[MUSIC] [MUSIC] [MUSIC] Cuts are caused by sharp, cutting objects. They reveal wounds with smooth edges and pointed angles to the wound. All skin layers are usually severed apart from the wound base. Cuts tend to produce strong instances of bleeding and demonstrate a good tendency towards healing. The important thing with all wounds caused by glass with sharp edges is that thought must be given to the possibility of foreign body penetration. This means that an imaging diagnostic investigation, e.g. by means of x-ray, is mandatory with all injuries. This slide shows the algorithm determining the procedure to be followed with injuries involving glass shards. First of all, it is important to know the patient history and to gather findings. In these processes, a record should be kept of the time the accident occurred, the accident mechanism, whether the patient has the feeling of a foreign body being in situ, the localisation of the injury and whether a visible foreign body can be identified. Furthermore, as is always the case, perfusion, motor function and sensitivity at the periphery must also be examined and recorded, together with any concomitant injuries being identified. A check must then be made as to whether the patient has adequate tetanus protection. If the injury is located in the head or neck region, a computerised tomogram should be conducted so as to exclude any foreign bodies which may be lying at a deeper level. The exclusion of foreign bodies can be undertaken for extremities by means of x-ray images or ultrasound. If vessels, nerves or tendons are involved, then revision of the injury under general or local anaesthetic is required. The administration of prophylactic antibiotics is important. If it is impossible to remove the glass, then the patient will have to undergo surgical treatment again. Clarification must be obtained as to whether in-patient treatment is indicated due to the injury mechanism. If yes, then the patient should be admitted for inpatient treatment and, if no, he or she can be discharged after detailed information has been given about the further treatment to be provided. Any localised or extensive tissue penetration or destruction caused by external influences is designated as a wound. The cuts described above are therefore a form of wound. In addition to these cuts, lacerations, crush injuries, burns and frostbite injuries, scratch and bite injuries can therefore also be found. Hello! Hello! My name is Prof. Kanz. My name is Anna Meier. So what have you been up to? I am a waitress and I slipped whilst holding a beer glas... and was picking up the shards when I cut myself. Hmm. An accident at work in that case. I now need to take a look at the wound. Oh, yes, we’ll need to stitch that up. Have you been vaccinated for tetanus? Yes, I have already been vaccinated, but.... When was that? ... I am not sure it is still effective? 5 Jahr, 10 Jahr? 5 years, perhaps. 5 would be appropriate. Do you have a vaccination card? Card? I’m not going to drag that around with me at work. OK. Then have a look for it at home, please. Ok. After 10 years, we would need to re-vaccinate you. Move your fingers please. Also against pressure when I hold them
Auch so gegen Kraft,
tightly here, ingers upwards, here, all of them. And can you feel everything here or is there a feeling of numbness there? No, no. I can feel that OK. That’s good. The next thing for us to do is to take an x-ray image and have a look as to whether any shards of glass have gotten into the wound. We don’t want to just stitch up the wound and leave any shards which may be left inside. But I have got to get back to work. Can't you just stitch up the wound? What, and leave the glass shards in there, which will then sever the nerves? Ok. Yes? Okay. Right. I’ll make an appointment for an X-ray. We’ll make an x-ray image, have a look at it and then we’ll provide the treatment needed. We can do that under local anaesthetic. Ok. We need to take a close look at the wound first, however, and then we’ll talk further. Given the way it looks, working will be difficult for you. You’ve got the bandage to begin with, though. Oh, it’ll be alright. Ok. So I'll come back once the x-ray has been taken. Is that OK? Yes, fine. And where should I go now? Complications with wounds essentially consist of the extravasation of blood and serum and the loss of fluids, humoral and cellular components of blood associated with this. Complications associated with wounds can be haematomas, infections, functional disorders, haermorrhagic shock etc. The loss of the protective function of the uninjured surface, and therewith the possibility of penetration by pathogens, foreign bodies, toxins etc., is an important factor. A distinction can basically be drawn between two different types of wound healing: primary and secondary wound healing. Primary wound healing is possible if the edges of the wound are smooth, well perfused and have low levels of contamination. They must be mechanically stable and capable of adapting well. Secondary wound healing means that wound healing can occur with extensive defects or concomitant infections. It takes place via the formation of granulation tissue or scar tissue. The three phases of wound healing can be distinguished as the exudative phase on Day 1-3, the proliferative phase on Day 2-20 and the reparative phase on Day 3 up to the sixth month. The principles of wound treatment provide initially for anaesthetic treatment of the area of the wound. This can either be undertaken employing very high local anaesthesia or infiltration anaesthesia. After this, haemostasis should be undertaken in the area of the wound. The wound should then be rinsed so as to remove any potential contamination or soiling. This is then followed by occlusion of the wound, conducting