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
Surgical
wounds
Accidental
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
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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).
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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
- the length of incision should be enough for safe surgery,
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- 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.
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.
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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.
5.7.4. Generalized
Bacteraemia, pyaemia (see: sepsis)
5.7. Late complications of wound closure
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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.
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The scheme of the sanatio per primam intentionem. According to Galen (129-199 BC) this is
the „first intention of a doctor”.
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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 abacterial 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.
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Phases
Inspection
Anamnesis
Diagnostic
procedures
Wound
management
Management
Under sterile circumstances (hat, mask, glove)
 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)
Exclusion of accompanying injury
 Examinations of the circulatory, sensibility and motoric functions
 Exclusion of bone fracture with X-ray
 The surgical wounds should be handled according to procedures described in
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
wound
management
(first aid)
Definite
primary wound
management
Aim: prevention of secondary infection
- cleansing
- handling of bleeding
- covering
Surgical wound closure is performed if the time
frame of injury is less than 12 hs.
- cleansing
- anesthesia
- excision (< 6-8 hs, except: face,
hand),
- sutures
(at punctured, bite, shot, bruised
wound: situating sutures* + drain)
Always primary
wound closure
is performed
Primary wound
management is
contraindicated:
 penetrating injury of the abdomen
 of the chest
 of the dura mater
In the cases below, after wound cleansing the
wound is covered with saline a surgical covering,
held in rest, than delayed sutures are placed after
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
primary wound
closure
War casualties
- hostility wound should always be regarded
infected with aerobic or aerobic bacteria
- the reaction time of the wounded person is
prolonged
- the circumstances of wound management are
poor:
- do not perform primary wound closure except
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- cleansing
- covering
- primary delayed suture (3-8 days)
Alternatives:
- primary delayed suture (3-8 days)
- Approximation of wound edges with
tapes, later: sutures
- situating sutures * + drain
- Early secondary wound closure (> 14
days)
- Late secondary wound closure (4- 6
cases of skull, chest and abdominal penetrating
injuries.
weeks)
- Plastic surgery solutions later.
Primary delayed
suture
If no signs of infection occur within the above 4-6
days, after excision of the wound edges, those are
sutured (or also situating sutures*).
3-8 days later:
- anesthesia
- excision (refreshment of the wound
edges)
- sutures
Early secondary
wound closure
If wound inflammation and necrosis took place,
but have healed with proliferation, the wound
edges should be refreshed and closed by suture.
2 weeks after the injury:
- anesthesia
- excision (refreshment of the wound
edges)
- sutures
- drain
Late secondary
wound closure
The proliferating former wound parts and scars
had to be first excised. In cases of greater defects,
plastic surgery solutions should also be
considered.
4-6 weeks after the injury:
- anesthesia
- excision (of the secondarily healing
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
management
Needs conservative
management
Cleansing, disinfection
Bruised, pyogenic
injury („excoriation”)
Conservative
management is followed
by surgical wound closure
Cleansing with H2O2
solution, rinsing with
saline
Deeper penetrating
mechanical injury
(vulnus scissum” and
vulnus caesum)
Requires surgical wound
closure
Cleansing with Betadine
solution
Deeper blunt
mechanical injury
(vulnus contusum)
Requires surgical wound
closure
Cleansing with Betadine
solution
Bruised, not pyodermic
superficial injury)
(„excoriation”)
Cleansing with Betadine
solution, removal of
foreign bodies
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Wound management,
covering, bandaging
Treatment with
mercurochrom solution,
after drying: sterile
bandaging (mull-sheet,
than mull strip or elastic
net). Open wound
management can also be
considered.
Disinfection with Betadine
solution, sterile bandage.
The wound is managed
with open wound
management and later
closed with secondary
surgical closure.
Handling of bleeding,
cleansing, excision of
bruised edges, open
wound management,
sterile bandaging. The
wound is closed later
secondarily.
Cleansing, excision of
bruised tissues, open
wound management,
sterile bandaging. The
wound is closed later
secondarily.
Transplantation can be
Vulnus morsum
Requires surgical wound
closure, but primary
wound closure is
forbidden (except face)!
Cleansing with Betadine
solution
Punctured and shot
wounds (vulnus
punctum et
sclopetarium)
Requires surgical wound
closure
Cleansing with Betadine
solution, probing of the
penetrating route,
removal of foreign
bodies.
Inflamed wounds (war
injuries, wound spoiled
with soil, foreign
bodies, if wound edges
are irregular, bad
immunological status)
Combined conservative
and surgical management
for days, than surgical
wound closure
Steam-bandage, keeping
in rest. If inflammatory
signs are accelerating:
- surgical exposition
under anesthesia
- the wound is opened
and the excretion is
removed, the necrotic
tissue and foreign bodies
are removed
- cleansing with H2O2
solution, rinsing with
saline
- (or with antiseptic,
Betadine, Braunol
solutions even diluted
with saline, intermittent
flushing/suctioning of the
wounds)
- (or disinfecting with
Octenisept which does
not irritate)
- (or soaking with
Neomagnol on the limbs)
- open wound
management with daily
cleansing
- bacteriological sampling
from the wound.
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necessary.
Cleansing, excision of
bruised edges, open
wound management,
sterile bandaging. The
wound is closed later
secondarily. Rabies
prophylaxis!
Cleansing, open wound
management, sterile
bandaging. The wound is
closed later secondarily.
Antibiotics prophylaxis in
special cases!
- Open wound
management until
completion of the
inflammatory process,
daily wound cleansing
sterile bandaging
- tranquillization of the
inflamed skin (Burow
ointment, ice, ZincAluminium-containing
pharmacy products)
- for epithelisation:
(Mercurochrom treatment
-Sol. Merbromi -Mikulitz
ointment, Dermasin
ointment, Bepanten,
Neogranormon, Actovegin
5%-os creams)
- Deodoration (alginate
and carbon-containing
bandages ie. Kaltostat,
Melgisorb etc.)
- Purification (fibrinolysis
with Fibrolan, Iruxol
mono, Mesalt etc.)
- Incision instead of
antibiotics
or
Friedrich-style wound
excision, drainage if
necessary complying with
the criteria of asepsis.
5.12.4. The schemes of wound management
.12.5. Solutions, ointments
H2O2
Betadine, Braunol
solutions
Octenisept solution
Mercurochrom
tincture
Vazelin ointment
Betadine ointment
Neogranormon
ointment
Burow ointment
Fibrolan,
Iruxol
mono,
Mesalt
ointment
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.
Iodine-containing disinfecting solutions which (in contrast to iodine tincture) can have
direct contact with the wound.
A non-irritating disinfecting solution.
Pharmacy product which is particularly excellent treatment for superficial wound.
Accelerates epithelization.
Prevents the adhesion formation between the wound and the bandage.
Prevents infection and also the adhesion formation between the wound and the
bandage.
Accelerates epithelization, applicable particularly at superficial erosions and sloughs.
Applicable under steam bandages, facilitates the exhaustion of purulent material.
Fibrinolytic enzyme containing substances, facilitate epithelization. Applicable at the
areas near by ulcers, stomas and fistulas.
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).
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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 selfadherent 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
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
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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
Schanz-collar. Used to immobilize the vertebras. Its material is special: 8-15-cm-wide. 1,5cm-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
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Desault-bandage
Gilchrist-bandage
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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.
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