Open Wound: Surgical Therapy

Wound cleansing precedes further surgical procedures: Wound cleansing (preferably with disposable gloves), i.e., removal of dirt or foreign bodies, followed by irrigation of the wound with plenty of fluid for bacterial germ reduction; saline solution (NaCl 0.9%) is suitable, but tap water is also sufficient. Notice:

  • Primary wound closure is achieved by primary suture (surgical skin suture placed for direct closure of fresh wounds within the first 6 hours after trauma) under local anesthesia (local anesthetic).
  • The “6-hour rule” within which a primary wound closure must be made, otherwise the primary wound healing (sanatio per primam intentionem) is endangered by the bacterial contamination that has occurred.
  • Human and cat bites are more dangerous than dog bites in terms of the germ spectrum.
  • Bite, scratch and puncture wounds must not be closed by a suture.
  • Octenidine (broad-spectrum antiseptic) should not be used in wound cavities without safe secretion drainage, as there is a risk of necrosis.
  • In patients with severe underlying internal diseases or immunosuppression, even minor injuries must be closely monitored.

Surgical procedure

  • Local treatment of minor wounds: Dry treatment with protective plasters and dressings; natural scabbing.
  • More elaborate treatment of the wound is required if:
    • The wound edges are further apart
    • The injury goes deeper
    • There is a lot of bleeding
    • Deeper layers and structures such as muscles, vessels, nerves are damaged
  • Local treatment of necrotic wounds: Debridement (wound toilet, i.e., removal of dead (necrotic) tissue), mechanical or enzymatic.
  • If necessary, removal of injected foreign bodies.
  • Conservative moist treatment for larger wounds, e.g. abrasions, with synthetic wound dressings (e.g. films, hydrogels, hydrocolloids).
  • If arterial bleeding is present, it can initially be stopped provisionally by compression or clamps.
  • Treatment also depends on the nature of the wound:
    • Leathers wound: because the wound area is large, there may be considerable blood loss. Surgical treatment is required.
    • Bite wound: Again, medical care is required. The wound is thoroughly cleaned, debrided (see above) and disinfected due to the very high risk of infection (about 85%). The wound is usually not closed. Notice:
      • Urgently discouraged is wound irrigation with button cannulas or infusion catheters! Small bite wounds – especially bite wounds of the hand – are often underestimated in their importance. Here generous indication for surgical debridement under anesthesia in the operating room.
      • Injured with a bite wound to the hand should be immediately presented to a hand surgery center; facial bite injuries to a plastic surgery facility.
    • Burn wound: local cooling. Followed by treatment with appropriate ointments and dressings. Depending on the severity of the injury, inpatient treatment may be required. See also under “Burns“.
    • Scratch wound: As a rule, the wound is not closed (due to risk of infection).
    • Laceration (laceration): For clarification of possible concomitant injuries, medical care is required. For fast and scarless wound healing, a skin closure must be made. This also prevents germs from entering the wound.
    • Cut wound: a closure of the skin should be made; however, injuries to deeper structures must be excluded beforehand.
    • Gunshot and blast injuries: Hemostasis! (Note: Hemodynamically relevant bleeding is the leading cause of death here). The procedure must be guided by DCS principles (DCS: “damage control surgery”):
      • Bleeding control (“stop the bleeding”).
      • Contamination control and lavage
      • Prevention of further injury or increase in the consequences of injury.
      • Ischemia prophylaxis (prevention of reduced blood flow), preservation of perfusion (blood flow) or reperfusion.
    • Abrasions: These are usually heavily soiled and therefore require special cleaning and disinfection. So that the wound is protected from germs until the scab is formed, wound dressings are applied.
    • Stab wound: Here, in any case, medical care is required to assess any concomitant injuries. As a rule, the wound is not closed (because of risk of infection), so the wound secretion can drain.

Note: For all bite injuries of the hand with bone and joint involvement, an inpatient admission is required. The consilium hand surgery is recommended in this case. Surgical therapy will be required:

  • For larger and more complicated wounds
  • When wound margin contusion necessitates debridement (e.g., bite wounds).
  • In impalement injuries (immediate surgical therapy).
  • In disfiguring or functionally limiting scars (subsequent surgery).

After primary surgical treatment, the wound is closed by a skin suture.

Checking the vaccination protection!

In case of no or insufficient tetanus vaccination protection or in case of doubt: simultaneous vaccination, active and passive (5-12 hours after injury)Rabies prophylaxis is rarely required. If necessary, consult with the official veterinarian for risk evaluation.

Thread pull

Suture traction (“suture pulling”) is performed depending on the location of the wound:

  • Head or neck – between the 4th-8th day (after surgery).
  • Trunk – between the 7th-10th day.
  • Extremities – after 10-15 days