Practical Plastic Surgery for Nonsurgeons

Practical 

Plastic 

Surgery for 

Nonsurgeons 

NADINE B. SEMER, MD 

Clinical Instructor 

Division of Plastic Surgery 

University of Southern California 

School of Medicine 

Los Angeles, California 

illustrations by 

MARTHE ADLER-LAVAN, MD 

Philadelphia, Pennsylvania 

HANLEY & BELFUS, INC. Philadelphia

Publisher: HANLEY & BELFUS, INC. 

Medical Publishers 

210 S. 13th Street 

Philadelphia, PA 19107 

(215) 546-4995 

FAX (215) 790-9330 

www.hanleyandbelfus.com 

Library of Congress Cataloging-in-Publication Data 

Practical plastic surgery for nonsurgeons / by Nadine B. Semer. 

p. ; cm. 

Includes bibliographical references and index. 

ISBN 1-56053-478-8 (alk. paper) 

1. Surgery, Plastic. 2. Rural health services. I. Semer, Nadine B, 1960– 

[DNLM: 1. Reconstructive Surgical Procedures. WO 600 P895 2001] 

RD118.P73 2001 

617.9'5—dc21 

00-054179 

PRACTICAL PLASTIC SURGERY 

FOR NONSURGEONS ISBN 1-56053-478-8 

© 2001 by Hanley & Belfus, Inc. All rights reserved. No part of this book may 

be reproduced, reused, republished, or transmitted in any form or by any 

means without written permission of the publisher. 

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Dedication 

To Chris and Jenny McConnachie, Cosimo Storniolo 

and Meredith Weir, and all health care providers 

worldwide who are working to bring quality medical 

care to people living in rural areas 

And to David, who helped me to see that anything is 

possible

International Medical Missions 

The following is a short list of organizations that sponsor international medical 

missions. There are many more. The World Wide Web and local medical/professional 

societies are other sources of information. The minimum time commitment 

ranges from a few days to several months to years. Some are religious-based organizations. 

Listing here does not imply recommendation or endorsement of any 

of these organizations. If you are interested in international work, research the 

organization well. 

The best advice I can offer to health professionals going to work in any rural area 

is to be open to anything, be as flexible as possible, and above all respect the 

people you are working with and the people you are serving. 

Nadine B. Semer, MD 

www.practicalplasticsurgery.org 

nadine@ppsurg.org 

Organization U.S. Contact Information and Internet Address 

American Medical Student Association 1902 Association Drive, Reston, VA 20191 

(703) 620-6600; www.amsa.org 

Catholic Medical Mission Board 10 West 17th Street, New York, NY 10011 

(800) 678-5659; www.cmmb.org 

CB International 1501 West Mineral Avenue, Littleton, CO 80120 

(800) 487-4224; www.cbi.org 

Doctors of the World-USA 375 West Broadway, 4th Floor, New York, NY 10012 

(888) 817-HELP; www.dowusa.org 

Doctors Without Borders, USA 6 East 39th Street, 8th Floor, New York, NY 10016 

Médecins San Frontières (212) 679-6800; www.doctorswithoutborders.org 

The Flying Hospital, Inc. 11836 Fishing Pointe Drive, Newport News, VA 23606 

(757) 873-6794; www.flyinghospital.org 

Global Volunteers 375 East Little Canada Road, St. Paul, MN 55117 

(800) 487-1074; www.globalvolunteers.org 

Health Volunteers Overseas P.O. Box 65157, Washington, DC 20035 

(202) 296-0928; www.hvousa.org 

Himalayan HealthCare, Inc. P.O. Box 737, Planetarium Station, New York, NY 10024 

(212) 829-8691; www.himalayan-healthcare.org 

International Medical Corps 11500 West Olympic Blvd., Suite 506, 

Los Angeles, CA 90064 

(310) 826-7800; www.imc-la.com 

International Rescue Committee 122 East 42nd Street, New York, NY 10168 

(212) 551-3000; www.intrescom.org 

Interplast, Inc. 300-B Pioneer Way, Mountain View, CA 94041 

(650) 962-0123; www.interplast.org 

Mercy Ships P.O. Box 2020, Garden Valley, TX 75771 

(800) 424-7447; http://mercyships.org/index.htm 

Operation Smile 6435 Tidewater Drive, Norfolk, VA 23509 

(757) 321-7645; www.operationsmile.org 

Physicians for Peace 229 West Bute Street, Suite 900, Norfolk, VA 23510 

(757) 625-7569; www.physicians-for-peace.org 

Presbyterian Church (USA), Worldwide 100 Witherspoon Street, Louisville, KY 40202 

Ministries Division, Mission Service (800) 779-6779; www.pcusa.org/msr 

Recruitment Office 

Project Hope 255 Carter Hall Lane, Millwood, VA 22646 

(800) 544-4673; www.projhope.org

Table of Contents 

Chapter 1 

Suturing: The Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

Chapter 2 

Basic Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 

Chapter 3 

Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 

Chapter 4 

Protecting Yourself from Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . 45 

Chapter 5 

Evaluation of the Acutely Injured Patient . . . . . . . . . . . . . . . . . . . . . . . . . . 49 

Chapter 6 

Evaluation of an Acute Wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 

Chapter 7 

Gunshot Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 

Chapter 8 

Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 

Chapter 9 

Taking Care of Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 

Chapter 10 

Secondary Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 

Chapter 11 

Primary Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 

Chapter 12 

Skin Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 

Chapter 13 

Local Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 

Chapter 14 

Distant Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 

Chapter 15 

Scar Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 

v

vi Contents 

Chapter 16 

Facial Lacerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 

Chapter 17 

Pressure Sores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 

Chapter 18 

Chronic Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 

Chapter 19 

Soft Tissue Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 

Chapter 20 

Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 

Chapter 21 

Fractures of the Tibia and Fibula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 

Chapter 22 

Skin Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 

Chapter 23 

Cleft Lip/Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 

Chapter 24 

Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 

Chapter 25 

Facial Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 

Chapter 26 

The Normal Hand Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 

Chapter 27 

Evaluating the Injured Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 

Chapter 28 

Hand Splinting and General Aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 

Chapter 29 

Fingertip and Nail Bed Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 

Chapter 30 

Finger Fractures and Dislocations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 

Chapter 31 

Traumatic Hand and Finger Amputations . . . . . . . . . . . . . . . . . . . . . . . . . 303 

Chapter 32 

Tendon Injuries of the Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

Contents vii 

Chapter 33 

Nerve and Vascular Injuries of the Hand . . . . . . . . . . . . . . . . . . . . . . . . . . 313 

Chapter 34 

Hand Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 

Chapter 35 

Hand Crush Injury and Compartment Syndrome . . . . . . . . . . . . . . . . . . . 329 

Chapter 36 

Hand Infections: General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 

Chapter 37 

Specific Types of Hand Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 

Chapter 38 

Chronic Hand Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 

Chapter 39 

Exploration of an Injured Hand or Forearm . . . . . . . . . . . . . . . . . . . . . . . . 367 

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

Preface 

The intent of this book is to bring relief to people who sustain commonly 

encountered injuries and wounds. Without corrective treatment, 

these problems can destroy livelihoods and families. Immediate, 

acute care often stabilizes the patient, but may leave the patient with a 

minor or major disability. Lacking the resources typical of wealthier 

populations, even minor disabilities can have a devastating economic 

and social impact. 

Plastic surgeons have developed reconstructive surgical techniques 

that can restore the injured person to a productive and fulfilling life. 

Unfortunately, this type of surgery has frequently been obscured by a 

cloud of unawareness or perceived difficulty. 

Practical Plastic Surgery for Nonsurgeons describes straightforward plastic 

surgical information and techniques. This book will be useful to 

health care providers with limited access to specialists, especially 

providers who serve in rural and non-industrial settings. Medical students, 

nurse practitioner students, and residents in a wide variety of 

specialties will also benefit from this knowledge. 

This book is intended for an audience far different from that of most 

other plastic surgery texts. There are many remarkable books that describe 

advanced techniques commonplace in my home city of Los 

Angeles. These excellent volumes describe superb results obtained by 

elite surgeons working with expensive equipment. 

This book describes practical techniques that may be easily learned by 

a variety of medical professionals who have access only to basic equipment. 

Plastic surgical procedures are described in a clear, concise, stepby-step 

fashion. Someone without advanced surgical skills can use this 

book and provide effective treatment. Illustrative cases are used to help 

the reader understand the importance of plastic surgery input in a variety 

of situations. Explanation is given as to when and why it may be 

prudent to transfer care to a specialist. 

It is my hope that this book will provide a greater understanding of 

how plastic surgical techniques can contribute to improved patient 

outcomes. This, in turn, should allow many injured patients to regain 

normal function and their rightful place in the community. 

Nadine B. Semer, MD 

Los Angeles, California 

ix

Chapter 1 

SUTURING: THE BASICS 

KEY FIGURES: 

Curved needles: tapered and cutting Simple sutures 

Eversion of skin edges Continuous vs. interrupted closure 

Instruments: needle holder Mattress sutures 

Instruments: forceps with teeth Buried intradermal sutures 

Instruments: suture scissors Figure-of-eight sutures 

Holding scissors and needle holder Instrument tie 

Needle in the needle holder Skin stapler in position 

Holding the forceps Staple remover: clamp removing the staple 

Face bites vs. body bites 

Needle entering tissues at 90° angle 

Adhesive strips 

Suturing is the joining of tissues with needle and “thread,” so that the 

tissues bind together and heal. The “thread” is actually specialized 

suture material. 

Health care providers frequently encounter wounds in need of suturing, 

and it is important to become proficient. You can practice your suturing 

skills on pigs’ feet, available at a butcher shop. This chapter gives 

you all the necessary information to perform basic suturing, including: 

• Types of needles and suture material 

• Selection of material for various wounds and situations 

• Techniques 

Information about the proper use of local anesthetics for pain control 

while placing sutures is discussed in chapter 3. 

SSuuttuurree NNeeeeddlleess 

There are two broad classifications of needles: curved and straight. A 

straight needle can be used without instruments. A curved needle must 

be handled with forceps and a needle holder. 

Although hand sewing with a straight needle does not require forceps, 

the technique is cumbersome and entails a much higher risk of accidentally 

sticking yourself. Hence, suturing with a straight needle is 

1

2 Practical Plastic Surgery for Nonsurgeons 

uncommon and not recommended if curved needles are available. 

Generally, forceps and needle holders are available, and a curved 

needle is used for suturing. There are two types of curved needles. 

Cutting Needle. A cutting needle is used primarily for suturing the 

skin. It has a very sharp tip with sharp edges, which are needed to pass 

through the skin. Since you will place primarily skin sutures, you generally 

will use a cutting needle. 

Tapered Needle. Tapered needles, or “round-bodied” needles, have 

a sharp tip with smooth edges and are less traumatic to the surrounding 

tissues. They are used primarily on the deeper, subcutaneous tissues, 

blood vessels, and intestinal anastomoses. A tapered needle is not 

good for simple skin suturing because it is difficult to pass the tapered 

needle through the skin. 

A, Tapered needle used for suturing subcutaneous tissue, fascia, and other 

deep structures. B, Cutting needle used for suturing skin. Note the difference 

specifically around the tip of each needle. 

SSuuttuurree SSiizzeess 

Sutures come in various sizes. The bigger the suture material, usually 

the bigger the needle. The sizing of sutures is similar to the sizing of 

needles for injection: the bigger the number, the smaller the size of the 

suture. Suture sizes range from 00 (very large, used to close the abdominal 

wall—about the size of large fishing line) to 10-0 (very tiny, used 

for microvascular anastomoses—as fine as a human hair). You generally 

will use sizes in the middle range: 3-0 to 5-0. 

It is best to use small sutures on the face, such as 5-0 or 6-0. Smaller sutures 

are associated with decreased scarring, which is a concern with 

facial wounds. (See chapter 16, “Facial Lacerations,” for more specific 

details.) On areas where cosmetic concerns are less important, 3-0 or 4- 

0 sutures are best, because the larger size makes the technique easier 

and the thicker sutures are stronger. The tendency is to use smaller sutures 

on children because of their more delicate skin. Rarely do you 

need anything larger than a 4-0 suture.

SSuuttuurree MMaatteerriiaall 

Suturing: The Basics 3 

Many different suture materials are available. The main classifications 

are absorbable or nonabsorbable. A more subtle subclassification is 

whether the suture material is braided or nonbraided. 

Unless there is a dire emergency, never use regular thread for sutures 

because of the risk of infection. 

Nonabsorbable Sutures 

Nonabsorbable sutures remain in place until they are removed. 

Because they are not dissolved by the body, they are less tissue-reactive 

and therefore leave less scarring as long as they are removed in a 

timely fashion. They are best used on the skin. 

Absorbable Sutures 

Absorbable sutures are dissolved by the body's tissues. The great advantage 

is that the sutures do not need to be removed. However, absorbable 

sutures tend to leave a more pronounced scar when used as 

skin sutures. Absorbable sutures are primarily used under the skin, 

where they are well hidden. 

It is sometimes difficult to get patients to return for suture removal. If 

this is a concern, use an absorbable suture for skin closure. You should 

warn the patient that absorbable sutures probably will result in a more 

noticeable scar than nonabsorbable sutures with later removal. 

Because it is often difficult to remove stitches from children (because of 

their crying and difficulty in staying still), absorbable materials should 

be used when suturing their wounds. 

Braided Sutures 

Braided sutures are made up of several thin strands of the suture material 

twisted together. Braided sutures are easier to tie than nonbraided 

sutures. However, braided sutures have little interstices in the suture 

material, which can be a place for bacteria to hide and grow, resulting 

in an increased risk of infection. 

Nonbraided Sutures 

Nonbraided sutures are simply a monofilament, a single strand. They 

are not made up of the little subunits found in a braided suture. 

Nonbraided sutures are recommended for most skin closures, especially 

wounds that may be at risk for infection.


Table 1. Characteristics of the Most Commonly Used Suture Materials 

Suture Tissue Non- Suture 

Material Reaction A or N Braided Braided Strength Primary Indication 

Chromic +++ A X Lasts 3–4 Facial wounds, 

catgut wks at lip/intraoral 

most mucosa, children’s 

wounds 

Nylon + N X Loses 20% 

per year 

Skin sutures 

Polydioxa- + A X Lasts 4–6 Intradermal sunone 

(PDS) mo tures 

Polyglycolic acid ++ A X Lasts about Intradermal su- 

(Dexon) 1 mo tures, sutures 

for fascia, 

muscle, mucosa, 

or subcutaneous 

tissue 

Prolene 0 N X Lasts a long 

time 

Skin sutures 

Silk +++ N X Loses Very clean skin 

strength wounds, eswithin 

pecially on 

1 yr eyelids 

A = absorbable, N = nonabsorbable, 0 = no tissue reaction, +++ = highly reactive. 

SSuuttuurriinngg TTeecchhnniiqquueess 

When suturing the edges of a wound together, it is important to evert 

the skin edges—that is, to get the underlying dermis from both sides of 

the wound to touch. For the wound to heal, the dermal elements must 

meet and heal together. If the edges are inverted (the epidermis turns 

in and touches the epidermis of the other side), the wound will not 

heal as quickly or as well as you would like. The suture technique that 

you choose is important to achieve optimal wound healing. 

Sutures should be placed so that the skin edges are everted to ensure that the 

dermis is touching.This technique is important for proper healing. (From McCarthy 

JG (ed): Plastic Surgery. Philadelphia, W.B. Saunders, 1990, with permission.)

Instruments Needed 


Needle holder: used to grab onto the suture needle 

Forceps: used to hold the tissues gently and to grab the needle 

Suture scissors: used to cut the stitch from the rest of the suture material 

Left, Needle holder. Center, Forceps with teeth. Right, Suture scissors. 

(Courtesy of Padgett Instruments, Inc.) 

How to Hold the Instruments 

Whenever you use sharp instruments, you face the risk of accidentally 

sticking yourself. Needlesticks are especially hazardous because of the 

risk of serious infection (hepatitis, human immunodeficiency virus). To 

prevent needlesticks, get in the habit of using the instruments correctly. 

Never handle the suture needle with your fingers. 

Scissors. Place your thumb and ring finger in the holes. It is best to 

cut with the tips of the scissors so that you do not accidentally injure 

any surrounding structures or tissue (which may happen if you cut 

with the center part of the scissors). 

Needle Holder. Place your thumb and ring finger in the holes. When 

using the needle holder, be sure to grab the needle until you hear the 

clasp engage, ensuring that the needle is securely held. You grab the 

needle at its half-way point, with the tip pointing upward. Try not to 

grab the tip; it will become blunt if grabbed by the needle holder. Then 

it will be difficult to pass the tip through the skin.


The needle holder and scissors are handled similarly. For maximal control, 

place the tips of your thumb and ring finger into the rings of the instrument. 

Your thumb does most of the work to open and close the instrument. 

The needle should be held in 

the jaws of the needle holder at 

its midpoint (where the curve of 

the needle is relatively flat). 

This technique prevents you 

from bending the needle as it 

passes through the tissues. 

Forceps. Hold the forceps like a writing utensil. The forceps is used 

to support the skin edges when you place the sutures. Be careful not to 

grab the skin too hard, or you will leave marks that can lead to scarring. 

Ideally, you should grab the dermis or subcutaneous tissue—not 

the skin—with the forceps, but this technique takes practice. For suturing 

skin, try to use forceps with teeth, which are little pointed edges at 

the end of the forceps.

Placing the Sutures 


Hold the forceps as you would hold a writing instrument. 

For most areas of the body, except the face (see chapter 16, “Facial 

Lacerations”), the sutures should be placed in the skin 3–4 mm from 

the wound edge and 5–10 mm apart. 

Sutures placed on the face should be approximately 

2–3 mm from the skin edge and 3–5 

mm apart. Sutures placed elsewhere on the 

body should be approximately 3–4 mm from 

the skin edge and 5–10 mm apart.


Start on the side of the wound opposite and farthest from you to 

ensure that you are always sewing toward yourself. By sewing toward 

yourself, the suturing process is made easier from a biomechanical 

standpoint. 

Do not drive yourself crazy by placing too many sutures. 

Simple Sutures 

Indication. This technique is the easiest to perform. It is used for 

most skin suturing. 

Technique 

1. Start from the outside of the skin, go through the epidermis into 

the subcutaneous tissue from one side, then enter the subcutaneous 

tissue on the opposite side, and come out the epidermis 

above. 

2. To evert the edges, the needle tip should enter at a 90° angle to 

the skin. Then turn your wrist to get the needle through the 

tissues. 

3. You can use simple sutures for a continuous or interrupted closure. 

The needle tip should enter the tissues perpendicular to the skin. Once the 

needle tip has penetrated through the top layers of the skin, twist your wrist 

so that the needle passes through the subcutaneous tissue and then 

comes out into the wound. This technique helps to ensure that skin edges 

will evert.

Interrupted or Continuous Closure 

A simple suture. 


Interrupted Sutures 

• Interrupted sutures are individually placed and tied. 

• They are the technique of choice if you are worried about the cleanliness 

of the wound. 

• If the wound looks like it is becoming infected, a few sutures can be 

removed easily without disrupting the entire closure. 

• Interrupted sutures can be used in all areas but may take longer to 

place than a continuous suture. 

Continuous Closure 

• Place the sutures again and again without tying each individual 

suture. 

• If the wound is very clean and it is easy to bring the edges together, a 

continuous closure is adequate and quicker to perform. 

• Continuous closure is the technique of choice to help stop bleeding 

from the skin edges, which is important, for example, in a scalp 

laceration.


Mattress Sutures 

A, Interrupted sutures are 

individually placed and 

tied. B, A continuous suture 

is done by passing the 

needle from side to side 

(across the wound) multiple 

times before finally 

tying the suture. 

Indication. Mattress sutures are a good choice when the skin edges 

are difficult to evert. Sometimes you may want to close a wound with a 

few scattered mattress sutures and place simple sutures between them. 

It is a bit more technically challenging to place mattress sutures, but it 

is often worth the effort because good dermis-to-dermis contact is 

achieved.

The vertical mattress suture. 


Technique 

1. Start like a simple suture, go from the outside of the skin through 

the epidermis into the subcutaneous tissue from one side, then enter 

the subcutaneous tissue on the opposite side, and come out the epidermis 

above. 

2. Turn the needle in the opposite direction and go from outside the 

skin on the side that you just exited and come out the dermis below. 

Then enter the dermis on the opposite side and come out of the epidermis 

above. 

3. Your suture is now back on the side on which you started. 

Buried Intradermal Sutures 

Indication. This technique is useful for wide, gaping wounds and 

when it is difficult to evert the skin edges. When buried intradermal 

sutures are placed properly, they make skin closure much easier. The 

purpose of this stitch is to line up the dermis and thus enhance healing. 

The knot needs to be as deep into the tissues as possible (hence the 

term buried) so that it does not come up through the epidermis and 

cause irritation and pain. 

Technique 

1. Use a cutting needle and absorbable material. 

2. Start just under the dermal layer and come out below the epidermis. 

You are going from deep to more superficial tissues.


Buried intradermal suture. 

3. Now the technique becomes a bit challenging. You need to enter the 

skin on the opposite side at a depth similar to where you exited the 

skin on the first side, just below the epidermis. To do so, you should 

position the needle with the tip pointing down and pronate your 

wrist to get the correct angle. It will help to use the forceps (in the 

other hand) to hold up the skin. The needle should come out of the 

tissues below the dermis. Try to get as little fat in the stitch as possible; 

it does not contribute to the suture. 

4. Tie the suture. 

Figure-of-eight Sutures 

Indication. This technique is useful for bringing together underlying 

tissues such as muscle, fascia, or extensor tendons. It is not commonly 

used for skin closure. 

Technique 

1. Usually a tapered needle and absorbable sutures are used. 

2. Start on the side opposite from you. Go through the full thickness of 

tissues on that side, then finish the first half of the stitch by going 

from bottom to top on the opposite side. Advance just a little farther 

(1.0–1.5 cm) along the tissue. The needle should now be back on top 

of the tissue. 

3. Now enter the first side (going from top to bottom) just across from 

the suture on the other side. Again go through the full thickness of 

the tissue and come out on the undersurface of the tissue. 

4. Now enter the undersurface of the other side even with the first 

suture and come out on top. 

5. The suture can now be easily tied.

Figure-of-eight suture. This technique 

is used primarily to reapproximate 

deep tissues such as muscle or fascia. 

Tying the Suture 


The simplest way to tie the suture is by doing an “instrument tie,” described 

below. 


1. Pull the suture through the skin so that just a short amount of 

suture material (a few centimeters) is left out. 

2. Take the needle out of the needle holder. 

3. Place your needle holder in the center between the skin edges parallel 

to the wound. One end of the suture should be on each side of 

the wound without crossing in the middle. 

4. Wrap the suture that is attached to the needle once or twice around 

the needle holder in a clockwise direction. 

5. Grab the short end of the suture with the needle holder. 

6. Pull it through the loops, and have the knot lie flat. The short end 

of the stitch should now be on the opposite side. 

7. Let go of the short end. 

8. Bring the needle holder back to the center, parallel to the wound 

edges. 

9. Repeat steps 4–8 at least one or two times more. 

10. Cut the suture ends about 1 cm from the knot.


Instrument tie. Two loops of suture are wrapped around the distal portion of the 

needle holder, and the free end of the suture is then grasped and pulled 

through the loop thus formed. A third suture loop is wrapped around the needle 

holder in the opposite direction and pulled in a direction opposite to the first tie 

to form a square knot. Note that the short end of the suture switches sides as it 

is passed through the loop to create each knot. (From Simon RR, Brenner BE 

(eds): Emergency Procedures and Techniques, 3rd ed. Philadelphia, Lippincott 

Williams & Wilkins, 1994, with permission.) 


1. Pull the suture through the skin so that just a short amount of suture 

material (a few centimeters) is left out. 

2. Take the needle out of the needle holder. 

3. Both ends of the suture are on the same side. Place your needle 

holder between the ends of the suture. 



5. Grab the short end with the needle holder. 

6. Pull it through the loops, and have the knot lie flat. The short end of 

the stitch should now be on the opposite side. 

7. Let go of the short end.


8. Bring the needle holder back to the center, between the suture 

ends. 


10. Cut the suture ends about 1 cm from the knot. 

Continuous Suture 

1. Do not pull the next to-the-last stitch all the way through; leave it 

as a loop. 

2. Place your needle holder between the loop and the suture attached 

to the needle. The needle holder should be almost perpendicular to 

the wound. 



4. Grab the loop with the needle holder. 

5. Pull it through, and have the knot lie flat. The short loop should 

now be on the opposite side. 

6. Let go of the loop. 

7. Bring the needle holder back to the center between the loop and 

the suture end. 


9. Cut the suture ends about 1 cm from the knot. 

SSuuttuurree RReemmoovvaall 

If the sutures are taken out within 7–10 days, suture removal is usually 

easy and should not cause more than a pinching sensation to the patient. 

(See chapter 11, “Primary Closure,” for more details concerning 

the timing of suture removal.) 


1. Cut the suture where it is exposed, crossing the wound edges. 

2. Remove the entire stitch by grabbing the knot with a clamp or forceps 

and pulling gently. 


Removal of mattress sutures can be a little more difficult. 

1. Grab the knot and try to lift it up a little; this should allow you to 

see a space between the suture strands.


2. Cut one strand of the suture under the knot. 

3. Remove the entire stitch by grabbing the knot with a clamp or forceps 

and pulling gently. This suture will be a little harder to remove 

than a simple suture. 

4. If you accidentally cut both ends of the suture, you will leave suture 

material behind. 

5. Look on the opposite side of the skin for the suture. Grab it with a 

clamp or forceps, and gently remove the remaining suture material. 

Continuous Sutures 

1. Cut the suture in several places where it is exposed, crossing the 

wound edges. 

2. Remove portions of the stitch by grabbing an end with a clamp or 

forceps and pulling gently. 

3. The sutures to the knot must be cut in several places for removal. 

AAlltteerrnnaattiivveess ttoo SSuuttuurriinngg 

Other techniques can bring skin edges together to “suture” a wound 

closed without using sutures. These techniques require more expensive 

equipment than regular suturing. 

Skin Stapler 

Indication. The skin stapler is a medical device that places metal staples 

across the skin edges to bring the skin together. The area must be 

anesthetized before placing the staples. The main advantage of staples 

over sutures is that they can be placed quickly. Speed may be an important 

advantage when you need to close a bleeding wound quickly 

(e.g., on the scalp) to decrease blood loss. Staples tend to leave more 

noticeable marks in the skin compared with sutures. They should not 

be used on the face. 

Technique 

1. The edges must be everted. Usually an assistant must help by using 

forceps to hold the skin edges so that the dermis on each side 

touches. 

2. Place the center of the stapler (usually an arrow on the stapler marks 

the center) at the point where the skin edges come together. 

3. Gently touch the stapler to the skin; you do not have to push it into 

the skin. Then grasp the handle to compress it; the compression releases 

the staple.


Close the skin with clips. The stapler should be centered over the skin edges 

before the staple is released. Be sure that the skin is everted. (From Skandalakis 

JE, et al (eds): Hernia Surgical Anatomy and Technique. New York, 

McGraw-Hill, 1989, with permission.) 

4. Release the handle, and move the stapler a few millimeters back to 

separate the staple from the stapling device. 

5. The staples should be placed about 1 cm apart. 

To Remove the Staples 

A staple remover device can be used to remove the staples easily (see 

figures on next page). Put the jaws under the staple, and close the 

device. This bends the staple and allows it to be removed. 

If you do not have a staple remover, a clamp can be placed under the 

staple. Then open the clamp to bend the staple so that it can be removed. 

Removing a staple in this fashion can be painful. 

Adhesives 

Specialized surgical adhesive materials allow the skin edges to be 

“glued” together. The advantage of adhesives is that the wound does 

not need to be anesthetized for closure. However, a traumatic wound 

must be thoroughly cleaned before closure, which often requires local 

anesthetic. Thus, this advantage may be only theoretical. 

Adhesive compounds are quite expensive, and the quality of the resultant 

scar has still not been fully evaluated and compared with the scar


Removing a staple with a staple remover. 

from a properly sutured wound. Thus only adhesive tapes are further 

discussed. Never use regular household adhesives to try to close a wound. 

Adhesive Tapes 

Adhesive tapes often are placed after sutures are removed to help 

keep the skin closure from separating. They also can be used as a 

means of closure for relatively small wounds whose edges easily come 

together.


A, Closing the wound with adhesive strips. B, Placing adhesive strips to reinforce 

wound closure when sutures are removed. 

After thoroughly cleansing the wound, gently hold the skin edges together 

with your fingers or a forceps. Cut the tape so that at least 2–3 

cm are on each side of the skin edge once the tape is in place. 

Place tape strips one at a time, several millimeters apart. The tapes 

should be placed across (perpendicular to) the long axis of the wound. 

Tapes stay in place for several days and should be allowed to fall off on 

their own. The patient can wash the area but should do so gently.


BBiibblliiooggrraapphhyy 

1. Edgerton M: The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988. 

2. McCarthy JG: Introduction to plastic surgery. In McCarthy JG (ed): Plastic Surgery. 

Philadelphia, W.B. Saunders, 1990, pp 48–54.

Chapter 2 

BASIC SURGICAL TECHNIQUES 

KEY FIGURES: 

Knife blades Tying off a vessel 

Holding the knife Stick tie 

Continuous locking suture 

The previous chapter discussed suturing techniques. This chapter describes 

additional basic surgical skills. All rural healthcare providers 

should be proficient in these techniques. 

MMaakkiinngg aann IInncciissiioonn 

Many of the procedures explained in subsequent chapters of this book 

involve making incisions into the skin. Whether it be to remove a suspicious 

lesion or to create a flap for wound coverage, you must learn 

how to make an incision safely and efficiently. You will use a knife with 

a very sharp blade. It is important to know how to use the knife properly 

to prevent accidental injury to the patient or yourself. 

Which Blade to Use 

Knife blades come in various sizes (see figure below). There is no orderly 

scale to follow as with needle sizes. A no. 11 blade comes to a sharp 

point, whereas a no. 15 blade has a rounded end. A no. 10 blade is twice 

the size of the no. 15, and a no. 20 blade is bigger than the no. 10. It can 

be confusing, but most blades come with a picture on the packaging. 

Commonly used knife blades. A, no. 11 blade; B, no. 15 blade; C, no. 10 blade. 

21


Table 1. Deciding Which Blade to Use 

Blade Size Optimal Setting for Use* 

No. 11 Draining an abscess, performing a shave biopsy 

No. 15 Performing a biopsy, making incisions < 5 cm, any incisions on the face 

Nos. 10, 20 Making incisions longer than 5 cm, debriding wounds 

* This table describes the optimal knife blade to use if you have a choice of sizes. If you do not have 

the luxury of choice, any blade can be used for almost any situation. 

Holding the Knife 

For safety, use a blade only when it is attached to a handle. Some disposable 

knives come with the blade already attached to the handle. 

When they are not available, you may have to put the blade onto a 

knife handle yourself. Never touch the blade with your fingers; it is 

very sharp. Use a clamp or needle holder to grasp the blade, and position 

it onto the handle. 

