Wound Exploration Research Articles

Novel use of a Sengstaken–Blakemore tube during a neck exploration of a carotid injury: A case report

Penetrating neck trauma can injure the major blood vessels, airway, gastrointestinal system, and neurological system. We present a case where a Sengstaken–Blakemore tube was emergently placed during surgical exploration of a stab wound to the neck to tamponade bleeding until surgical control was obtained and the vascular injuries were managed.

A retained surgical drain in the abdomen for five years

Retained surgical drain in the peritoneal cavity is very rare but potentially dangerous error. Most cases are unreported because of the fear of medico-legal problems. Management of such iatrogenic complications requires repeated laparotomy or wound exploration. We reported a case of a large corrugated rubber drain migrated and retained accidently in the abdominal cavity in a patient who underwent exploratory laparotomy for peritonitis secondary to perforated appendix about five years ago.

Laparoscopic Management of Stab Wound of Anterior Abdominal Wall: A Prospective Stud

Background: The anterior abdominal wall is one of the most common regions affected in penetrating stab wound injuries. Tradionally, wound exploration and exploratory laparotomy are used as a diagnostic and therapeutic modality in the management of such injuries. Recently, laparoscopy has gained popularity in the management of such cases with favorable results in carefully selected patients. The aim of the present study was to assess the role of laparoscopy in the diagnosis and management of patients with stab wounds of the anterior abdominal wall. Patients and methods: 52 hemodynamically stable patients with stab wound of the anterior abdominal wall were included in this study at the emergency department of Ain Shams University Hospitals. Patients were selectively subjected to, physical examinations, focused abdominal sonography in trauma (FAST), computed tomography (CT), exploratory laparotomy, diagnostic and therapeutic laparoscopy. Results: Out of 39 patients that underwent laparoscopy, the laparoscopy succeeded to rule out visceral injury in 14 patients (35.9%) and was nontherapeutic in 5 patients (12.8%). 17 patients (43.6%) needed therapeutic management through laparoscopy and conversion to open laparotomy was done in 3 patients (7.7%). One case of missed injury with laparoscopy was recorded (accuracy 97.4%). Conclusion: Laparoscopy is a feasible and useful modality for evaluating and managing hemodynamically stable patients with abdominal stab wounds. Increased use of laparoscopy will help to decrease the rate of negative and nontherapeutic laparotomies, thus lowering morbidity and decreasing length of hospitalization.

The Second Look after Fights: Why Wounds Might Not Only Be Superficial.

Introduction. We present a case of intraosseous foreign body penetration due to knife attack and its emergency service management. Case. Seventeen-year-old patient was admitted to the emergency department with a knife cut over the right knee. In the local wound exploration during the extension position of the knee, deep tissue penetration was not observed. Therefore, the patient was discharged after a primary wound saturation without any radiographic evaluation. During the second admission, the detailed anamnesis revealed that the injury occurred while the knee was in the flexion and the radiographic examination displayed a broken knifepoint in the sagittal plane of the femur's medial patellar region penetrated in the intraosseous tissue. Conclusion. Intraosseous foreign body cases due to the knife attacks are quite rare. There is no algorithm, indicating the necessity of radiographic examination in the stab wounds. Local wound exploration of stab wounds should be done in accordance with the mechanism of injury.

Management of Homicidal Cut Throat Injury at a Peripheral Set up: A Case Report

Homicidal cut-throat injuries are potentially life threatening because of the many vital structures that course through this area. Definite incidence of homicidal cut-throat injuries is unavailable as many are fatal before making it to a medical echelon. These patients need emergency and multispecialty care with multidisciplinary approach, managing these cases at peripherally located sub-optimally equipped medical setups is a challenge in itself, despite being apparently stable and breathing spontaneously, these patients rapidly deteriorate. Expertise in managing airway is pivotal in securing a definitive airway in such cases thereby facilitating the wound exploration and surgical repair. We present a patient who was the victim of a homicidal cut-throat injury at a peripherally located medical setup at north eastern part of India.

