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Clinical Summary

Infection is suggested by pain, warmth, erythema, edema, and purulent drainage. While dehiscence can occur at any time, 7 to 10 days after repair, a wound is at its weakest (this also closely coincides with suture removal). Impaired wound healing, primarily from infection, medications (especially corticosteroids), foreign bodies, advanced age, poor nutritional status, diabetes mellitus, and peripheral vascular disease, contributes to dehiscence. Wound closure strips can be applied after suture removal and may reduce dehiscence. Some degree of scarring is inevitable, but not considered a complication of wound repair. This should be discussed with the patient or caregiver. Wound myiasis is infestation by fly larvae (see also Chapter 21) that invade necrotic tissue.

Management and Disposition

Infections are treated with suture removal, thorough irrigation, and low threshold to explore for missed foreign bodies. A 7-day course of a first-generation cephalosporin or antistaphylococcal penicillin is appropriate; however, if methicillin-resistant Staphylococcus aureus (MRSA) is suspected, the antibiotic choice should be adjusted (eg, trimethoprim-sulfamethoxazole or other current recommendations for your area). For animal bites, other antibiotics (eg, amoxicillin-clavulanate) may be more appropriate. Sepsis, advanced infections, or infections in persons with chronic medical problems (eg, diabetes, immunocompromised) should be managed with parenteral antibiotics and possible inpatient admission.

FIGURE 18.42

Wound Infection Versus Inflammation. Intense erythema that extends from the wound margins peripherally (A) and purulent drainage (B) in postoperative wound infections. Compare this erythema to the pink inflammatory changes from the staples (C). This mild erythema extends from stable entrance into the skin; wound margins appear normal and are healing well. (Photo contributors: Lawrence B. Stack, MD [A and C]; Matthew D. Sztajnkrycer, MD, PhD [B].)

FIGURE 18.43

Wound Dehiscence. After suture removal, the patient returned with dehiscence. The wound had a clean base of granulation tissue and was allowed to close by secondary intention. (Photo contributor: Alan B. Storrow, MD.)

FIGURE 18.44

Keloid. The degree of excessive scar bulk extending beyond the original wound margins may be dramatic and cosmetically significant. (Photo contributor: Thea James, MD.)

FIGURE 18.45

Wound Myiasis. Necrotic tissue can be invaded by fly larvae (maggots). (Photo contributor: Lawrence B. Stack, MD.)

Wound dehiscence is managed conservatively by treating the underlying causes and allowing healing via secondary intention. Dehiscence of wounds in cosmetically sensitive areas is best managed in conjunction with a consultant. Myiasis is treated with wound cleaning and irrigation.



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