Hold the handle with your dominant hand, as if you were using a writing 

instrument. To have the best control over the instrument, hold the 

handle 3–4 cm away from where the blade meets the handle. 

Hold the knife like a writing instrument 3–4 cm behind the point where the 

blade meets the handle. 

Using the Knife 

When you are about to make the incision, place the tissue under some 

tension. Use the index finger and thumb of your nondominant hand to 

push down on the skin, spread it apart, and make the skin taut. This 

technique makes the skin easier to incise.

Basic Surgical Techniques 23 

Make the incision with the flat part of the knife, not the very tip. Push 

the blade down with just enough pressure to cut through the skin. You 

do not have to go exactly to the proper depth with the first cut. It is 

better to be too timid than too forceful. If you use too much force to 

make the incision, your knife may penetrate too deeply into the tissues 

and accidentally cut an important structure. 

Which Side to Incise First 

When you have to make two incisions (for example, to remove a suspicious 

skin lesion), look at their orientation. If they are to be made one 

above the other (for example, if you are working on the side of the leg), 

do the bottom skin incision first. If the top incision is made first, blood 

from the skin edges will drip down and obscure the area below. The presence 

of the blood makes it more difficult to perform the lower incision. 

WWhhaatt ttoo DDoo aabboouutt BBlleeeeddiinngg ffrroomm tthhee SSkkiinn EEddggeess 

1. Apply pressure. Most bleeding from skin edges stops on its own 

after pressure is applied over the area for a few minutes with a 

gauze pad. 

2. If you have access to an electrocautery device. An electrocautery 

device applies an electrical current that coagulates the tissue and 

stops bleeding. When this device is used, the patient must be attached 

to a grounding pad. Wipe away the blood, and touch the 

bleeding spot with the cautery device. The bleeding usually stops. If 

you see bleeding from a small blood vessel, grab it with the tips of a 

metal clamp. Then touch the clamp with the cautery device. Be sure 

that the clamp is not touching any surrounding tissue. The current 

will pass through the clamp and burn the surrounding tissue as well. 

Caution: Be sure that your gloves are intact before touching the clamp 

with the cautery device. If you have a hole in the glove on the hand holding 

the clamp, you will get zapped when you touch the clamp with the 

cautery device. You may experience a painful, small burn in your finger 

or even feel the electric current pass through your body. 

3. Close the wound with a continuous locking suture. This technique 

places more tension on the skin edges than the usual continuous closure 

and often stops the bleeding. A continuous locking suture is 

often quite useful to control a bleeding scalp wound. 

How to Place Continuous Locking Sutures 

For the typical continuous suture technique, the thread should always 

remain behind the needle. With the locking technique, the thread lies in front


of the needle as it comes out of the tissues. The suture, therefore, comes out 

of the tissues inside the loop. When the stitch is pulled through the 

loop, it places the suture material along the outside skin edge, putting 

pressure on the tissue. The pressure helps to control bleeding. 

Top, Continuous locking suture. Bottom, Continuous nonlocking suture. Note 

the differences in where the suture loop comes out of the skin relative to the 

needle as well as the appearance of the sutures on the skin. 

HHooww ttoo MMaannaaggee BBlleeeeddiinngg ffrroomm aa BBlloooodd VVeesssseell 

1. Apply pressure. Application of pressure is always a good first choice. 

It prevents further blood loss and may allow the vessel to clot, 

thereby stopping the bleeding. Try this technique for at least 5–7 minutes. 

If it is unsuccessful, the following alternatives should be tried. 

2. If you have access to an electrocautery unit. If the vessel is a vein or 

small (1–2 mm) artery, grab it with the tips of a metal clamp and 

touch the clamp with the cautery device. Be sure that your gloves 

are intact and that the clamp is applied only to the vessel. 

3. If you do not have access to an electrocautery unit or if the vessel is 

a larger vein or larger (3–4 mm) artery, the end of the vessel should 

be tied off with a suture for secure hemostasis. There are two basic 

techniques for tying off a vessel (see figures on following pages).

Regular Tie 


Regular ties are adequate for most veins and small (2–3 mm) arteries. 

Grasp the end of the vessel with a small clamp, and gently hold the 

vessel away from the surrounding tissues. Pass a piece of 3-0 or 4-0 silk 

or Vicryl suture material (the needle is not needed) around the vessel 

and under the clamp. Tie the suture securely, placing at least 3 or 4 knots. 

Four major steps (A–D) in tying off a vessel with the regular stitch. (From 

Edgerton M: The Art of Surgical Technique. Baltimore, Williams & Wilkins, 

1988, with permission.)


Stick Tie 

A stick tie is a more secure technique to control bleeding from a blood 

vessel. It is especially useful for arteries, because the thicker wall and 

increased interior pressure of an artery can cause a regular tie to come 

off of the vessel. 

Grasp the end of the artery with a small clamp, and gently lift the 

vessel. Use a 3-0 or 4-0 silk or Vicryl suture with a needle (a tapered 

needle is best). Pass the needle through the center of the vessel just 

under the clamp. Bring both ends of the suture toward yourself (again, 

under the clamp), and tie the suture securely (just once). 

Now take one of the suture ends and pass it completely around the vessel, 

making sure to pass the string under the clamp. Again, tie the suture. As 

you are tightening it, remove the clamp. Finish with 3–4 more knots. 

Stick tie: a more secure way to control bleeding from a blood vessel. (From 

Edgerton M: Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988, 

with permission.) 

BBlluunntt DDiisssseeccttiioonn 

Blunt dissection is a technique for gently separating tissues while 

avoiding injury to important nearby structures such as blood vessels, 

nerves, or veins. Unless you use too much force, subcutaneous tissue 

and muscle will separate easily, while the surrounding nerves, vessels, 

and tendons will remain intact. For healthcare providers with 

limited surgical skills, blunt dissection is the technique of choice for 

separating tissues (for example, in exploring a wound or operating on 

a hand). 

Blunt Dissection Technique 

Insert the closed blunt tips of a scissors or the closed jaws of a clamp into 

the tissues (to a depth of approximately 1–2 cm). Then gently open the 

instrument. This action separates the tissues. Any fibrotic connections


that are not important structures can then be safely cut with the scissors. 

Repeat these maneuvers as needed. 

Alternatively, you can gently use your index finger covered with a 

gauze pad to separate tissues. This technique is especially useful for 

elevating a skin flap off an underlying muscle. 

SShhaarrpp DDiisssseeccttiioonn 

Sharp dissection is a technique for separating the tissues using a knife 

or scissors. You must be careful not to cut accidentally an important 

structure. For healthcare providers without surgical expertise, sharp 

dissection should be used primarily in emergencies, for making a hole 

in the neck to create an airway, or for trying to enlarge a deep hole to 

control life-threatening bleeding. In addition, sharp dissection is used 

for undermining tissues (see below) or excising a lesion. 

UUnnddeerrmmiinniinngg SSkkiinn EEddggeess 

To undermine skin edges, you cut beneath the skin along the edge of a 

wound to free the skin from its deep tissue attachments. The purpose 

is to increase skin mobility, which is important for a tension-free 

wound closure. It is also a necessary skill for performing local flaps. 

Technique 

Pinch the tissues around the edge of the wound with the forceps to 

ensure that the local anesthetic is still working. Give additional anesthetic 

as required. Lift the skin edge with the forceps, and with a knife 

or a scissors cut into the deep subcutaneous tissue along the length of 

the wound (try to stay at the same depth) until the skin has the required 

mobility. 

An alternative method involves separating the skin and subcutaneous 

tissue from the underlying muscle. The plane of dissection is just above 

the fascia, the thin layer of connective tissue that overlies the muscle. 

By undermining the skin along this deeper plane, you may encounter 

less bleeding than if you cut directly into the subcutaneous tissue layer. 


Edgerton M: The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988.

Chapter 3 

LOCAL ANESTHESIA 

KEY FIGURES: 

Digital block/anatomy Ulnar nerve infiltration 

Sensation to hand Facial block: 

Median nerve infiltration skeleton 

Full surgical evaluation of a wound and suture placement can be 

quite painful. You must anesthetize the injured area to perform these 

procedures properly. The administration of a local anesthetic allows 

you to evaluate and treat wounds in the emergency department or 

clinic. If you are unable to attain adequate pain control, the patient 

should be taken to the operating room for exploration under general 

anesthesia. 

Local anesthetics work by reversibly blocking nerve conduction. They 

primarily block the sensation of sharp pain; they do not block pressure 

sensation. Therefore, in an area that has been adequately anesthetized, 

the patient will not feel the sharp needle stick during suture placement 

but may feel a vague sensation of pressure. This information should be 

shared with the patient. 

The duration of effect depends on how long the agent stays in the immediate 

working area before being absorbed into the circulation or 

broken down by the surrounding tissues. 

TTooppiiccaall AAggeennttss 

Topical agents (agents applied on top of the surrounding skin and absorbed 

into the area to provide anesthesia without injections) are now 

available. However, they are quite expensive and can be used only on 

the surface, not deep within an open wound. They can be quite effective 

for performing simple excisions or starting intravenous lines. 

Although topical agents may become important in the future, because 

of their expense and limited usefulness, they are not discussed further 

in this chapter. 

29


Application of cold works for only a few minutes but may allow 

enough time to place one or two stitches. Cold also may help by decreasing 

the pain of local anesthetic injection. It can be especially useful 

in children. Have the patient hold ice over the area for 5 minutes before 

injection. Another way to apply cold is to spray the area with ethyl 

chloride solution. 

IInnjjeeccttaabbllee LLooccaall AAnneesstthheettiiccss 

The easiest and most reliable way to anesthetize a wound is to inject a 

local anesthetic. There are two techniques: (1) direct injection of the 

local anesthetic agent into the area around the wound and (2) injection 

of the anesthetic agent around a sensory nerve that supplies sensation 

to the injured area. Both methods are addressed below, but first the two 

most commonly used anesthetic agents are discussed. Neither needs to 

be refrigerated, which is important in the rural setting. 

Lidocaine (Lignocaine) 

Lidocaine is the most commonly used and least expensive agent. The 

usual total dose that can safely be given is 3–5 mg/kg body weight. Do 

not give more than this amount at one time. The anesthesia becomes effective 

after 5–10 minutes and lasts, on average, from 45 minutes to 1 hour. 

Bupivacaine (Marcaine) 

Bupivacaine is a longer-acting agent than lidocaine, but it is also more 

expensive. The usual total dose that can safely be administered at one 

time is 2.0–3.0 mg/kg. Bupivacaine takes a few minutes longer to 

become effective than lidocaine (10–15 vs. 5–10 minutes), but its effect 

can last 2–4 hours. 

The longer duration of effect can be valuable. Some wounds take more 

than 1 hour to clean and suture. In addition, bupivacaine gives residual 

pain control after the procedure is completed. Hand injuries are especially 

prone to pain, making bupivacaine a good choice for treating 

hand and finger injuries. 

If both lidocaine and bupivacaine are available, they can be mixed together 

in equal parts and administered with one syringe. This combination 

gives the advantages of the quicker onset of anesthesia from the 

lidocaine with the longer duration of action of the bupivacaine. 

Calculating the Amount to Administer 

To calculate the mg dose, multiply the ml of solution that you plan to 

give by the concentration of the solution (mg/ml). The following table

Local Anesthesia 31 

converts the commercially available anesthetic solutions to the mg/ml 

concentration of the anesthetic agent. 

Concentration of Agent in Commercially Available Anesthetic Solutions 

Agent Commercial Solution (%) Concentration (mg/ml) 

Lidocaine 0.5 5 

1.0 10 

2.0 20 

Bupivacaine 0.25 2.5 

0.50 5.0 

Example: You expect to inject 30 ml of 1.0% lidocaine to anesthetize a 

relatively large wound: 

30 ml × 10 mg/ml = 300 mg of lidocaine 

The patient is a 70-kg man. A 70-kg man can receive 3–5 mg/kg or 

210–350 mg of lidocaine. Your 30-ml dose is on the high end of the 

“safe” range. 

Additives 

It is sometimes useful to add additional drugs to the local anesthetic 

solutions to optimize their effect. 

Bicarbonate 

Both lidocaine and bupivacaine are acidic and therefore painful when 

injected. One way to lessen this pain is to add injectable sodium bicarbonate 

to the local anesthetic solution. Your patient will be grateful for 

this extra step. It is essential to use commercially prepared bicarbonate 

for injections. Do not try home-grown formulations. Be careful: adding 

too much bicarbonate to the anesthetic solution can lead to the formation 

of crystals. The proper mixtures are as follows: 

• Lidocaine: add 1 ml of bicarbonate to each 9 ml of lidocaine before 

injection. 

• Bupivacaine: add 1 ml of bicarbonate to each 19 ml of bupivacaine 

before injection. 

Epinephrine 

Epinephrine is a vasoconstrictor that shrinks blood vessels and thus 

reduces bleeding from the wound and surrounding skin edges. This 

makes wound examination and repair easier to perform. Epinephrine 

also decreases absorption of the anesthetic agent, which 

may allow safe injection of more than the usually recommended


amount of anesthetic agent. Epinephrine requires 5–7 minutes to take 

effect. The maximal dosages of lidocaine and bupivacaine with epinephrine 

are as follows: 

• Lidocaine with epinephrine increases to 7 mg/kg, and its effect lasts 

11 ⁄2–2 hours. 

• Bupivacaine with epinephrine: dosing essentially stays the same at 

2.0–3.0 mg/kg, and its effect still lasts 2–4 hours. 

Lidocaine and bupivacaine are available in solutions premixed with 

epinephrine , but you can add it to the anesthetic solution yourself. Be 

very careful, however, because the amount of epinephrine to add is 

very small: 

1. Add 0.25 ml of 1:1000 epinephrine to 50 ml of local agent (50 ml is 

the usual-sized vial). This will give a 1:200,000 dilution—safe for 

most procedures. 

2. Err on the side of adding a little less rather than a little more if you 

are drawing the epinephrine with a syringe larger than 1 ml. 

Contraindications to Adding Epinephrine 

In certain circumstances the vasoconstricting effects of epinephrine can 

be detrimental and may lead to tissue loss. Examples include: 

• Digital block (numbing the whole finger) 

• On the tip of the nose 

• On the penis 

• Injury that results in a very ragged and irregular laceration. Epinephrine 

worsens the already compromised circulation of the skin edges. 

Indications for Adding Epinephrine 

• Straight cut with healthy-looking skin edges 

• On the face, oral mucosa, and scalp, which have excellent blood circulation 

Overview of Anesthetic Agents: Dosage and Duration of Action 

Agents Maximal dose (mg/kg) Duration of Action 

Lidocaine plain 3–5 45–60 min 

Lidocaine with epinephrine* 5–7 1.5–2 hr 

Marcaine plain 2.0–3.0 2–4 hr 

Marcaine with epinephrine 2.0–3.0 2–4 hr 

* You can add the same amount of bicarbonate to solutions with epinephrine as you add to plain solutions 

without epinephrine (see above for proper amounts).

SSaaffeettyy HHiinnttss 


Caution about injections: It is quite dangerous to insert the syringe 

needle in the wrong place and inject the solution into an artery by mistake. 

A good habit to develop when giving any type of injection is to 

draw back on the syringe (i.e., pull back on the plunger) before injecting the 

solution. If you draw back and get blood, reposition the needle and 

draw back again. This technique prevents an accidental intra-arterial 

injection, which can cause serious complications. If you draw back 

blood with the initial insertion, you have not created a major problem. 

Because you are using a small needle, you should not do significant 

damage to the blood vessel, but you may need to hold pressure over 

the area for a few minutes to decrease bruising. 

Caution about maximal safe dosage: Be aware of how much you are 

injecting to avoid exceeding the safe doses. Average-sized wounds (up 

to 4–5 cm) usually present no problem, but it is easy to forget about 

dosage concerns when you are working on larger wounds. All anesthetic 

agents have systemic as well as local effects. The safe dosage is 

based on the total weight of the patient (thus the maximal doses are 

given as mg of agent/kg of patient body weight). Overdose can lead to 

seizures and even cardiovascular collapse or death due to the myocardial 

depressant and vasodilator effects of these agents. 

HHooww ttoo AAddmmiinniisstteerr tthhee LLooccaall AAnneesstthheettiicc 

Direct Infiltration Around the Wound 

In many cases, injecting the anesthetic agent around the wound is 

an easy and reliable way to anesthetize the area. It is best to use as 

small a needle as possible. The bigger the number, the smaller the 

needle: use a 25- or 27-gauge needle, and inject slowly. Injection of 

the anesthetic agent can be painful, and a slower injection rate 

causes less pain. 

You can inject directly into the wound to get the anesthetic into the surrounding 

skin if the wound is reasonably clean. Alternatively, inject in 

the noninjured skin along the outside of the wound. Inject until you 

see the skin start to swell. 

One technique is to push the needle into the tissues completely to the 

hub, and then slowly infiltrate the anesthetic as you bring the needle 

out of the tissues. Be sure to allow enough time for the agent to take 

effect before starting your procedure (at least 5 minutes).


Nerve Blocks 

In some areas of the body, discrete nerves that are responsible for sensation 

to the injured area are easy to locate. In these instances, local 

anesthesia can be infiltrated around (not into) the sensory nerve for 

pain control to the area around the wound. This approach is advantageous 

because the patient needs to undergo fewer injections than if 

you anesthetize the entire wound margins directly. 

Nerve blocks are also a good choice when the wound is deep, because 

they often give a more complete block of the entire area, not 

just the skin. This approach is especially appropriate for larger 

wounds, because it usually requires less anesthetic agent than direct 

infiltration. 

Whenever possible, use a relatively small needle (23- or 25-gauge) for 

the injection. Always draw back on the syringe before injecting the anesthetic. 

The nerves that you are blocking often are located near blood 

vessels. 

Caution: You are probably injecting the anesthetic directly into the 

nerve if the patient complains of strong electric shocks or severe pain 

radiating along the distribution of the nerve. Stop the injection immediately 

and reposition the needle. 

It usually takes a few minutes longer for the anesthetic to take effect 

than with direct wound injection. Often you must wait 10–15 minutes 

after giving a nerve block before proceeding with the procedure. 

NNeerrvvee BBlloocckkss ffoorr HHaanndd IInnjjuurriieess 

Lidocaine, bupivacaine, or a combination of the two solutions can be 

used. Add bicarbonate if it is available. Epinephrine should not be used 

for anesthetizing the hand and fingers. 

Digital Block 

A digital block is the best way to evaluate and treat a wound on the 

finger. The digital nerves supply sensation to the volar and dorsal surfaces 

of the finger. 

Anatomy. Each finger and the thumb have two digital nerves that 

travel with the digital vessels along the lateral and medial sides of the 

digit. Look at your own finger from the side, bend it at the two joints 

(distal interphalangeal [DIP] and proximal interphalangeal [PIP] 

joints). The line that connects the joint creases is a good estimate of 

where each digital nerve runs.


Digital nerve block, dorsal approach. Care must be taken to ensure that the 

anesthetic is not injected entirely circumferentially around the finger. 

(Illustration by Elizabeth Roselius. From Green DP, et al: Operative Hand Surgery, 

4th ed. New York, Churchill Livingstone, 1999, with permission.) 

Procedure 

1. The injection is done from the dorsal (not volar) surface near the 

metacarpophalangeal (MCP) knuckle. 

2. Insert the needle into the web space, when present (the thumb and 

little finger are not bordered on both sides by web spaces). 

3. Aim the needle toward the MCP joint of the affected finger, moving 

in a volar direction. 

4. Be careful not to inject too superficially on the volar side, or your injection 

will miss the area around the nerve. 

5. Inject 2–3 ml of solution into each side of the affected finger. 

6. Infiltrate 1–2 ml along the dorsal skin of the digit, just distal to the 

MCP knuckle.


Pattern of sensory innervation of major peripheral nerves. (From Jurkiewicz 

MJ, et al (eds): Plastic Surgery: Principles and Practice. St. Louis, Mosby, 

1990, with permission.) 

Wrist Block 

Three nerves supply sensation to the hand: the median nerve, ulnar 

nerve, and superficial branch of the radial nerve. If you infiltrate around 

all three nerves, you effectively anesthetize the entire hand. If an injury 

is within the distribution of any one or two nerves, simply infiltrate 

around the nerves that you need to anesthetize, based on the injury. 

Median Nerve 

The median nerve supplies sensation to the volar surface of the hand, 

from the lateral half of the ring finger to the thumb, and to the dorsal 

aspect of the fingers distal to the PIP joint, from the lateral half of the 

ring finger to the thumb. 

Anatomy. At the wrist the median nerve lies between the palmaris 

longus (PL) and flexor carpi radialis (FCR) tendons. If the PL is absent 

(15% of the population), the landmark for injection is just medial to the 

FCR tendon.


Wrist block, median nerve. PL = palmaris longus, FCR = flexor carpi radialis. 

(Illustration by Elizabeth Roselius. From Green DP, et al (eds): Operative Hand 

Surgery, 4th ed. New York, Churchill Livingstone, 1999, with permission.) 

Procedure 

1. Have the patient flex the wrist. The FCR and PL (if present) become 

noticeable in the distal forearm; the FCR is the more lateral of the 

two tendons. 

2. Insert the needle just proximal to the wrist crease and medial to the 

FCR tendon. 

3. Draw back on the syringe and slowly inject 3–5 ml of anesthetic in the tissues 

deep to the skin. 

4. If the patient describes minor tingling, the needle is in the proper 

position. If the patient describes electric shocks or severe pain, the 

needle may be in the nerve. Stop injecting the anesthetic, and back 

the needle out a few mm before continuing to inject the anesthetic 

solution. Do not inject the anesthetic directly into the nerve. 

Ulnar Nerve 

The ulnar nerve supplies the remainder of the volar surface of the hand 

and the volar and dorsal surfaces of the ring and little fingers. The 

dorsal ulnar side of the hand is innervated by a branch of the ulnar 

nerve that comes off proximal to the wrist in the distal forearm. 

Anatomy. At the wrist, the ulnar nerve lies with the ulnar artery lateral 

to the flexor carpi ulnaris (FCU) tendon. The artery is lateral to the 

nerve.


Wrist block, ulnar nerve. 

Note that the nerve lies between 

the artery and flexor 

carpi ulnaris (FCU) tendon. 

(Illustration by Elizabeth 

Roselius. From Green DP, 

et al (eds): Operative Hand 

Surgery, 4th ed. New York, 

Churchill Livingstone, 1999, 


Procedure 

1. Have the patient flex the wrist. The FCU is palpable along the 

medial edge of the distal forearm. 

2. Insert the needle just proximal to the wrist crease and just lateral to 

the FCU tendon. 

3. Draw back on the syringe before injecting the anesthetic to ensure that the 

needle is not in the ulnar artery. If blood is drawn back, remove the 

needle and hold pressure over the area for several minutes. 

4. Slowly inject 1–2 ml of local anesthetic. 

5. To block the nerve branch that supplies sensation to the dorsal 

aspect of the hand, inject 1 ml of local anesthetic subcutaneously in 

the tissues overlying the ulnar nerve. 

6. Advance the needle onto the dorsum of the wrist, and inject another 

3–4 ml. Go about halfway around the wrist on the dorsal surface. 

Superficial Branch of the Radial Nerve 

The superficial branch of the radial nerve supplies sensation to the 

dorsum of the hand from the ring finger to the thumb; the dorsum of 

the thumb; and the dorsum of the index, middle, long, and ring fingers 

to the PIP joint. 

Anatomy. The superficial branch of the radial nerve often has several 

branches traveling in the tissues of the dorsolateral surface of the distal 

forearm and wrist.


Procedure 

1. Feel for the radial artery pulse in the distal forearm, approximately 

2 cm proximal to the wrist crease. 

2. Insert the needle laterally to the point where you feel the pulse, and 

inject 1–2 ml of local anesthetic subcutaneously. Draw back on the syringe 

before injection. 

3. Advance the needle into the tissues on the dorsum of the distal forearm. 

4. Inject an additional 3–4 ml of solution halfway around the dorsal 

surface of the wrist. 

NNeerrvvee BBlloocckkss ffoorr FFaacciiaall IInnjjuurriieess 

The nerves that supply sensation to the areas most commonly affected 

by facial trauma exit the skull along a line drawn perpendicular to the 

midpoint of the pupil. These nerves, designated as V1, V2, and V3, are 

branches of the fifth cranial (trigeminal) nerve. 

Lidocaine and/or bupivacaine can be used for facial nerve blocks. Add 

bicarbonate if it is available. Epinephrine is often a useful addition to 

the anesthetic solution. 

V 1: Supraorbital Nerve Block 

The supraorbital nerves supply sensation to the upper eyelid and overlying 

forehead. A supraorbital nerve is located on each side of the face. 

Anatomy. If you divide the supraorbital rim into thirds, the supraorbital 

nerve exits the skull at the point where the central and medial 

thirds meet. 

Procedure 

1. Insert the needle into the eyebrow overlying the point where the 

nerve exits the skull. 

2. Inject 1 ml of anesthetic solution into the superficial tissues. 

3. Advance the needle downward to the bone. You will feel the needle 

hitting against a hard surface when it meets the bone. 

4. Back the needle 1–2 mm away from the bone, and inject another 2–3 

ml of local anesthetic.


Anatomy of the trigeminal nerve branches (V 1, V 2, and V 3). These nerves provide 

sensation to the face and are amenable to nerve blocks. 

V 1: Supratrochlear Nerve Block 

The supratrochlear nerve supplies sensation to the medial upper 

eyelid, upper nose, and medial forehead. 

Anatomy. The supratrochlear nerve exits the skull along the medial 

aspect of the supraorbital rim just lateral to the area where the rim 

meets the nose. 

Procedure 

1. Insert the needle into the soft tissues overlying the point where you 

expect the nerve to exit the skull. 

2. Inject 1 ml of anesthetic solution into the superficial tissues. 

3. Advance the needle tip downward to the bone. 

4. Back the needle 1–2 mm away from the bone, and inject another 1–2 

ml of the solution.


Caution: For a forehead wound above the medial third of the eyebrow, 

both the supraorbital nerve and supratrochlear nerve probably need to 

be blocked on the side of the injury. 

V 2: Infraorbital Nerve Block 

The infraorbital nerves supply sensation to the upper lip, cheek, lateral 

aspect of the nose, and lower eyelid. There is one nerve on each side of 

the face. 

Anatomy. The infraorbital nerve comes out of the skull about 1 ⁄2 cm 

below the orbital rim along the vertical line drawn perpendicular to 

the midpoint of the pupil. 

Procedure 

1. Insert the needle into the cheek skin at the point where the vertical 

line drawn perpendicular to the midpoint of the pupil meets a horizontal 

line drawn from the bottom of the nose. 

2. Advance the needle tip 2–3 mm into the tissues. 

3. Inject 1 ml of solution. 

4. Advance the needle tip further, going in a slightly superior direction 

as you pass through the tissues until you hit the underlying bone. 

The tip ultimately should travel superiorly about 1 cm. 

5. Back the needle out 1–2 mm, and inject another 2–3 ml of the anesthetic. 

V 3: Mental Nerve Block 

The mental nerves supply sensation to the lower lip and the skin immediately 

below it. There is one mental nerve on each side of the 

face. 

Anatomy. The mental nerve exits from the mandible a few mm below 

and 5–10 mm lateral to the inferior aspect of the lower canine tooth 

root. 

Procedure. 

1. The mental nerve block is performed in the mouth. 

2. Insert the needle into the mucosa a few mm below and 5–7 mm lateral 

to the root of the lower canine tooth. 

3. Advance the needle tip until it hits the bone. 

4. Inject 2–3 ml of solution.


Nerve Block Overview 

Injury Block 

Finger Digital block 

Palm of hand Median and ulnar nerve block 

Multiple cuts on both surfaces of hands Wrist block 

Left inner cheek/upper lip Left intraorbital nerve block 

Right lower lip Right mental nerve block 

Center of forehead Supraorbital and supratrochlear block on 

both sides of face 

SSeeddaattiioonn 

Sedation can be a useful adjunct to local anesthetic. A sedative decreases 

the patient’s anxiety about the upcoming procedure and increases 

the patient’s cooperation. This, in turn, makes the procedure 

easier and safer to perform. 

In the setting of exploring or closing a wound, the purpose of sedative 

medications is not to put the patient to sleep, but to make him or her 

somewhat drowsy and less anxious. 

Caution: Sedative medications can cause respiratory depression. 

Always start with small doses, and gradually give additional medication 

until the desired amount of sedation is obtained. Patients should 

be monitored closely (blood pressure, heart rate, and respiratory rate) 

during and for at least 1 hour after the procedure is completed. 

There are many sedatives from which to choose. The following table 

gives information about two commonly used benzodiazepines.

Useful Agents for Sedation 


Route of Onset of 

Agent Administration Dose Sedation (min) 

Midazolam IV Adult: 0.5–2 mg as initial dose; 2–3 (adult and 

(Versed) Adult: inject repeat cautiously with 0.5– child) 

over 1 min 1.0 mg after 3–4 min until 

Child: inject desired effect is reached 

slowly, over Child (6 mo–13 yr): 0.05–0.1 

3 minutes mg/kg/dose; repeat after 4–5 

min until desired effect is 

reached to maximal total 

dose of 0.5 mg/kg 

Child > 13 yr: follow adult dosing 

IM Adult: 2–5 mg Adult: 15–20 

Child: 0.1–0.5 mg/kg Child: 5 

Diazepam IV Adult: 5–10 mg 5–10 (adult and 

(Valium) Child: 0.04–0.2 mg/kg/dose child) 

IM Adult: same as IV dose 30 (adult and 

Child: same as IV dose child) 

IV = intravenous, IM = intramuscular. 

FFoorr IInnffoorrmmaattiioonn OOnnllyy:: AAddddiittiioonnaall BBlloocckkss ffoorr 

PPrroocceedduurreess oonn tthhee UUppppeerr EExxttrreemmiittyy 

These procedures are technically more difficult and require special equipment. 

Although discussed for completeness, they are beyond the realm of 

a health care provider without expertise in delivering anesthesia. 

Bier Block 

In a Bier block, also called intravenous regional anesthesia, the affected 

hand or forearm is exsanguinated and an upper arm tourniquet is inflated. 

The venous circulation of the hand or forearm is then filled with 

lidocaine via a catheter placed in a hand vein before exsanguination. In 

this manner, the hand and forearm are anesthetized. The block lasts 

about 45–60 minutes. 

Warning: The tourniquet must work perfectly. If the tourniquet does 

not hold its pressure, the injected lidocaine may become systemic and 

cause serious side effects (e.g., seizures, cardiac arrhythmias/arrest). In 

addition, for a very short procedure (< 15–20 minutes), the lidocaine in 

the veins will still be at too high a concentration for the tourniquet to 

be deflated. Usually, the tourniquet can be released safely after 25–30 

minutes. 