Accidental Bolt Gun Injury to Femur - A Case Report

Introduction:Bolt gun or slaughterer’s guns are used in meat industry for “humane killing” of animals. Injuries caused by bolt gun are rare, reported exclusively from central European countries. We report a case of 28 year old male, who accidentally shot himself with a bolt gun to his right thigh.Case Report:A 28 years old male presented to our Accident and Emergency department after accidental injury to his right thigh with bolt gun. He had an entry wound measuring 2 cm in length and 1 cm in breadth over anterior aspect of lower one third of thigh at lower and sustained Grade II compound fracture of right femur shaft at distal one third. The wound was treated with multiple debridements, negative pressure wound therapy and intravenous antibiotics based on culture and sensitivity.Conclusion:Bolt gun or slaughterer’s guns are weapons used in meat industry for slaughtering animals. Wounds inflicted by bolt guns have specific morphological feature, distinctive from wounds made by other kinds of hand firearms. Most of the time wound will be infected at presentation. Lesions caused by these weapons are likely to have a more serious character than is to be expected from the size of the entrance wound. The mainstay of treatment is liberal wound exploration, multiple debridement’s and intra venous antibiotics based on culture reports to treat infection and prevent morbidity.

Post-exposure vaccination with tetanus toxoid alone, does not protect against tetanus: An illustrative case

Tetanus is a life threatening infectious disease caused by the anaerobic Gram-positive bacillus Clostridium tetani which enters the body through an open wound. A 60-years-old male patient who was referred to our institute with a history of a rusted iron with complaints of nail prick injury and difficulty in opening the mouth. This individual previously not receive tetanus immunoglobulin. Prior to coming to our institute, the rusted iron nail was extracted and he had received tetanus toxoid. After he was admitted in the tetanus ward at our institute, he developed spasms. He was treated with intravenous diazepam and tetanus immunoglobulins. Wound exploration revealed a retained residual foreign body that was a part of his rubber foot wear in the wound. He died on the sixth day of admission. The present case highlights the need for administering appropriate active and passive immunization for tetanus along with meticulous wound care.

WOUND UP MALAYSIAN COMPANIES' PATTERN EXPLORATION USING DATA MINING METHODS

A company is wound up when the company is unable to pay financial debts or is experiencing serious financial distress. From the year 1998 until 2003, an average of 1166 companies were wound up yearly. This research focuses on the knowledge exploration of wound up companies in Malaysia using association rules mining techniques (quantitative) and the involvement of domain expert in knowledge evaluation (qualitative). Association Rules Mining technique is used to mine the implicit patterns of wound up companies by analyzing relationships between attributes such as total asset, total liability and profit and loss. The human expert functions to verify the significant relation between attributes and the mined patterns. This research succeeded to mine 2 quantitative criteria and 9 qualitative criteria related to wound up companies. The criteria combination can be utilized for evaluating the risk of wound up Malaysian companies in the future.

Soft Tissue Reconstruction After Total Ankle Arthroplasty.

