Minor surgical aspects of closed wounds

Abstract

Basic surgica1 principIes are appIicabIe in any situation but there is much to be considered in the attempt to restore the injured tissue, member, organ or individua1 to its pre-trauma function. Christopher2 defines a wound as an injury or forcible soIution of continuity of any tissue of the body caused by external violence. A cIosed wound is a wound without a break in the skin or mucous membrane. AIthough the term viotence generaIIy indicates physica force, thermal or chemica1 disturbances are incIuded. (TabIe I.) A contusion or bruise is a traumatic soIution of continuity of tissue without compIete anatomic separation. It is accompanied by an effusion of bIood or Iymph by sweIIing and occasionaIIy by the formation of blebs. When the skin is unbroken, the fluid collection can be considered steriIe and severa methods may be applied to hasten reabsorption of the effusion. In general, the time-honored treatment of bruises or contusions has been a preIiminary attempt to IocaIize and prevent edema by the immediate appIication of coId, be it a coId tabIe knife, ice packs or ethy1 chIoride spray. KessIer and Van Emburgh treated 198 cases of trauma with antihistamines on the theory that the edema was on the basis of JocaJIy liberated histamine. They were greatIy impressed with their resuIts and found that pain and IocaI edema were markedly decreased. After gathering their materia1, Kessler and Van Emburgh were somewhat dismayed by Mayer’s6 report which indicated that the inffammatory reaction in tissue produces a high hyaIuronidase concentration. As it is known that the antihistamines have the capacity to destroy or Jimit the action of hyaluronidase, it was their amended conclusion that the action of the antihistamines was that of destroying the hyaIuronidase-spreading factor. When the initial phase of edema and vasospasm has been controIIed by coJd applications or the use of antihistamines, some methods of removing IocaI Auid accumuIations is indicated. Needle aspiration wiJ1 frequentIy be sufficient, but contaminated or infected hematomas may require incision and drainage. Hyaluronidase can be used in aseptic conditions in an attempt to disseminate ffuid accumuIations under tension. The usuaJ dose, $00 viscosity units aIidase@* mixed in a small amount of normal saline, is injected into the localized Auid. Mixing the hyaluronidase in I per cent procaine soIution wiI1 aIso produce IocaI vasodilatation, relief of IocaI pain and more rapid absorption of the fluid mass. This method can aIso be applied to traumatized bursae or synovia1 spaces which do not respond to repeated aspirations. The treatment of sprains and strains can be considered as a single entity. They both consist of incompIete tears or overstretching of the invoIved structure, producing spasm and Iimited function. The initia1 concept of treatment of a torn muscIe or Iigament was that of immobiIization and rest unti1 the injured tissue healed. It is surprising that this misconception has persisted with the use of adhesive tape strapping, pIaster casts and compIete disuse being the most wideIy accepted method of treatment for a sprained joint or strained back, shouIder or hip. Leriche and ArnuIf6 described