Axillary Block 

An axillary block essentially anesthetizes the proximal portions of the


nerves that become the median, ulnar, and radial nerves in the forearm 

and hand. Technically these portions of the nerves are called the cords 

of the brachial plexus. The axillary block is commonly used to provide 

anesthesia for hand procedures. 

Usually a mixture of lidocaine and bupivacaine is used for infiltration. 

An axillary block is useful for procedures that take up to 21 ⁄2 hours. 

The landmark for injection of the anesthetic is the axillary artery, which 

is easy to feel in the inner aspect of the upper arm. However, injecting 

in the vicinity of the axillary artery is not without risk; possible complications 

include injury to the artery or accidental intra-arterial injection. 

A nerve stimulator can be used to help to identify the nerve and 

thereby lessen these risks. Even so, an axillary block should be done 

only by health care providers with expertise in delivering anesthesia. 


1. Cousing MJ, Bridenbaugh PO: Neural Blockade in Clinical Anesthesia and 

Management of Pain, 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 1997. 

2. Longnecker DE, Morgan GE, Tinker JH: Principles and Practices of Anesthesiology, 

2nd ed. St. Louis, Mosby, 1997.

Chapter 4 

PROTECTING YOURSELF 

FROM INFECTIOUS DISEASES 

Healthcare providers are at risk for contracting serious infectious diseases. 

Although the human immunodeficiency virus (HIV) is often 

the most feared, the hepatitis B virus (HBV) and hepatitis C virus 

(HCV) are actually much more contagious than HIV, because a 

smaller inoculum can cause infection. 

Healthcare workers who are inexperienced at technical procedures 

and find themselves having to treat open wounds and perform invasive 

procedures are especially at risk for two important reasons. First, 

treatment of an open wound almost always necessitates exposure to 

blood and body fluids. Blood and body fluids represent the primary 

mode of transmission of these contagious agents. Second, the treatment 

of open wounds and the performance of even simple procedures 

(for example, suturing) involves the use of sharp instruments. 

Inexperience on the part of the healthcare provider is a major risk 

factor contributing to an accidental needlestick or other traumatic 

injury during such procedures. 

SSccooppee ooff tthhee PPrroobblleemm 

These statistics are presented not to scare you, but to emphasize that 

the risk is genuine. 

Human Immunodeficiency Virus 

World Prevalence: Over 47 million people worldwide have been infected 

with HIV since the start of the epidemic. In 1998, HIV caused 

over 2 million deaths. In some countries in Africa, 1 in 4 people is infected 

with HIV. Ninety-five percent of cases occur in the developing 

world. 

Prevalence in the U.S. Approximately 1 in 200 people carries HIV. 

45


Hepatitis B Virus 

World Prevalence. There are over 350 million chronic carriers of HBV 

worldwide. In developing nations, 8–15% of the population are chronic 

carriers. This percentage drops to less than 5% in developed nations. 

Five to ten percent of chronically infected people will develop chronic 

liver disease that may lead to death. 

Prevalence in the U.S. Approximately 1 million people are chronically 

infected with HBV. 

Hepatitis C Virus 

World Prevalence. Three percent of the world’s population is infected 

with HCV. There are more than 170 million chronic carriers of HCV. 

About 50–70% of infected people will develop chronic liver disease. 

HCV infection is the leading disease necessitating liver transplantation. 

Prevalence in the U.S. Approximately 4 million people are chronically 

infected with HCV. 

Delta Hepatitis Virus 

The delta hepatitis virus (HDV) primarily affects patients infected with 

HBV. A patient infected with both HBV and HDV has an increased risk 

for the development of fulminant hepatitis compared with a patient infected 

with HBV alone (the risk doubles to 20%). About 70–80% of 

people infected with HBV and HDV develop chronic hepatitis. 

Prevalence in the U.S. Unknown 

SSiimmppllee PPrreeccaauuttiioonnss tthhaatt MMaakkee aa DDiiffffeerreennccee 

• Wash your hands before and after examining every patient. This is 

the single most important way to prevent the spread of infectious 

diseases. 

• Wear gloves. Gloves should be worn whenever you anticipate contact 

with mucous membranes, open wounds, or body substances 

(e.g., urine, feces, blood). Also wear gloves when handling items 

soiled with blood or body fluids or performing any type of invasive 

procedure. Do not go from patient to patient wearing the same pair 

of gloves. Gloves are not a substitute for proper hand washing. After 

removing your gloves, remember to wash your hands. 

• Double-glove whenever possible during procedures involving 

sharp instruments. Double gloves may feel uncomfortable at first, 

but you will get used to them. Try wearing a glove a half size larger 

next to your skin, and wear your regular size over the larger glove.

Protecting Yourself from Infectious Diseases 47 

• Wear goggles. Eye protection is always advisable during procedures. 

Get your own pair, and keep them in your pocket. You will be 

amazed at how much material accumulates on the lenses, even when 

you are not aware that any material has been sprayed. The goggles 

used for racket sports are quite comfortable and often very useful. 

When you wear a mask over your mouth, the goggles may fog up because 

exhaled air escapes from under the mask around the edges of 

your nose. To prevent your lenses from fogging, tape the mask to 

your cheeks and to the bridge of your nose to prevent air escape. 

• Get vaccinated against HBV. All healthcare providers should be immunized 

against HBV. The vaccine is 95% effective in preventing infection. 

The current vaccine is completely artificial, i.e., no human 

products are part of the vaccine. There is no chance of contracting 

HBV, HCV, or HIV from the vaccine. The vaccine is administered as a 

series of three intramuscular injections. The second dose is given 1 

month after the first injection, and the third dose is given 6 months 

after the first injection. 

• Observe proper use and disposal of all sharp instruments. Needles 

for injection should not be recapped by hand. Accidents often occur 

during manual recapping. Keep the cap on your tray, and slide the 

needle back into the cap when you have finished using it. Do not 

attempt to bend needles or other sharp objects. Use your instruments 

when placing sutures—not your fingers! Suturing is often difficult 

for the novice, but get in the habit of using only instruments 

to hold and reposition the needle. With practice, this technique becomes 

easier. Do not leave needles or other sharp instruments lying 

around. Always place them in a container marked “sharp instruments” 

after use. 

• Adequately sterilize all reusable materials. This practice is vital to 

protect healthcare providers and their patients from serious infectious 

diseases. Never reuse needles or syringes without properly sterilizing 

them. 

• Keep all countertops and other surfaces clean. It is important to regularly 

clean all surfaces that may have become contaminated by 

blood or other body fluids. HBV can survive for at least 1 week in 

dried blood on various surfaces. A disinfectant made of dilute bleach 

should be used for regular cleaning.


PPoosstteexxppoossuurree TTrreeaattmmeenntt 

Exposure to potentially infectious blood or body fluids includes needlesticks, 

splashing of fluids in the face or eyes, and contact with body 

fluids or blood through an open wound on your skin. Although intact 

skin is usually a good protective barrier, irritated or chapped skin (for 

example, from cold weather) can be penetrated by some viruses. If, despite 

following all of the above recommendations, you are exposed to 

potentially infectious blood or body fluids, certain steps can be taken 

to decrease your risk for becoming ill. 

• If you are exposed to HBV and have not been previously vaccinated: 

Hepatitis B immunoglobulin (HBIG) should be given (5.0 ml 

intramuscularly). HBIG is most effective when administered within 

24 hours of a needlestick, but some protection is still afforded if it is 

given in the first few days after exposure. You also should begin the 

HBV vaccination regimen. 

• If you are exposed to HCV: Unfortunately, there is no way to prevent 

infection after HCV exposure. However, close observation is warranted, 

and at the first sign of hepatitis, interferon therapy should be 

instituted. Although early interferon therapy, before any signs or 

symptoms of hepatitis have developed, does not prevent illness, once 

signs and symptoms become apparent, interferon may prevent serious 

illness. 

• If you are exposed to HIV: If you have access to drugs used to treat 

HIV infection, a short course of medication is often recommended 

after a significant exposure. Usually, exposure to infected urine does 

not warrant treatment. Recommendations for treatment usually are 

related to the patient’s HIV titer and to the healthcare worker’s 

degree of exposure. For example, a hollow needlestick from a patient 

with a high HIV titer definitely warrants postexposure treatment— 

optimally, a combination of zidovudine, 200 mg 3 times/day; 

lamivudine, 150 mg 2 times/day, and indinavir, 800 mg 3 times/day. 

All are given orally. 


1. Gilbert DN, Moellering RC, Sande MA (eds): The Sanford Guide to Antimicrobial 

Therapy, 29th ed. Vermont, Antimicrobial Therapy Inc., 1999, pp 112, 128. 

2. www.cdc.gov/epo/mmwr (Postexposure prophylaxis). 

3. www.osha.gov (Universal precautions). 

4. www.who.int (World Health Organization surveillance statistics).

Chapter 5 

EVALUATION OF THE ACUTELY 

INJURED PATIENT 

KEY FIGURES: 

Emergency cricothyrotomy 

Emergency needle thoracostomy 

This book primarily describes treatments for stable patients who have 

a specific injury or problem wound. They have been evaluated previously 

by a general surgeon, trauma surgeon, or emergency department 

physician, who has ruled out other, more life-threatening 

injuries. 

Because health care providers cannot know what situation they may 

face, all of us must be aware of how to evaluate a patient with potentially 

serious injuries. This chapter provides basic principles for the important, 

life-saving initial evaluation and treatment of a patient who 

may have suffered a serious traumatic injury. It is not intended to be a 

full, detailed description of first-line treatments, but it does provide 

useful information for all health care providers. 

Be sure to get as detailed a history as possible (from the patient, family, 

or whoever brought the patient to medical attention), but do not waste 

time. Your primary objective is to identify and treat potentially lifethreatening 

injuries. 

AABBCCss ooff TTrraauummaa CCaarree 

Following the ABCs (airway, breathing, circulation) and DE (disability 

and exposure) of trauma care prevents you from getting sidetracked by 

the patient’s obvious injury (arm fracture, for example) and thereby 

missing a more life-threatening but less obvious injury. 

Airway 

An open airway (i.e., the path from the nose/mouth to the lungs) is 

vital for the patient to be able to breathe. You need to determine 

49


quickly whether the airway is blocked. Blockage may be due to the 

tongue, vomit, blood, or foreign bodies. 

Signs of Airway Obstruction 

In patients breathing on their own, signs of airway obstruction include 

noisy breathing on inspiration and retractions of the supraclavicular 

space (area above the clavicle) or intercostal space (between the 

ribs) with attempts at respiration. In nonbreathing patients, it may be 

difficult to diagnose airway obstruction. You must look directly into 

the mouth and examine for signs of obstruction. 

How to Maintain an Open Airway 

• Clear out any blood or vomitus in the mouth. 

• In an unconscious patient, the tongue may obstruct the airway because 

of loss of tone in the muscles of the lower jaw (mandible). 

• Proper patient positioning often relieves obstruction due to a posteriorly 

displaced tongue. 

• To position the tongue forward, gently lift the chin to bring the 

mandible forward. Be careful not to extend the cervical spine (because 

of concerns about possible undiagnosed cervical spine injury). 

• An artificial oral or nasal airway tube can be useful, but in a conscious 

patient it may cause gagging and agitation. Use with caution—such 

devices are not comfortable. 

• Intubation with an endotracheal tube is often the best way to maintain 

an open airway. 

• When intubation is impossible, a surgical airway (cricothyroidotomy 

or tracheotomy) is required. 

Surgical Cricothyroidotomy. A cricothyroidotomy is done only in 

emergency situations when no other means is available to maintain an 

open airway. The following guidelines are helpful: 

1. The cricothyroid membrane can be located by running your finger 

down the center of the neck and feeling the wide thyroid cartilage 

(Adam’s apple). The depression just below the Adam’s apple is 

where you want to place the incision. The rings of the trachea are 

palpable just below this area. 

2. Try to clean the area with Betadine. 

3. If you have time, inject the skin with lidocaine and epinephrine to 

decrease bleeding from the skin edges and to make the procedure a 

little easier to perform.

Evaluation of the Acutely Injured Patient 51 

Emergency cricothyroidotomy. A, The larynx is stabilized between the left thumb 

and middle finger. The tip of the index finger is inserted over the cricothyroid 

membrane. Keep the index finger in this position to identify the position of the 

cricothyroid membrane as you perform the procedure. B, The endotracheal tube 

in position. (From Simon RR, Brenner BE (eds): Emergency Procedures and 

Techniques, 3rd ed. Baltimore, Williams & Wilkins, 1994, with permission.) 

4. The neck should be in neutral position with the chin held slightly 

forward. 

5. Hold the thyroid cartilage between your thumb and middle finger 

(actually you are stabilizing the larynx). Use your index finger to 

help identify the cricothyroid membrane. 

6. Using a no. 15 knife blade, make a horizontal incision no more than 

2 cm long, just below the Adam’s apple. Be sure to stay in the 

center of the neck. Do not make this incision too large, or you may 

injure a nearby vein, thereby causing significant bleeding and 

making the procedure very difficult. 

7. Staying in the midline, gently push the knife so that it goes through 

the cricothyroid membrane. Do not push inward too far; use only 

the knife tip. You do not want to injure the esophagus, which is immediately 

behind the trachea. 

8. Insert the back of the knife handle (not the blade) through the 

opening that you have just made, and rotate the handle to enlarge 

the opening. 

9. Place the largest possible pediatric endotracheal tube through the 

opening. Give oxygen and ventilate the patient through this tube. 

10. Secure the tube in place with tape or sutures.


Breathing 

Breathing relates to getting oxygen to the tissues. All patients with any 

possibility of having sustained a head injury or with an altered level of 

consciousness should be given supplemental oxygen, which usually 

can be administered with a face mask or nasal prongs. 

Listen for bilateral breath sounds, demonstrating that both lungs are inflated 

(see “tension pneumothorax” below). Problems that interfere with 

oxygen getting to the tissues are often related to significant chest trauma. 

Circulation 

Circulation pertains to the patient’s blood pressure and secure intravenous 

access. Start an intravenous line with the largest available 

catheter, and hang a liter of 0.9% saline. 

The most common reason for hypotension (low blood pressure) in a trauma 

patient is blood loss, either external or internal. Control obvious hemorrhage. 

Be careful of scalp wounds—a lot of blood can be lost from 

the scalp. A closed fracture of the femur can result in the loss of a 

liter of blood into the tissues of the thigh, which may not be immediately 

obvious. 

A head injury in and of itself does not cause hypotension. Look for another 

source. In contrast, a spinal cord injury can result in profound 

hypotension without blood loss (see “Neurogenic shock” below) because 

of loss of vascular tone. 

How to Determine Blood Pressure 

Without a Working Blood Pressure Cuff 

Feel for palpable pulses at the wrist (radial artery), groin (femoral 

artery), and neck (carotid artery). 

Location of Palpable Pulse 

Minimal Approximate 

Systolic Blood Pressure (mmHg) 

Radial artery 80 

Femoral artery but not radial artery 70 

Carotid artery but not femoral and radial arteries 60 

Other Causes of Hypotension/Shock that Can Lead 

to Death if not Quickly Diagnosed 

Tension pneumothorax occurs when the lung has collapsed and air surrounds 

the lung. If the air is not removed and the lung reexpanded, buildup 

of pressure in the chest may cause the lung, great vessels, and even


heart to be compressed and pushed to the opposite side. This process impairs 

blood flow to and from the heart and leads to hypotension. 

Cardiac tamponade is a build-up of fluid in the sac around the heart. It 

can lead to cardiac dysfunction and shock. 

Neurogenic shock occurs with an injury that causes paralysis—i.e., a 

spinal cord injury, not a head injury. Because of the loss of nerve input, 

the blood vessels dilate. Even with minimal blood loss, the patient 

cannot maintain proper vascular tone, and hypotension develops. 

Acute myocardial infarction (heart attack) or any cause of cardiac dysfunction 

can result in hypotension. 

Disability 

The following brief exam helps to evaluate patients for the presence of 

a neurologic deficit: 

1. Check the pupils. Are they equal, round, and reactive to light? 

2. Is the patient conscious? 

3. Can the patient move the fingers and toes? 

4. For patients with a suspected head injury, the Glasgow Coma Score 

(GCS) should be determined. Fifteen, the highest (best) score, indicates 

that the patient is awake and alert; three, the lowest (worst) 

score, indicates that the patient is unconscious and unresponsive. 

Glasgow Coma Score 

Category Best Response Points Assigned 

Eye opening None 1 

Opens eyes to painful stimulus 2 

Opens eyes to voice 3 

Opens eyes spontaneously 4 

Verbal response None 1 

Unintelligible sounds 2 

Inappropriate words 3 

Disoriented but converses 4 

Fully oriented and converses appropriately 5 

Motor response None 1 

Decerebrate posturing (abnormal extension) 2 

Decorticate posturing (abnormal flexion) 3 

Moves randomly to painful stimulation 4 

Localizes pain 5 

Obeys commands 6 

Add up the points. An uninjured patient who is not intoxicated should 

score 15 points. A score of 13 points may indicate minor injury; scores 

of 9–12, moderate injury; and scores < 8, severe injury.


Caution: Do not assume that a low GCS is due to intoxication. A drunk 

person can definitely have a serious head injury. Do a thorough workup 

(usually a computed tomography [CT] scan is required). 

Exposure 

All clothing should be removed so that the patient is fully exposed. 

Removal of clothing allows you to examine the patient thoroughly for 

signs of injury. It may seem silly, but you do not want to be fooled. 

Patients usually are lying on their back during the evaluation. To examine 

the back for evidence of spine injury, log-roll the patient (i.e., 

roll the patient in one motion, keeping the back straight and preventing 

any twisting motion of the spine). 

CCaassee SSttuuddyy 

An 18-year-old man is brought into the hospital after being stabbed in 

the right upper arm with an icepick. He complains of pain in the arm 

but otherwise seems to be uninjured. You roll up his sleeve to examine 

the arm and see entrance and exit sites. Since he has good pulses in 

the extremities, you think that he is stable. While you are doing some 

paperwork, he becomes very short of breath and hypotensive. What 

happened? 

If you had removed his shirt, you would have seen that the puncture 

went through the arm and into the right chest. A pneumothorax developed. 

Because he was young and healthy, he was able to tolerate it 

until the pressure built up in the chest cavity. At that point he developed 

a tension pneumothorax—a true emergency! 

Only when the patient is stable from the perspective of the ABCs can you undertake 

specific evaluation of more obvious injuries. 

NNeeeeddllee TThhoorraaccoossttoommyy 

Needle thoracostomy is a life-saving procedure that is easy to do in patients 

with tension pneumothorax. All health care providers should be 

aware of this technique. 

If conscious, the patient with tension pneumothorax is severely short 

of breath and blood pressure is low. If unconscious, the patient may 

simply be hypotensive and not breathing well. 

If you listen over the chest for breath sounds, you may appreciate a 

loss of breath sounds on the side of the pneumothorax, but this may be 

difficult to appreciate in the emergency setting.


Another method is to feel the patient’s neck. The trachea shifts away 

from the side with the tension pneumothorax. 

If you cannot hear breath sounds in either side of the chest, the trachea 

is in the midline, and the patient is in shock, treat both sides of the 

chest. The patient may have bilateral tension pneumothoraces. 

Equipment Needed 

1. Large catheter for intravenous access (12 or 14 gauge). A large-bore 

needle can be used if a catheter is not available, but the catheter is 

safer. The needle can injure an underlying structure more easily. 

2. Betadine, if available. 

Procedure 

1. Apply Betadine to the chest. Simply pour it on—this is an emergency! 

2. Place the catheter, with the needle in place, into the affected side of 

the chest at the second interspace in the midclavicular line (the 

imaginary line drawn perpendicular to the clavicle at its midpoint). 

3. Locate the second interspace. 

• The second interspace is the space between ribs 2 and 3. 

• It can be located by feeling for the spot on the breastbone (sternum) 

where the manubrium and sternum meet (the point where 

you can feel an elevation in the bone as you rub your fingers up 

and down the breastbone). 

• Move your fingers to the right or left chest (depending on where 

the problem is). You should be at the second interspace when you 

are at the midclavicular line. 

4. The intercostal vessels run just below each rib. To prevent injury to 

these vessels, the catheter should be inserted into the chest at the 

second interspace just above the third rib. 

5. If you inserted a catheter, remove the needle, but leave the catheter 

in place. You will hear a big whoosh from the escaping air. 

6. Leave the catheter in place until help arrives. 

7. If you used a needle, you should hear the air escape as soon as you 

enter the pleural space. Leave the needle in place until help arrives. 

8. The patient requires a chest tube for definitive treatment of the 

pneumothorax, but you may have just saved the patient’s life.


Emergency needle thoracostomy. At the midclavicular line, insert a large (14gauge) 

needle or vascular catheter into the chest at the second interspace just 

above the third rib. You will hear a large rush of air when the needle enters the 

chest. 


1. Creech O, Pearce CW: Stab and gunshot wounds of the chest. Am J Surg 105: 469–483, 

1963. 

2. Melio FR: Priorities in the multiple trauma patient. Emerg Med Clin North Am 

16:29–43, 1998. 

3. Simon RR, Brenner BE: Emergency Procedures and Techniques, 3rd ed. Baltimore, 

Williams & Wilkins, 1994, pp 71–75. 

4. Walls RM: Cricothyroidotomy. Emerg Med Clin North Am 6:725–736, 1988. 

5. Walls RM: Management of the difficult airway in the trauma patient. Emerg Med Clin 

North Am 16:45–61, 1998.

Chapter 6 

EVALUATION OF AN ACUTE WOUND 

KEY FIGURE: 

Irrigating a wound 

This chapter explains the basics for evaluation and treatment of an 

acute wound. Proper evaluation helps to determine the appropriate 

next step—formal wound exploration or wound closure. 

The first step is to control blood loss and evaluate the need for other 

emergency procedures (see chapter 5, “Evaluation of the Acutely 

Injured Patient”). The second step is to obtain a thorough history 

about the patient and the events surrounding the injury. 

AAbboouutt tthhee PPaattiieenntt 

Tetanus Immunization Status 

Tetanus is a devastating disease, causing muscle spasms that can lead 

to muscle rigidity and seizures. Without adequate treatment, one in 

three adults with tetanus will die. Although immunization has made 

tetanus uncommon, it always lurks in the background. 

If the patient has not had a tetanus booster within 5 years, and the 

wound is tetanus-prone (see Table 2), a booster should be given. If the 

wound is not tetanus-prone but the patient has not had a tetanus 

booster within 10 years, a booster should be given. Patients who have 

never been immunized need human tetanus immunoglobulin as well as 

tetanus toxoid followed by completion of the full tetanus toxoid series. 

Table 1. Doses of Antitetanus Drugs 

Drug Number of Doses Dosage 

Tetanus toxoid: booster 1 0.5 ml intramuscularly 

Tetanus toxoid: full immuni- 3 0.5 ml intramuscularly; repeat in 4 wk 

zation regimen and 6–12 mo after second injection 

Human tetanus immunoglobulin 1 250 U, deep intramuscular injection 

57


Note: Tetanus toxoid and immunoglobulin must be kept refrigerated at 

all times during transport from the factory. This requirement may be a 

problem in remote areas. 

Pulsatile Bleeding at Time of Injury 

Even if the patient is not bleeding at the time of your examination, the 

history of bright red, pulsatile bleeding at the time of injury implies an 

arterial injury. A thorough vascular exam is required, and formal surgical 

wound exploration is almost always indicated. 

Medical Illnesses 

Patients with diabetes are more prone to infections and wound-healing 

problems. Encourage diabetic patients to keep glucose levels well controlled 

to decrease the risk of complications. Malnourished patients 

and patients with human immunodeficiency infection (HIV) or a history 

of cancer also have wound-healing difficulties. 

Smoking History 

Tobacco smoking dramatically decreases circulation to the skin and 

slows down the wound-healing process. Medical professionals have a 

duty to tell all patients not to smoke. But the patient with an open 

wound should be specifically warned that smoking interferes with and 

perhaps prevents the healing process. Smoking also increases the risk 

for wound complications and poor cosmetic outcome. 

EEvveennttss SSuurrrroouunnddiinngg tthhee IInnjjuurryy 

Timing of the Injury 

It is best to close an open wound within 6 hours of injury. Do not close 

a wound after 6 hours because the risk of infection becomes unacceptably 

high. 

Wounds on the face are exceptions to this rule. The face has an excellent 

blood supply, which makes infection less likely. In addition, cosmetic 

concerns are important. It is therefore acceptable to close a 

wound on the face that is older than 6 hours (perhaps up to 24 hours or 

at most 48 hours), as long as you can clean it thoroughly. 

Nature of the Injury 

• A wound caused by a clean knife has a low risk of infection. 

•Adirty wound carries a risk for tentanus. Wood may break off and 

leave pieces behind, increasing the risk for subsequent infection if 

the wound is not explored and washed out thoroughly.

Evaluation of an Acute Wound 59 

• Any wound that may contain a foreign body should be explored and 

the foreign body removed. 

• Animal bites, especially cat bites, often penetrate more deeply than 

you think. Bites on the hand should raise concern about involvement 

of an underlying joint. Oral bacteria may cause severe infections (see 

chapter 36, “Hand Infections”). Always consider the risk of rabies. 

• Human bites also are associated with specific oral bacteria that may 

cause serious infections (see chapter 36, “Hand Infections”). 

• If any object penetrated the patient’s clothing or shoes before piercing 

the skin, the chance for infection is increased because pieces of 

clothing may become embedded in the underlying tissues. If an 

object penetrated the patient’s tennis shoes, be concerned about a 

possible pseudomonal infection. 

• Crush injuries may be associated with greater underlying damage 

than initially appreciated (see chapter 35, “Crush Injury”). 

• Gunshot wounds: see chapter 37, “Gunshot Wounds.” 

• Thermal or electrical injury: see chapter 20, “Burns.” 

Concerns about Tetanus 

Table 2. Risks for Tetanus 

Wound Characteristics Tetanus-prone Not tetanus-prone 

Time since injury > 6 hr < 6 hr 

Depth of injury > 1 cm < 1 cm 

Mechanism of injury Crush, burn, gunshot, frostbite, Sharp cut (knife, clean 

puncture through clothing glass) 

Devitalized tissue Present in None present 

Contamination (e.g., 

dirt, saliva, grass) 

Yes No 

Concerns about Rabies 

Be aware of the risk of rabies in the area where you work. Some countries—England, 

for example—have no cases of rabies because of tight 

animal controls. In most other countries, rabies is a real concern. 

The primary animals associated with rabies infections include bats, 

raccoons, skunks, and foxes. Because different areas have a different 

risk for specific animals, know your area. Dogs and cats also can be infected; 

be sure to ask if the animal has been vaccinated against rabies. 

Livestock, rodents (e.g., rats, mice, squirrels), and rabbits are almost 

never associated with a risk of rabies.


If you have fears that the animal is rabid: 

1. Thoroughly clean the wound with soap and water. 

2. Administer human rabies immunoglobulin, 20 IU/kg total. If possible, 

administer one-half of this around the wound, and give the rest 

in the gluteal area intramuscularly (IM). 

3. Administer one of the three types of rabies vaccines currently available: 

1.0 ml IM in the deltoid area of adults and older children, outer 

thigh (not gluteal area) in younger children. Repeat on days 3, 7, 14, 

and 28. 

EExxaammiinnaattiioonn ooff tthhee WWoouunndd 

The wound must be cleansed thoroughly to allow full evaluation of the 

extent of injury. 

Cleansing the Wound 

Cleansing a wound hurts. Often you must start by anesthetizing the 

area. Infiltrate a local anesthetic around the wound, or administer a 

nerve block using a few milliliters of lidocaine (see chapter 3, “Local 

Anesthesia,” for a more thorough discussion). 

For most simple wounds (i.e., no exposed bone or other vital organ), 

clean technique is adequate. You can use clean gloves and gauze instead 

of sterile ones. 

The wound needs to be fully washed out to remove all foreign material 

and decrease bacterial content. 

Irrigate the wound with several hundred milliliters of sterile saline 

until all dirt and foreign material are removed. Then irrigate a bit more 

(an additional 50–100 ml, depending on the size of the wound). 

In patients with a puncture wound, you need to irrigate into the puncture, 

not just the external opening. You may need to cut into the puncture 

wound and enlarge it by 1–2 cm to appreciate the full depth of 

penetration and allow proper cleansing. 

Wound Irrigation 

Irrigation does not mean merely pouring some saline over the wound. 

You must apply the solution with some force to remove embedded 

debris and decrease the bacterial count. 

The best method is to make an irrigating device out of a syringe (20–50 

ml) with a 20-gauge angiocatheter (or whatever you use for intravenous 

access) or a blunt-tipped needle (a sharp needle can be used,


but be careful not to stick yourself). Draw the saline into the syringe and 

then squirt it out onto the wound. The 20-gauge catheter is best because 

it delivers the saline at an appropriate pressure to cleanse the wound 

and costs much less than larger-diameter catheters and needles. 

Wound irrigation. Draw saline into a syringe. 

Place a 20-gauge, blunt-tipped catheter 

(preferably) or needle on the end of the syringe. 

Squirt the saline from the syringe onto 

the wound. Use some force. Repeat until the 

wound is clean. Usually a few hundred milliliters 

of irrigation are required. 

Removal of Foreign Material, Devitalized Tissue, and Old Blood 

Foreign material such as dirt, pieces of wood or grass, and parts of clothing 

must be removed because they are potential sources of infection. 

An exception to this rule is a needle, bullet, or piece of glass deeply embedded 

in the tissues. In the absence of significant injury to surrounding 

tissue, these foreign materials usually can be left alone. They often 

are difficult to locate (even with x-ray guidance), and exploration may 

cause more local damage. Explain to the patient that the surrounding 

tissues usually wall off the foreign body. It may then gradually work 

its way to the skin surface, where it can be easily removed. Warn the 

patient that the foreign body may cause the area to become infected. If 

infection develops, localization and removal become much easier because 

you can follow the pus to the foreign body. 

Obviously dead tissue in or around the wound should be removed. 

Remove any fat that appears to be almost completely detached from 

the wound, dark purple or black skin, or tissue embedded with debris 

or foreign material.


Old blood also must be removed. Blood is an excellent media for bacteria 

proliferation and infection. 

If you are unable to remove the objectionable material completely, 

formal surgical exploration in the operating room with more adequate 

anesthesia (general and more local) is required. 

EEvvaalluuaattiioonn ffoorr IInnjjuurryy ttoo UUnnddeerrllyyiinngg SSttrruuccttuurreess 

Vascular Injury 

If the injury is near a pulse point (e.g., in the groin near the femoral 

artery), check to be sure that a pulse is palpable in the nearby vessel— 

even if there is no active bleeding at the time of examination. 

Check also for a palpable pulse in the vessel distal to the injury; for example, 

check pulses behind the knee or in the foot for a possible 

femoral artery injury. 

Look for pulsatile bright red arterial bleeding or dark red venous oozing. 

Ensure that circulation to structures distal to the wound is adequate. 

Do so by checking capillary refill in the fingers or toes, as appropriate. 

Testing Capillary Refill 

A well-vascularized finger or toe generally has a pink hue under the 

nail. If it is blue or very pale, circulation may be impaired. Compare 

with the uninjured side to determine the patient’s baseline status. 

