Disruption of the Continuity of Tissues Produced by External Mechanical Force. It Can Be

5. Wounds

5.1. Definition Disruption of the continuity of tissues produced by external mechanical force. It can be a cut or break in the continuity of any tissue, caused by injury or operation resulting in a moderate, severe or even life threatening clinical condition. In case of superficial wounds the protective function of the skin is lost and plasma and blood cells are leaving and concomitantly, microorganisms and foreign materials can enter the body. Opening up of cavities and vital organs represents further risk. Surgical wounds are usually made under sterile circumstances and are closed layer by layer upon completion of the surgical intervention. Accidental wounds, however, are caused by mechanical trauma and could be either open or closed. Wounds can be resulting from mechanical, thermal, chemical forces and irradiation. The term injury is used synonymously with wound, but can have a wider meaning. Wound (in surgery) = mechanical injury (the pathophysiology and management of mechanical injuries will be described).

Mechanical injury

Accidental Surgical wounds wounds

Open Closed

5.2. Classification of accidental wounds 1. morphology / origin, 2. bacterial contamination 3. time elapsing from the trauma 4. thickness 5. factors affecting wound healing 6. wound closure.

5.2.1. Classification by etiology Wound (etymology: old English „wund”, old Norse „und”) types: Punctured wound (vulnus punctum): is caused by a sharp pointed tool and usually misleadingly seems to be negligible. Its danger: anerobic infection, and the injury of large vessels and nerves under a relatively minor skin discontinuity. Treatment may be necessary to prevent infection, the object that caused the wound may carry bacteria or spores of tetanus into the skin and tissue. Incised wound (vulnus scissum): is caused by sharp objects; a linear cut in the skin, usually superficial, but may involve deep structures (surgical incisions). The best healing. The extent of opening of the wound depends on the tissue flexibility and the directions of the Langer lines. These wounds are accompanied by considerable amount of bleeding. Cut wound (vulnus caesum): similar to incision + direct, perpendicular force. The impact bursts tissues open (axe). Crush wound (vulnus contusum): caused by blunt forces and can be either open or closed. Heavy objects are splitting the skin and shattering or tearing the underlying structures. Fingers

97 and toes are commonly involved. Painful injury with much swelling. The wound edges are usually uneven and torn. The bleeding is negligible, but the pain is in-proportionately bigger than it would be expected from the size of the injury (termed as wound stupor). Torn wound (vulnus lacerum): caused by great tearing or pulling forces and can result in incomplete amputation of certain body parts. Shot wound (vulnus sclopetarium): is composed of an aperture, a slot tunnel and an output. A nearby shot is usually accompanied by some burn injury at the aperture. Other characteristic features are the incorporated foreign materials: textile fibers, bullets and the various types of tissues in the way of the penetration. Bite wound (vulnus morsum): ragged wounds with crushed tissue characterized by the shape of the biting teeth and the force of bite. It is accompanied also by the features of the torn wounds. High risk of infection (transmission of malaria, rabies, etc., human bites carry a very high risk of infection of transmission of HIV, hepatitis B). Should not be sutured.

5.2.2. “Cleanliness” - bacterial contamination Clean wounds (operation or sterile conditions, only normally present skin bacteria are detectable) with no signs of inflammation. Clean-contaminated wounds (contamination of clean wounds is endogenous and comes from the environment, the surgical team, or the patient's skin surrounding the wound). This also includes opening of the digestive, respiratory or the urogenital tract). Contaminated wounds (large contaminates infect the wound) when incision is performed at a purulent area or in case of a leakage from the GI tract). Dirty wounds (the contamination comes from the established infection), residual non viable tissues and chronic traumatic wounds).

5.2.3. Time elapsing from the trauma Acute (mechanical and other injuries) 1. fresh: within 8 hrs 2. old: min 8 hrs after discontinuity of the skin Chronic (venous, arterial, diabetic and other ulcers, skin- soft tissue defects): 1. does not heal within 4 weeks after beginning of wound management, 2. the wound does not heal within 8 weeks.