Wound complications following total ankle replacement (TAR) may potentially lead to devastating consequences. Soft tissue coverage of the prosthesis and tendons with a flap potentially prevent a catastrophic cascade leading to infection and implant failure. The aim of this study was to investigate the success and complications of flaps following soft tissue defects as a result of total ankle arthroplasty. We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014 whose data were prospectively collected. We then identified patients who required a secondary surgery to treat soft tissue defects that were not amenable to split-thickness skin grafting. Clinical outcomes including secondary procedures, wound healing failure, complications, and implant failure rate were recorded. Nineteen patients had a total of 44 operative procedures to treat wound issues (1.9% of all prostheses). The follow-up time from the flap procedure is 24.1 months. More than two-thirds (13/19) of patients had 1 or more previous surgeries on the ankle, for an average of 1.2 procedures. The mean time to the flap procedure was 13.1 weeks after the index TAR. The most common reason for flap coverage was a non-healing anterior wound. Thirteen of 19 patients (68.4%) underwent formal operative wound exploration and debridement prior to their definitive flap coverage. The average size of the wound was 5.4 × 3.8 cm with an average area of 24.9 cm(2). The most common type of flap performed was a sural pedicle flap followed by a propeller flap. There were 4 flap failures (21.1%), with 2 subsequent below-the-knee amputations. No TAR patients developed a deep infection following a flap unless they had a preexisting infection. In patients who had a successful flap, there were significant improvements in their American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, visual analog scale (VAS), and Short Musculoskeletal Function Assessment bother index, but not their Short Form-36 scores. Ankle wounds that occur after TAR can result in a devastating outcome, but management with a coordinated effort with surgeons with microvascular experience can help achieve salvage of the prosthesis. A variety of flap reconstruction options are available and should be employed to improve the rate of implant survival and retention. Level IV, case series.

Serial Clinical Examinations of 100 Patients Treated for Anterior Abdominal Wall Stab Wounds: A Cross Sectional Study.

Background:The current approach in stab wounds of the anterior abdominal wall is still unclear.Objectives:The goal of this study was to evaluate serial clinical examinations of patients with abdominal wall stab wounds referred to Poursina Hospital in Rasht.Patients and Methods:In a cross sectional study, 100 cases with stab wounds to the anterior abdominal wall were examined serially (admission time, 4, 8, 12, and 24 hours) after wound exploration. Serial hemoglobin test was performed every 8 hours. Laparotomy was performed in cases who were not hemodynamically stable or who showed symptoms of peritonitis. The results were analyzed with SPSS software version 21.Results:Ninety-one men (91%) and 9 women (9%) with mean age of 27 ± 10.7 years were included. Coexisting injuries were prevalent in 12 cases. The duration of hospitalization was 1 day in 31%, 2 days in 30%, 3 - 4 days in 32% and more than 5 days in 7%. Late laparotomy was performed 12 hours after admission in 8% of patients due to peritonitis. There was visceral damage in these cases. No mortality occurred. The cost and duration of hospitalization was significantly higher in cases with coexisting injuries and those who underwent laparotomy.Conclusions:It seems serial clinical examinations are safe and decrease the cost and duration of hospitalization in stable patients with anterior abdominal wall stab wounds.

‘Darling Adopted Daughter’: A practice-led exploration of adoption wounds through the writing of a memoir

This paper discusses my quest for a narrative means to give voice to the story of my adoption. Using practice-led research to explore my adoption experience, I wrote a memoir entitled ‘Darling Adopted Daughter’ for the degree of Doctor of Creative Arts at the University of the Sunshine Coast (USC). The memoir investigates the adoption wounds I sustained when separated at birth from my biological mother and was adopted three weeks later into a family with three existing biological children.

75. Endoscopic radial artery harvest reduces forearm complications when compared to conventional methods: A pooled Analysis

Impetus on total arterial revascularization has led to increased use of the radial artery as a conduit for coronary artery bypass grafting. The radial artery conduit is being increasingly as alternative to saphenous vein as conduit. Recent interest has focused on endoscopic harvest using a single small incision in the wrist. However, data comparing this with the earlier open surgical technique is limited. We have performed aggregate level meta-analysis pooling 1340 patients from six studies. The Peto odds ratio (OR) was obtained using fixed effect modeling. Continuous data was pooled as weighted mean difference (WMD). Conduit length was comparable between methods [WMD 0.6(0.2–1.7) mm; p = 0.3]. Endoscopic radial artery harvest led to lower rates of wound hematoma formation [OR 0.2 (0.08–0.47); p ≤ 0.01] and wound infection [OR 0.4(0.1–0.9); p = 0.04]. However, the incidence of forearm wound exploration was comparable [OR 0.6(0.2–1.7); p = 0.34]. Endoscopic radial artery harvest may reduce forearm complications after radial artery harvest. It may be the procedure of choice for harvesting the radial artery when needed.

