Chapter 80

Blunt and penetrating trauma can lead to a myriad of soft tissue injuries. The management of the majority of these injuries is discussed elsewhere in this text. Some soft tissue injuries require detailed explanations for their repair. These injuries are discussed below.

Wounds of unequal thickness are not suited for repair with simple interrupted sutures. Unequal tissue loss on each edge of a wound creates a thick edge–thin edge wound. The depressed edge must be elevated to the level of the nondepressed edge in order to attain proper wound apposition and cosmesis.

There are two techniques to repair wounds with edges of unequal thickness. One technique utilizes a half-buried horizontal mattress suture (Figure 80-1).1 Place the suture through the thick edge of the wound, across the wound and buried into the subcutaneous tissue of the thin edge, and back out the skin of the thick edge (Figure 80-1A). Apply traction to the suture and tie it to approximate the wound (Figure 80-1B). Apply an ointment-based compressive dressing.

Figure 80-1

Closing a wound with edges of unequal thickness using half-buried horizontal mattress sutures.

The second technique requires undermining both wound edges at the same depth in the subcutaneous tissue plane (Figure 80-2).2 Make an incision in the subcutaneous tissues of both wound edges and at the same level (Figure 80-2A). Undermine the area to free the tissue flaps (Figure 80-2B). Grasp the subcutaneous tissue flap from the thicker side and insert it under the thinner side beneath the undermined area (Figures 80-2B and C). Place a buried horizontal mattress suture to maintain the flaps in position. This “flap” elevates the depressed wound edge and facilitates appropriate wound approximation (Figure 80-2).2 Place interrupted sutures to approximate the wound edges (Figure 80-2C).

Figure 80-2

An alternative technique to close a wound with edges of unequal thickness. A. Make an incision in the subcutaneous tissue of both wound edges. B. Undermine the edges. Transpose the subcutaneous tissue of the thicker side into the undermined area of the thinner side (arrow). C. Approximate the wound edges using interrupted sutures.

Tangential flap lacerations over thin skin, such as the dorsum of the hand or the pretibial area, where there is very little subcutaneous tissue can be approximated with a specially placed simple interrupted suture. Insert the needle through the tip of the thin edge, across the wound, into the dermis of the thick edge, and out the skin of the thick edge. Apply traction to the suture to pull the thick edge up to meet the thin edge, producing good ...

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