5.2.4. Thickness Grade 1: non-blanchable erythema of intact skin. Discoloration of the skin, warmth, oedema, induration or hardness may also be used as indicators in people with dark skin. Grade 2: partial-thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion or blister. Grade 3 full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. Grade 4: Deep wounds or complex wounds (e.g. laceration, vessel, nerve injury) or that of the bone or supporting structures, opening of body cavities, penetrating injuries of organs

5.4.5. Factors affecting wound healing Glycocorticoids inhibit fibroblast activity, protein synthesis, immune responses. Some antibiotics inhibit collagen biosynthesis. Cytostatic agents delay metabolic processes. Anti-inflammatory agents reduce hyperemia and blood supply to the wound (may slow down the healing process if they are taken after the first several days of healing. After this period, anti-inflammatory drugs should not have an effect on the healing process).

98 The role of nutrition, protein, vitamin (B, C, K), and trace element (Zn, Mg) status is also inevitable. Diabetes mellitus increases the risk of infection, micro- and macrocirculatory dysfunction and hyperglycemia predisposes to chronic wound formation. An altered liver function during icterus, anemia and bacterial/other forms of infection also wound healing.

5.4.6. Wound closure Paul Leopold Friedrich (1898) founder of primary wound management. Primary suture: immediate surgical wound closure can be performed within 12 hrs after the injury if no signs of inflammation or contamination can be detected (see below). Delayed primary wound closure: after a 3-8-day open wound management, surgical wound is performed (see below). Early secondary surgical wound closure: after an open wound management, surgical wound is performed after 2 weeks (see below). Late secondary surgical wound closure: after an open wound management, surgical wound is performed after 4-6 weeks (see below).

5.5. Determinants of healing of surgical wounds 1. The preparation of the operating site, hygiene, shaving, disinfection and isolation. 2. The incision should be parallel with the Langer lines. The skin is stretched, the scalpel is held in a vertical position and the incision is performed until reaching the subcutaneous layer. 3. It is important to be aware of the anatomical aspects of the involved area. The muscle is separated along its fascia, handling of bleeding is of importance, etc.

5.6. Skin incision Skin incision is made on prepared (cleansed, draped) operative fields. During incision the surgeon and the assistant stretch the skin with sterile towels on both sides of the operative field. Usually a scalpel (e.g. #20 blade, #4 handle) is used. The type of the scalpel depends on the place of incision. Holding the scalpel varies according to the use. 1. For delicate, curved incision of fine structures hold the scalpel like a pen. 2. For long straight incision hold the scalpel like a fiddle bow.

The requirements of skin incision

99 - the length of incision should be enough for safe surgery, - do not hurt vessels, nerves, - skin edges should be smooth, - do the incision perpendicularly to the skin with a single definite cut (attempts result in ragged edges and prevent wound healing), - the direction of the incision depends on the location of the organ being operated, - incise the skin parallel to the Langer’s lines (better wound healing, less scar formation), - usually incise toward oneself, and from the left side to right, - the depth of the incision must be the same in the whole length: a. at the beginning insert the tip of the scalpel perpendicularly into the skin, b. cut at 45° angle with the blade of scalpel (not with the tip!), c. finish the incision holding the scalpel perpendicularly. Discard the skin scalpel into the container after skin incision. In the deeper layers use another one.

5.6.1. Main types of skin incisions Kocher’s transverse incision at the base of the neck (thyroid gland) Sternotomy, thoracotomy Subcostal (gallbladder, spleen) Median/paramedian laparotomy (may be upper or lower according to the umbilicus), transrectal/pararectal/transversal laparotomies Pfannenstiel suprapubic incision (bladder, uterus, ovaries) McBurney incision (appendectomy) Inguinal incisions (hernia)

5.5. Closure of surgical wounds Fascia and subcutaneous layer: interrupted stitches. Do no suture the fat (fat necrosis). Skin: tissue sparing technique, accurate approximation of skin edges. Avoid tension and ischemia of the skin edges. Simple interrupted stitch is the most fundamental type in cutaneous surgery (other possibilities: Donati-type vertical mattress suture, Allgöwer, continuous intracutaneous etc. Steri-strips, clamps, tissue glues may be applied). Dressing: sterile, moist, antibiotics, non-adhesive dressings. Gauze placed directly on the wound makes dressing removal difficult and painful, tearing of the closure is possible. Holding the dressing: stretchable adhesive tape, such as Hypafix. Dressing removal: on 2nd postoperative day, daily in case of infection. Suture removal: usually after 4-6 days. Areas of good blood supply such as face: after 5-7 days. Trunk and extremities: after 10-14 days.