If you pinch the tip of the finger or toe, as appropriate, it should blanch 

(i.e., turn pale.) 

Release the pressure. The color should return to normal within 2–3 seconds. 

A longer period may imply an arterial injury. A shorter period 

may imply a problem with venous circulation. 

An arterial injury usually necessitates urgent surgical exploration in 

the operating room. 

Nerve Injury 

If injury occurs along the course of an important nerve, check for sensory 

and motor function. 

A nerve injury in and of itself does not warrant urgent operation at the 

time of injury. A surgeon should explore the wound thoroughly and 

repair any injured nerves in the near future. The acute needs are thorough 

cleansing and loose closure to prevent infection and allow the 

wound to be fully explored at a later date.

Tendon Injury 


If the injury occurs over the course of a tendon, evaluate the action of 

the affected tendon to ensure that it is appropriate. 

A tendon injury in and of itself also does not warrant urgent operation 

at the time of injury. A surgeon should explore the wound thoroughly 

and repair any injured tendons in the near future. Again, the acute 

needs are thorough cleansing and loose closure to prevent infection 

and allow the wound to be fully explored at a later date. 

Fracture or Joint Dislocation 

In patients with an obvious bony deformity or a bone that is tender to 

palpation, get an x-ray to look for fracture or dislocation. 

An open wound over a fracture or dislocation classifies it as an “open” 

or “compound” fracture or dislocation. This distinction is important 

because an open bone injury is associated with a higher risk of infection 

than a closed injury. Therefore, patients with an open injury must 

be placed on antibiotics immediately (a first-generation cephalosporin 

with or without an aminoglycoside, depending on the amount of bone 

and soft tissue contamination). 

Unless the patient will be treated by an orthopedic surgeon within 24 

hours, the wound should be cleansed thoroughly under general or regional 

anesthesia in the operating room. A finger fracture can be 

cleansed thoroughly with a digital block for local anesthesia. This procedure 

can be done in the emergency area or office. 

If the wound can be closed, do so loosely. If soft tissue loss is apparent 

or if the skin is too tight to close primarily, the wound should be 

packed with sterile gauze moistened with saline or dilute Betadine. 

Reduce (align) the fracture or dislocation as best as possible, and immobilize 

the area. The patient should be evaluated by an orthopedic 

surgeon and possibly a reconstructive plastic surgeon if there is soft 

tissue loss. 

WWhhaatt ttoo DDoo NNeexxtt 

Active Bleeding 

Apply point pressure over the wound. It is not enough to place gauze 

in the wound and wrap the area with an Ace wrap. You should place a 

wad of gauze over the injured area and use two fingers to apply point 

pressure. Push down firmly onto the wound. You may need to hold the 

pressure for 10–15 minutes before the bleeding will stop. If the bleeding 

is arterial, exploration is required.


If the patient has an exsanguinating (life-threatening) hemorrhage due 

to an extremity injury, place a tourniquet or blood pressure cuff proximal 

(closer to the heart) to the injury. The blood pressure cuff must be 

inflated to at least 50 mmHg above arterial pressure. This technique 

hurts and places the tissues at risk for ischemic injury. Therefore, the 

tourniquet should not be left in place for more than 15–20 minutes. If a 

tourniquet is needed, urgent operative exploration is required. 

Foreign Body in the Depths of a Wound 

Get an x-ray. Although many materials do not show up on x-rays, you 

may be able to see air or other indicators that give information about 

the depth of injury. The x-ray also can tell you whether an underlying 

joint was violated; air in the joint indicates injury. 

Stab Wound over the Chest or Abdomen 

You need to be concerned about penetration into the chest or abdominal 

(sometimes both) cavities. Such injuries should not be closed; they 

require further examination and evaluation to rule out internal injuries. 

Call a general surgeon. 

* * * 

Before further treatment, “paint” (i.e., wipe) the wound and the surrounding 

tissues with a small amount of Betadine or some other antibacterial 

agent. 

The wound is now ready for one of the following definitive treatments. 

FFoorrmmaall WWoouunndd EExxpplloorraattiioonn 

The patient is taken to the operating room and given general or regional 

anesthesia so that the wound can be fully cleaned and surgically examined 

under sterile conditions. Formal wound exploration is indicated in 

wounds with underlying vascular injuries, open fractures or dislocations, 

and wounds with extensive contamination, debris, or devitalized tissue. 

WWoouunndd CClloossuurree 

The method of closure often depends on the specific characteristics of 

the wound. Reconstructive plastic surgeons have organized the various 

techniques for wound closure into a hierarchy, sometimes called 

the “reconstructive ladder,” that ranges from the simplest to the most 

complex techniques. This hierarchy is set up so that if the first “step” 

does not work, it will not hinder attempts at the next step on the 

ladder. The “reconstructive ladder” gives you a logical way to think 

about how to close an open wound, regardless of its cause. Whether it


be an acute, traumatic wound or a wound that resulted from excising a 

tumor, the same principles apply. A brief overview follows; each step 

on the ladder is discussed more completely in subsequent chapters. 

1. Secondary closure (leave the wound open). Sometimes it is best not to 

close a wound. Treat it with dressings, and allow it to heal on its own 

(healing by secondary intention). This technique is useful if soft tissue loss 

is apparent, if the wound cannot be closed without tension, or if you have 

concerns about infection. Certain wounds, however, require formal closure: 

• Wounds with exposed vital structures, such as exposed bone, tendon, 

or nerve. 

• Wounds in areas overlying creases; for example, the front of the 

elbow (antecubital fossa), back of the knee (popliteal fossa), or 

armpit. Subsequent scar contracture may severely limit function. 

If formal closure is required, one of the following options should be used: 

2. Primary closure. Skin edges around the wound are sutured together. 

The wound must be “clean” (i.e., no foreign material, no devitalized 

tissue, and no active bleeding). Tension in the closed wound 

should be minimal; therefore, there must be adequate skin to bring together 

without tension. As described earlier, primary closure is best 

done within 4–6 hours of injury. Except on the face or over a vital structure, 

delayed closure results in an unacceptably high infection risk, 

even with adequate cleansing. 

3. Skin grafting. When the wound requires closure but cannot be 

closed primarily, a skin graft is often useful. Skin is taken from one area 

of the body as a free graft and placed over the wound. There are essentially 

two types of skin grafts: split thickness and full thickness. Skin 

grafts will not survive over exposed tendon or bone if the thin connective 

tissue covering is destroyed by the injury. A flap is required. 

4. Local flaps. Like skin grafts, local flaps are used when the wound 

cannot be closed primarily. Flaps are needed for wounds with exposed 

underlying structures that require more than skin graft coverage. A 

local flap is created by moving nearby tissue—sometimes skin, sometimes 

muscle, sometimes both—to the wound for closure. 

5. Distant flaps. When no useful local tissue is available to close the 

wound, tissue can be brought from a distant area. Sometimes the tissue 

is temporarily disconnected from the body; this technique is also called a 

free flap or a free tissue transfer. Tissue transfers also may be “walked” 

along the body in stages. 


Gross A, et al: The effect of pulsating water jet lavage on experimental contaminated 

wounds. J Oral Surg 29:187, 1971.

Chapter 7 

GUNSHOT WOUNDS 

KEY FIGURES: 

Entrance/exit wounds 

This chapter describes how to treat the external, surface wounds 

caused by a bullet. The evaluation for underlying injury related to gunshot 

wounds in an extremity also is discussed. A plastic surgeon is 

often called to help manage such injuries. 

The evaluation of a patient with chest, abdomen, or head/neck gunshot 

wounds is beyond the scope of this text. However, chapter 5 addresses 

the initial evaluation of any patient who has sustained a 

significant traumatic injury. 

IInniittiiaall TTrreeaattmmeenntt ooff SSttaabbllee PPaattiieennttss 

By definition, a stable patient is awake and alert with stable vital 

signs. Especially in patients with a gunshot wound, it is preferable 

that a general surgeon or experienced emergency physician complete 

a full evaluation before your arrival to ensure that the patient is truly 

“stable.” 

Expose the Injured Area 

You need to evaluate the injured area thoroughly. All clothing should 

be removed to ensure that no injury is missed and to allow you to estimate 

the trajectory (path) of the bullet. This information is important, 

because knowing the approximate course of the bullet helps you to determine 

the probability for injury to underlying structures. 

Do not probe the wound blindly. Blind probing of the gunshot wound can 

be dangerous. It may dislodge the clot in an injured blood vessel that 

has stopped bleeding, thus leading to significant blood loss. 

67


Radiographs 

Especially when the gunshot wound is in an extremity, a radiograph is 

indicated to rule out an underlying fracture and to determine whether 

the bullet remains in the tissues. It is often helpful to mark the external 

bullet holes with a small metal object to identify the path of the bullet 

on the radiograph. Sometimes markers are available in the radiology 

department for this purpose. Otherwise, a paper clip can be taped to 

each of the bullet sites. 

Neurovascular Exam 

When the bullet traverses the path of a major nerve or blood vessel, 

check for signs of nerve or vascular injury. 

• Check the circumference of the injured area. Is it becoming larger (an indication 

of ongoing bleeding), or is it essentially staying the same size? 

• Check for pulses in the vicinity of and distal to the bullet wounds. 

• Palpate nearby pulses for a thrill (vibration), and listen with a stethoscope 

for a bruit. Thrills and bruits may be signs of arterial injury, 

even if a pulse is palpable. 

• Adequate assessment of motor function is often difficult because of 

pain related to the traumatic injury, but always make the effort. 

Sensation should not be affected by pain. Test sensation in the extremity 

distal to the wound to evaluate for nerve injury. 

Case Example 

A patient arrives with a gunshot wound to the upper thigh. After removing 

his trousers and undergarments, you note one bullet wound 

along the inner aspect (medial side) of the thigh, about 15 cm from the 

pubic symphysis. The thigh is swollen but does not feel very tight. 

There is no active bleeding from the wound, and the thigh is not increasing 

in size. 

A radiograph shows a bullet lodged in the soft tissues of the upper lateral 

thigh, and small fragments are noted in the soft tissues anterior to 

the femur. There is no fracture of the bone. This radiograph tells you 

that the bullet traversed the soft tissues in front of the femur where the 

femoral artery and femoral nerve travel. You must evaluate the patient 

for injury to these structures. 

Feel the femoral pulse. Does it feel as strong as the opposite, uninjured 

femoral pulse? Can you feel a thrill with pulsation? Place your 

stethoscope over the pulse. Can you hear a bruit?

Gunshot Wounds 69 

Feel for the distal pulses of the popliteal artery (behind the knee), dorsalis 

pedis artery (top of the foot), and posterior tibial artery (behind 

the medial malleolus). The popliteal artery often is difficult to find 

even in uninjured patients. 

Check motor function of the femoral nerve. Can the patient extend the 

knee? Extension may be difficult because of pain in the thigh. The patient 

should be able to move his toes and ankle. These functions are 

under the control of the sciatic nerve, which travels along the posterior 

aspect of the thigh. 

Check sensation. The femoral nerve is responsible for sensation to the 

anterior and medial aspects of the thigh. Touch the patient with your 

hand or with the end of a clean needle. Can he feel the touch? 

If you identify a problem, further studies (possibly an arteriogram for 

an injured vessel) or exploration is warranted. The care of this patient 

then should be transferred to a specialist. 

Typically the entrance wound is 

smaller and tidier than the exit site.


CCaarree ooff tthhee EExxtteerrnnaall WWoouunndd 

The amount of injury at the entrance and exit (if present) sites is related 

to the caliber of the bullet, the angle at which the bullet traverses the tissues, 

the distance from the gun, and even the type of bullet. Usually, 

there is more damage to the skin at the exit site than at the entrance site 

(see figure on preceding page). 

Excision of the edges of all bullet wounds used to be recommended, 

but now it is not always necessary. 

When the bullet wound is relatively clean: Often the entrance wound 

is very clean, with regular skin edges and no gunpowder imbedded in 

the surrounding skin. 

• Clean the area well with gentle soap and water or an antibacterial 

scub solution. Then rinse with saline. The wound then may be covered 

with gauze. If necessary, anesthetize the area with lidocaine 

before cleansing. 

• Such wounds should not be closed primarily (i.e., with sutures). 

• Wet-to-dry dressings or antibiotic ointment with dry gauze should 

be applied 1–2 times/day until the wound has healed. 

• Oral antibiotics are not needed. 

When the bullet wound has irregular edges embedded with foreign 

material: Risk for infection is high. Excision of the skin edges is indicated 

to minimize the risk. 

How to Excise the Skin Edges 

1. Infiltrate the area around the wound with local anesthetic. 

2. Use a scalpel to excise the necrotic skin. Remove only the tissue that 

is purple or black (i.e., seems dead). 

3. If gunpowder is embedded in surrounding skin, which otherwise 

looks alive, use the flat edge of the scalpel to scrape off the foreign 

material. Alternatively, use a forceps to grab the debris, and cut it 

out with the scalpel. 

4. Remove any dead fat or subcutaneous tissue visible in the wound. 

5. The wound should not be closed primarily. Treat the wound as previously 

described. 

GGuunnsshhoott WWoouunnddss ttoo tthhee FFaaccee 

Gunshot wounds to the face should be cleansed as described above. 

Because of the cosmetic concerns, most facial wounds should be

Gunshot Wounds 71 

loosely closed to reduce the amount of subsequent scarring. Full-thickness 

wounds (i.e., wounds that communicate with the oral cavity or go 

down to bone) must be closed in layers. See chapter 16, “Facial Lacerations” 

for specific details. 

DDoo YYoouu NNeeeedd ttoo RReemmoovvee tthhee BBuulllleett?? 

Contrary to television medical shows, the presence of a bullet in the 

soft tissues, in and of itself, is not an absolute indication for surgery. 

Operations are required to repair underlying injured structures, not 

specifically to remove the bullet, unless it is near an important structure 

and may cause trouble if it migrates. 

In certain cases, however, the bullet must be removed. These exceptions 

are related to the nature of the ammunition. For this reason it is 

important to have information about the type of gun and bullet that 

caused the injury. 

A shotgun/buckshot injury causes a great deal of damage to underlying 

soft tissue, and numerous pellets and foreign debris are lodged in 

the tissues. Most importantly, wadding is part of the ammunition and 

often becomes lodged in the soft tissues along with the pellets. Shotgun/buckshot 

injuries warrant exploration to remove dead tissue, to 

remove as many of the pellets as possible, to remove the wadding, and 

to wash out the wound. If such exploration is not done, the risk for serious 

infection is high. 

It may be tempting to try to remove a single bullet that on radiographs 

does not seem too deeply embedded in the tissues. If the bullet cannot 

be easily palpated in the superficial skin, removal is not recommended. 

Removal is always more difficult than you think, and you risk injury to 

surrounding structures. It is usually best to leave the bullet alone. Over 

time, the bullet will either be walled off by the body and stay in place, 

causing no subsequent problems, or gradually work its way to the surface. 

Once the bullet can be felt directly under the skin, it can be removed 

easily with local anesthetic. 


1. Fackler ML: Civilian gunshot wounds and ballistics: Dispelling the myths. Emerg 

Med Clin North Am 16:17–28, 1998. 

2. Modrall JG, Weaver Fam Yellin AE: Diagnosis and management of penetrating vascular 

trauma and the injured extremity. Emerg Med Clin North Am 16:129–144, 1998.

Chapter 8 

NUTRITION 

Poor nutrition can negate all the benefits of proper wound care or advanced 

medical interventions. Studies have shown that malnourished 

patients often require longer hospitalizations, have more postoperative 

complications, and have delayed wound and fracture healing compared 

with well-nourished patients. 

Usually, patients who do not ingest adequate amounts of calories and 

protein are also not meeting vitamin and mineral requirements. 

Malnutrition essentially depletes physiologic reserves and leads to 

many problems, including impaired wound healing and impaired 

immune function. 

Elective surgery is often contraindicated and therefore not performed 

in malnourished patients. This illustrates the importance of understanding 

the basics of nutrition as they affect wound healing. 

TTyyppeess ooff MMaallnnuuttrriittiioonn 

Marasmus 

Malnutrition due to inadequate caloric intake is called marasmus. The 

patient has severe physical wasting due to the loss of fat and somatic 

(skeletal) muscle. This condition is seen not only in the developing 

world and in times of famine but also in patients with cancer or 

anorexia. Although the patient is not taking in sufficient calories, he or 

she is getting sufficient protein. As a result, measured serum protein 

stores (see below) are adequate. 

Kwashiorkor 

Patients with kwashiorkor take in sufficient calories but do not meet 

their protein needs. The typical patient has thin arms and legs with 

a large protruding belly and peripheral edema (swelling in the soft 

tissues). 

73


Marasmic Kwashiorkor 

Marasmic kwashiorkor is a combination of protein and calorie malnutrition. 

It is the most common form of malnutrition in the developing 

world and occurs when a chronically starved patient (e.g., a patient 

with cancer) suffers an additional stress (e.g., injury, infection). 

AAsssseessssmmeenntt ooff NNuuttrriittiioonnaall SSttaattuuss 

Evaluation of protein stores provides a good estimate of nutritional 

status. 

How to Evaluate Protein Stores 

The liver produces various proteins, including albumin, prealbumin, 

and transferrin, that can be measured in the serum. These proteins 

have been found to correlate well with general nutritional status. 

Albumin does not correlate with nutritional status as well as prealbumin 

and transferrin. However, measurement of albumin is useful if the 

more expensive tests for prealbumin and transferrin are unavailable. 

Table 1. Serum Protein Measurements as a Guide to Nutritional Status 

Protein Normal Value Moderate Malnutrition Severe Malnutrition 

Albumin (gm/dl) 3.5–5.0 2.1–2.7 < 2.1 

Prealbumin (mg/dl) 15–40 5–10 < 5 

Transferrin (mg/dl) 200–400 100–150 < 100 

How to Estimate Caloric Needs 

A patient’s daily caloric requirements are affected by a number of factors. 

Most calories are used to provide the energy for the basic body 

functions in a resting state, also called the basal metabolic requirements 

(BMR). These body functions include breathing, maintaining an 

upright posture, maintaining stable blood pressure, and digestion. The 

need for additional calories depends on various stresses. Examples of 

stresses that increase caloric requirement include burns, blunt trauma, 

fever, infection, surgery, and exercise. 

Harris-Benedict Equation 

The Harris-Benedict equation is commonly used to estimate the BMR 

in healthy people. Height (in cm), weight (in kg), and age (in years) are 

factored into the equation: 

BMR for men = 66.47 + [13.75 × weight] + [5.0 × height] – [6.76 × age] 

BMR for women = 655.1 + [9.56 × weight] + [1.85 × height] – [4.68 × age]

Nutrition 75 

To determine total energy needs, the BMR must be multiplied by factors 

for activity and stress levels. Activity factors are 1.2 for patients at 

bedrest and 1.3 for ambulatory patients. Stress factors range from 1.2 for 

minor surgery or a fracture, to 1.8–2.0 for severe sepsis or severe burns. 

Example 

A 35-year-old women weighs 60 kg and is 5 feet tall. While working 

she fell and broke her arm. What are her caloric needs? Because height 

must by in cm, 5 feet must be converted to 152.4 cm: 

BMR = 655.1 + [9.56 × 60] + [1.85 × 152.4] – [4.68 × 35] 

BMR = 655.1 + 573.6 + 281.94 – 163.8 = 1346.84 kcal/day 

Total needs = 1346.84 × 1.3 (she is ambulatory) × 1.2 (minor fracture) 

Total needs = 2101.07 kcal/day 

A Simpler Formula to Estimate Caloric Needs 

To get a general estimate of daily caloric requirements, multiply the patient’s 

weight in kg by 25–40, depending on stress level (25 = low 

stress, 40 = high stress, as in patients with burns or sepsis). For the patient 

above: 

Total needs = 60 × 30 (the fracture adds a little to the stress level) = 1800 

kcal/day 

PPrrootteeiinn 

Protein is probably the most important nutrient. It is broken down into 

individual amino acids, which are important building blocks for bone, 

muscle, and skin. Thus, adequate protein intake is vital for normal 

wound healing. Protein is found in food derived from animals and 

plants. Not all sources of protein contain all of the necessary amino 

acids required to maintain adequate protein stores; in other words, 

they are not considered to be “complete” protein sources. 

In general, animal sources (e.g., eggs, meat, milk) contain all of the required 

amino acids. Dried beans, peanuts, and soy-derived foods are 

the best nonanimal sources of protein. Although protein is present in 

cereals and grains, they are not complete sources of protein. Corn may 

be a good source, but often much protein is lost during processing. 

Fruits and vegetables contain little protein. 

Patients who have limited access to animal protein must combine vegetable 

protein sources carefully to provide complete proteins each day. 

Sources of vegetable protein include rice and beans, cereal with milk, 

and noodles with cheese.


How to Estimate Protein Needs 

The adult U.S. recommended dietary allowance (RDA) for protein is 

0.75 gm/kg of body weight/day, which for an average-sized adult is 

45–60 gm/day. Children and infants have higher protein requirements 

(1–2 gm/kg/day). 

Stress, such as infection, burns, or traumatic injury, increases protein 

breakdown and thus protein requirements. Even under these circumstances, 

the requirements usually do not increase by more than 50% of 

the RDA. 

During times of stress, precise measurements of nitrogen loss can be 

determined by collecting the urine produced over a 24-hour period 

and measuring its urea nitrogen content. Multiply this number by 1.25 

to estimate total nitrogen lost. Determine how much nitrogen the patient 

took in based on diet. If the patient is losing more nitrogen than 

he or she is taking in, more nitrogen must be ingested to prevent depletion 

of protein stores. 

IImmppoorrttaanntt VViittaammiinnss aanndd MMiinneerraallss 

The following vitamins and minerals are important for proper wound 

healing. Because vitamins and minerals cannot be made by the body, 

they must be ingested. They serve as cofactors in many enzymatic 

reactions that are necessary for normal physiologic functioning. 

Although supplements are indicated in patients with deficiencies, little 

evidence indicates that higher supplemental doses have beneficial effects 

in patients with adequate vitamin/mineral stores. 

Note: These nutrients have other important physiologic effects, but 

only their effect on wound healing is discussed below. All of the listed 

minerals (calcium, copper, iron, magnesium, manganese, and zinc) are 

important in collagen synthesis. 

Vitamin A 

Because vitamin A is fat-soluble, it can be stored by the body. It is 

needed for the formation and maintenance of healthy skin and hair. It 

is a cofactor for collagen synthesis and is also important for normal 

immune function. Studies have shown that in patients taking chronic, 

high-dose steroids, Vitamin A is particularly important for proper 

wound healing. In this specific population, higher daily doses than the 

RDA may be beneficial for a short period (few weeks). In patients who 

are not taking steroids and who ingest a healthy diet, extra doses of vitamin 

A can be harmful.

Nutrition 77 

RDA: 5,000 IU/day. 

In patients taking steroids with an open wound: 25,000 IU/day 

orally; 200,000 IU/8 hr topically. 

Sources: liver, egg yolks, fortified milk and cheese, dark green leafy 

vegetables, deep orange fruits/vegetables, fortified cereals. 

Vitamin C (Ascorbic Acid) 

Because vitamin C is water-soluble, it is not stored in significant 

amounts in the body. Patients must take in enough vitamin C on a 

daily basis to prevent deficiency. It is an important cofactor for collagen 

synthesis. 

RDA: 60 mg/day. 

Sources: citrus fruits, potatoes, tomatoes, broccoli, green peppers. 

Vitamin E 

Vitamin E is needed to maintain proper immune function and proper 

cell health. In patients with wounds exposed to radiation, vitamin E 

can counteract the negative effects of radiation on wound healing. 

RDA: 30 IU/day. 

Sources: vegetable oils, wheat germ, whole grain cereals, dried beans, 

nuts, green leafy vegetables, eggs, seeds. 

Calcium 

Calcium is found primarily in bones and teeth. Every day 700 mg of 

calcium is turned over between plasma and bone. 

RDA: 400–1200 mg/day. 

Sources: dairy products, green leafy vegetables, dried beans, nuts, 

whole grains. 

Copper 

RDA: none at present, but the estimated safe and adequate daily dietary 

intake (ESADDI) is 1.3–3 mg/day. 

Sources: shellfish, dried beans, nuts, organ meats, whole grains, potatoes. 

Iron 

RDA: men, 10 mg/day; women, 15 mg/day. 

Sources: liver, shellfish, meat, poultry, and fish; dried beans and whole 

grains.


Magnesium 

RDA: 250–350 mg/day. 

Sources: found widely in vegetables and nuts. 

Manganese 

ESADDI: 2–5 mg/day. 

Sources: whole grains, nuts, dried beans, vegetables, fruits, tea, instant 

coffee. 

Zinc 

Zinc is important for wound epithelialization and increases wound 

strength. 

RDA: men, 15 mg/day; women, 12 mg/day. 

Sources: meat, fish, poultry, milk products, beans, whole grains, nuts. 


1. Mora RJF: Malnutrition: Organic and functional consequences. World J Surg 23: 

530–535, 1999. 

2. Ruberg RL: Role of nutrition in wound healing. Surg Clin North Am 64:705–714, 1984. 

3. Van Way CW: Nutrition Secrets. Philadeplhia, Hanley & Belfus, 1999.

Chapter 9 

TAKING CARE OF WOUNDS 

KEY FIGURE: 

Gauze 

Wound care represents a major area of concern for the rural health 

provider. This chapter discusses the treatment of open wounds, with 

emphasis on dressing techniques. These techniques can apply to an 

acute wound allowed to heal on its own (see chapter 10) or to a 

chronic/longstanding wound. 

DDeeffiinniittiioonnss 

Cellulitis: diffuse infection of the soft tissues. 

Clean wound: a wound in the process of healing; usually it has a bed 

of healthy granulation tissue (see below) without overlying exudate or 

surrounding cellulitis. 

Debridement: the process of removing dead/unhealthy tissue from a 

wound. 

Dirty wounds: wounds covered with exudate or eschar (scab), but not 

infected. 

Exudate: the tan/grayish material that often forms over an open 

wound. It consists of proteinaceous material from the wound itself. 

The presence of exudate does not mean that the wound is infected. 

Granulation tissue: the red, shiny tissue that forms at the base of an 

open wound during the healing process. It is composed of inflammatory 

cells necessary for wound healing, and bacteria. Granulation tissue 

is highly vascular and bleeds easily. For this reason, a wound covered 

with granulation tissue frequently bleeds with dressing changes or 

minor trauma. 

Infected wounds: wounds caused by injury with a dirty source (such 

as a rusted metal object) or associated with dirt/grass contamination. 

79


A chronic wound, covered with necrotic (dead) material and surrounded 

by cellulitis, also is described as an infected wound. 

SSuupppplliieess 

The following supplies are basic for taking care of a wound. 

Newly Developed Materials 

Currently, in affluent areas of the world, hydrocolloid-type dressings 

and growth factor formulations aid in the wound-healing process. 

However, these products are quite expensive and not readily available. 

As of yet, they do not necessarily yield the superior results that warrant 

the added expense. For these reasons, hydrocolloid-type dressings 

and growth factor formulations are not discussed. 

Gauze usually comes folded into a square. For dressings, it is best to open the 

gauze so that a single layer is in contact with the open wound. 

Dressing Materials 

The best material to use for dressings is plain cotton gauze. Usually, 

all that is needed is just enough gauze to cover the wound lightly; multiple 

layers are unnecessary and wasteful. 

There is nothing sterile about your skin or an open wound. Bacteria 

colonize the surface of both. For this reason, you do not have to use 

sterile technique to change dressings. Clean technique is usually 

sufficient. 

Sterile Technique vs. Clean Technique 

Sterile technique uses instruments and supplies that have been specifically 

treated so that no bacterial or viral particles are present on their 

surfaces. Examples of sterilized supplies include instruments that have

Taking Care of Wounds 81 

been autoclaved (subjected to high temperatures to kill microorganisms) 

and gauze and gloves that have been especially prepared at the 

factory and are individually packaged. Procedures in an operating 

room are usually done with sterile technique. 

Clean technique uses instruments and supplies that are not as thoroughly 

treated to rid surfaces of all microorganisms. Nonsterile gloves 

and gauze, which come many in a package, are examples of “clean” 

supplies. Clean supplies are less expensive than sterile supplies. Hence, 

appropriate use of clean techniques can save valuable resources. 

The occasions when a sterile dressing should be used are noted 

throughout the text. 

Solutions 

Various solutions are available for wound care. They are poured onto 

the gauze, and then the moistened gauze is placed over the wound. 

They also can be used to cleanse the wound. The following table describes 

commonly used solutions. 

Table 1. Solutions for Dressings 

Solution Preparation Usage Notes 

Betadine Purchased premade in container To clean wounds, Toxic to healthy tis- 

Best diluted for dressings: 1 part to use for sues; best used 

Betadine to at least 3 or 4 dressings in diluted form for 

parts saline or sterile water Especially good few days at time. 

for infected Then use another 

wounds solution for 

dressings. 

Safe on face and 

around eyes. 

Saline* To 1 liter of water add 1 tsp salt To clean wounds, Safe anywhere on 

Boil solution for at least 60 sec to use for body 

Cool before use 

Essentially equivalent to and 

cheaper than prepackaged 

liter of saline solution 

dressings 

Sterile Boil 1 liter of water for at least To clean wounds Safe anywhere on 

water* 60 sec 

Cool before use 

body 

Dakin’s To 1 liter of saline solution add To use for Better antibacterial 

solution* 1–2 tsp (5–10 cc) liquid bleach dressings agent than saline 

Some pharmacies keep Dakin’s Do not use around 

solution in stock 

When available, best diluted: 1 

part Dakin’s to 3–4 parts 

saline or sterile water 

eyes 

* Keep the solution in a sealed container; refrigerate if possible. Solutions stay fresh for several days.


Useful Antibiotic Ointments 

Some wounds (e.g., burn ) are best treated with antibiotic ointments. 

The antibiotic is absorbed into the tissues of the wound to prevent infection. 

The ointment keeps the wound moist and helps to decrease the 

pain caused by a wound that has become too dry. 

Table 2. Examples of Antibiotic Ointments and Their Uses 

Ointment Indication Comments 

Silver sulfadiazine 

(Silvadene) 

Burns Do not use around eyes 

Bacitracin Open wounds, face burns Do not use around eyes* 

Triple antibiotic Open wounds, face burns Do not use around eyes 

* Use only a topical antibiotic ointment specifically labeled for ophthalmologic use around the eyes. 

Bacitracin has an ophthalmologic formulation, as do garamycin and erythromycin ointments. 

TTyyppeess ooff DDrreessssiinngg TTeecchhnniiqquueess 

The following dressing techniques are easy to do and require the least 

amount of materials. Unless otherwise noted, clean technique is sufficient. 

Pain medication is sometimes needed to make the dressing 

change process more tolerable for the patient. Usually, an oral agent 

can be used; it is best to administer it 30 minutes before the dressing 

change. 

