Traumatic surface wounds are caused by one of three mechanisms: shearing, tension, or compression. Such a division helps to guide management decisions involving infection risk and scar formation.
Shearing injuries are caused by sharp objects, such as glass shards or knives, which impart low-energy injury and minimal tissue destruction. Most uncomplicated shearing injuries (ie, those not involving neurovascular or anatomically important structures) are repaired primarily in the emergency department (ED). The risk of infection is low, and scar formation is typically cosmetically acceptable. Puncture wounds occur from sharp objects that pierce the skin and penetrate deeper tissues. Such wounds are at a higher risk for infection, foreign-body retention, and underlying structural injury.
Uncomplicated Linear Laceration. A linear leg laceration. Given the depth and gaping, it can be sutured using a layered closure to remove surface tension at the wound edges and promote a more cosmetically acceptable outcome. (Photo contributor: Alan B. Storrow, MD.)
Complicated Linear Laceration. High-energy circular saw laceration with significant depth, tissue destruction, and likely neurovascular involvement. (Photo contributor: Lawrence B. Stack, MD.)
Puncture Wound. A puncture wound to the foot with a contaminated garden instrument. Tetanus status must be carefully addressed in such an injury. A radiograph of the foot demonstrated no associated bony injuries. (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)
Tension or partial avulsion injuries occur when an object strikes the skin at a sharp angle creating a triangular flap. This results in potential vascular disruption, greater tissue destruction, and a higher risk for infection and tissue ischemia. During the repair, vascular supply to the flap must be meticulously preserved; otherwise, the flap may become ischemic.
Partial Avulsion Injury. A typical partial avulsion laceration from a fall onto the edge of a staircase. Note the triangular “flap” in the upper left wound quadrant. Closure of partial avulsion injuries must be particularly meticulous to reduce any further compromise of the flap tip’s vascular supply (see Complex Wound Closures and Animal Bite Wounds). (Photo contributor: Alan B. Storrow, MD.)
Crush or compression injuries occur when a blunt object strikes tissue at a right angle, imparting a high degree of kinetic energy. This results in significant tissue destruction of the skin and its underlying supportive fascial layers. Crush injuries are typically ragged, with irregular wound edges and a complex laceration pattern. Despite meticulous wound care and careful primary closure, the resulting scars may be cosmetically poor.
Management and Disposition
Update the tetanus status of all patients requiring wound management (Table 18.1). ...