a check on tetanus protection and, if applicable, a booster for this being administered as well as possibly the administration of antibiotics. Injuries penetrating deeper than the basal layer must be treated under aseptic conditions in the operating theatre. Primary wound closure should occur within six hours and in exceptional cases within twelve hours. OK. We are now going to do the following: to begin with, I’ll apply a local anaesthetic here and then we’ll give you an injection through the skin. The main nerve controlling the fingers and the inside surface of the hand is located here under the skin. We will then make it numb at this site which will mean it is numb below here as well and then you won't feel anything there anymore. This region of your hand will then be numb.. Hmm... ... but this part won’t be. Ok. We’ll take a look at the wound and see how deep it is. If it goes particularly deep and any flexor tendons are injured, then we will need to provide treatment in the operating theatre. If it is only superficial, then we can apply stitches right away and it will only need 10 to 14 days until it is healed. If you are going to carry on working today, you will need a dressing. I would really not recommend it, but if you insist on doing it, then I cannot stop you. There were no shards of glass in the wound. Ok. We don’t need to search for any as none showed up in the x-ray image. You just need to tell me if you feel an electrifying feeling as that will mean I have hit a nerve and have to go to another site. This is the tendon here and I am going to make the injection next to the tendon. Can you feel any pressure? Mhhh. Electrical? No, no, it's OK. Still alright. Mhhh. I’ll be back in 15 minutes and the hand will then be numbed. And then we’ll stitch up the wound. Ok. The anaesthetic is washing around the nerve. Yes? Yes, it’s OK. Yes, it takes a certain time and then - very good. Okay. And how long will it feel numb? Roughly one or two hours. Ok. The anaesthesia for treating a wound can either be administered by means of local anaesthesia or by means of regional or conductive anaesthesia. This happens either by means of direct infiltration for local anaesthesia or by means of field or nerve block for regional or conductive anaesthesia. Very great importance is attached to surgical débridement. The wound must be especially carefully cleared of any foreign bodies or cleaned of any contamination in cases where the edges of the wound are not smooth or the wound is strongly soiled. The sparing surgical removal of devitalised tissue, as refreshing of the edges of wounds is described, is important. As only vital tissue has curative properties, it is important to remove any destroyed tissue completely. Diese Grafik zeigt, This slide shows how devitalised tissue can be removed by means of excision. Wounds in the face present a special problem. No excision is usually required here as crushed and strongly contaminated wounds show a good tendency to heal due to the good vascularisation which takes place. Infections rarely occur. Wounds crossing the “relaxed skin tension lines” as defined by Borges leave scars which are cosmetically more appealing than wounds running obliquely. This corresponds to the skin cleavage lines. >> That does not look bad in your case. The wound is only a superficial one and there is an intermediate layer in the hand, called the palmar aponeurosis, and that has not been opened. We can just put a stitch in that and nothing has happened with the deep tendons. I’ll stitch this up for you now. If you experience any pain there, then just tell me. Then we’ll give you a second injection, OK? Yes. Okay. Good. Here you are. Superficial wounds can be occluded either by means of spirit gum or wound occlusion strips, also referred to as Steri-Strips. Wounds penetrating deeper than the basal layer have to be occluded by means of wound suture, usually employing interrupted sutures or Donati back-and-forth sutures. Stapling can also be undertaken in this regard in individual cases. This slide shows the principles underpinning interrupted sutures. It can be seen in Image B how both edges of a wound can be deeply pierced by means of the needle. It can be seen in Image C how the needle is held by means of the needle holder and the suture is pulled through. What then follows, as can be recognised in Image E, is the tying of a knot in the suture which, as can be recognised in Image F, is knotted down onto the skin. Image G shows the distance between the individual interrupted sutures. For head lacerations, the rule is that the removal of the needle insertion point is to have a distance from the edge of the wound corresponding to approx. half the depth of the wound. This usually amounts to between 5 and 7 mm. The distance from suture to suture is between 10 and 15 mm. The knotting of the interrupted suture should be placed parietal in each case. In terms of removal of the suture material, the rule of thumb to be applied is approx. 10 days. As healing occurs significantly more quickly in the face and neck region, the sutures can already be removed after 3-5 days. >> We’ll soon be finished. >> Mmmm. >> Yes, you were right. I won't be able to go back to work. >> Yes, that is what I would have advised. If there had been any doubt, I would have said, I am afraid I am going to have to report to your professional association that you are not acting sensibly. And if anything happens, then just come back here immediately, at any time of the day or night, such as if you experience strong pain or if this bleeds, for example. >> Yes, I’ll see you in two days when I’ll come back again for this cleaning of the wound. >> Your GP can do that as well. >> But you said that I could also come here, at any time of the day or night. [MUSIC]