Note: At least once a day, usually at the time of a dressing change, the 

wound should be cleaned with gentle soap and water or washed with 

saline. 

Wet-to-Dry 

Indication 

The objective of the wet-to-dry dressing technique is to clean a wound 

or to prevent build-up of exudate. It is called a “wet-to-dry” dressing 

because you place a moist dressing on the wound and allow it to dry. 

When the dressing is removed, it takes with it the exudate, debris, and 

nonviable tissue that have become stuck to the gauze. Wet-to-dry 

dressings are indicated for wounds that are dirty or infected. 

Technique 

Moisten a gauze dressing with solution, and squeeze out the excess 

fluid. The gauze should be damp, not soaking wet. Completely open 

the gauze (it usually comes folded), and place it on the wound. You do 

not need many layers. Then cover with a thin layer of dry gauze.

Taking Care of Wounds 83 

When changing the dressing, pour a few milliliters of saline (or water) 

on the bottom layer of gauze if it has completely dried out. This 

techique prevents the removal of healthy new tissue from the surface 

of the wound. Remove the dressing gently to avoid causing pain. 

How Often? 

Optimally, a wet-to-dry dressing should be changed 3–4 times/day, 

depending on how much debridement is needed. The dressing should 

be changed more frequently for a dirty wound than for a clean wound. 

However, depending on the availability of dressing material and personnel, 

the dressings may be changed less often. Gradually the wound 

will become cleaner and heal. 

Wet-to-Wet 

Indication 

A wet-to-wet dressing does not debride the wound, which remains as 

it is. The dressing remains wet so that when the gauze is removed, the 

top layers of the healing wound are not removed with it. This dressing 

should be used on clean, granulating wounds with no overlying exudate 

in need of removal. 

Technique 

Moisten the gauze dressing with solution. It should not be soaking 

wet, but it should be a little wetter than damp. Unfold the gauze, place 

it over the wound, and then cover with dry gauze. The dressing should 

still be wet or damp when it is changed. If the bottom layer of gauze 

has dried out, saturate the gauze with saline or water before removal. 

How Often? 

The wet-to-wet dressing should be changed at least twice a day to prevent 

drying. 

Antibiotic Ointment 

Indication 

Antiobiotic ointment may be used as an alternative to wet-to-wet 

dressings for a clean wound that is healing well and has no need for 

debridement.


Technique 

Coat the wound with a small amount of ointment. A thick layer of antibiotic 

ointment over the wound offers no advantage and wastes supplies. 

Cover with a dry gauze if the wound is large or if it is in an area 

that will be covered with bedclothing or rubbed by clothing. Otherwise 

the wound can be left open to air with the antibiotic ointment alone. 

How Often? 

Remove the old ointment with gentle soap and water or saline, and 

reapply the ointment once or twice a day. 

WWhheenn ttoo UUssee WWhhiicchh DDrreessssiinngg 

• For wounds that are infected or covered with exudate, use a wet-todry 

dressing. 

• For uninfected wounds that are in the process of healing and have no 

need of debridement, use a wet-to-wet dressing or antibiotic ointment. 

You may use a wet-to-dry dressing, but it may cause more pain 

than the other two options. 


1. Ladin DA: Understanding dressings. Clin Plast Surg 25:433–441, 1998. 

2. Steed D: Modifying the wound healing response with exogenous growth factors. Clin 

Plast Surg 25:397–405, 1998.

Chapter 10 

SECONDARY WOUND CLOSURE 

KEY FIGURE: 

Dead space under skin closure 

Secondary wound closure is also referred to as closure by secondary 

intention. The skin edges of the wound are not sutured together; the 

wound is left “open.” Dressings are applied regularly to keep the 

wound clean, and the wound gradually closes and heals on its own. 

Secondary wound closure requires little technical expertise. It is the 

simplest and, therefore, lowest rung on the “reconstructive ladder.” 

This chapter discusses the important background knowledge you must 

have when deciding to allow secondary wound closure. 

CCaavveeaattss 

Although it is often true that the easiest treatment is the one to choose, 

you must be aware of what secondary wound closure involves from 

the patient’s perspective. 

Extended Healing Period 

It may take several weeks to even months for the wound to heal using 

dressings alone. This extended healing period can cause considerable 

hardship for the patient. From a financial standpoint, the patient may 

not be able to return to work with the open wound. In addition, dressing 

supplies, no matter how simple you make them, can get expensive. 

Wound Location 

The location of the wound may make it impossible for the patient to 

change the dressings. For example, the patient will require outside assistance 

to care for a wound on the back or the buttocks. It also may be 

difficult to keep the dressings in place during treatment of a facial 

wound. 

85


Pain 

The sensation associated with an open wound can range from somewhat 

bothersome to quite painful. Dressing changes are often painful 

as well. Some pain medications are addictive when given for the long 

period required for a large wound to heal. 

Scarring 

Wounds that are allowed to heal secondarily tend to have larger and 

more noticeable scars than the scars that results from primary closure. 

Secondary healing also has a greater tendency for hypertrophic 

scar/keloid formation, which can be bothersome and unsightly. 

Scar tightness and contracture can be especially problematic in areas 

such as the upper cheek, where a tight scar can pull down and distort 

the lower eyelid, or in the arm pit (axilla), where scar problems can 

lead to limited shoulder mobility and function. 

A wound that heals secondarily has a less stable scar—that is, the scar 

is more easily injured than the scar from a wound with primary closure. 

Over the years less stable scars may be chronically injured. They 

may reheal only to be reinjured again and again. This cycle can be quite 

troublesome and also is associated with a risk for the development of 

an aggressive skin cancer. 

AAcccceeppttaabbllee SSeettttiinnggss ffoorr SSeeccoonnddaarryy CClloossuurree 

Wounds that will heal with an acceptable scar if the skin edges are not 

sutured together can be allowed to heal secondarily. Examples include: 

• Relatively small wounds. Wounds smaller than 11 ⁄2 cm often heal 

quite well by secondary intention. Even wounds with a diameter of 

3–4 cm or larger, with no exposed tendons, bones, or other important 

structures, can be allowed to heal secondarily when lack of surgical 

expertise allows no other option. Be sure to keep in mind the above 

caveats when wounds > 2 cm are allowed to close by secondary intention. 

• Second-degree burns. Second-degree burns are often allowed to heal 

with local wound care alone. See chapter 20, “Burns,” for a more 

thorough discussion. 

SSeeccoonnddaarryy CClloossuurree aass tthhee TTrreeaattmmeenntt ooff CChhooiiccee 

Some wounds should not be closed with sutures. Instead, they should 

be left open and treated with dressing changes until they heal. 

Examples include:

Secondary Wound Closure 87 

• Wounds that come to your attention more than 6 hours after occurrence. 

With the exception of facial wounds, you should not use primary 

repair for a wound that is more than 6 hours old. The risk of 

infection is greatly increased after this amount of time has lapsed. 

• Highly contaminated wounds. A dirty wound should not be closed 

because of concerns about wound infection. Examples of dirty 

wounds include human bites on the hand or wounds deeply embedded 

with dirt or grass. 

• Wounds with dead space under the skin closure. Sometimes empty 

space rather than subcutaneous tissue is seen beneath the repaired 

skin when you try to bring the skin edges together. This “dead” space 

occurs due to loss of subcutaneous tissue or swelling of the skin 

around the wound. If such wounds are closed primarily, the risk for 

blood collecting under the skin closure is high, increasing the likelihood 

of infection and problems with wound healing. 

After the skin is sutured together, the underlying tissues are not well approximated. 

This dead space promotes hematoma (a collection of old blood) formation 

and infection. 

• Wounds with too much swelling or skin loss. Excessive swelling or 

skin loss makes the skin closure very tight. A tight skin closure decreases 

blood circulation to the skin edges, thereby causing the tissues 

to become ischemic (low supply of oxygen and nutrients). If the 

tightness does not soon resolve, the skin may die. Skin death results 

in a wound that is larger than the initial wound and even more problematic 

to close.


CCoonnttrraaiinnddiiccaattiioonnss ttoo SSeeccoonnddaarryy CClloossuurree 

Certain wounds should not be allowed to heal by secondary intention. 

These are wounds that are associated with exposure of an important 

underlying structure or are located in areas where a tight scar will be 

particularly problematic. Such wounds should be closed primarily. If 

primary closure is not possible, one of the other options from the reconstructive 

ladder must be chosen (see following chapters). 

Exposure of a Vital Structure 

Sometimes wounds occur over important structures such as fracture 

sites, tendons, or prosthetic devices (e.g., artificial joints). If these structures 

are not covered by healthy soft tissue, there is an almost 100% 

risk for the structure to become infected or die. 

To avoid permanent disability, a wound that results in exposure of an 

important structure should optimally be closed quickly (within days) 

with healthy tissue. 

Areas Where a Tight Scar is Undesirable 

Wounds over Creases 

Secondary closure is not useful on wounds that are larger than 3–4 cm 

and located over creases (e.g., front of the elbow [antecubital fossa], 

armpit [axilla]). The scar that results from secondary closure will cause 

tightness across the crease and may result in significant limitation of 

movement. If splints and movement exercises are used diligently (see 

chapter 15, “Scar Formation”), this problem may be avoided. But even 

with the best of care, limitation of movement often results. 

Face Wounds Near the Lower Eyelid 

In many areas of the face, a wound can be allowed to heal secondarily 

without significant cosmetic ill effects. However, wounds on the cheek 

near the lower eyelid may pull the eyelid downward if allowed to heal 

secondarily. The result not only is cosmetically unacceptable but also 

may expose the eye to injury. 

GGuuiiddeelliinneess ffoorr UUssee ooff SSeeccoonnddaarryy CClloossuurree 

If you decide to treat a wound by secondary intention, the wound must 

be evaluated thoroughly and cleaned rigorously. The appropriate 

dressing regimen must then be implemented. See chapter 9, “Taking 

Care of Wounds,” for specific dressing recommendations.

Secondary Wound Closure 89 

Unless the wound involves a human or a deep animal bite, antibiotics 

(oral or intravenous) are not required. However, you should see the patient 

within a few days to ensure that no signs of infection are present 

and that the wound is being cared for properly. 

Signs of Infection 

Signs of wound infection include redness, warmth, swelling, and tenderness 

in the tissues around the wound. Drainage of pus from the 

wound is also a sign of infection. 

Gray exudate on top of the wound does not mean that the wound is infected. 

It is often just proteinaceous debris from the wound itself. A 

green, somewhat sweet-smelling, creamy material is a sign of colonization 

by Pseudomonas bacteria. Without signs of surrounding soft tissue 

infection, antibiotics are not required. However, you should treat the 

wound with wet-to-dry dressing changes, preferably with Dakin’s solution, 

and increase the number of changes each day. 

Change in Dressing Regimen 

Do not be afraid to change dressing regimens. You may start with a 

dressing regimen of antibiotic ointment covered with dry gauze. After 

a few days, a lot of exudate covers the wound. At this point you should 

change to a wet-to-dry dressing and observe how the wound progresses. 

Once the wound has improved in appearance, you can go back 

to the antibiotic ointment or continue with the wet-to-dry dressings. 

Duration of Wound Dressing 

The dressings should be continued until the wound heals. Often 

during the course of secondary healing, the wound develops a dry 

eschar (scab). The patient can cover the area with dry gauze or even 

leave it uncovered. As the wound heals, the eschar gradually falls off. 

If the wound is near a crease, encourage the patient to exercise the area 

to prevent formation of a tight scar. Splints also may be useful. See 

chapter 15, “Scar Formation,” for more details. 


1. Goldwyn RM, Rueckert F: The value of healing by secondary intention for sizable defects 

of the face. Arch Surg 112:285, 1977. 

2. Montandon D, D’Andiron G, Gabbiani G: The mechanism of wound contraction and 

epithelialization. Clin Plast Surg 4:325, 1977.

Chapter 11 

PRIMARY WOUND CLOSURE 

KEY FIGURE: 

Everting skin edges 

In primary wound closure, the skin edges of the wound are sutured together 

to close the defect. Whenever possible and practical, primary 

closure is the best way to close an acute open wound. 

AAddvvaannttaaggeess ooff PPrriimmaarryy WWoouunndd CClloossuurree 

• Primary wound closure simplifies wound care for the patient, who 

simply needs to keep the suture line clean and dry. Secondary 

wound closure requires several dressing changes per day. 

• A wound closed primarily heals much more quickly and with less 

pain than a wound allowed to heal with dressings alone. 

• Primary closure involves fewer problems with abnormal scarring 

and has a better cosmetic outcome. 

• All vital, underlying structures are covered. 

CCoonnttrraaiinnddiiccaattiioonnss ttoo PPrriimmaarryy WWoouunndd CClloossuurree 

Concern about wound infection is the main reason not to close a 

wound primarily. If infection develops, the resultant deformity may be 

worse than that caused by the initial injury alone. The following circumstances 

are associated with an unacceptably high risk of infection: 

• An acute wound > 6 hours old (with the exception of facial wounds) 

• Foreign debris in the wound that cannot be completely removed 

(e.g., a wound with a lot of embedded dirt that you cannot clean 

completely) 

• Active oozing of blood from the wound 

• Dead space under the skin closure 

• Too much tension on the wound 

91


BBeeffoorree PPrriimmaarryy CClloossuurree 

Clean Wound 

The wound must first be evaluated thoroughly for injury to underlying 

structures to rule out the need for urgent exploration in the operating 

room. (See chapter 6, “Evaluation of an Acute Wound,” for specific 

details.) 

The wound must then be cleansed. 

Evaluating and cleansing a wound can hurt; remember pain control. 

Anesthetize the Area Before Suturing 

If local anesthetic was administered for wound cleansing, check to 

ensure that the anesthesia is still effective. 

Pinch the tissues with your forceps, or gently touch the skin edges with 

a needle. If the patient feels sharp pain, more anesthetic is required. 

Pressure sensation is not dulled by local anesthetics. With adequate 

anesthesia, the patient may still feel a sensation of pressure when you 

pinch the tissues with the forceps, but it should not hurt. 

Agents 

Injectable lidocaine (lignocaine) or bupivacaine should be used. For 

wounds of the face or scalp, the addition of epinephrine decreases 

bleeding caused by the placement of sutures. The effects of lidocaine 

last approximately 1 hour; the effects of bupivacaine last 2–4 hours. 

Administration 

1. Inject the anesthetic with as small a needle as possible. A 25–gauge 

needle is acceptable, but use the smallest needle that you have. The 

larger the number, the smaller the needle: a 25-gauge needle is much 

smaller than an 18-gauge needle. 

2. Inject slowly. It is acceptable to inject into the wound after it has 

been cleaned. If the tissues are dirty, however, inject into the skin 

surrounding the wound to prevent foreign material from being 

pushed into the uninjured surrounding tissues. 

3. Inject enough anesthetic to make the tissues swell just a little. 

4. If the injury is in an area where a nerve block can be done (e.g., on 

the finger), do a nerve block. It provides better anesthesia. 

5. Allow 5–10 minutes for the anesthetic to take effect. 

See chapter 3, “Local Anesthetics,” for more details.

HHooww ttoo SSuuttuurree tthhee WWoouunndd 

Primary Wound Closure 93 

Most wounds can be closed by suturing the skin edges together. 

Chapter 1, “Suturing: The Basics,” contains a detailed description of 

the various suturing techniques, but some reminders are included 

below. 

Suture Size 

On the Face 

Small sutures such as 5-0 or 6-0 should be used to repair facial lacerations. 

Smaller sutures decrease scarring, which is a major concern with 

facial wounds. Again, the bigger the number, the smaller the suture. 

(See chapter 16, “Facial Lacerations,” for more details.) 

All Other Sites 

Usually, in areas where cosmetic concerns are less important, 3-0 or 4-0 

sutures are best because of their larger size and increased strength. 

Absorbable vs. Nonabsorbable Sutures 

For most skin suturing, nonabsorbable sutures are best because they 

are associated with less noticeable scarring. Exceptions include patients 

who cannot return for suture removal, children (because of the 

difficulty in removing sutures from a frightened, crying child), and 

some facial lacerations. 

Suture Placement 

When you suture a wound, it is important to evert the skin edges—that 

is, the underlying dermis from both sides of the wound should touch 

(see figure at top of following page). If the edges are inverted (i.e., the 

epidermis turns in and touches the epidermis of the other side), the 

wound will not heal as quickly or as well as you would like. 

Choose the suture technique (simple vs. mattress sutures) that allows 

the best dermis-to-dermis closure for optimal wound healing. 

For most areas of the body except the face, the sutures should be 

placed 3–4 mm from the skin edge and 5–10 mm apart. There is no 

need to drive yourself crazy by placing too many sutures.


For optimal healing, sutures should be placed so that the skin edges are 

everted, allowing the dermis on both sides of the wound to be well approximated. 

(From McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. Saunders, 


Interrupted vs. Continuous Closure 

In an interrupted closure, you tie the suture once it has passed through 

each side of the wound. In a continuous closure, you place the sutures 

one right after the other without tying each suture individually. 

In a relatively simple laceration with smooth edges that line up easily, 

it makes no difference which method you choose. On the average, a 

continuous closure is faster to perform, but you should choose the 

method with which you are most comfortable. 

In a laceration with irregular edges, an interrupted closure is preferred 

because it allows better alignment of the tissues. 

If you have any concern that the wound may become infected, it is 

better to do an interrupted closure. If an area of the wound begins to 

look inflamed, the sutures in that area can be removed and the other 

sutures left in place. By removing a few sutures and placing the patient 

on oral antibiotics, you may be able to treat the infection adequately 

without having to reopen the entire wound. This approach results in a 

smaller scar and a happier patient. 

Closure in Layers vs. Simple Skin Closure 

Although most wounds require only skin closure, sometimes it is necessary 

to close the wound in layers. The layers may involve muscle, 

fascia (the layer of connective tissue that overlies the muscle and is actually 

quite strong), or dermis, depending on the particular wound. 

If the muscle or fascia is widely separated, a few absorbable sutures 

can be placed in a figure-of-eight fashion to bring the tissues together.

Primary Wound Closure 95 

If the wound is widely separated or the closure will be under some tension, 

a few buried dermal sutures are useful. Such sutures are placed in 

the skin layer just below the epidermis and should be made of an absorbable 

material. 

AAfftteerrccaarree 

1. After suturing the wound closed, apply a small amount of antibiotic 

ointment over the suture line and cover the area with a dry gauze. 

2. After 24 hours, remove the original dressing. 

3. The patient can wash the area with gentle soap and water the day 

after the repair. A shower is fine, but if the patient wants to take a 

bath, the injured area should not be allowed to soak in the water for 

more than a few minutes. 

4. A small amount of antibiotic ointment can be applied daily for the 

first few days; then leave the area open to air. 

5. If the injured area is on the hand, foot, or calf, have the patient elevate 

the affected extremity. Elevation decreases swelling in the injured 

area and thereby improves healing. 

SSuuttuurree RReemmoovvaall 

Sutures should be removed according to the following guidelines: 

• Face: 5–7 days 

• Hand: 10–14 days 

• Elsewhere: 7–10 days 

To decrease scarring, skin sutures are removed while the scar tissue is 

still relatively weak compared with the final scar strength (which is not 

attained for several months). To help maintain the wound closure, it is 

useful to place Steristrips (if available) across the scar once the sutures 

have been removed. These strips fall off on their own, and the patient 

can wash the area, even with the strips in place. 

WWhhaatt ttoo DDoo iiff tthhee SSuuttuurree LLiinnee BBeeccoommeess RReedd 

If the suture puncture sites start to become red and irritated-looking 

but the surrounding skin area is not tender or red, simply remove the 

sutures. No antibiotics should be needed. This reaction probably represents 

nothing more than inflammation and irritation from the sutures. 

As a precaution, you should check the patient within 24–48 hours to be 

sure.


If the area around the sutures becomes red, tender, and swollen, an infection 

probably has developed. Remove a few sutures, and open the 

wound. Try to express any underlying fluid or pus, and clean the area 

with saline or other antibacterial solution. If you cannot fully drain the 

underlying fluid or fully cleanse the area by taking out a few sutures, 

all of the sutures should be removed, the wound opened, and the area 

treated with wet-dry dressings. Oral antibiotics are also needed. 

DDeellaayyeedd PPrriimmaarryy CClloossuurree 

Delayed primary closure is a compromise between primary repair and 

allowing an acute wound to heal secondarily. This option may be considered 

for a wound with characteristics that require secondary closure 

(e.g., a wound over 6 hours old) even though primary closure is preferable 

(e.g., a large wound or a wound near a skin crease). 

In delayed primary closure, you initially treat the wound with wet-todry 

dressing changes for a few (2–3) days with the hope of being able 

to suture the wound closed within 3–4 days. 

During the few days of dressing changes, the reasons for not closing 

the wound initially may resolve. The dressings should clean the 

wound, the tissue swelling caused by the trauma may subside, and all 

bleeding may be fully controlled. If the wound shows no signs of infection 

and can be closed without tension, it may be possible to close the 

wound primarily within a few days. 

Delayed primary closure is a relatively simple technique and avoids 

having to choose a more complex method for wound closure. 


Millard DR: Principlization of Plastic Surgery. Boston, Little, Brown, 1986.

Chapter 12 

SKIN GRAFTS 

KEY FIGURES: 

Skin anatomy with Mesher 

graft thickness Skin graft 

Humby knife Tying the dressing 

Using the dermatome in place 

Using the Humby knife Defatting the FTSG 

A skin graft involves taking a piece of skin from an uninjured area of 

the body (called the donor site) and using it to provide coverage for an 

open wound. When primary closure is impossible because of soft 

tissue loss and closure by secondary intention is contraindicated, a skin 

graft is the next rung on the reconstructive ladder. It is not a technically 

difficult procedure but does require some surgical skills. For a successful 

result, you need a thorough understanding of how skin grafts heal 

and how to perform the procedure. 

BBaacckkggrroouunndd iinnffoorrmmaattiioonn 

Anatomy of Skin 

The thickness of human skin is quite variable. The eyelids have the 

thinnest skin (0.5 mm), and the thickest skin is found on the soles of 

the feet (> 5.0 mm). 

Epidermis 

The epidermis is the top portion of the skin. The outer layers of the epidermis 

are formed by essentially dead, nonreplicating cells. The innermost 

layer contains the cells capable of replication, which are responsible 

for wound healing and skin pigmentation. 

Dermis 

Immediately below the epidermis is the dermis. It is made primarily of collagen 

and is much thicker than the epidermal layer. The dermal-epidermal 

97


junction is irregular and has the appearance of ridges. This anatomic 

arrangement accounts for the skin’s strength and prevents injury from 

normal shear forces. Nerve endings, hair follicles, and sweat glands are 

located in the dermis. All skin grafts must include at least a portion of the 

dermal layer for survival. 

Subcutaneous Tissue 

The subcutaneous fatty tissue below the dermis provides padding for 

the skin. The base of many hair follicles and sweat glands, as well as 

many important nerves for pressure sensation, reside in the subcutaneous 

tissue. Because of these important skin components, I include 

the subcutaneous tissue as a layer of the skin. However, it is not included 

in a skin graft. Fat attached to the graft interferes with transport 

of nutrients to the important upper skin layers. Therefore, no fat 

should be included in the skin graft. 

Cross-section of human skin showing the epidermis and dermis (derived from 

two different germ layers). The relative thickness of skin grafts is shown. The 

thicker the graft, the more characteristics of normal skin it will provide. (From 

Cohen M (ed): Mastery of Plastic and Reconstructive Surgery. Boston, Little, 

Brown, 1994, with permission.) 

How a Skin Graft Survives 

When the skin graft is harvested from the donor site, it is completely 

separated from its blood supply. In its new position covering the open 

wound, the graft initially survives by diffusion of nutrients from the 

wound bed into the graft. Diffusion of nutrients keeps the skin graft

Skin Grafts 99 

alive for, at most, 3–5 days. During this period, blood vessels begin to 

grow from the wound bed into the graft. By the time the graft is no 

longer able to survive by diffusion of nutrients alone, this vascular network 

has formed and becomes the primary mechanism for providing 

nutrients to the graft. 

In the first several weeks after the procedure, the skin graft looks quite 

red and irregular compared with normal surrounding skin. Reassure 

the patient that the appearance will improve dramatically over the next 

several months, but the skin-grafted area will never look completely 

normal. It can take at least 1 year to see the final appearance of the 

graft. See chapter 15, “Scar Formation,” for more details 

When is a Wound Ready for Grafting? 

A wound will accept a skin graft when there is no overlying dead 

tissue and the wound is clean, beefy red (from granulation tissue), and 

without surrounding infection. Skin grafts heal well over muscle. 

Therefore, if muscle is exposed in the wound, skin can be grafted at 

any time, as long as the wound is otherwise clean. 

Table 1. Compensating for Factors that Interfere with Graft Survival 

Factor Compensation 

Dirty wound (e.g., Debride the wound and treat it with wet-to-dry dressings 

surrounding in- until the wound looks clean. Use antibiotics to clear 

fection, necrotic signs of surrounding infection. The skin graft can be 

tissue over wound) done once the wound has improved in appearance and 

there are no signs of surrounding infection. 

Fat in base of wound Fat has a poor blood supply and may not be able to support 

the graft. Treat the wound with wet-to-dry dressings 

until granulation tissue* begins to appear. Then do the 

skin graft. 

Shear forces between Movement of the graft over the wound interferes with vasgraft 

and base of cular ingrowth. The graft must be kept well secured to 

wound the wound by the dressing. If the graft is on an extremity, 

consider using a splint for immobilization of the limb. 

Blood or serum Fluid collection under the graft prevents the ingrowth of 

collection under blood vessels necessary for graft survival. Fluid collection 

graft can be prevented by cutting holes in the graft and keeping 

the graft well secured to the wound. If the graft is on 

the leg, the patient should be kept on bedrest, with the 

leg elevated at all times for at least the first 4–5 days. 

* Granulation tissue is the beefy red tissue that develops as a wound heals. It has an excellent blood 

supply but also contains bacteria in its crevices. 

Contraindications to Wound Closure with a Skin Graft 

A wound that has exposed tendon or bone can be successfully covered 

with a skin graft only if the thin layer of tissue connecting the tendon or


bone (paratenon or periosteum, respectively) is intact. These connective 

tissues contain the vascular structures necessary for skin graft survival. If 

the paratenon or periosteum is absent, the graft will not survive. Under 

these circumstances, some type of flap is needed for wound closure. 

SSpplliitt--tthhiicckknneessss SSkkiinn GGrraafftt 

A split-thickness skin graft (STSG) is composed of the top layers of skin 

(the epidermis and part of the dermis). The graft is placed over an open 

wound to provide coverage and promote healing. The STSG donor site 

is essentially a second-degree burn because only part of the dermis is 

included in the graft. The donor site will heal on its own because some 

dermal elements remain. 

Indications 

An STSG is indicated in most wounds that cannot be closed primarily 

and when closure by secondary intention is contraindicated. It is also 

indicated for a relatively large wound (> 5–6 cm in diameter) that 

would take many weeks to heal secondarily. A skin graft provides 

more stable coverage for large wounds than the scar that results from 

secondary closure. A large wound also heals more quickly with a skin 

graft than with dressing changes alone. The wound must be clean. All 

necrotic tissue must be removed before skin grafting, and there should 

be no signs of infection in the surrounding tissues. 

Anesthesia of the Donor Site 

Because of the relatively large size of the graft to be taken, the patient 

usually requires either general or spinal anesthesia for adequate pain 

control. However, if the required graft is no more than several centimeters 

in diameter, the donor site can be anesthetized by local infiltration 

of tissues with lidocaine or bupivacaine. 

Preparation of the Donor Site 

The most common donor site is the anterior or lateral aspect of the 

thigh. If the wound to be covered is on the back, try to take the graft 

from the lateral thigh, but the posterior thigh is also acceptable. Use of 

the posterior thigh as a donor site is a bit more painful and difficult for 

the patient to care for postoperatively. 

Any betadine or other antibacterial solution used to prepare the donor 

site should be washed off with saline. Then the donor site should be 

dried. Apply a sterile lubricant (e.g., mineral oil, K-Y jelly) to the donor 

site and to the instrument you will be using to harvest the graft.

Procedure for Taking the Graft 


A thin layer of skin (epidermis with some underlying dermis) is 

taken with a dermatome or a Humby knife (sometimes called a 

Watson knife). A dermatome is powered by air or electricity, but it is 

not available in all hospitals, especially in rural settings. Remember: 

you are not taking full-thickness skin; some dermis must be left at the 

donor site. 

Skin-graft (Humby) knife. (From Padgett Instruments, Inc., with permission.) 

Both the Humby knife and dermatome have settings that can be adjusted 

to set the thickness of the graft. Place the settings at 0.011–0.015 

inch (0.25–0.4 mm). Unfortunately, these settings are often unreliable. 

Another technique to ensure proper thickness of the graft is to adjust 

the opening of the blade so that you can snuggly fit the beveled edge of 

a no. 10 blade into the opening. 

Caution: Always check the knife settings just before you take the graft. 

This safety check prevents the accidental taking of too thick or too thin 

a graft. 

An assistant should help to spread and flatten out the donor site by 

placing tension on the skin with gauze or tongue depressors. 

If you have a dermatome: 

1. Turn on the power while the dermatome is in the air before it comes 

into contact with the skin. 

2. Hold the dermatome at a 45° angle with the skin and hold it firmly 

against the skin. 

3. Slowly move down the donor site until you have taken the properly 

sized graft. 

4. At this point do not turn off the power. Remove the dermatome 

from the skin with the power on so that the graft is completely freed 

from the donor site. 

5. The entire movement is evocative of landing an airplane and taking 

off again right away.


Harvesting a split-thickness skin graft with a power-driven dermatome. (From 

Cohen M (ed): Mastery of Plastic and Reconstructive Surgery. Boston, Little, 

Brown, 1994, with permission.) 

If you have a Humby knife: 

1. Hold it with the sharp edge at about a 45° angle with the skin. 

2. With a back-and-forth motion run the knife over the tight skin. 

3. When you have taken a large enough graft, continue the back-andforth 

motion, and twist your wrist into supination to remove the 

knife from the skin. Another option is to stop the knife movement 

and then use a scalpel to cut the skin graft from the donor site at the 

Harvesting a split-thickness graft with the Humby knife. (From McCarthy JG 

(ed): Plastic Surgery. Philadelphia, W.B. Saunders, 1990, with permission.)


blade edge. You may need to open the knife fully to remove the skin 

from the instrument. 

Preparation of the Skin Graft 

It is best to cut multiple slices in the graft to prevent blood and serum 

from accumulating under the graft. The cuts also help to expand the 

graft, allowing you to take a graft that is slightly smaller than the open 

wound. Use the tip of a knife or a small scissors to create the cuts in the 

graft. Some operating rooms have special equipment, called meshers, 

for this purpose. The mesher is a hand-cranked instrument that creates 

pie-cuts in the skin. 

A, The mesher, a device used to 

make fine cuts in skin grafts. B, The 

skin graft is placed on the rough side 

of the carrier and passed through the 

mesher. C, The meshed graft can 

now be spread over a larger area. 

