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Clinical Summary

Proper wound assessment and preparation are essential to management. Consider the age and mechanism of injury; contamination or foreign-body risk; risk to the nerve, blood vessel, and tendon; and tetanus status. Identify comorbid conditions that may alter healing.

Management and Disposition

Patient compliance is integral to achieving adequate wound exploration. The use of local or regional anesthesia is usually sufficient; however, procedural sedation may be required. Document neurovascular status prior to any anesthesia. Direct pressure is often the easiest way to achieve hemostasis. Other methods include the use of blood pressure cuff or tourniquet to achieve temporary hemostasis. Anesthetic solution containing epinephrine (1:100,000 dilution) may help constrict small vessels; however, caution should be exercised when using in areas of end arterial circulation (eg, fingers, nose, toes, ears, and penis).

While hemostats or retractors may help achieve exposure, care must be exercised to avoid damaging the dermis and vascular integrity. If exposure is not adequate despite hemostasis and separation, wound margins may be slightly extended with fine iris scissors or a scalpel. The wound is extended from one end, through the epidermis and dermis only, to avoid further injury to underlying structures. Once the superficial fascia has been exposed, it may be carefully and bluntly dissected using forceps or scissors.

FIGURE 18.3

Finger Ring Tourniquet. The ring tourniquet is an effective means of hemostasis. Removal after the procedure is important to prevent finger ischemia. Another effective method of hemostasis involves using a Penrose drain tightened with hemostats. (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)

Pearls

  1. Never probe a wound blindly or blindly attempt to control bleeding with hemostats.

  2. If epinephrine-induced tissue ischemia occurs, injection of phentolamine around the area may help restore flow.

FIGURE 18.4

Epinephrine Injection. Although epinephrine can be used to help achieve hemostasis, it should be used with caution on areas with poor collateral blood supply. Lidocaine with epinephrine injected near the thenar eminence shows the pallor of finger and thenar eminence due to the vasoconstriction. (Photo contributor: Kevin J. Knoop, MD, MS.)

FIGURE 18.5

Wound Exploration. A blood pressure cuff is an alternative means to obtain hemostasis before wound assessment. (Photo contributor: Alan B. Storrow, MD.)

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