Management of wound infection after lumbar arthrodesis maintaining the instrumentation

<sec><title>OBJECTIVE:</title><p> To determinate whether a surgical protocol with immediate extensive debridement, closed irrigation system and antibiotic therapy would be effective to achieve healing of deep wound infection without removing the instrumentation.</p></sec><sec><title>METHODS:</title><p> Prospective cohort study with 19 patients presenting degenerative spinal stenosis or degenerative spondylolisthesis, who developed infection after posterior lumbar arthrodesis. The diagnosis was confirmed by a microbial culture from subfascial lumbar fluid and/or blood. Patients were treated with a protocol of wound exploration, extensive flushing and debridement, placement of a closed irrigation system that was maintained for five days and intravenous antibiotics. The instrumentation system was not removed.</p></sec><sec><title>RESULTS:</title><p> Mean age was 59.31 (±13.17) years old and most patients were female (94.7%; 18/19). The mean period for the identification of the infection was 2 weeks and 57.9% underwent a single wound exploration. White blood count, erythrocyte sedimentation rate and C-reactive protein showed a significant decrease post-treatment when compared to pre-treatment values. A significant reduction of erythrocyte sedimentation rate and C-reactive protein was also observed at the final evaluation. No laboratory test was useful to predict the need for more than one debridement.</p></sec><sec><title>CONCLUSION:</title><p> Patients with wound infection after instrumentation can be treated without removal of the instrumentation through wound exploration, extensive flushing, debridement of necrotic tissue, closed irrigation system during 5 days and proper antibiotic therapy. The blood tests were not useful to predict surgical re-interventions.</p></sec>

Benefits of CT tractography in evaluation of anterior abdominal stab wounds

IntroductionThe study aimed to identify the presence of peritoneal penetration in management of anterior abdominal stab wound by using computed tomography (CT) tractography. Material and methodsHemodynamically stabile, CT tractography-performed patients who were admitted to our emergency clinic with anterior abdominal stab wounds between the years 2012 and 2014 were included in this study, and all images were evaluated in terms of peritoneal penetration and possible intra-abdominal injury. ResultsIn the study CT tractography identified necessity of laparotomy accurately in 90% of the patients, and none of the patients without peritoneal penetration needed surgical treatment in their follow-up. ConclusionThe procedure may be used for some selected cases of hemodynamically stable patient with anterior abdominal stab wounds to abstain from local wound exploration.

Looking For The Glass In Hand

HISTORY: An otherwise healthy 22-yo male fell on an outstretched hand shattering a glass mug he was carrying in his right (dominant) hand. He sustained multiple lacerations to the palm, and had no loss of sensation or motion of forearm, wrist, hand, and fingers. He presented urgently for wound care and to ensure there was no retained glass. PHYSICAL EXAMINATION: — Picture attached — No active bleeding — No bony tenderness to palpation — Full range of motion and muscle strength in all digits with no detectable neurovascular deficits DIFFERENTIAL DIAGNOSIS: 1. Lacerations +/-retained foreign bodies TEST AND RESULTS: Plain films of the hand- superficial 1mm x 3mm retained foreign body, proximal to the first metacarpal phalangeal joint metacarpal FINAL WORKING DIAGNOSIS: 1. Laceration with single retained foreign body TREATMENT AND OUTCOMES: 1. After failing to visualize the foreign body on exploration of wounds, an ultrasound was used to localize the foreign body. No other retained fragments were noted. 2. Ultrasound visualization allowed for real-time anatomic location and ensured complete removal of the retained foreign body - a single shard of glass. 3. Retained foreign body(ies) may inhibit wound healing and possibly cause further skin infections. Complete removal of the foreign bod(ies) would improve wound healing and decrease the likelihood of skin infections. 4. With radiographic x-rays, radio opaque foreign body(ies) may or may not be seen. 5. Moreover, radiographic x-rays and technicians may not be readily available to perform such images. 6. Lastly, radiographic x-rays emit radiation albeit minute but more so than ultrasound. 7. Ultrasounds are becoming a mainstay in primary care and sports medicine clinics.