(From Chase CA: Altas of Hand Surgery. 

Philadelphia, W.B. Saunders, 



How to Use the Mesher 

1. Place the skin on a plastic carrier. Carriers are available in different 

sizes, but the best size to use is 1.5:1 (i.e., the graft is expanded 1.5 

times). 

2. Spread out the skin graft on the rough side of the carrier. If you put 

it on the smooth side, you will get spaghetti when you place the 

graft through the mesher. It does not matter which side of the 

skin faces upward on the carrier, but the dermis side is the more 

shiny side. 

3. Pass the carrier with the skin graft through the mesher, taking care 

that the graft stays on the carrier and is not pulled into the blades of 

the mesher. 

Placement of the Graft onto the Recipient Site 

1. Be sure that the wound is clean. Remove any small areas that appear 

unhealthy. 

2. To decrease the amount of contamination in the top layers of the 

healing wound, scrape the wound with the edge of a knife. Do not 

push the knife edge into the wound; instead, scrape it over the 

wound. Rinse the wound with saline. 

Wound covered with a split-thickness skin graft. The graft has been meshed 

1.5:1.


3. Scraping the wound will make it bleed, but the bleeding is easily 

controlled by placing gauze over the wound and applying gentle 

pressure for a few minutes. Remember: hemostasis is important. 

4. Place the skin graft over the wound with the dermis side (the 

shinier side) down, next to the raw surface of the wound. 

5. Suture the graft in place with absorbable sutures. Leave a long tail 

on a few of these sutures so that they can be used to hold the dressing 

in place (see below). 

6. Alternatively, the skin graft can be stapled in place, but the staples 

must be removed. Removal can be painful. 

Application of Wound Dressing 

1. A layer of nonstick material, such as antibiotic-impregnated gauze, 

should be placed directly over the graft. If you do not have this type 

of gauze, apply a layer of antibiotic ointment over the graft. 

2. Moisten a sterile gauze with mineral oil (if available) or saline. 

3. Fluff the gauze and place it over the nonstick layer; then cover the 

area with dry gauze. 

4. Try to keep the dressing as secure as possible, either by wrapping 

with gauze or by tying the dressing in place. 

Tying the dressing in place. In suturing the skin graft to the wound edges, leave 

the ends of each suture long (A). Then use the long ends to secure the dressing 

in place (B). This technique immobilizes the dressing and underlying graft. 

(From Edgerton M: The Art of Surgical Technique. Baltimore, Williams & 

Wilkins, 1988, with permission.)


Removal of Wound Dressing 

• The dressing should be kept in place for 3–5 days. Check the dressing 

each day. If it develops an odor or has a lot of drainage, remove 

the dressing sooner. 

• Be careful not to lift the graft from the wound with the dressing 

change. Wet the dressing with saline (mixed with a little hydrogen 

peroxide, if available) to prevent the dressing from sticking. 

Aftercare 

• Gently apply antibiotic ointment, or use a wet-to-wet saline dressing 

once or twice a day for the next few days. The area can be cleansed 

very gently with saline at each dressing change. 

• After 10–14 days, once the wound looks like it is healing (i.e., the 

graft is pink and well-adherent to the wound), the dressings can be 

left off. A gentle moisturizer should be applied daily. 

• The skin graft site should be kept out of the sun as much as possible. 

Sunscreens can be used once the graft has fully healed. 

• Vigorously counsel the patient not to smoke during the healing 

period. Smoking probably will cause the skin graft to die. 

Care of the Donor Site 

• At the time of surgery, the donor site should be covered with a layer 

of antibiotic gauze. A thick layer of gauze should be placed on top. 

• After 24 hours, remove the outer gauze dressing—not the antibiotic 

layer—and leave the entire area open to air. The layer of antibiotic 

gauze will dry out over the next 24–48 hours and gradually peel off 

as the underlying wound heals. 

• An alternative treatment is to treat the donor site like a burn: apply 

antibiotic ointment twice a day until the wound has healed. 

• Apply moisturizer regularly to the donor site once it has healed. 

• The donor site also should be kept out of the sun. Sunscreens can be 

used once the wound has fully healed. 

FFuullll--tthhiicckknneessss SSkkiinn GGrraafftt 

A full thickness skin graft (FTSG) includes the epidermis and entire 

dermis but no subcutaneous fat. Because the entire thickness of skin is 

taken, the graft donor site must be closed primarily.

Indications 


FTSGs are rarely done, because the wound must be very clean for the 

graft to survive. Most often they are used for a small wound, usually 

one created surgically (such as a wound on the face created by excision 

of a malignant skin lesion). 

The other common use is for open wounds on the palmar surface of 

the hands and fingers. These areas may scar too tightly if the thinner 

STSG is used. 

Preparation of the Donor Site 

The best donor site is usually just above the inguinal crease on the 

lower abdomen. If the graft is needed to cover a facial wound, extra 

skin of a reasonable color match often can be taken from the supraclavicular 

area in the neck or from behind the ear. 

An ellipse is drawn at the donor site. Make sure that it is large enough 

to cover the defect but not too large to close the donor site. 

You can tell how large a graft you can take by seeing how much skin 

you can pinch or pull up at the donor site. At the inguinal area, you can 

flex the patient’s hip to decrease tension on the closure. After a few 

days the patient will be able to extend the hip fully. This approach 

causes no long-term problems. 

Anesthesia of the Donor Site 

Because you are taking a relatively small graft, the FTSG can be harvested 

with a local anesthetic. Lidocaine and marcaine work equally well. 

Procedure for Taking the Graft 

1. The ellipse of skin is excised with the full layer of dermis. To facilitate 

the procedure, take the graft with some underlying fat attached. 

2. You must remove the attached fat, which will interfere with graft 

survival. 

How to Defat the Graft 

1. The skin graft should be placed under tension. Place clamps on the 

ends of the graft, lay the graft over your hand, and let the clamps 

hang freely. 

2. Use scissors to remove the fat on the dermis. Place the scissors flush 

with the skin, and cut away the fat. Do not worry if you take a little 

dermis or cut into small areas of the epidermis.


Defatting the undersurface of a full-thickness skin graft with a pair of scissors. 

(From McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. Saunders, 1990, 


Placement of the Graft onto the Recipient Site 

1. The recipient site must be very clean. 

2. If you are using the FTSG for a wound on the palmar surface of the 

hand, decrease the amount of contamination in the top layers of the 

healing wound by scraping the wound with the edge of a knife. Do 

not push the knife edge into the wound; simply scrape it over the 

wound and then rinse with saline. 

3. Scraping makes the wound bleed, but the bleeding is easily controlled 

by placing gauze over the wound and applying gentle pressure 

for a few minutes. Remember: hemostasis is important. 

4. A few small slits can be cut in the graft to prevent fluid from accumulating 

under the graft. In general, the graft is placed as an intact 

sheet. Do not mesh a FTSG. 

5. The graft is placed over the wound, dermis side down, and sutured 

in place with absorbable sutures. Leave a long tail on a few of these 

sutures so that they can be used to hold the dressing in place. 

Application of Wound Dressing 

1. A layer of nonstick, antibiotic-impregnated gauze should be placed 

directly over the graft. Alternatively, place a thin layer of antibiotic 

ointment over the graft. 

2. Moisten sterile gauze with mineral oil (if available) or saline. 

3. Fluff the gauze and place it over the nonstick layer and cover with 

dry gauze.


4. Keep the dressing as secure as possible, either by wrapping with 

gauze or by tying the dressing in place. 

Removal of Wound Dressing 

The dressing should be kept in place for 3–5 days. Check the dressing 

each day. If the wound develops an odor or has a lot of drainage, 

remove the dressing sooner. 

Be careful not to lift the graft off of the wound with dressing changes. 

If necessary, wet the dressing with saline (mixed with a little hydrogen 

peroxide if available) to prevent it from sticking. 

Aftercare 

Apply antibiotic ointment, or use a wet-to-wet saline dressing once or 

twice a day for the next few days. 

Cleanse the area gently with saline at each dressing change. 

The epidermis (very top layer) may become black and peel off. Do not 

be overly concerned. As long as the underlying dermis is attached and 

vascularized, the graft should heal. 

After 7–10 days, once the graft looks like it is healing (i.e., it is pink and 

well-adherent), the dressings can be left off. A gentle moisturizer 

should be applied. 

The skin graft site should be kept out of the sun as much as possible. A 

gentle sunscreen should be used. 

Vigorously counsel the patient not to smoke during the healing period. 

Smoking probably will cause the skin graft to die. 

Care of the Donor Site 

The donor site should be closed primarily and covered with antibiotic 

ointment and dry gauze. The dressing can be removed after 24 hours. 

Apply a small amount of antibiotic ointment and dry gauze for 2–3 

days. Then the area can be left open. 

Clean daily with gentle soap and water. 

Remove the sutures after 7–10 days. 


Reus WF, Mathes SJ: Wound closure. In Jurkeiwicz MJ, Krizek TJ, Mathes SJ, Ariyan S 

(eds): Plastic Surgery: Principles and Practice. St. Louis, Mosby, 1990, pp 20–22.

Chapter 13 

LOCAL FLAPS 

KEY FIGURES: 

Axial flap noting pedicle Rhomboid flap 

Random flap noting Rotation flap 

pedicle and 3:1 ratio V-Y advancement flap 


A flap is a piece of tissue with a blood supply that can be used to cover 

an open wound. A flap can be created from skin with its underlying 

subcutaneous tissue, fascia, or muscle, either individually or in some 

combination. Depending on the reconstructive requirements, even 

bone can be included in a flap. 

A local flap implies that the tissue is adjacent to the open wound in 

need of coverage, whereas in a distant flap, the tissue is brought from 

an area away from the open wound. 

Local flap coverage of a wound is the next higher rung up the reconstructive 

ladder after a skin graft. Examples of wounds that require flap 

coverage include wounds with exposed bone, tendon, or other vital 

structure and large wounds over a flexion crease, for which a splitthickness 

skin graft or secondary closure would result in tight scarring. 

Donor site: where the flap originates. 

Recipient site: the open wound/soft tissue defect in need of coverage. 

Pedicle: the blood supply of the flap (i.e., its arterial inflow and 

venous outflow). The pedicle varies from a wide bridge of tissue (skin, 

subcutaneous tissue, muscle, or some combination) to an isolated 

artery and vein. 

Most local flaps can be classified as either (1) skin flaps, which are skin 

and subcutaneous tissue with or without the underlying fascia, or (2) 

muscle flaps, which are created from a muscle with or without the attached 

overlying skin. 

111


SSkkiinn FFllaappss 

A portion of skin and subcutaneous tissue and, when possible, the underlying 

fascia (the thin layer of connective tissue overlying muscle that has 

an excellent vascular supply) is moved to fill the defect. This movement of 

tissue results in a new defect at the donor site. Often the donor site can be 

closed primarily, but sometimes a skin graft is needed. 

Classification 

Skin flaps are classified as either axial or random. The classification is 

based on the blood supply. 

Axial Flaps 

The circulation of an axial flap is supplied by specific, identifiable 

blood vessels. Careful anatomic study has identified several donor 

sites with a single artery and vein responsible for circulation to a particular 

area of skin. Examples include the volar forearm skin supplied 

by the radial artery and skin on the back supplied by the circumflex 

scapular artery (a branch of the thoracodorsal artery). 

Circulation based on specific vessels results in a highly reliable blood 

supply and a reliable flap. You can be confident that unless there is an 

injury to the vessels, the majority of the flap tissue should survive in its 

new position. 

Axial flap. Note that the blood supply comes from an identifiable vessel. As a 

result, the pedicle can be quite thin, which makes transferring the flap to its 

new site an easier task.

Local Flaps 113 

An axial flap can be completely detached from all surrounding tissue as 

long as it remains connected to its supplying blood vessels. These vessels 

serve as the pedicle. The thin pedicle allows axial flaps to be easily 

positioned to fill the wound defect (unlike the random flap [see below]). 

The difficulty with an axial flap is locating the blood vessels. You must 

be very careful not to injure the vessels when creating the flap. The necessary 

technical expertise is beyond the realm of most providers without 

reconstructive surgical training. Thus, no specific axial skin flaps 

are discussed in this chapter. 

Random Flaps 

Circulation to a random flap is provided in a diffuse fashion through 

tiny vascular connections from the pedicle into the flap. The pedicle 

must be bulky to increase the number of vascular connections. The 

more vascular connections, the better the circulation to the flap. The 

better the circulation to the flap, the better its survival. 

In general, a random flap does not have as reliable a blood supply as 

an axial flap. Nonetheless, the relative ease of creating random flaps 

makes them useful almost anywhere on the body. The circulation and 

thus the reliability of the flap can be increased by “delaying” the flap 

before final transfer. 

Random skin flap. The blood supply comes diffusely from the remaining skin 

attachment, which serves as the pedicle. For optimal circulation and flap survival, 

the flap should be designed so that the length is no more than three times 

the width. 

Delay Procedure 

Before the flap is created, the tissue gets its blood supply via all of the 

surrounding skin and underlying tissue attachments. When the flap is 

created, the circulation to the flap comes only from the pedicle.


The purpose of the delay procedure is to enable the pedicle to assume 

its role as the main source of circulation before the flap is moved to its 

new position. This goal is obtained by making some of the incisions 

needed to create the flap but not separating the flap from the underlying 

tissues. The flap is not moved to its new position; instead, the skin 

edges are sutured together loosely. 

The total blood supplied to the flap initially decreases when the incisions 

are made. This decrease promotes opening of new vascular channels 

between the pedicle and flap. Thus, more blood will flow into the 

flap through the pedicle than if the delay procedure had not been done. 

Delaying the flap before final transfer allows more confidence in the 

viability of the flap. Wait about 7–10 days after the delay procedure 

before moving the flap to the recipient site. 

TTeecchhnniiqquueess ffoorr CCrreeaattiinngg RRaannddoomm LLooccaall FFllaappss 

When creating a random local skin flap, you take advantage of the relatively 

loose, excess skin in the vicinity of the skin defect. Random 

flaps require less technical expertise than axial flaps. Because they can 

be quite useful for covering an open wound, several types of random 

flaps are discussed in detail below. 

General Information 

Random flap procedures often can be done under local anesthesia if 

the area (flap plus defect) is not too large (< 8–10 cm). For larger areas, 

general anesthesia probably will be required. 

Be sure to clean the wound thoroughly before creating and placing the flap. 

Use a scrub brush or the flat part of a scalpel to scrape away the top layer 

of granulation tissue from the wound. Then wash with saline. The wound 

probably will bleed, but gentle pressure should control the bleeding. 

Hint: Outline the flap before making any incisions. A water-based magic 

marker allows you to make corrections to your design before making any 

incisions. Incorrect marks can be removed by wiping with alcohol. 

The part of the flap at highest risk for poor circulation is the tip of the 

flap (the tissue farthest from the pedicle). Unfortunately, the tip of the 

flap is usually the most important part of the flap because it is the part 

that provides coverage for the open wound. 

To optimize circulation and reliability of a random flap, plastic surgeons 

heed the 3:1 rule. The flap should not be longer than 3 times its width. 

Delaying the flap is also useful.


Unfortunately, the thickness of the pedicle can make it difficult to 

move the flap to its new position. Minimal tension should be applied to the 

flap when it is sutured into place. Tension on the flap decreases circulation 

and can lead to tissue necrosis (death). You can tell that too much tension 

has been applied if portions of the flap look pale once it is in its 

new position. 

If the donor site cannot be closed primarily without placing tension on 

the flap, avoid primary closure. A skin graft can be used to cover the 

donor site defect—or, if the defect is just a few cm, it can be allowed to 

heal secondarily. 

For coverage of a wound > 7–8 cm, it is useful to place a drain under 

the flap to prevent collection of fluid, which will interfere with healing. 

The drain can be a suction drain, if available, or a passive drain (e.g., 

Penrose drain). A piece of sterile glove can substitute for a Penrose 

drain. The drain usually can be removed after 48 hours. 

Rhomboid Flaps 

Indications 

Rhomboid flaps are useful for wounds up to 4 or 5 cm in diameter on 

the face, trunk, or extremity. They are especially useful when there is 

not enough laxity in the surrounding tissues to create one of the other 

flaps discussed below. 

Procedure 

1. Measure the diameter of the defect. 

2. Determine the site of greatest surrounding skin laxity (pinch the tissues 

to see where it is easiest to pull up on the skin). Draw a line 

from the wound edge into this tissue. This line, which represents the 

first incision, should be approximately 75% of the wound diameter. 

3. Draw another line at a 60° angle to this extension, parallel to the 

edge of the defect. This line should be the same length as the line in 

step 2. These lines outline your flap. 

4. Be careful not to make the pedicle of the flap too narrow. 

5. Make the incisions along the lines placed in steps 2 and 3. Incise the 

skin and subcutaneous tissue of the flap down to, but not including, 

the underlying muscle. 

6. Use a knife to lift the flap off the underlying muscle, trying to keep 

the fascia attached to the flap to enhance circulation. You should 

also separate the pedicle and some of the tissues around the wound


defect from the underlying muscle. This technique is called undermining. 

Undermining allows more mobility in the flap and surrounding 

tissues, which in turn facilitates wound and donor site closure. 

7. The flap now should be ready to be moved into the wound, and the 

donor site should be closed primarily. 

8. Loosely suture the flap in place, taking care to avoid tension on the 

pedicle. Place a few dermal sutures, and then do an interrupted skin 

closure. Be sure that the skin closure is not tight. It is better to have 

small gaps in the skin closure (which will heal) than to make a tight 

closure and lose part of the flap. 

Rhomboid flap. 1: Open wound in need of coverage. 2: Draw a circle or rhomboid 

around the defect and, at the area of maximal skin laxity, a line 75% of the 

wound diameter. 3: Draw another line of the same length at a 60° angle to the 

first line, taking care not to narrow the base of the flap. 4, 5, and 6: Incise the 

lines. Undermine the area widely to allow transfer of the flap to the desired position 

and primary closure of the defect. 7: Final appearance of closed wound.

Indication 

Rotation Flaps 


Commonly used for coverage of sacral pressure sores. This type of flap 

can cover wounds of various sizes. 

Procedure 

1. Draw the flap before making any incisions so that you can make 

corrections. 

2. Determine the site of greatest laxity in the surrounding tissues. 

3. Make the flap larger than you think you need. 

4. Extend the wound in a curved fashion until you think the flap can 

be moved into the defect. Be sure that the flap has a wide base (at 

least 8–10 cm). 

5. Separate the flap from the underlying tissue attachments, and undermine 

the flap pedicle and surrounding skin edges. 

Rotation flap for closure of a 

sacral pressure sore. The donor 

site can be left open and allowed 

to heal secondarily, or a skin 

graft may be used if primary closure 

seems tight.


6. If necessary, a small back cut can be made at the lateral edge of the 

base of the flap to help it turn onto the wound. Do not narrow the 

base by more than 1–2 cm. 

7. Loosely suture the flap in place, avoiding tension on the pedicle. 

Place a few dermal sutures, and then do an interrupted skin closure. 

Be sure that the skin closure is not tight. It is better to have small 

gaps in the skin closure (which will heal) than do a tight closure and 

lose part of the flap. 

8. Sometimes the donor site may need to be closed with a split-thickness 

skin graft or allowed to heal secondarily. 

V-Y Advancement Flaps 

Indications 

V-Y advancement flaps are useful for covering ischial pressure sores 

and other wounds with very lax surrounding tissues. They may be 

used for both large (> 7–8 cm) and small wounds. V-Y advancement 

flaps are slightly different from those described above. The pedicle is 

not a bridge of surrounding skin and subcutaneous tissue; it is the 

deep tissue underlying the flap. 

Procedure 

1. Determine the site where the laxity of the surrounding skin is 

greatest. 

2. Draw the flap before making any incisions so that you can make 

corrections. 

3. Mark the V with the widest area at the edge of the wound, tapering 

gradually to a point. 

4. Incise the skin edges through the subcutaneous tissue down to, but 

not into, the underlying muscle. The flap remains attached to the 

deep tissues. 

5. The flap then should be advanced into the wound defect. 

6. Close the defect primarily at the narrow point of the V. This step creates 

the Y limb. 

7. Suture the flap loosely, under no tension. Place a few dermal sutures, 

and then close the skin with interrupted sutures. Do not make the 

skin closure too tight. It is better to have small gaps in the skin closure 

(which will heal) than do a tight closure and lose part of the flap.

General Postoperative Care 


Cleanse the suture lines with gentle soap and water and apply antibiotic 

ointment 1–2 times per day. 

Remove the sutures within 7–10 days. 

TTRROOUUBBLLEE--SSHHOOOOTTIINNGG 

V-Y advancement flap. A, Open 

wound in need of coverage. B, The 

V flap is drawn so that its base (the 

side opposite the point of the V) is 

at the defect. Once the incisions are 

made, the tissue moves into the 

defect for coverage. C, The resulting 

wound is closed in a Y fashion. 

What to Do if the Flap Becomes Swollen and Bluish 

Within Hours after the Operation 

A swollen, bluish flap indicates a problem with circulation into or out 

of the flap. Usually it is a venous (i.e., outflow) problem. 

Make sure that the patient is positioned properly and that nothing is 

compressing or pulling on the pedicle. Loosen surrounding dressings 

and tape. Sometimes it is helpful to remove a few stitches to ensure 

that the flap is not under too much tension. 

Be sure that no fluid has collected under the flap. Any collection of 

fluid requires drainage. Place a clamp between some of the sutures, 

and spread the skin edges. This technique helps to drain the fluid. 

Ensure adequate pain control. Pain stimulates the sympathetic nervous 

system, which decreases blood flow through the pedicle.


What to Do If Part of the Flap Dies 

A few days after the procedure, you may notice that a part of the flap 

has become purplish. A purple color indicates inadequate circulation 

to that part of the flap, and the tissue may eventually die. 

If there is no evidence of infection, you may simply leave the flap 

alone. With time, this tissue will demarcate and die and then separate—or 

you may have to cut off the dead tissue. While this process is 

occurring, the underlying tissues will heal. 

MMuussccllee FFllaappss 

Muscle flaps involve moving a local muscle to cover a defect. A muscle 

flap is often done to cover an exposed bone or fracture, usually in the 

calf. The muscle is freed from the surrounding tissues but left attached 

to its blood supply. A muscle flap is an axial flap. 

Compared with skin flaps, muscle flaps bring in a robust, new circulation 

to the injured site and thus enhance wound healing. The use of 

muscle flaps to cover exposed fractures has markedly decreased the 

morbidity associated with open (compound) fractures. 

For rural practitioners without access to a specialist, the muscle flaps of 

greatest utility involve primarily the lower extremity (see chapter 21, 

“Fractures of the Tibia and Fibula”). 


1. Dhar SC, Taylor GI: The delay phenomenon: The story unfolds. Plast Reconstr Surg 

104:2079–2091, 1999. 

2. Taylor GI, Corlett RJ, Caddy CM, Zelt RG: An anatomic review of the delay phenomenon. 

II: Clinical applications. Plast Reconstr Surg 89:408–418, 1992.

Chapter 14 

DISTANT FLAPS 

KEY FIGURES: 

Chest flap Design of groin flap 

Cross arm flap Examples of groin flap 

Cross leg flap Examples of free flaps 

A distant flap involves moving tissue (skin, fascia, muscle, bone, or 

some combination) from one part of the body, where it is dispensable, 

to another part, where it is needed. A distant flap is required when 

there is no healthy soft tissue adjacent to an open wound with which to 

provide adequate coverage. 

These complex procedures are at the highest rung of the reconstructive 

ladder. Therefore, a distant flap is the treatment of choice when other, 

simpler procedures are not applicable. 

TTyyppeess ooff DDiissttaanntt FFllaappss 

Distant flaps are divided into two categories: attached and free. 

An attached distant flap implies that the area with the open wound 

initially is attached to the flap at the distant donor site. For example, 

the patient may have an open wound on the hand that requires soft 

tissue coverage. The donor site for the distant flap may be the chest 

(see chest flap below). Thus, the patient’s hand initially is attached to 

the chest. 

The blood supply to the flap initially comes from its pedicle (the bridge 

of tissue connecting the flap to its donor site). Gradually, over a few 

weeks, the flap develops in-growth of vessels from the recipient site 

(the wound). These new vessels bring blood to the flap, and the flap 

gradually becomes less dependent on the donor site circulation for survival. 

After a few weeks, the flap can be separated from its donor site 

and survive in the new area. 

121


Patient inconvenience is a major drawback to attached flaps. Also, attached 

flaps are usually random flaps (see chapter 13, “Local Flaps”); 

therefore, they are not always completely reliable. 

Free flaps, which are axial flaps, were developed to circumvent the 

problems inherent in attached distant flaps. Tissue supplied by a 

named vascular pedicle is detached completely from the donor site. 

The flap is then transferred to the open wound. With the aid of a microscope 

or other form of magnification, the flap’s blood vessels (often 

just a few millimeters in diameter) are painstakingly connected to 

blood vessels at the recipient site. As you can imagine, a free flap is a 

technically difficult procedure and requires special equipment not 

readily available in many rural areas. 

In contrast, attached distant flaps do not require such highly skilled 

specialists, but they do require basic surgical skills. Attached flaps 

often are quite useful when specialty care is unavailable. For example, 

an attached flap can make the difference between a healed functional 

hand and a severely damaged dysfunctional hand in a rural patient 

who has sustained severe soft tissue injury. This chapter focuses primarily 

on attached distant flaps. 

AAttttaacchheedd DDiissttaanntt FFllaappss 

The procedure for creating and placing attached distant flaps follows 

many of the same rules that apply to local flaps. You should review 

chapter 13, “Local Flaps,” for important background information. 

Remember the 3:1 rule: for optimal circulation the flap length should 

be no more than 3 times the flap width. A delay procedure should be 

done if a larger flap is required. 

As always, be sure that the wound is thoroughly cleansed before attaching 

the flap. All necrotic tissue must be removed. For a wound on 

the hand, it is best to debride the wound using a tourniquet. This technique 

allows you to remove the dead tissue carefully and avoid injury 

to important nearby structures. Be sure to remove the tourniquet and 

stop all bleeding before suturing the flap to the defect. 

If the wound is covered by necrotic tissue, debride the wound a day or 

two before flap closure. If the wound is clean and granulating, use a 

scrub brush or the flat part of a scalpel blade to remove the top layer of 

granulation tissue before covering the wound with the flap.

Indications 

Chest Flap 

Distant Flaps 123 

An open wound on the hand or forearm with exposed tendons/bones. 

Anesthesia 

A chest flap can be done under general anesthesia. However, local 

anesthesia for the donor site and a block for the recipient site is sometimes 

preferable. Local anesthesia and recipient site block ensure that 

the patient will not accidentally pull the flap attachments apart when 

awakening from general anesthesia. 

Procedure 

1. Ask the awake patient to position the injured hand over the chest in 

the most comfortable position. Stay away from breast tissue. 

2. Mark this area. The flap should be drawn in such a way that the 

hand can be comfortably attached to the chest, but you must make 

sure that the pedicle does not become kinked. Usually the flap is 

drawn so that the pedicle is based inferiorly, but it can be designed 

with almost any orientation. Be sure that no scars from previous injuries 

are located within the flap or pedicle. 

3. Design the flap so that it is slightly larger than the defect. 

4. Make the incision through skin and subcutaneous tissue and into 

the underlying fascia (the thin layer of connective tissue over the 

muscle). Do not incise the muscle. The fascia contributes to the 

blood supply of the flap; therefore, it is important to keep it attached 

to the flap whenever possible. 

5. Elevate the flap off the deep underlying tissues. 

6. Loosely stitch the three free sides of the flap in place. Use a few dermal 

sutures, and then close the skin with interrupted, simple sutures. The 

closure does not have to be perfect. If the flap is stitched too tightly, it 

may compromise circulation and result in partial flap loss. 

7. If possible, the donor site on the chest should be closed primarily, 

but usually a split-thickness skin graft is needed. Alternatively, if 

the wound is just a few cm in diameter, the donor site may be allowed 

to heal secondarily. 

8. Antibiotic ointment and saline-moistened gauze dressings should 

be placed on the exposed undersurface of the flap. Apply antibiotic 

ointment around the edges of the flap.


Postoperative Care 

Donor site: Dressings should be changed daily as appropriate, depending 

on how you decide to treat the donor site. For example, use 

wet-dry dressings if the wound is allowed to close secondarily, antibiotic 

ointment with dry gauze if it is closed primarily. 

Flap: Keep the recipient site and flap uncovered so that the patient and 

caregivers can be sure that the flap pedicle has not kinked. Any signs 

of venous congestion (the flap becomes purplish and swollen, with fast 

capillary refill) necessitates repositioning of the recipient site. 

While the patient is in bed, it often helps to place a pillow under the 

elbow to help support the forearm and wrist. Change the dressings 

daily, and clean the suture lines with saline or gentle soap/water. The 

patient can get out of bed after surgery but must take care not to pull 

on the flap. 

Chest flap. A, Open wound on the dorsum of the hand. B, An inferiorly based 

chest flap is created to cover the defect. A split-thickness skin graft is used to 

close the chest skin defect. (From Chase RA: Atlas of Hand Surgery. 

Philadelphia, W.B. Saunders, 1973, with permission.)

Indications 

Cross Arm Flap 


A cross arm flap is a good choice to cover a relatively small (maximal 

diameter of 2–4 cm) open wound on the hand or fingers. Usually such 

wounds are associated with an exposed tendon or bone. 

A cross arm flap is useful when positioning makes the chest flap too 

uncomfortable for the patient. It is also the flap of choice if the patient 

prefers not to have scars on the chest or if no donor sites are available 

on the chest. 

The inner aspect of the upper arm is the donor site. 

Anesthesia 

A cross arm flap can be done under general anesthesia, but local anesthesia 

with a nerve block is preferable. Local anesthesia and nerve 

block ensure that the patient will not accidentally pull apart the flap attachments 

on awakening from general anesthesia. 

Procedure 

1. Before surgery, ask the patient to hold the injured hand so that the 

wound is next to the inner aspect of the opposite upper arm. 

2. The flap should be designed so that the hand can be comfortably attached 

to the inner arm, making sure that the attached part of the 

flap does not become kinked. Pick a position that allows some 

gentle shoulder motion to prevent shoulder stiffness. 

3. Mark this area. 

4. Draw the flap so that it is slightly larger than the defect. Stay away 

from any scars. 

5. Make the incision through the skin and subcutaneous tissue; do not 

include muscle. 

6. Elevate the flap off the underlying tissues. 

7. Loosely stitch the three free sides of the flap in place. Use a few 

dermal sutures, and then close the skin with interrupted, simple sutures. 

The closure does not have to be perfect. 

8. If possible, loosely close the donor site primarily. Alternatively, a 

wound no larger than a few centimeters may be allowed to close 

secondarily.


9. Antibiotic ointment covered with saline-moistened gauze dressings 

should be placed on the free undersurface of the flap. Antibiotic 

ointment should be placed around the edges of the flap. 