5.6. Drainage Drains are inserted to evacuate establish collections of pus, blood or other fluids (e.g. lymph) and drain potential collections. Arguments for their use include: drainage of fluid removes potential sources of infection, drains guard against further fluid collections, may allow the early detection of anastomotic leaks or haemorrhage. Arguments against their use include: presence of a drain increases the risk of infection, damage may be caused by mechanical pressure or suction, drains may induce an anastomotic leak, most abdominal drains infective within 24 hours.

100 5.6.1. Main types of drains Passive (without suction): stripes, tubes, glove-fingers are running on the base of the cavity entering a surface through a distinct aperture. Active (with negative pressure): open, open-closed and closed tube systems. Partially closed: a fenestrated tubing is leaving the body through a distinct aperture and connected to a sterile reservoir (Robinson drainage). Low-pressure suction: compressible harmonica bottle (Polyvac) Closed system with strong active suction: Redon drain (an approx. 50 cm long plastic tubing with X-ray positive stripes and perforations).

5.6.1. Drain removal Drain = foreign material. It should be removed as soon as possible, if indicated: decreasing fluid volume, changing cellular composition (type, number). In case of postoperative bleeding the removal is usually indicated in 1-2 days, bacterial infections: 2-5 days, large space, dead space: 3-14 days.

5.7. Complications of wound closure 1. Haematoma, seroma, etc. (see there) 2. Wound infection (see SSI also)

5.7.1. Superficial infections (1) Diffuse superficial (e.g. erysipelas). Streptococcus haemolyticus-induced lymphangitis, linear, diffuse subcutaneous inflammation. Treatment: rest, antibiotics, dermatology consultation. (2) Localized (e.g. stitch abscess, filum suppuratio). Can occur everywhere: under the skin, between muscles, subfascially, chest, brain, liver. Therapy: radical surgery, drainage. Foreign material (corpus alienum – filum suppuration). Even after years (X-ray!).

5.7.2. Deep infections (1) diffuse (e.g. anaerobic necrosis). (2) localized (e.g. empyema). In body cavities (chest, joints). Therapy: surgical exploration, drainage (Staphylococcus aureus!)

5.7.3. Mixed Gangrene: necrotic tissues, putride and anaerobe infection, highly lethal, severe state. Therapy: combination of aggressive surgical debridement and effective antibiotic therapy.

101 5.7.4. Generalized Bacteraemia, pyaemia (see: sepsis)

5.7. Late complications of wound closure Scar formation at the penetration sites, hypertrophic scar, keloid, necrosis, inflammatory infiltration, abscess containing foreign materials.

5.8. Prevention of wound infection Basic general surgical education Throughout examination and preparation before surgery Compliance with asepsis „Fast” decisions, optimal exposition Atraumatic techniques Correct handling of bleedings.

5.9. Symptoms of wound infections: Inflammatory infiltration („Notae vero inflammationis sunt quattuor: rubor et tumor cum calore et dolore”. Aulus Cornelius Celsus (25-50 BC:.–45-50 AD) De Medica (1478) Liber III. 10) + functio laesa (Virchow 1858). General therapy, rest and steam bandage if necessary. In case of aggravation of symptoms: - Wound exploration under local anesthesia; - Surgical removal of pus, necrotic tissues, foreign material; - Swabs are sent for culture. - Rinsing with 3% H2O2 solution (or with antiseptics, povidon-jodid: Betadine, Braunol) - Open wound management; - Daily wound toilette.