Effective Protocol to Treat Patients with Deep Wound Infection after Spinal Lumbar Fusion

Introduction Deep wound infection (DWI) is a complication associated with poorer outcome and increased costs. The DWI rates increased in the last decade especially because of the use of spinal instrumentation. Although this condition is important for the surgical outcome, there is still no agreement about the about the need to remove the instrumentation. The objective is to describe the authors' experience in managing DWI without the removal of instrumentation after performing a procedure on the lumbar spine and the clinical and functional long-term course of these patients. Patients and Methods A prospective cohort study with the patients who presented deep infection of the surgical wound. All the patients with a clinical suspicion of this complication were submitted to an aggressive protocol of wound opening, collection of material for a microbiological examination, exhaustive washing, debridement, implementation of a continuous washing system, primary suturing of the wound, and treatment with antibiotics IV and then orally. The instrumentation was not removed from any patient. The patients were evaluated radiologically, clinically, functionally, and by blood test examination, white blood cell count, erythrocyte sedimentation rate, and C-reactive protein, during the follow-up. Paired analyses were performed using the Wilcoxon test to evaluate changes in the instrument scores. Results The mean age was 59.31 ( ± 13.17) and most of the patients were female (94.7%; 18/19). At least one comorbidity was observed in 68.4% of the patients, the most frequent being obesity, present in 26.3% of the patients. The mean period for the identification of DWI was 2 weeks and 57.9% underwent only one wound exploration. Staphylococcus aureus was the most common microorganisms ( n = 13 cases, 68.4%). Blood tests showed a significant decrease of the WBC, ESR, and CRP 6 weeks' posttreatment when compared with pretreatment values. Comparing the 6 weeks' posttreatment evaluation and the final evaluation, a significant reduction of ESR and CRP was also observed. Conclusion Patients with DWI after posterior lumbar spinal instrumentation fusion can be treated without removal of the instrumentation through an aggressive protocol of wound exploration, extensive washing, debridement of necrotic tissue, closed irrigation system during 5 days, and proper antibiotic therapy. The WBC, ESR, and CRP blood tests were not useful to predict the need for surgical reinterventions. Despite the complication, the patients presented improvement with respect to pain, functional capacity, and preoperative quality of life.

Tracking Anatomical Variation of the Bifurcation of the Radial Nerve: Clinical Implication for Physicians

Regional nerve blocks of the upper limb are usually performed in the brachial plexus, specifically in the supra- or infra-clavicular or axillary nerve regions, in cases where minor surgical procedures are required in the distal portion of the extremity. These approaches may not be optimal due to the close proximity of major vascular structures to the needle entry site. This quantitative study measured the site of the radial nerve bifurcation using calipers and ultrasound (US) to determine whether minor surgical procedures (i.e., wound exploration, laceration repair and distal radius reduction) could rely on nerve blocks within a single nerve distribution, in a defined region of the cubital fossa. A metal cylinder was aligned along the medial and lateral epicondyles of 59 donor body arms. A digital caliper, perpendicular to the cylinder, allowed for measurement above (+) or below (-) the epicondylar line (0mm). The average bifurcation occurred at -13.84mm, with 85% of bifurcations arising in the forearm below 0mm. US digital data from a cross-sectional sample of live patients were included in our analysis. US guided needle nerve blocks are presently used by physicians for cases involving injury distal to the elbow. Our results indicate that it is possible to establish “safe zone” parameters in regional nerve blocks to maximize functional recovery while minimizing collateral vascular damage.