Donor site: Dressings should be changed daily as appropriate, depending 

on how you decide to treat the donor site. 


caregivers can be sure that the flap has not kinked. Any signs of venous 

congestion (the flap becomes purplish and swollen, with fast capillary 

refill) necessitates repositioning of the hand. 

While the patient is in bed, it often helps to place a pillow under the 

elbow to help support the forearm and wrist. Change the dressings 

daily and clean the suture lines with saline or gentle soap and water. 

The patient can get out of bed after surgery but must take care not to 

pull on the flap. 

Cross Leg Flap 

The cross arm flap is useful 

for smaller defects, especially 

those involving the fingers. 

Indications 

The most common indication for a cross leg flap is an open wound 

with an exposed fracture or exposed tendons of the lower third of the 

calf or foot. The lower calf or foot is sewn to the calf of the opposite 

leg for 3–4 weeks. Keeping the legs in this position can result in 

marked leg and hip stiffness. Therefore, a cross leg flap is best used in 

children or young adults; it is not recommended in patients older 

than 35 years.

Anesthesia 


Either general or spinal anesthesia is required for cross leg flaps. 

Procedure 

1. Before administration of anesthesia, determine the best position for 

the patient’s legs so that a flap of tissue taken from the noninjured 

posteromedial calf will lie easily over the defect with the least discomfort. 

2. Draw the flap on the posteromedial side of the calf, overlying the 

gastrocnemius muscle. The flap should be slightly larger than the 

wound defect. 

3. The flap should be designed so that it is superiorly based. 

4. Incise the skin, subcutaneous tissue, and fascia overlying the gastrocnemius 

muscle. Elevate the flap along the plane between the fascia 

and underlying muscle. The fascia must stay attached to the flap. 

5. Move the flap over to the open wound. 

6. Loosely stitch the three free sides of the flap in place. Place a few 

dermal sutures, and then close the skin with interrupted sutures. 

The closure does not have to be perfect. 

7. The donor site should be covered with a split-thickness skin graft. 

8. Place antibiotic ointment and saline-moistened gauze along the 

free undersurface of the flap. Apply antibiotic ointment around all 

suture lines. 

9. The patient’s legs must be immobilized together to prevent accidentally 

separating the legs and tearing the suture line. This is best 

achieved with plaster. Use a lot of padding under the plaster. 

10. Cut out a window in the plaster and padding over the flap so that 

the flap can be observed and cleansed daily. 


Donor site: Treat as you would the site of a split-thickness skin graft. 


caregivers can be sure that the flap has not kinked. Any signs of venous 

congestion (the flap becomes purplish and swollen, with fast capillary 

refill) necessitates repositioning of the legs. 

In adults, plaster immobilization often can be removed after 4–5 days. 

Then a splint or gauze wrap can be created to keep the legs in the 

proper position.


Children must be fully immobilized in plaster until the flap is divided. 

You may need to change the plaster in the operating room under anesthesia. 

Change the dressings daily and clean the suture lines with saline or 

gentle soap and water. Be careful not to pull on the flap. 

Division of Distant Flaps 

Gradually the flap will experience an in-growth of circulation from its 

new site. After no less than 2 weeks, you can start to divide the pedicle, 

using local anesthesia such as lidocaine or bupivacaine. Do not add epinephrine 

to the anesthetic solution. 

Cut approximately one-fourth of the way across the pedicle, and 

loosely stitch down the free edge to the recipient wound. A week later 

continue another fourth of the way across the pedicle of the flap. At 4 

weeks you should be able to divide the flap completely. 

Alternatively, you may divide the flap completely in one stage 4 weeks 

after the initial procedure. Gradual division, however, gives the flap 

time to adjust to less input from the pedicle. 

Suture the flap loosely to the skin edges of the recipient site. Small 

areas of skin separation will heal; all areas along the edge of the wound 

do not have to be closed completely. 

Cross leg flap. A, Child with a congenital deformity that caused the foot to grow 

in an inverted position. Several previous operations failed to correct the problem. 

Definitive treatment required excision of the tight scar and repositioning of 

the foot. B, This procedure resulted in an open wound with exposed tendons in 

need of soft tissue coverage. (Figure continued on following page.)

Groin Flap 


Cross leg flap (continued). C, Design of the cross leg flap. D, The flap after 

being sewn in place. E, The legs immobilized together in plaster. F, A window 

cut in the plaster to allow dressing changes and observation of the flap. 

The groin flap is an axial flap, whereas the previously discussed distant 

flaps are random flaps. The groin flap is more reliable but also more 

technically difficult. Thus, only providers with advanced surgical skills 

should attempt this procedure. Because the groin flap may be used to 

save a hand with a large soft tissue defect but otherwise intact tendons 

and nerves, it is described in detail below.


Design of groin flap. In contrast to the previously mentioned distant flaps, the 

groin flap is an axial flap, and its blood supply is by way of an identifiable 

vessel. It is a highly reliable flap for coverage of hand wounds. (From Cohen M 

(ed): Mastery of Plastic and Reconstructive Surgery. Boston, Little, Brown, 

1994, p 59, with permission.) 

Indications 

The indication for a groin flap is an open wound on the hand or fingers 

in which the tendons or bones are exposed. It is also possible to take a 

piece of iliac bone with the flap, if needed, to reconstruct a bony defect 

in the hand. 

Anesthesia 

The groin flap is usually done under general anesthesia. However, it is 

possible to perform the procedure using spinal anesthesia with a wrist 

block. 

Design 

Landmarks 

• Anterosuperior iliac spine (ASIS) 

• Pubic tubercle 

• Course of the inguinal ligament 

• Femoral artery 

The artery that nourishes the flap comes off the femoral artery within 

two finger widths below the point where the femoral artery meets the 

inguinal ligament. This artery travels in the direction of the axis of the 

flap toward the ASIS.


Medial flap border The course of the femoral artery 

Upper flap border Two fingerwidths above the inguinal ligament 

parallel to the artery nourishing the flap 

Lower flap border Two fingerwidths below the take-off of the 

nourishing artery from the femoral artery; 

again, it runs parallel to the direction of the 

femoral artery 

Lateral flap border Lateral to the ASIS, as determined by the size 

of the wound. Once the flap is lateral to the 

ASIS, keep the length-to-width ratio at 1:1. 

Always draw the flap first. The portion of the flap overlying and lateral 

to the ASIS is used to cover the open wound. Most of the medial 

portion of this flap is tubed and serves as the pedicle (see below). 

Dissection 

1. Proceed from lateral to medial. 

2. Start by incising the lateral half of the upper and lower markings 

and the lateral border of the flap. 

3. Elevate the skin and subcutaneous tissue off the underlying fascia. 

Dissect medially until you reach the lateral aspect of the sartorius 

muscle; look for the muscle fibers traveling in an inferomedial direction 

from the ASIS to the medial knee. 

4. At the lateral border of the sartorius muscle, make an up-and-down 

incision into the fascia. 

5. Keeping the fascia attached to the skin and subcutaneous tissue of 

the flap, continue the dissection until enough of the flap is raised to 

allow inset of the flap over the wound. 

6. If a branch of the blood vessel runs deep to the fascia, ligate it to prevent 

accidental injury. 

7. Take care to avoid injury to the lateral femoral cutaneous nerve 

when you incise the sartorius fascia. 

Inset of the Flap 

1. The pedicle of the flap (approximately the medial half of the flap) is 

sutured loosely to itself to make a tube. Simple, interrupted skin sutures 

are adequate. The tube allows the patient to move the shoulder 

without risking injury to the flap or hand attachment. It also 

increases postoperative comfort and makes dressing care easier.


Groin flap. A, Elevation of the groin flap; the medial portion is sewn together to 

form a tube. The donor site has been closed primarily. B, The patient with the 

hand attached to the flap. 

2. Manipulate the hand/forearm into pronation or supination to determine 

the appropriate hand position for suturing the flap to the 

wound. 

3. The lateral portion of the flap should be loosely sutured to the edges 

of the wound. 

4. If the portion of the flap used to cover the wound seems too bulky, 

you can thin it by removing some of the subcutaneous tissue. Do not 

be too aggressive. The flap can be thinned at a later date once it has 

been divided from the donor site. Better a bulky flap than a dead one. 

5. Do not thin the flap medially, where you are making it into a tube. You 

may injure the blood supply to the flap. 

Donor Site 

The donor site should be closed primarily. You may need to flex the patient’s 

hips to bring the wound edges together. The patient should


remain flexed for a few days after surgery. Then you may allow the patient 

to straighten the leg gradually over a few days. 

Place a Penrose drain or a strip of sterile glove to prevent fluid from accumulating 

under the suture line. The drain can be removed on the 

day after surgery. 


Apply antibiotic ointment along the suture lines and saline-moistened 

gauze along the undersurface of the flap between the part of the flap 

that is tubed and the patient’s hand. Change the dressing daily. 

You may want to wrap the patient’s arm to the chest for the first day to 

prevent too much arm movement. Once the patient is fully awake, this 

precaution is usually unnecessary. 

Watch for signs of venous congestion. Check the flap regularly to 

ensure that the pedicle is not twisted or kinked. 

Division of the Flap 

1. Gradually the flap will develop an in-growth of circulation from its 

new site. 

2. After no less than 3 weeks, you may start to divide the pedicle. Cut 

one-fourth of the way across the pedicle, and loosely stitch down 

the edge to the recipient site. Local anesthetic without epinephrine 

should be used. 

3. One week later, divide another small portion of the pedicle. 

4. At 5 weeks you should be able to divide the flap completely from its 

pedicle. Gradual division is best; do not completely separate the 

flap at one time. However, if gradual division is not possible, it 

should be safe to divide the flap all at once at 5 weeks. 

5. Suture the flap very loosely. Small areas of skin separation will heal; 

so do not worry that all skin edges have to be completely closed. 

What to Do if Part of the Flap Dies 

If a portion of the flap becomes ischemic and dies, the wound often 

heals with local care. See chapter 13, “Local Flaps,” for further details. 

FFrreeee FFllaapp 

A free flap involves complete detachment of a piece of tissue (skin, 

fascia, muscle, bone, or some combination) with its blood supply 

(artery and vein). The tissue is transferred to the wound in need of


coverage. The blood vessels of the flap are then reattached to an artery 

and vein near the wound. 

To reconnect the blood vessels requires magnification capabilities (4 × 

glasses at least or a microscope), tiny suture material (8-0, 9-0 nylon), 

and delicate instruments. The procedure takes several hours and is 

most efficiently done with two teams of surgeons (one working to find 

the vessels at the wound site, one working to dissect the flap). 

In experienced hands, a free flap can achieve remarkable results. 

Examples include reconstruction of the tongue or jaw after ablative oncologic 

surgery, breast reconstruction after mastectomy, or coverage of 

a badly fractured ankle with soft tissue loss. Obviously, these procedures 

can be done only by highly experienced reconstructive surgeons 

with extensive microvascular training and expertise. 

The following photographs show a patient with a squamous cell carcinoma 

of the lateral aspect of the tongue. Because of the extent of the 

tumor, almost one-half of the tongue and floor of the mouth needed 

Free flap reconstruction. A, Squamous cell 

cancer of the lateral tongue. B, Design of the 

radial forearm flap. C, Blood vessels from the 

flap are reattached to blood vessels in the 

neck. D, Final result 1 year postoperatively.


to be resected. The reconstruction was done with a free flap taken 

from the volar surface of the forearm and based on the radial artery 

(called a radial forearm flap). 

The reconstructed tongue is almost normal in size. Thus the patient 

was able to eat and speak normally. The flap also tolerated postoperative 

radiation treatment without complication. These results would be 

hard to attain with any other reconstructive technique. 


1. Chase RA: Atlas of Hand Surgery. Philadelphia, W.B. Saunders, 1973, pp 120–127. 

2. Chuang DCC, Colony LH, Chen HC, Wei FC: Groin flap design and versatility. Plast 

Reconstr Surg 84:100–107, 1989. 

3. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomoses. 

Plast Reconstr Surg 52:111–117, 1973. 

4. Puckett CL, Reinisch JF: Gastrocnemius musculocutaneous cross-leg flap. In Strauch 

D, Vasconez LO, Hall-Findlay EJ (eds): Grabb’s Encyclopedia of Flaps. Boston, Little, 

Brown, 1990, pp 1703–1705. 

5. Strauch B, Yu HL (eds): Atlas of Microvascular Surgery. New York, Thieme Medical 

Publishers, 1993.

Chapter 15 

SCAR FORMATION 

KEY FIGURES: 

Hypertrophic scar 

Buried dermal suture 

This chapter gives background information about the scarring process. 

Treatment options for problematic scars are also discussed. 

NNoorrmmaall CCoouurrssee ooff SSccaarr MMaattuurraattiioonn 

Strength 

Scar tissue is never as strong as normal, uninjured skin. For the first 

3–4 weeks after injury, the wound can easily be reopened by minimal 

trauma. By 6 weeks, the scar has attained approximately 50% of its 

final strength. During the next 12 months, the scar gradually increases 

its ability to withstand injury, but it never attains normal strength. 

Appearance 

The period of maximal collagen production (the primary component of 

skin and scar tissue) is the first 4–6 weeks after a wound has closed. 

During this period the scar may appear red and be slightly firm and 

raised. 

Over the next several months, changes in the rate of collagen production 

and degradation occur. Normal healing results in normal types 

and amounts of collagen in the area. On the surface, normal healing is 

illustrated by the fading of redness and softening of the scar. 

I usually tell patients that it will take at least 1 year for the scar to 

achieve its final appearance. Scars in children may continue to change 

and improve for several years. 

137


AAbbnnoorrmmaall SSccaarrrriinngg 

For various reasons, such as genetics, nature of initial injury, or bad 

luck, some scars become exceptionally red, thick, and tight. Such scars 

can be problematic on the hand or other flexor surfaces, because they 

may lead to limitation of movement and loss of function. 

Hypertrophic scars are a bit thicker and redder than the fine scar that 

usually results after primary healing. At the extreme, scars may 

become keloids—that is, they may enlarge beyond their initial area. 

Keloids can become large and unsightly. They also can cause annoying 

symptoms, such as itching and pain. 

Typical hypertrophic scar. Note that the scar is thick and raised but still within 

the confines of a normal scar. 

In addition, the scar may be unstable. An unstable scar is easily reinjured 

with minimal trauma; it heals but is easily injured again. This 

cycle can go on for years and ultimately result in the development of 

an aggressive form of skin cancer. 

Abnormal scarring is usually the result of abnormal collagen production 

and degradation. Although we do not know the exact cause of 

these abnormal processes, the manner in which a wound is closed may 

play a role. In addition, there are interventions that can improve an abnormal 

scar.

MMeetthhoodd ooff WWoouunndd CClloossuurree 

Primary Wound Closure 

Scar Formation 139 

Usually, the best (i.e., least noticeable) scar results when a wound is 

closed by suturing the skin edges together. Usually the sutures are removed 

before the 14th day after repair. As explained above, at this point 

the scar is not very strong; in fact, it has < 15% of its final strength. 

Normal everyday movements will pull on the scar and may result in 

widening of the scar. 

For this reason, most plastic surgeons place buried dermal sutures as 

well as the usual skin sutures when they close a wound (see figure 

below). Buried dermal sutures are not difficult to place, but this extra 

step is time-consuming. The dermal sutures add strength to the repair 

site during the weeks to months required for their absorption. The 

anticipated result is less widening and an improved appearance of 

the scar. 

Buried dermal sutures are used to hold together the skin edges and thereby decrease 

tension on the external sutures. In theory, placement of a few buried 

dermal sutures decreases the risk for hypertrophic scarring and keloid formation. 

When dermal sutures are not used, be sure that the skin sutures provide 

good dermis-to-dermis approximation. It also is important to 

remove the sutures at the appropriate time (see chapter 1, “Suturing: 

The Basics”). Sutures that are left in place too long cause an inflammatory 

response that worsens scar appearance. 

If Steristrips are available, put them across the suture line when the sutures 

are removed. This simple step gives the scar a bit of extra strength 

during the period when it is vulnerable to injury. 

Secondary Wound Closure 

Wounds that are allowed to heal secondarily often have larger, more 

noticeable scars than ones closed primarily. Secondary wound closure


also is associated with a higher incidence of hypertrophic scarring and 

keloid formation. 

HHooww tthhee PPaattiieenntt CCaann HHeellpp 

Once the sutures have been removed and the wound looks well healed, 

rubbing or gently massaging the scar with a mild moisturizing cream 

(e.g., Vaseline, aloe, cocoa butter) a few times each day promotes softening 

and lightening of scar tissue, especially on the face and hands. A cream 

with vitamin E may be helpful. Patients should not spend a large sum of 

money on fancy creams because no conclusive evidence indicates that expensive 

formulations improve the scar’s final appearance. Gentle massage 

should be continued for at least 4–6 weeks. 

Patients should stay out of the sun as much as possible, and always use 

a sunscreen (SPF > 20). Scars exposed to the sun (especially if sunburn 

dvelops) not only stay red longer but also may not fade as much as 

normally expected. 

All patients should maintain good nutrition, and diabetics should 

maintain good glucose control. 

Providers must counsel patients aggressively about the ill effects of 

tobacco products on wound healing. Some of the components in cigarettes 

cause a decrease in blood circulation to the skin, which results in 

poor wound healing and may even lead to tissue loss. Dramatic adverse 

reactions due to the effects of smoking have been reported. 

IInntteerrvveennttiioonnss ffoorr PPrroobblleemmaattiicc SSccaarrss 

Scars that are Too Tight 

These treatments can be tried individually or in some combination. 

Gentle Massage 

Instruct the patient in the massage techniques described above. 

Silicone Gel Sheets 

Once the sutures have been removed and the wound looks well 

healed, you can cover the wound with silicone gel sheets. Although it 

is not entirely understood how they work, silicone gel sheets can be 

quite effective. They can be obtained from pharmacies but usually require 

a prescription (although this policy is changing in the United 

States).


How to use the silicone gel sheet 

1. Cut a piece large enough to cover the scar completely. 

2. The sheet should be left in place as long as tolerated—even all day. 

The longer it is in place, the better. 

3. The patient should remove the sheet to wash. Deodorant soaps 

should not be used to cleanse the area; they may cause a rash. One 

piece of gel sheet can be used repeatedly. 

4. Sheets should be used for at least 2–3 months to make an appreciable 

difference. 

Splinting 

The purpose of splinting is to prevent loss of function and restriction of 

movement from a tight scar. Especially on the hand and in a crease, 

splinting can be quite useful. The splint should be molded so that it 

stretches the tight scar. 

Case example: If a tight scar across the front of elbow prevents the patient 

from fully extending the forearm, the following steps may help: 

• Make a splint that holds the elbow in as much extension as tolerated. 

Gradually the scar will become less tight because of the remodeling 

due to splinting and scar massage (remember, you can add other 

“scar is too tight” treatments). With time the patient will be able to 

extend the elbow more fully. 

• The splint can be made out of simple plaster of Paris (see chapter 28, 

“Hand Splinting and General Aftercare”). 

• If the splint interferes with the patient’s ability to work, encourage 

the patient to wear it at night. 

• New splints should be made as the patient can more fully extend at 

the elbow. 

• This process may take many months, but is worth the effort to improve 

function. 

Pressure Garments 

Pressure garments, measured and fitted to the individual patient, can 

be worn under everyday clothing. They are designed to apply continuous 

pressure over the area of concern. Theoretically, the pressure causes 

the underlying scar to become ischemic and thus leads to remodeling. 

Pressure garments should be worn 18–24 hours/day for a minimum of 

4–6 months. Medical supply stores and pharmacies can order pressure 

garments, which are expensive. Prescriptions usually are required.


Reassurance and Reminders 

Scars that are Too Red 

Reassure the patient that scars will fade on their own, but the process 

takes time. Remind the patient to avoid sun exposure whenever possible 

and to use sunscreen when exposure cannot be avoided. Ultraviolet 

light injures normal skin as well as scars. A sunburned scar may not 

fade as well as normally expected. 

Make-up 

Once the sutures have been removed and the wound looks well healed, 

the patient can apply gentle make-up until the scar fades on its own. It 

is best to use make-up with a sunscreen to prevent sun injury. Make-up 

alone does not protect the tissues from the ill effects of the sun. 

Keloids and Hypertrophic Scars 

Try the treatments described under “Scars that are Too Tight.” Massage, 

silicone gel sheets, splinting, and pressure garments may help. In addition, 

the treatments listed below may be useful. Each can be tried individually, 

but often they work better in combination with another 

method. For example, inject the keloid with steroids and use a pressure 

garment daily. Or excise the keloid, close the wound meticulously, and 

then use silicone gel sheeting after the sutures have been removed. 

Steroid Injection 

Inject triamcinolone acetonide into the dermis of the keloid—approximately 

1 mg for every 1–2 cm of scar. It is best to use a tuberculin syringe 

because you are working with small amounts of medication. Be 

sure to check the mg/ml of the solution (different bottles may have different 

drug concentrations). The total amount of injected triamcinolone 

should not exceed 30 mg. 

Caution: Steroid injection hurts. You can add 0.5–1.0 ml of lidocaine to 

the steroid solution. 

It takes several weeks to see any noticeable change in the scar. Steroid 

injection can be repeated after 4–6 weeks, but I do not recommend injecting 

the same area more than 2 or 3 times. The response to steroid injection 

is quite variable. The reported percentages of patients obtaining 

some improvement (not necessarily resolution of the scar) after steroid 

use range from 50% to 100%. 

The patient should be warned of the risks associated with the injection 

of steroids. Infection may develop at the injection site, and the injected


area may become lighter in color than the surrounding skin. Be especially 

careful in treating diabetic patients. Steroids may cause an elevation 

of blood glucose level. 

Pressure Earrings 

Some patients develop keloids after ear piercing. Earrings designed to 

apply pressure to the earlobe are commercially available. They work 

best on small keloids (< 1 cm). Pressure earrings are especially useful 

when combined with excision of the keloid. Once the excision sutures 

have been removed, the patient should wear the earring for at least 2 

or 3 months (longer is better). This approach may prevent recurrence 

of the keloid. 

Excision 

Caution: Excision of a keloid often results in formation of another 

keloid. The recurrence rate after excision ranges from 45% to 100%. 

At times, however, it is worthwhile to excise the bothersome keloid. For 

example, patients with a keloid associated with ear piercing may have a 

successful outcome if, as previously described, after excision they wear a 

compression earring regularly. Another example when excision may be 

successful is if the initial injury was not closed with sutures (i.e., it was 

allowed to heal secondarily). In this case, excision of the keloid followed 

by primary skin closure may be helpful. Even under these more favorable 

circumstances, you must warn patients that the keloid may recur. 

If you excise the keloid, a close dermal approximation of the skin edges 

is especially important. Close approximation requires placement of 

buried dermal sutures prior to skin closure. Therefore, excision of a 

keloid and primary closure should be undertaken only by clinicians 

with excellent suturing skills. 

Radiation Therapy 

If radiation therapy facilities are available, low-dose therapy helps to 

prevent the development of a keloid. Usually it is performed only on 

patients known to develop severe keloids who are scheduled for surgical 

procedures. The radiation is administered as early as the first postoperative 

day. 

As with other treatment methods, the success rate is variable, ranging 

from 10% to 94% in different studies.


Unstable Scars 

When larger wounds or wounds over creases are allowed to heal secondarily, 

the scar may be easily injured and reopen. Although usually 

it heals with local wound care measures, this cycle often repeats itself 

again and again. Excision of the entire scar may be indicated. The resultant 

skin defect requires closure with a more durable skin graft or 

flap (see chapters 12, 13, and 14 on “Skin Grafts,” “Local Flaps,” and 

“Distant Flaps” for details about these techniques). 


Niessen FB, Spauwen PHM, Schalkwijk J, Kon M: On the nature of hypertrophic scars 

and keloids: A review. Plast Reconstr Surg 104:1435–1458, 1999.

Chapter 16 

FACIAL LACERATIONS 

KEY FIGURES: 

Tissue flap Lip anatomy 

Suture bites: face vs. rest of body Soft tissue loss 

The face has several unique properties that dictate the choice of treatment 

after injury. This chapter describes basic principles for the treatment 

of facial wounds as well as treatment recommendations for 

injuries involving specific areas of the face. 

UUnniiqquuee PPrrooppeerrttiieess ooff FFaacciiaall LLaacceerraattiioonnss 

Cosmetic Concerns 

Although most people do not want an unsightly scar anywhere on the 

body, they are especially concerned about scars on their face. Thus, primary 

closure, which usually results in the least noticeable scar, is the 

preferred treatment for most facial lacerations. Fortunately, because of 

the laxity of facial skin, most wounds can be repaired primarily unless 

they have significant tissue loss or tissue swelling. 

Better Blood Supply and Circulation 

The skin of the face has a more abundant blood supply compared with 

other areas of the body. As a result, lacerations on the face can be closed 

more than 6 hours after injury (the usual time limit for closure of an 

acute laceration) without a high risk for subsequent wound infection. 

As long as the wound can be cleansed thoroughly, facial lacerations 

often can be closed even the day after injury. 

Because of the better blood supply, a wound that is closed primarily 

can tolerate more tension on the suture line than is usually allowed. 

But do not take this principle to an extreme. If there is significant 

blanching of the skin with the closure, you may not want to close the 

wound completely. In this instance, merely place a few sutures to close 

the wound partially and thus decrease the size of the scar. 

145


IInniittiiaall CCaarree 

The initial care of a facial wound is the same as the care applied to any 

wound. As explained in chapter 6, “Evaluation of an Acute Wound,” 

the wound needs to be cleansed fully and examined thoroughly. All 

foreign material, blood, and necrotic tissue should be removed. Debridement 

of skin edges should be kept to a minimum, unless the tissue is 

obviously dead. Because of the excellent blood supply of the face, 

tissue that seems ischemic often survives. 

Paint the injured area with an antibacterial solution before closing the 

wound. Be careful: some solutions can cause injury to the eyes. Ten 

percent povidone iodine solution is commonly available and will not 

injure the eyes. It also can be used safely on oral mucosa. 

AAnneesstthheessiiaa 

A more thorough description of the administration of local anesthetics 

is found in chapter 3, “Local Anesthesia.” Below is a brief overview. 

Agents 

Lidocaine with epinephrine is the best choice of anesthetic with one 

exception: when a flap is raised by the injury. In this case, it is best to 

use plain lidocaine in order not to diminish circulation to the flap. 

Tissue flap in patient who fell through a 

glass window. A, Irregular forehead laceration. 

B, The skin is separated from the 

deep tissue layers of the forehead, creating 

a skin flap with marginal blood supply. 

Do not add epinephrine to the anesthetic 

solution; it will decrease circulation to the 

flap and may cause the tissue to die. C, 

One month after repair. All of the skin has 

survived and is healing without complication.

Facial Lacerations 147 

Bupivacaine is also acceptable. Add bicarbonate to decrease the pain of 

injection. 

Administration of Local Anesthetic 

For smaller lacerations (a few centimeters or less), it is often easiest to 

inject the anesthetic along the wound edges. 

For larger lacerations or lacerations around the edge of the lip (where 

local injection can distort landmarks), a nerve block is usually more 

effective. 

Nerve Blocks on the Face 

Mental nerve block: lower lip, skin below the lip. 

Infraorbital nerve block: upper lip, lateral nose, lower eyelid, medial 

cheek. 

Supraorbital/supratrochlear nerve block: forehead. 

Suture Choice 

Nylon is the suture material of choice to close a skin wound on the 

face. 

Chromic or other absorbable material should be used for mucosal 

lacerations. 

If you believe that the patient will not return for suture removal or if 

the patient is a child in whom suture removal is likely to be quite difficult, 

chromic (absorbable material of choice) sutures can be used on 

facial skin. 

The appropriate size of the suture is discussed in the sections describing 

specific injuries. 

Suture Placement 

Sutures on the face should be placed a little closer together than usually 

recommended because of cosmetic concerns. The sutures should 

be placed 1–2 mm from the skin edge and 3 mm apart to achieve better 

tissue approximation. Exceptions are noted in specific descriptions 

below. 

If you have access to magnifying glasses, use them. They help to 

achieve better tissue alignment because the magnification allows more 

accurate placement of the sutures. 

Most facial lacerations can be closed in one layer. Exceptions will be 

noted.


Suture bites: face vs. rest of the body. Sutures placed on the face should be 

approximately 1–2 mm from the skin edge and approximately 3 mm apart. This 

technique requires the use of small suture material. 

Continuous vs. Interrupted Closure 

A laceration in which skin edges can be aligned easily and without tension 

can be closed with either technique. 

Irregular lacerations or lacerations in which you are concerned about 

the potential for infection should be closed in an interrupted fashion 

for the following reasons: 

1. If, a few days after wound closure, a localized area starts to look infected, 

you can treat the infection without having to open the entire 

wound. Just remove a few sutures in the area that looks red, open the 

skin, and wash the wound with saline. This will allow the wound to 

drain and may allow the infection to resolve while keeping the resultant 

scar relatively small. The patient also should be given antibiotics. 

2. If the wound had been closed by placing the sutures in a continuous 

fashion, partial removal of the suture is not possible. If the wound 

looks infected, the entire suture will need to be removed and thus 

the entire wound will reopen. This results in a much larger scar.

Suture Removal 


Sutures should be removed after 5–7 days to minimize scarring. 

Postrepair Instructions 

1. After the wound edges are sutured together, apply a small amount 

of antibiotic ointment over the suture line. Cover with a dry gauze. 

The dressing can be removed on the following day. 

2. The area should be cleansed once or twice daily with gentle soap 

and water. The patient can shower and wash the face as usual on the 

day after the repair. 

3. After cleansing, a small amount of antibiotic ointment or a petrolatum 

type ointment should be applied over the suture line. If the patient 

desires, dry gauze can be used to cover the area, although it 

usually is not necessary unless the patient is in a dirty environment. 

4. Facial injuries cause the tissues to swell. Be sure to warn your patient 

that the face will be swollen for several days after injury. To 

minimize swelling, instruct the patient to keep the head elevated at 

all times. When reclining, an extra pillow (or folded sheet) should 

be placed under the head. 

5. The patient also should avoid bending and heavy lifting for several 

days after the injury because such activities promote facial swelling. 

SSppeecciiffiicc WWoouunnddss 

Lip Lacerations 

The vermilion border is the edge of the lip where the red part of the lip 

ends and the white skin begins. It is vital to realign the vermilion 

border meticulously to prevent a noticeable notched irregularity. 

The red part of the lip is the mucosal surface, which can be divided 

into two parts. The part of the lip that you see when the lips are barely 

separated is called the dry mucosa because it feels dry to touch. The 

mucosal surface that lies against the teeth and appears and feels wet is 

called the wet mucosa. These distinctions are important. Try to align 

the border between these two surfaces to prevent a relatively subtle, 

but noticeable irregularity. 

To make it easier to see the various “borders,” it is best to use a nerve 

block for repair of lip lacerations. If you are unable to do this, inject the 

local anesthetic a few millimeters away from the wound edge and wait 

longer than usual (5–10 min) for the swelling from the injection to resolve.