5.10. Phases of wound healing All wounds heal following a specific sequence of phases which may overlap. The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption. 1. Hemostasis–inflammation (0-2 days). Signs of inflammation (rubor, tumor, calor, dolor). The wound fills with blood clot and thrombocyte aggregates, fibrin production develops. Blood flow is increased, macrophage and leukocyte mediators are released. Development of a chemical gradient, removal of non vital cellular material and bacterial components. 2. Granulation–proliferation (3-7 days). Characterised by the formation of granulation tissue: fibroblasts, inflammatory cells, new capillaries embedded in a loose extra cellular matrix (angiogenesis) of collagen, fibronectin (model the ECM) and hyaluronic acid providing a good basis of re-epithelialization. The healthy sprout is red and does not bleed. 3. Remodeling (from day 8 lasting for months). (A) Maturation = ECM remodeling, continuous collagen deposition. The scar is characterized by intensive strand formation, the vascularity is reduced and becomes brighter. The ECM is loose and relatively weak (20% of final strength after 3 weeks). (B) The fibers contract and become smaller in size and become stronger. This contraction can cause reduction of joint functions. This is pronounced for a year, but remodelling prolongs for undefined time. (C) Final strength of wound is around 70%-80% of that of uninjured tissue.

102 The scheme of the sanatio per primam intentionem. According to Galen (129-199 BC) this is the „first intention of a doctor”.

103 The scheme of sanatio per secundam intentionem. Tissue loss is accommodated by proliferation according to the „second possible intention of a doctor” (as a result of either a- bacterial or purulent inflammation, a connective tissue proliferation occurs which turns into scar formation).

5.11. Wound healing disorders

5.11.1. Keloids Unknown etiology, resembles a benign tumor, affect mostly African, and Asian populations; Well-defined edges, pinkish brown, emerging, tough structures which is resulting form the proliferation of the subcutaneous; Particularly affects scars on the pre-sternal and deltoid areas, ears; Does not cause any pain, but constantly develops; Treatment: intralesional corticosteroid injections, cryosurgery, excision, radiation therapy, laser therapy, interferon therapy, imiquimod 5% cream. Prevention with atraumatic technique.

5.11.2. Hypertrophic scars Develops at areas of thick chorium; Composed of non-hyalinic collagen fibers and fibroblacts; Confined to the incision line. Treatment: regress spontaneously starting 12-18 months after surgery and lower back to the level of the skin in 1-2 years.

Keloid and hypertrophic scar

5.12. Wound management of accidental wounds 5.12.1. Principles Each accidental (not surgical) wound should be regarded infected therefore we should remove the causative agents and the devitalized tissues. The accidental wound should be transformed to a surgical one.

104 Phases Management Inspection Under sterile circumstances (hat, mask, glove) Anamnesis  Elucidation of the circumstances of injury. Wan did it occur? The earlier we manage the wound and smaller possibility of infection. Is the patient suffering from diseases which are associated with a worse tendency of healing (diabetes)? Clarification of the circumstances of injury helps to judge the danger or infection.  Validity of Tetanus vaccination should be clarified. In the presence of spoiled wounds, an at least vaccination with anti-tetanus immune-globulin is recommended. The vaccination and its registration take place at the corresponding traumatology department.  Prophylaxis of rabies: in case of bitten wounds (vaccination with Rabipur on days 0, 3, 7, 14, 30, and 90) Diagnostic Exclusion of accompanying injury procedures  Examinations of the circulatory, sensibility and motoric functions  Exclusion of bone fracture with X-ray Wound  The surgical wounds should be handled according to procedures described in management chapter focusing on suture types.  The accidental wound should be managed based on the depth of injury and the danger of infection with primary or with delayed wound closure (see next table).

5.12.2. Types of wound management Temporary Aim: prevention of secondary infection - cleansing wound - handling of bleeding management - covering (first aid) Definite Surgical wound closure is performed if the time - cleansing primary wound frame of injury is less than 12 hs. - anesthesia management - excision (< 6-8 hs, except: face, hand), - sutures (at punctured, bite, shot, bruised wound: situating sutures* + drain) Always primary  penetrating injury of the abdomen wound closure  of the chest is performed  of the dura mater Primary wound In the cases below, after wound cleansing the - cleansing management is wound is covered with saline a surgical covering, - covering contraindicated held in rest, than delayed sutures are placed after - primary delayed suture (3-8 days) : 4-6 days in the presence of :  infectious signs  severely spoiled  if foreign body could not completely be removed  pouched, greatly bruised wounds  special injury forms of some professions: of surgeons, butcher, veterinarian, pathologist, bacteriologist  bite, shot, deep incised wound