Acute Onset of Guillain-Barré Syndrome After Elective Spinal Surgery

Guillain-Barré syndrome (GBS) is an acute peripheral neuropathy caused by an autoimmune response against myelin of peripheral nerves. GBS has been reported after surgery, in general, and after spinal surgery, in particular. In most cases, GBS developed 1-3 weeks after surgery. Report of 2 cases of GBS after elective spine surgery that developed in the immediate postoperative period. Within 1 and 3 hours after surgery, respectively, both patients developed ascending loss of motor and sensory function. They were taken back urgently to the operating room for wound exploration to ensure that an epidural hematoma had not developed. Cerebrospinal fluid studies and electromyography/nerve conduction velocity were then rapidly obtained and were compatible with acute inflammatory demyelinating polyradiculoneuropathy. Therapy was initiated with administration of intravenous immunoglobulin and plasmapheresis. Both patients made substantial motor recovery during the course of 1-2 years but have residual sensory abnormalities. GBS developing acutely after spinal surgery is a rare occurrence but should be considered in the differential diagnosis of neurological deterioration after surgery. Rapid diagnosis and treatment are essential for recovery of neurological function.

Nail in my heart

Stab wound (SW) exploration to assess thoracic or abdominal fascia integrity is a highly invasive procedure which is performed under challenging circumstances in the Emergency Department (ED). Presenting a case report whereby bedside ultrasound was used to detect life threatening thoracic injury secondary to penetrating trauma of the chest.

Recent NICE guidance of interest to surgeons

COMMENT ON Hariharan D, Lobo DN. Retained surgical sponges, needles and instruments. Ann R Coll Surg Engl 2013; 95: 87–92 doi 10.1308/003588413X13511609957218 I read with interest the review by Hariharan and Lobo in which they discuss the incidence of retained surgical items and the seriousness of outcomes to patients, particularly when sponges are retained. Clearly, this issue has not been resolved and requires attention. The authors rightfully point out that the surgical count, a primary preventive measure, has limitations. Discrepancies in the count are a common event and the sensitivity of the surgical count is only 77%. 1 We conducted a healthcare failure mode and effect analysis that identified potential failures in the processes of preventing retained sponges. 2 Distraction and multitasking were the most frequent causes, and are especially difficult, if not impossible, to eliminate. In their algorithm, Hariharan and Lobo propose using a standardised count process, the surgeon confirming the final count, and the use of radiography if the surgical count is incorrect. This poses a challenge clinically. In addition to the limitations of the count, the sensitivity of intraoperative radiography for detection of a retained surgical item is only 67%. 3 If we rely on these two interventions, we will not likely eliminate retained surgical items. The more sensitive postoperative survey images are taken outside of the operating theatre. This would require tremendous expense and a return trip to theatre if an item is identified. The algorithm would be enhanced by including methodological wound exploration by the surgeon, to search for sponges prior to closure, and a hard stop when a count is reported as being incorrect. We should also comprehensively evaluate adjunct technology. There are currently three adjunct technologies available to supplement the current processes for prevention of retained sponges. Hariharan and Lobo provide a comprehensive review of the evidence regarding two: the barcoded counting system and the radiofrequency identification system. The third, a radiofrequency (RF) detection system, involves low energy RF chips sewn into sponges and a scanner for detection of the sponges. Two scanners are available: a wand that is passed over the patient and a mat that is placed under the patient. Studies have found the sensitivity and specificity of the RF wand to be 100%, even in morbidly obese subjects. 4,5 The mat is slightly less sensitive for detection in morbidly obese than in non-morbidly obese patients (97% vs 100%). 5 RF technology has been shown to be highly effective in reconciling miscounts and preventing retained sponges. 6,7 In a study including 2,285 patients, no retained sponges occurred while using the RF technology within the 12 months of data collection. 7 I thank Hariharan and Lobo for highlighting a very important patient safety issue. Through teamwork and effective communication, we can improve patient care. However, as we cannot eliminate distraction and multitasking, we should evaluate adjunct technology to determine its applicability in the prevention of retained sponges.