Management of the Traumatic Wound by Primary Closure

Chapter 55 Management of the Traumatic Wound by Primary Closure



Mark W. Bohling, Steven F. Swaim


Following proper initial management of a traumatic wound by debridement and lavage, the wound may be closed. Sufficient viable tissue must be present to allow closure without excessive tension. Wounds may be closed by primary closure, delayed primary closure, or secondary closure. See Chapter 56 for a discussion of open wound management.



ANATOMY



• Dogs and cats have abundant skin on the trunk and neck but a sparsity of skin on the distal limbs, tail, ear, and rostral areas of the head.

• Direct cutaneous vessels run parallel to the skin’s surface and supply the subdermal plexus of the skin. See Chapter 57 for more details regarding blood supply to the skin.

• Some areas of the body have panniculus musculature underlying the skin. The skin’s blood supply runs both superficial and deep to this musculature.

• Other areas of the body have loose areolar fascia deep to the dermis in which vasculature is located, and in other areas the skin is closely associated with underlying fascia.


PREOPERATIVE CONSIDERATIONS




Key Point


If a traumatically induced wound is to be closed, it is imperative that the tissues be viable and clean enough that wound healing can progress uneventfully. Perform adequate debridement and lavage.



• Perform a thorough physical examination and appropriate diagnostic tests on all traumatized animals to rule out associated injuries.

• Perform primary closure when:
• The animal is in good condition.

• A short time (6–12 hours) has elapsed since injury.

• Minimal contamination and tissue trauma have occurred.

• Adequate debridement and lavage have been done.

• Adequate hemostasis has been attained.

• Perform delayed primary closure when:
• Wounds show evidence of heavy contamination, purulent exudate, residual necrotic or questionable tissue, edema, erythema at the wound margins, lymphangitis, and skin tension.

• Local infection has been controlled by staged debridement, lavage, topical and/or systemic antibiotics, and appropriate bandages. This is usually 3 to 5 days after wounding.

• Perform a secondary closure when:
• The wound is in the reparative stage of healing at presentation, with a healthy bed of granulation tissue and evidence of epithelialization.

• The wound has disrupted and has subsequently developed a healthy bed of granulation tissue.

• It has been necessary to leave the wound open for longer than 5 days to control infection (see Preoperative Considerations, Delayed Primary Closure, Local Infection Control).


SURGICAL PROCEDURES



Primary or Delayed Primary Closure without Tension



Objectives



• Close the wound.

• Provide drainage if necessary.


Equipment



• Standard general surgical pack

• Undyed polyglactin 910, polyglecaprone, dyed or undyed polydioxanone, 2-0 to 4-0 (Vicryl, Monocryl, or PDS II; Ethicon, Somerville, NJ.) and polypropylene or nylon, 2-0 and 3-0 (Prolene or Ethilon, Ethicon, Somerville, NJ.)

• Wound lavage solution of 0.05% chlorhexidine diacetate or gluconate (Nolvasan Solution, Fort Dodge, IA. or ChlorhexiDerm Disinfectant, DVM Pharmaceuticals, Miami, FL.)


Technique



1. Pack the wound with sterile surgical sponges moistened with physiologic saline, or with water-soluble sterile lubricant (K-Y Jelly, Johnson & Johnson, New Brunswick, NJ.) or water-soluble sterile lubricant that contains chlorhexidine gluconate (Surgilube, E. Fougera & Co., Mellville, NY.)

2. Prepare the area around the wound for aseptic surgery.

3. Remove the wound packing or sterile lubricant.

4. Lavage the wound frequently with sterile isotonic fluids (or a solution of 0.05% chlorhexidine diacetate or gluconate) during surgery along with removal of devitalized tissue and debris as indicated.

5. Use as few simple interrupted absorbable sutures as necessary to close dead space in deep layers of the wound.

6. Be careful not to entrap major vessels or nerves in the sutures.

7. Place a drain (Penrose drain, or a closed suction drain [Jackson-Pratt]) if there is any possibility of residual dead space and/or wound drainage.

8. Place a simple continuous suture in the subcutaneous tissue at the wound edge using absorbable suture material.

9. Close the skin with non-absorbable simple interrupted sutures.


Postoperative Care and Complications



• Postoperative care
• Place absorbent surgical sponges over the suture line, with extra sponges over the end of a Penrose drain.

• Apply an absorbent secondary wrap to the area, followed by an outer wrap of porous adhesive tape.

• Change the bandage every second or third day if there is no concern about possible complications. Change the bandage daily if there is concern about possible complications and/or a drain has been placed. The amount and nature of drainage should be assessed at each bandage change.

• Remove the drain and discontinue bandaging when the drainage becomes minimal and is the same in quantity at successive bandage changes.

• Remove the skin sutures 7 to 10 days postoperatively.

• Complications: Hematoma, seroma, or infection may result from improper wound evaluation, debridement, lavage, closure, or drain management.


Primary, Delayed Primary, or Secondary Closure with Tension



Objectives



• Close the wound.

• Relieve tension on the skin edges.

• Provide drainage if necessary.


Equipment



• See equipment under Primary or Delayed Primary Closure Without Tension.


Technique



1. The general techniques for closure of wounds with tension are the same as those for primary or delayed primary closure without tension (see previous section), with the exception of suture pattern (see tension-relieving suture patterns discussed subsequently).

2. Wounds that are in the reparative stage of healing with healthy granulation tissue and epithelialization.
a. Excise epithelium from the edge of the wound, leaving healthy granulation tissue in the center.

b. Gently clean the surface of the granulation tissue with 0.05% chlorhexidine solution (Fig. 55-1).

3. Gently undermine the skin surrounding the wound.
a. Undermine bluntly, using Metzenbaum scissors, leaving some loose areolar connective tissue on the dermis or undermine beneath panniculus musculature if present.

b. Undermine sharply with scissors or scalpel blade in areas where skin is closely associated with the underlying fascia.

image

Figure 55-1 Preparation of a wound in the reparative stage of healing for secondary closure. A, Incising the epithelium. B, Removing the epithelium. C, Cleaning the surface of the healthy granulation tissue.

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Aug 27, 2016 | Posted by in SMALL ANIMAL | Comments Off on Management of the Traumatic Wound by Primary Closure

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