Never perform War casualties Alternatives: primary wound - hostility wound should always be regarded - primary delayed suture (3-8 days) closure infected with aerobic or aerobic bacteria - Approximation of wound edges with - the reaction time of the wounded person is tapes, later: sutures prolonged - situating sutures * + drain - the circumstances of wound management are - Early secondary wound closure (> 14

105 poor: days) - do not perform primary wound closure except - Late secondary wound closure (4- 6 cases of skull, chest and abdominal penetrating weeks) injuries. - Plastic surgery solutions later.

Primary delayed If no signs of infection occur within the above 4-6 3-8 days later: suture days, after excision of the wound edges, those are - anesthesia sutured (or also situating sutures*). - excision (refreshment of the wound edges) - sutures

Early secondary If wound inflammation and necrosis took place, 2 weeks after the injury: wound closure but have healed with proliferation, the wound - anesthesia edges should be refreshed and closed by suture. - excision (refreshment of the wound edges) - sutures - drain

Late secondary The proliferating former wound parts and scars 4-6 weeks after the injury: wound closure had to be first excised. In cases of greater defects, - anesthesia plastic surgery solutions should also be - excision (of the secondarily healing considered. scar) - sutures - drain

*Situating suture: The suture is performed at the time of the primary management, but the distance between the stitches is approx. 2-3 times than that of the primary surgical wound closure.

5.12.3. Management of accidental wound types Severity/depth of injury Conservative/surgical Cleansing, disinfection Wound management, management covering, bandaging Bruised, not pyodermic Needs conservative Cleansing with Betadine Treatment with superficial injury) management solution, removal of mercurochrom solution, („excoriation”) foreign bodies after drying: sterile bandaging (mull-sheet, than mull strip or elastic net). Open wound management can also be considered.

Bruised, pyogenic Conservative Cleansing with H2O2 Disinfection with Betadine injury („excoriation”) management is followed solution, rinsing with solution, sterile bandage. by surgical wound closure saline The wound is managed with open wound management and later closed with secondary surgical closure. Deeper penetrating Requires surgical wound Cleansing with Betadine Handling of bleeding, mechanical injury closure solution cleansing, excision of (vulnus scissum” and bruised edges, open wound vulnus caesum) management, sterile bandaging. The wound is closed later secondarily. Deeper blunt Requires surgical wound Cleansing with Betadine Cleansing, excision of mechanical injury closure solution bruised tissues, open (vulnus contusum) wound management, sterile bandaging. The wound is closed later secondarily.

106 Transplantation can be necessary. Vulnus morsum Requires surgical wound Cleansing with Betadine Cleansing, excision of closure, but primary solution bruised edges, open wound wound closure is management, sterile forbidden (except face)! bandaging. The wound is closed later secondarily. Rabies prophylaxis! Punctured and shot Requires surgical wound Cleansing with Betadine Cleansing, open wound wounds (vulnus closure solution, probing of the management, sterile punctum et penetrating route, bandaging. The wound is sclopetarium) removal of foreign closed later secondarily. bodies. Antibiotics prophylaxis in special cases! Inflamed wounds (war Combined conservative Steam-bandage, keeping - Open wound injuries, wound spoiled and surgical management in rest. If inflammatory management until with soil, foreign for days, than surgical signs are accelerating: completion of the bodies, if wound edges wound closure - surgical exposition inflammatory process, are irregular, bad under anesthesia daily wound cleansing immunological status) - the wound is opened sterile bandaging and the excretion is - tranquillization of the removed, the necrotic inflamed skin (Burow tissue and foreign bodies ointment, ice, Zinc- are removed Aluminium-containing - cleansing with H2O2 pharmacy products) solution, rinsing with - for epithelisation: saline (Mercurochrom treatment - (or with antiseptic, -Sol. Merbromi -Mikulitz Betadine, Braunol ointment, Dermasin solutions even diluted ointment, Bepanten, with saline, intermittent Neogranormon, Actovegin flushing/suctioning of the 5%-os creams) wounds) - Deodoration (alginate - (or disinfecting with and carbon-containing Octenisept which does bandages ie. Kaltostat, not irritate) Melgisorb etc.) - (or soaking with - Purification (fibrinolysis Neomagnol on the limbs) with Fibrolan, Iruxol - open wound mono, Mesalt etc.) management with daily - Incision instead of cleansing antibiotics - bacteriological sampling or from the wound. Friedrich-style wound excision, drainage if necessary complying with the criteria of asepsis.

