Patient Evaluation

With an infinite variety of medical conditions and circumstances requiring ED management, each patient has a unique environment for wound healing. Hosts also change over time: thinning of the dermis, varying degrees of vascular compromise, increased likelihood of fractures, and medication use. Assessment of patient status before the injury, as well as prediction of the patient’s capacity for healing, is important before initiating wound repair.

A wound is the physical manifestation of an injurious force exerted on the body. Accordingly, careful evaluation of the patient as a whole is critical. A common pitfall is focusing on the most visible injury and not recognizing other lesions that were caused by one event, such as trauma. Understanding the injurious mechanism also enables better prediction of the wound’s severity. As an example, blunt force injuries have significantly greater potential for diffuse tissue nonviability and are consequently more prone to infection.³ Once all injuries have been catalogued, each may be addressed. Important considerations include knowing how the patient was injured (shear, abrasion, compression), whether the location of the wound is in a cosmetically or functionally vital area, and whether potentially confounding influences on the potential for healing are present.

Injury to Underlying Structures

When sufficiently breached, skin fails in its protective role and may allow underlying structures to be injured (Fig. 186.2). Diligent assessment of the functionality of surrounding anatomic structures is of utmost importance.

Fig. 186.2 Injury to underlying structures.

Missing an associated nerve, tendon, vascular, or bony injury is a significant pitfall in wound care. This patient had partial facial nerve palsy from her injury that was slightly exacerbated by anesthesia, but it resolved almost completely over time.

Tendon function should be assessed throughout its range of motion. It may help to ask the patient to estimate the position of a body part at the time of the injury, especially with hand injuries. Tendons may be partially lacerated but their range of motion may remain intact, thereby misleading the practitioner. Patients’ complaints of pain or subjectively decreased range of motion, despite objectively normal findings on examination, should raise suspicion for partial disruption.

Nerves can be injured by the wounding mechanism itself or by iatrogenic maneuvers, especially indiscriminate ones. Clamping, blind probing, and injudicious débridement may all disrupt adjacent nerves. The hands and face are at greatest risk because nerves run in close proximity to the vasculature; zealous attempts to control bleeding vessels can result in damage to adjacent nerves. Injected anesthetics may also injure nerves as a result of pressure necrosis in finite spaces. Examples include injections into the olecranon grooves or foramina in the hard palate of the mouth.

Muscles are highly vascular tissue and are often disrupted with deep wounds. Because muscles are dynamic units, subsequent hematomas, scars, or infection can result in dysfunction. Unnecessary débridement should be avoided and bleeding controlled with direct pressure. Muscle can usually be repaired by securing the surrounding structures, thereby placing the cut surfaces of the muscle in direct apposition. Muscle tissue should be repaired directly only when the foregoing maneuver is insufficient.

Occasionally, a wound is the first sign of an underlying fracture, either because the skin was injured with the force carried onto the bone or because the broken bone edges penetrated the skin from inside.

Foreign Bodies

Foreign bodies can be driven into wounds through innumerable routes of entry. Common situations include shattered glass in motor vehicle accidents, vegetative material in wounds during outdoor pursuits, and puncture wounds through footwear. Foreign bodies increase the risk for infection and may prevent healing. The following section on puncture wounds specifically addresses foreign bodies in these situations. For additional discussion of foreign body evaluation and management, see Chapter 187.

Wound Preparation

To meet the goals of reducing risk for infection, minimizing damage to underlying structures, and forming a functional and cosmetically acceptable scar, preparation of the wound can be tantamount to or may surpass closure in importance. An appropriately prepared wound has been anesthetized, has been decontaminated of large particles or foreign bodies, has minimized bacterial counts, and has edges amenable to optimal repair.