoma – 2d
Laceration, incised wound – 3d
5. Injured structures (skin, fascia, muscles, tendon, bones)
6. Nature of weapon: blunt or sharp cutting
7. Duration of injury : According to the statement of victim/ identifying person
Interval between time of injury to time of examination in UHC

19. Home message
• Repair of the wound should be justified – we shouldn’t be neither reluctant nor
over enthusiastic
• Primary resuscitation must be ensured before referring a patient to higher centre
• Paediatric injuries should be dealt with more empathy
• Prophylaxis against tetanus and rabies should be ensured
• Proper counselling should be done about the fate of wound repair to prevent
future conflicts

20. Thank You All