5.12.4. The schemes of wound management

107 .12.5. Solutions, ointments

H2O2 3%-solution which removes necrotic tissues. Bubbling can be observed on the surface when necrotic parts are present. Let it act for minutes on the wound than rinse it thoroughly with saline. Betadine, Braunol Iodine-containing disinfecting solutions which (in contrast to iodine tincture) can have solutions direct contact with the wound. Octenisept solution A non-irritating disinfecting solution. Mercurochrom Pharmacy product which is particularly excellent treatment for superficial wound. tincture Accelerates epithelization. Vazelin ointment Prevents the adhesion formation between the wound and the bandage. Betadine ointment Prevents infection and also the adhesion formation between the wound and the bandage. Neogranormon Accelerates epithelization, applicable particularly at superficial erosions and sloughs. ointment Burow ointment Applicable under steam bandages, facilitates the exhaustion of purulent material. Fibrolan, Iruxol Fibrinolytic enzyme containing substances, facilitate epithelization. Applicable at the mono, Mesalt areas near by ulcers, stomas and fistulas. ointment

5.13. Bandaging Definition: stringy materials which protect and spare the injured body parts.

5.13.1. Layers of bandages 1. Layer in direct contact with the wound (sterile, hypoallergenic, not irritating). - simple sheet (e.g. mull sheet: good fluid absorbent, but easily sticks to the wound), - impregnated sheet (vazeline, paraffin: i.e. “Jelonet”, but there are also sheets impregnated with antiseptic materials). Does not stick to the wound and protects it from drying out. There are also sheets impregnated with saline which melt when get into contact with body fluids and help cleaning of the wound, i.e. Mesalt. 1. Absorbent layer (to absorb and store blood and excretions) 2. Fixing layer to secure the bandage (adherent tapes i.e. Centerplast, Leukoplast or Mefix, Mepore; the latter two for bigger surfaces).

5.13.2. Types of bandages Adherent/taped bandages Used to fix covering bandages or for the approximation of edges of small wounds. Conditions of the application: should stick well to the skin surface and be hypoallergenic. There are self- adherent types with a surface in the middle ready to contact the wound. Those should be permeable to air and good fluid absorbents. Covering bandages Used to protect the wound and absorb secretion. These should be non-sticking into the wound, good fluid absorbents and well permeable to air. The bandage protects the wound from

108 secondary infection and mechanical forces. Absorption of the secretion is very important, because Absorption protects the skin from the irritation caused by soaking in body fluids which also predisposes to infections. When great amount of secretion is dried in the bandage, it compresses the neighbouring skin causing further injury. The frequency of bandage changing depends on the fluid produced in the wound. During these procedures, we also check the healing process. The swollen, painful, red skin implicates infection. The bandage can be produced of natural fibers (cotton, silk), semi-synthetic, synthetic or synthetic materials. The advantage of natural fibers is the good fluid absorbent capacity, but these easily stick into the wound. The synthetic materials have the opposite features. The primarily closed wounds are protected with sterile covering bandages for 2-3 days. If the is a hint for secondary bleeding or infection, earlier changing is necessary. The causeless frequent changing facilitates infection. After the 5th postoperative days, the tranquil operative field can be left uncovered. At greater traumatic areas or burn injury, multi-layered poly-urethane sheets are applicable (i.e. Epigard). These are well permeable to air and good fluid absorbents and provide ideal circumstances for skin transplantation. Pressing bandages For temporary handling of capillary and venous bleedings under 40-60 mmHg. Wedging bandage Used for temporary handling of capillary arterial and venous bleedings to prevent great blood loss before the final surgical intervention. The wound is covered by a sheet, than we put a gauze sponge ball on the source of the bleeding and fix it with a considerably tight bandage. The force of the compression must not exceed the arterial blood pressure. The tourniquet can cause in-adequate blood supply therefore it should be relieved in every 2 hrs. Compressing bandages Used to prevent postoperative bleeding on the limbs, and for the prophylaxis of thrombosis and for the reduction of chronic lymph-edema. Can consist of different materials: - Mull-strip: disadvantage the crease formation, not elastic, - elastic strip, - synthetic, self-adherent strip, - elastic sock. The window or crease formation should be prevented, because those can cause circulatory disorders. The upper limbs are more endangered, because the tissues are finer, the vessels and nerves are more superficial. The nerve injury caused by compression (neuropraxy) and the circulatory disorders (Volkmann-contracture, Sudeck-dystrophy) can develop. The compressing bandage should always be started distally to prevent venous stasis. The circumferential application is forbidden because of the danger of strangulation! Special compressing bandages Ear-bandage. Special striping of the extremities. Advantage: stability, non-creasy. Placed from distal to proximal (see figure). Esmarch-tourniqet. Maximal compression is elicited by using a 10-cm-rubber string to stop arterial bleeding on the limbs. Duration should not be longer than 2 hrs. Fixing/retention bandage Used to immobilize the injured body part or to fix the reposition. The material used should be light and be worn with minimal strain. Can be made of elastic strip, cast, plastic or metal rails, or pneumatic rails, cotton embedded tubes (rucksack-bandage, Charnley-loop). Special fixing/retention bandage

109 Schanz-collar. Used to immobilize the vertebras. Its material is special: 8-15-cm-wide. 1,5- cm-thick, 50-cm-long padded stripe. It can be made also of cotton-embedded elastic band. It should be places loosely to prevent the movements of the jugular vertebras. Desault-bandage (see figure). Used to immobilize the shoulder and elbow. It can be made of cotton-embedded elastic band or a textile net. The skin should be talc-powdered first to protect from perspiration. We fix the injured arm (with flexed elbow) to the trunk with some circumferentially positioned bands. The route of the bandage around the chest follows an “8” shape connecting the shoulder to the injured arm. Gilchrist-bandage (see figure). Used to immobilize the shoulder and elbow. Hanging of the arm over neck towards the back prevents the movements of the shoulder and elbow. Rucksack-bandage (see figure). For the reposition and immobilization of the clavicula. It can be made of cotton-embedded elastic band and the route of the string is the same as that of the stripes of the rucksack. The radial pulse and the venous perfusion should be often checked. Should be checked and adjusted on the daily basis. Charnley-loop (see figure). Used to fix the elbow in cases of infant supracondyler humerus fractures. After reposition, the elbow junction should be fixed in a sharp angle elicited by nagging of the arm in the neck. The radial pulse should be checked. Triangle-scarf bandage. Used to fix the areas of the shoulder and arm upon injury. The arm is placed into a triangle-scarf and the corners are tightened behind the neck. Sling-bandage: to stop the bleeding of the noose. We place a pressing bandage on the noose made of a gauze sponge and tighten in behind the head using a Mull-band. Cast bandages: see traumatology manuals.

Ear bandage

110 Desault-bandage

Gilchrist-bandage

111 Charnley-loop

Rucksack bandage

5.14. Innovations in wound treatment 1. Lucilia sericata, Phaenicia sericata (greenbottles): 2 mm large sterile fly larvae („biobag”). The larvae ingest bacteria which are destroyed in their gut (e.g. MRSA - Methicillin-resistant Staphylococcus aureus). Advantages: can be applied on a wide range of infected wounds, removes slough and malodour, Associated problems: potentially infected larvae, allergic reaction, tickling sensation, ethical issues, aesthetic issues 2. VAC (Vacuum-Assisted Closure) therapy: negative pressure suction drainage. It is not a brand new idea as drainage methods were employed for years, the fundamental difference: application of topical negative sub-atmospheric pressure across the surface of the wound Advantages: provides a moist environment, prevents bacterial activity, evacuates excess exudate, kills anaerobic bacteria in the wound bed, controls odour. Contraindications: fistula of unknown source, opening into a body cavity, vulnerable body organs, malignancy, necrotic tissue with scar, untreated osteomyelitis.