Mucosal Lacerations 

Important anatomic landmarks of the lip. 

• The key to successful repair is to realign the wet-dry mucosal border, 

as explained above. 

• Place the first stitch at the border between the wet and dry surfaces. 

• Use absorbable sutures, 4-0, and try to sew the wet mucosa to wet 

mucosa and the dry mucosa to dry mucosa. 

• It is important to evert the edges; use mattress sutures if necessary. 

• Tie at least 4 or 5 knots in the sutures to prevent the sutures from 

coming undone because the patient unconsciously pulls at them with 

the tongue. 

Partial-thickness Lacerations that Cross the Vermilion Border 

• The key to successful repair is to approximate the vermilion border 

as well as possible. 

• Align the red/white margin first. Place the initial suture just above 

the vermilion border in the white upper lip skin. Use a 5-0 or 6-0 

suture. 

• If the stitch does not seem to be well-placed, remove it and try again. 

• Place the remaining sutures in the lip skin (5-0 or 6-0) and lip mucosa 

(4-0 or 5-0). Be sure to evert the skin edges. 

Full-thickness Lacerations 

In full-thickness lip lacerations, the outer skin, lip muscle, and mucosa 

have all been cut. Full-thickness lip lacerations often look scary. 

Because muscle retracts when cut, the lip wound looks larger and more 

complex than it is. Most of these wounds can be repaired easily. 

Primary repair is possible even if approximately one-fourth of the 

upper or lower lip is lost. Repair includes the following steps:


1. It often helps to place a gauze pad between the gums and lip to collect 

blood or other fluids. 

2. If bleeding is significant: injection of lidocaine with epinephrine 

usually controls bleeding from the lip surface. However, if the 

bleeding is coming from a cut artery, you may need to place a stitch 

in the artery. Use a 4-0 absorbable suture, and place a simple or 

figure-of-eight suture at the site of bleeding. When you tie the 

suture, the bleeding should stop. 

3. Repair the mucosa: repair the inner aspect of the lip first, as described 

above under “Mucosal Lacerations.” Use an absorbable 4-0 

suture, and try to evert the edges. 

4. Irrigate the wound with saline again after the mucosa is closed to 

cleanse the wound. 

5. Repair the muscle: use an absorbable suture, 3-0 or 4-0, and place 

one or two figure-of-eight sutures in the muscle. If you look carefully 

at the wound edges, the muscle and musosa have a different 

appearance and texture. Take care not to catch any mucosa in the 

stitches; if you do, you will cause a pucker in the mucosa. 

6. Repair the skin: as well as possible, align the vermilion border as described 

above. Remember to tie 4 or 5 knots in the lip sutures, which 

often come undone because the patient unconsciously pulls at them. 

Intraoral Mucosal Lacerations 

Lacerations may occur inside the mouth. When they occur along the 

inside of the cheek, you must be careful to avoid injury to the opening of 

the parotid duct (through which the secretions of the parotid gland enter 

the mouth) during the repair. The opening of the duct into the mouth is 

a small, raised mound of mucosa inside the cheek across from the 

upper second molar. You do not want to accidentally place a suture 

across this structure. 

• Use absorbable sutures, 4-0 or 3-0. 

•Donot take big bites of tissue. Go about 2–3 mm from the edge of the 

wound and include only the mucosa in your suture. Do not include 

muscle or other underlying tissues. 

• Be sure to evert the edges. 

• You do not need to place the sutures close together. Usually only a 

few are needed (0.5–0.7 cm apart) to approximate the edges.


Tongue Lacerations 

• Use lidocaine with epinephrine to control bleeding. 

• Because the tongue is a muscle, the edges retract when it is cut, 

making the wound appear more complicated than it is. 

• If you can, place an absorbable 3-0 suture in a figure-of-eight fashion 

in the inner muscle. If you cannot place this stitch, take deeper than 

usual bites when repairing the tongue edges. Use 3-0 or 4-0 absorbable 

sutures. 

• Take larger bites, 4–5 mm from the edge, and include the underlying 

muscle to control bleeding. 

Full-thickness Cheek Lacerations 

A full-thickness cheek laceration implies that the cheek skin, underlying 

subcutaneous tissue/muscle, and intraoral mucosa have been injured. 

Such wounds must be repaired in layers. 

Intraoral Mucosa 

• The intraoral mucosa should be repaired first, using the previously 

described technique. 

• When the mucosa is closed, it separates the oral cavity from the outer 

wound. 

• To decrease contamination by oral flora, the wound again should be 

irrigated with saline once the opening into the mouth is repaired. 

Paint the area with an antibacterial solution. 

Skin and Subcutaneous Tissue/Muscle 

• Skin and subcutaneous layers often can be brought together simply 

by repairing the skin. Use 5-0 nylon sutures for skin closure. 

• If bringing the skin edges together does not allow the subcutaneous 

tissue to fill in the wound, place one or two (depending on the size of 

the wound) 4-0 absorbable simple sutures to approximate the muscle 

or subcutaneous tissue. 

• Do not place too many sutures, or you risk injury to the facial nerve 

or other deep structures. 

Full-thickness Nasal Lacerations 

A full-thickness nasal laceration includes injury to the external skin, 

cartilage, and nasal mucosa.

Skin 


• It is best to use plain lidocaine on the skin of the nose. 

• Small, 5-0 nonabsorbable sutures are preferable, placed a few millimeters 

from the edges. 

• Try to align the alar rim (the edge of the nostril) as well as possible to 

prevent notching. This goal is often problematic if the laceration 

completely tears the alar rim. 

Cartilage 

The cartilage usually is brought to an acceptable position when the 

skin laceration is repaired. Placement of sutures directly in the cartilage 

is not usually recommended. 

Nasal Mucosa 

• Primary repair of nasal mucosa can be challenging because you are 

working in a small, dark space; nevertheless, it is important to try. If 

the nasal mucosa is not properly repaired, the result may be a tight 

scar inside the nose, which can obstruct nasal breathing. 

• To control bleeding from the mucosa, use lidocaine with epinephrine 

for local anesthesia. 

• Use small, absorbable 5-0 chromic sutures. You do not need many. 

• Once the repair is complete, loosely pack the affected nostril with 

gauze coated with antibiotic ointment. Leave the gauze in place for a 

few days to encourage healing with less scar contracture. The patient 

should take an oral antibiotic (e.g., cephalosporin) as long as the 

packing is in place. 

Eyelid Lacerations 

Caution is mandatory when an antibiotic ointment is used around the 

eye. Use only an ophthalmic ointment because regular antibiotic ointment 

can cause conjunctivitis. 

Eyelid Skin Alone 

The eyelid skin should be repaired loosely with simple sutures. Use 5-0 

or 6-0 sutures, absorbable or nonabsorbable. If you use nonabsorbable 

sutures, remove them in 3–4 days.


Full-thickness Injuries 

In full-thickness eyelid lacerations, skin, muscle, usually tarsal plate, 

and underlying conjunctiva are cut. The conjunctiva does not usually 

need to be closed as a separate layer. It will heal if the overlying tissues 

are well aligned. Use the following procedure: 

1. Start by placing a small suture (5-0 or 6-0 is best) to reapproximate the 

gray line (where the eyelid meets the conjunctiva, i.e., the lash margin). 

2. Keep the knot away from the eyeball because irritation or potentially 

an ulceration may result if the knot rubs on the conjunctiva or cornea. 

3. Use absorbable 5-0 sutures to reapproximate the tarsal plate and orbicularis 

muscle in one layer. 

4. Close the skin as described above. 

Tearduct Injuries 

An injury to the tearduct should be considered in full-thickness eyelid 

lacerations within 6–8 mm of the medial canthus (where the upper and 

lower eyelids meet near the side of the nose). If tearduct probes and stents 

are available, the duct should be probed and possibly stented. Probing a 

tearduct is quite difficult and requires special technical expertise and 

training. Do not attempt to probe a tearduct if you have not done it before. 

Injuries with Tissue Loss 

Primary closure of the eyelid can be done even with up to 25% fullthickness 

tissue loss. More than 25% full-thickness tissue loss requires 

more complicated flaps. 

Partial-thickness loss (i.e., skin loss with underlying muscle and conjunctiva 

intact or repairable) can be covered with a full-thickness skin 

graft. In the medial canthal area, a defect smaller than 1 cm often can 

be allowed to heal by secondary intention. 

The full-thickness skin graft can be taken from the other upper eyelid, 

if the patient has redundant upper eyelid skin. See more details in 

chapter 12, “Skin Grafts.” 

Eyebrow Lacerations 

A laceration that involves the eyebrow should be reapproximated to 

recreate the natural curve of the eyebrow as well as possible. Leave the 

suture ends long so that you can easily distinguish them from the 

eyebrow hairs. 

One caveat: do not shave the eyebrow. The hair may not grow back 

normally.

Full-thickness Forehead Lacerations 


A full-thickness forehead laceration involves skin and underlying 

muscle. The bone of the skull is usually exposed. Such wounds must 

be repaired in layers to prevent a significant contour irregularity. 

Frontal Sinus Fractures 

The paired frontal sinuses are found at the center of the forehead, just 

above the bridge of the nose. If you can see a fracture of the anterior wall 

of the frontal sinus, the patient must have a computed tomography (CT) 

scan of the head to evaluate injury to the posterior wall of the frontal 

sinus and brain. If such injuries are present, a neurosurgeon is needed. 

If the anterior wall is depressed, try to bring the bones outward to the 

appropriate position before closing the wound. Optimally, the bones 

should be immobilized with tiny plates and screws. This procedure requires 

a specialist and may be done at a later date. The following sections 

describe only soft tissue repair. 

Frontalis Muscle with Overlying Fascia 

The muscle and fascia should be brought together with a few simple or 

figure-of-eight, 3-0 or 4-0 absorbable sutures. 

Skin 

Repair the skin with 5-0 simple sutures. 

Full-thickness Scalp Lacerations 

Full-thickness scalp lacerations can be quite serious. Because of the 

abundant blood supply to the scalp, patients can lose a significant, 

even life-threatening amount of blood. It is acceptable to shave the surrounding 

hair to allow thorough examination of the wound. The hair 

will grow back. 

Layers of the Scalp 

Classically, the scalp is described as having five layers. From outside to 

inside, they can be remembered with the mnemonic SCALP: 

S = Skin 

C = subCutaneous tissue 

A = galea Aponeurosis (essentially the muscle layer) 

L= Loose connective tissue 

P = Periosteum (also called pericranium), which overlies the bone


For practical purposes, in patients with a full-thickness scalp laceration 

(i.e., all layers of the scalp are divided and the skull is exposed), you 

must close the galea and the skin. 

Closing the galea layer often controls the brisk bleeding associated 

with scalp wounds. If a wound infection develops at the site of injury, 

closure of the galea layer also prevents the infection from spreading 

under the entire scalp. Once infection reaches the loose connective 

tissue plain (deep to the galea), it can spread widely. Closure of the 

galea prevents this potentially serious complication. 

How to Control Bleeding as Well as Close the Wound 

1. Lidocaine with epinephrine should be used whenever possible for 

local anesthesia. 

2. Suture together the galea layer with 3-0 or 4-0 Vicryl or chromic sutures. 

They can be placed in a simple fashion or in a figure-of-eight 

fashion. 

3. Close the skin with a continuous locking suture of 3-0 nylon or 

Vicryl. The skin stapler (if available) is a useful, fast technique for 

scalp closure. 

Full-thickness External Ear Lacerations 

Posterior Side of the Ear 

Use 4-0 or 5-0 absorbable sutures. It is best to place them in an interrupted 

fashion. 

Cartilage 

1. If the cartilage is highly irregular, gently trim the edges to smooth it 

out. 

2. Be sure to cleanse the wound meticulously when the cartilage is involved. 

All foreign material must be removed. If dirt is embedded 

in the cartilage, the cartilage should be trimmed to remove the dirt 

particles. 

3. No sutures need to be placed in the cartilage. When placing sutures 

in the skin, try to include the perichondrium (the thin layer of loose 

tissue overlying the cartilage). In this way, the cartilage edges are 

brought together as the skin is repaired.

Anterior Side of the Ear 


Use 4-0 or 5-0 nonabsorbable sutures placed in an interrupted fashion. 

Absorbable sutures also may be used. 

How to Prevent Hematoma Formation 

A particularly concerning complication associated with ear lacerations 

is the development of a hematoma. If blood collects and pressure 

builds up between the skin and cartilage, the result may be a noticeable 

ear deformity, so-called cauliflower ear. A properly placed dressing 

helps to prevent this complication. You should see the patient on 

the next day, if possible, to check for a hematoma. 

Dressing 

1. Add antibiotic ointment to a piece of gauze, and place it over the 

repair site. Gently press it onto the external ear to conform to the 

shape of the ear. 

2. Open and fluff up several dry gauze pads, and place them around 

the ear, filling the contours of the ear with gauze. Make sure to place 

some gauze behind the ear as well. 

3. Gently wrap the head and ear with gauze wrap and a light Ace 

wrap. Do not make the wrap tight. Try to leave it in place for 24–48 

hours. 

What to Do if a Hematoma Develops 

If the patient returns (usually within the first few days after injury) 

with pain and swelling of the ear, a hematoma may be present. The 

ear looks purplish, and the swelling demonstrates some “give” when 

you push on it. Blood may ooze out of the suture line, and the ear may 

be slightly warm. If a hematoma develops, follow the procedure outlined 

below: 

1. The sutures should be removed and the blood drained. 

2. The wound should be thoroughly washed and then closed loosely. 

3. Use fewer sutures than you used the first time. 

4. Apply a dressing similar to the original one. 

5. An oral antibiotic, taken for 24 hours, may be a useful precaution.


Summary of the Optimal Suture Material for Specific Facial Wounds 

Optimal Optimal Suture Material 

Site of Injury Suture Size* (Good Alternate Choice) 

Cheek, forehead, or nose 5-0,6-0 Nylon, Prolene † (chromic for chilskin 

dren or patients who cannot 

return for suture removal) 

Ear skin 4-0 Nylon (chromic) 

External tongue mucosa 4-0 Chromic (Vicryl/Dexon) ‡ 

Eyelid skin 5-0, 6-0 Nylon (chromic) 

Frontalis (forehead) muscle 3-0, 4-0 Polydioxanone (Vicryl/Dexon, 

chromic) 

Galea (scalp) 3-0, 4-0 Polydioxanone (Vicryl/Dexon, 

chromic) 

Lip or intraoral mucosa 4-0 Chromic (Vicryl/Dexon) 

Lip muscle 4-0 Vicryl/Dexon (chromic, polydioxanone) 

Lip skin 5-0, 6-0 Nylon (chromic) 

Nasal mucosa 5-0 Chromic 

Scalp skin 3-0, 4-0 Nylon (staples, chromic) 

Subcutaneous tissue 4-0, 5-0 Vicryl/Dexon (chromic) 

Tongue muscle 3-0 Vicryl/Dexon (chromic, polydioxanone) 

* If you have a choice, these sizes are recommended. 

† Prolene can be substituted whenever nylon is recommended. 

‡ Vicryl is a polyglactic acid; Dexon is a polyglycolic acid. They are essentially interchangeable. 

Facial Lacerations with Soft Tissue Loss 

If the laceration is relatively small (< 1 cm), it often may be left alone 

and allowed to heal secondarily, especially if it is located in the medial 

canthal area, the skin around the upper and lower lip, or the lateral aspects 

of the bridge of the nose. 

Larger wounds (even a few cm in size) involving the lateral cheek area 

(in front of the ear but not near the lower eyelid) and the forehead also 

may be allowed to heal secondarily with good results. 

Be careful around the cheek near the lower eyelid. Allowing a skin defect 

to heal secondarily in this area may result in a pulling down of the lower 

eyelid (called an ectropion). This serious complication may result in 

injury to the cornea. To prevent an ectropion, a full-thickness skin graft 

or local flap should be used for soft tissue loss near the lower eyelid. 

A local flap or full-thickness skin graft also may be required for other 

larger face wounds or wounds involving the nasal tip. See chapter 12, 

“Skin Grafts,” and chapter 13, “Local Flaps,”for details. Significant soft 

tissue loss of the lip or eyelid (> 25%) requires the help of a specialist.



Soft tissue loss. A, Dog bite to the upper lip resulting in soft tissue loss. The 

wound was allowed to heal secondarily. B, One year after injury. the lip has a 

nice contour with minimal scarring. 

Goldwyn RM, Rueckert F: The value of healing by secondary intention for sizable defects 

of the face. Arch Surg 112: 285, 1977.

Chapter 17 

PRESSURE SORES 

KEY FIGURES: 

Pressure sore Trochanteric pressure sore 

Sacral pressure sore Ischial pressure sore 

Pressure sores are chronic wounds caused by prolonged pressure applied 

to a specific area of the body. The involved tissue usually overlies a 

bony prominence. When a pressure sore develops because the patient is 

in the recumbent position for long periods, it is called a decubitus ulcer. 

Pressure sores are often large wounds and may seem difficult to 

manage. However, by combining the wound care knowledge from previous 

chapters with the information given here, you will find these 

wounds more manageable. Often they can be treated successfully with 

debridement of necrotic (dead) tissue and local wound care measures 

alone. The result is a healed wound. 

Only in specific instances is a flap indicated for the treatment of a pressure 

sore. 

Large ischial pressure sore. 

(Photo courtesy of Jeffrey 

Antimarino, M.D.) 

161


CCaauusseess ooff PPrreessssuurree SSoorreess 

The basic problem that leads to the development of a pressure sore is 

application of elevated pressure to soft tissue for too long a time. The 

pressure causes direct injury to the tissues. Unrelieved pressure elevation 

for as little as 2 hours can cause permanent tissue injury and subsequent 

tissue death. 

PPeeooppllee aatt RRiisskk 

Communication between the central nervous system and the body (via 

the peripheral nervous system) allows detection of elevated pressure at 

the tissue level. Feedback mechanisms result in the diminution of pressure 

so that tissue injury does not occur. People who are ambulatory 

and without neurologic abnormalities make regular, subtle position 

changes without conscious effort because of these feedback mechanisms. 

Thus, under normal circumstances, people do not develop a pressure 

sore when they sleep in a recumbent position for several hours. 

Any condition that prevents these subtle position changes or interferes 

with the communication between the central nervous system and peripheral 

nervous system places the person at risk for the development 

of a pressure sore. 

Patient Populations at High Risk 

• Paraplegic or quadriplegic patients, who usually are wheelchair-dependent 

or bedridden and need help in changing positions. They 

also may lack the ability to sense an elevation in tissue pressure 

when they remain in the same position for too long a time. 

• Patients with decreased sensation due to neurologic disorders. For 

example, children with meningomyelocele have diminished sensation 

below the spinal cord abnormality. Thus, the central nervous 

system cannot monitor the pressure in the insensate areas. 

• Patients with impaired mental capacity. Patients with severe dementia 

or patients who have suffered debilitating head injuries are 

often bedridden and move very little when left alone. 

• Seriously ill patients in an intensive care unit. Patients who have 

sustained serious burns or multiple fractures are particularly at risk. 

They are often in considerable pain, which may be exacerbated by 

movement. Thus they tend to stay in one position unless assisted by 

a caregiver. In addition, pain medications keep them drowsy, which 

also inhibits movement.

Additional Risk Factors 

Pressure Sores 163 

• Malnutrition makes the tissues more prone to injury. It also delays 

wound healing. 

• Incontinence can cause the skin in the buttocks and perineal area to 

be chronically moist. The tissues become macerated and more susceptible 

to breakdown with minimal trauma. In addition, contamination 

of an open wound with urine and feces interferes with wound 

healing. 

• Tobacco use. The nicotine in tobacco decreases circulation to tissues, 

thus exacerbating the lack of circulation caused by the effects 

of pressure on the tissues. Tobacco use also contributes to poor 


Table 1. Areas Prone to the Development of Pressure Sores 

Area of Body 

Underlying 

Bony Prominence Comments 

Base of buttocks Ischium Tends to occur in patients confined to 

wheelchair and in seated position for 

much of the time 

Upper outer thigh Greater trochanter Tends to occur in patients who spend 

prolonged periods in bed 

Heel of foot Calcaneus May occur in both of above patient 

populations 

Back of head Occiput of skull Tends to occur in patients who spend 


Lower back Sacrum Tends to occur in patients who spend 


PPrreevveennttiioonn 

For patients at high risk for developing a pressure sore, prevention is 

the key. To avoid the development of pressure sores in bedridden patients, 

encourage the patients (and their caregivers) to change positions 

regularly (at least every 2 hours). Paraplegic patients who spend prolonged 

periods in a wheelchair should lift themselves off their buttocks 

for just a few seconds every 15 minutes. 

Cushioning of pressure points is also important. For example, place 

pillows or cushions between the patient’s knees and ankles to prevent 

pressure in these areas. Have the patient sit on a pillow as well. Special 

pressure-dissipating cushions can be fitted to the patient’s wheelchair. 

Cessation of smoking and maintenance of adequate nutrition are vital 

for prevention. Proper hygiene of the buttocks and perineum is also 

important.


PPrreessssuurree SSoorree SSttaaggiinngg SSyysstteemm 

A staging scale is important for documentation and communication. 

Recognition of a pressure sore in its early stages allows aggressive intervention, 

which may prevent the development of a large, full-thickness 

wound. 

The staging system is based on skin appearance. However, the skin is 

much more resistant to the effects of pressure than the underlying fat 

and muscle. Thus by the time you see significant changes in the skin, 

damage has already occured in the underlying soft tissue fat and 

muscle. You must institute treatment measures quickly. 

Stage I Redness of intact skin that does not blanch (when you press 

on the area the redness does not go away). Earliest stage, 

before start of skin breakdown. 

Stage II Partial-thickness skin loss involving the epidermis and 

dermis. The ulcer is superficial and may look like a blister 

or shallow crater. 

Stage III Full-thickness skin loss involving the underlying subcutaneous 

fat but not the muscle. 

Stage IV Full-thickness skin loss with extensive destruction, tissue 

necrosis, or damage in muscle, bone, or supporting structures 

(e.g., tendon, joint capsule). 

From U.S. Department of Health and Human Services: Pressure Ulcers in Adults: 

Prediction and Prevention. Clinical Practice Guideline No. 3, Publication 97-0047, 1992. 

TTrreeaattmmeenntt 

All Patients in the Process of Developing a Pressure Sore 

1. Reinforce the necessity of regular position changes to patient and 

caregivers. 

2. Institute measures to relieve the pressure in the at-risk area. Pillows, 

foam mattresses, and foam splints are useful. 

3. Proper nutrition is a must. High-protein drinks and puddings are 

useful. Supplemental vitamins and minerals also should be given 

(especially vitamin C and zinc). 

4. Patients should remain active. They should not be placed on bed rest 

or kept from their usual activities. 

5. The patient should refrain from using tobacco products. 

6. The wound should be kept free from urine or fecal contamination. 

Temporary use of a Foley catheter (or intermittent catheterization)


should be considered. A diverting colostomy should be considered 

if persistent fecal contamination is a problem. 

Stage I or II Pressure Sore 

1. Keep the affected tissue clean and the surrounding area dry. 

2. Apply antibiotic ointment (e.g., Bacitracin, silver sulfadiazine) daily 

to areas that have blistered. 

3. DuoDERM (also called Granuflex or Varihesive) is a useful dressing 

alternative for the treatment of a relatively superficial pressure sore. 

Cut it to the proper size (a little larger than the wound), and place it 

directly over the injured tissue. You may need to put tape around 

the edges to keep it in place. DuoDERM promotes healing by providing 

a moist environment for the injured tissue. This dressing 

often may be left in place for up to 7 days, which makes it convenient 

for patients and caregivers. 

Stage III or IV Pressure Sore 

If the wound is covered with a dry, dark, leathery eschar (scab): If the 

wound has no surrounding cellulitis and no drainage, leave it alone. 

This dry eschar is easy to care for. Clean the area with saline or povidone-iodine 

solution daily. You may cover the wound with dry gauze 

if the patient desires. The underlying tissues will gradually heal, and 

the eschar will separate and detach. The eschar should be removed if 

signs of infection (e.g., redness, warmth, fever) are present. 

If the wound has a red, granulating base but is covered with areas of 

gray exudate: Apply wet-dry saline dressing changes at least twice 

daily, if possible. Once the wound is clean, you may change to wet-wet 

dressings, an antibiotic ointment with dry gauze dressings, or other 

topical material. 

If the wound contains foul-smelling, necrotic tissue: Surgical debridement 

(described below) is necessary to remove large amounts of 

dead tissue. Follow with wet-dry dressings, using saline or preferably 

Dakin’s solution to clean the wound and promote healing. 

If the wound is surrounded by cellulitis: Red, warm, and indurated 

skin around the pressure sore indicates an infection in the soft tissues 

(cellulitis). Treat the patient with a course of antibiotics. Ordinarily, a 

pressure sore without signs of surrounding tissue infection does not require 

antibiotics. Use antibiotics only if the wound is infected. 

With the above treatments, most pressure sores heal on their own. 

The key is to institute treatment early, before the wound gets out of 

control. Serial debridement of necrotic tissue and the above treatments


promote gradual healing even of a large pressure sore. Although it may 

take weeks to months for the wound to close completely, this is the optimal 

course of treatment for a pressure sore. On rare occasions, local 

flaps can be used to obtain wound closure (see descriptions below). 

SSuurrggiiccaall IInntteerrvveennttiioonn 

Surgical intervention is required when the wound has so much dead 

tissue that formal debridement is needed to clean the wound. Occasionally, 

the wound can be closed with a local flap. 

Debridement 

Debridement of small, necrotic areas can be performed at the bedside. 

But for large or deep wounds, it is better to do the debridement in the 

controlled environment of the operating room. 

The patient will lose blood when large amounts of dead tissue are cut 

away. Be sure to check the patient’s hemoglobin/hematocrit before debriding 

a large pressure sore. A transfusion may be required. 

Often the patient has no feeling in the area of the pressure sore. 

Sedation (to allay fears and increase comfort on the operating table) 

may be all that is needed. 

Using a scalpel (or a scissors) and forceps, cut away all dead tissue. 

If the tissue bleeds, it is probably healthy; if it does not bleed, it is probably 

dead. 

Dead bone or tendon in the wound must be removed. Place a clamp on 

the tendon, and put the tendon under tension (i.e., pull on the clamp). 

Then cut off all of the exposed tendon. Bone can be removed with a 

bone rongeur or an osteotome. Remove the outer layers of the exposed 

bone until you reach bleeding bone. 

Clean the wound with saline mixed with a small amount of povidoneiodine 

solution if available, and pack the wound with a gauze dressing. 

Leave the dressing in place for 24 hours. Then remove the packing, 

and start regular wet-dry dressings. 

Debridement may be repeated (serial debridement) if, because of concerns 

about blood loss, all necrotic tissue cannot be removed at one 

time. 

Local Flaps 

Closing a pressure sore with a local flap is an advanced treatment that 

requires surgical expertise. A local flap is not indicated for all pressure


sores. Most heal with local care. Unless you are particular about whom 

you operate on, the risk for recurrence of the pressure sore is quite high 

(often over 50%). 

If you perform a flap on a patient who is not a good surgical candidate 

(e.g., a patient who is malnourished, actively smoking, or noncompliant 

with position changes), he or she may end up not only with a recurrent 

pressure sore but also with a poorly healing donor site. 

Indications 

Specific reason for development of the pressure sore. For example, a 

paraplegic patient who has had no previous pressure sores (despite 

being in a wheelchair for 10 years) but develops one when he or she is 

hospitalized for pneumonia and unable to change positions. 

Excellent nutritional status. Albumin > 3.5 gm/dl, prealbumin > 20 

mg/dl, transferrin > 250 mg/dl (2.5 gm/L). If the patient is malnourished, 

the flap will not heal and surgery is pointless. There is also a 

high risk that the donor site will heal poorly. 

The patient must not smoke. 

Highly motivated patients who want to be at home. Some patients 

live alone or have little home support. They may be unable to go 

home because of concerns about wound care. If patients in this situation 

meet the nutritional requirements and show that they are motivated 

enough to change positions regularly, local flap closure may be 

indicated. 

Preoperative Considerations 

Before flap closure, the pressure sore must be debrided thoroughly. It is 

often useful to debride the wound surgically a day or so before the 

planned flap. All necrotic tissue and dead bone must be removed. 

Caution: Debridement of pressure sores and flap closure can lead to 

significant blood loss. The patient’s hematocrit must be above 27 

(hemoglobin at least 8–9), and blood must be available for the operating 

room. 

A closed suction drain should be available to place under the flap to 

prevent fluid accumulation postoperatively. If a closed suction drain is 

not available, a passive drain (Penrose drain or a piece of sterile glove) 

should be placed under the flap. See chapter 13, “Local Flaps,” for additional 

information.


SSaaccrraall PPrreessssuurree SSoorreess 

Buttocks Rotation Flap 

1. Draw the flap before making any incisions. This step allows you to 

make corrections. 

2. Design the flap larger than you think you will need to ensure a tension-free 

closure. 

3. Design the flap so that it extends in a curvilinear fashion superiorly 

(a few cm) and laterally from the wound. It should have a wide base 

(at least 8–10 cm). 

4. Separate the flap from the underlying tissues and transfer it into the 

wound. Undermine the surrounding skin edges as needed to allow 

the flap to be sutured in place without tension. 

5. If necessary, a small back cut can be made at the lateral edge of the 

base of the flap to help it turn into the wound. Do not narrow the 

base more by more than 1–2 cm. 

A, Sacral pressure sore. B, Diagram 

of inferiorly based sacral rotation flap. 

C, Flap rotated and sutured into position.


6. Suture the flap in place over a drain. Place a few dermal sutures, 

and then do an interrupted skin closure. The skin closure should not 

be tight. It is better to have little gaps in the closure, which will heal, 

than to do a tight closure and lose part of the flap. 

TTrroocchhaanntteerriicc PPrreessssuurree SSoorreess 

Tensor Fascia Lata Flap 

The tensor fascia lata (TFL) flap is the most commonly used flap for 

closure of a trochanteric pressure sore. The TFL flap is adjacent to the 

wound and runs anterior to it, along the lateral aspect of the thigh. The 

widest donor defect that can be closed primarily is approximately 6 

cm. Pinch the thigh tissues to see how much skin you should be able to 

remove while still being able to close the donor site primarily. The flap 

is composed of the skin and fascial extension from the TFL muscle. 

A tensor fascia lata flap is the best choice for coverage of a trochanteric pressure 

sore. A, Outline of tensor fascia lata musculocutaneous flap. B, Tensor 

fascia lata flap used to reconstruct trochanteric pressure sore. (From 

Jurkiewicz MJ, et al (eds): Plastic Surgery: Principles and Practice. St. Louis, 

Mosby, 1990, with permission.)




2. The anterior border of the flap is a line drawn from the anterior superior 

iliac spine to the lateral margin of the kneecap. 

3. The posterior border is about 5 cm posterior to the anterior border. 

4. The flap can extend inferiorly to within 10 cm of the kneecap. 

5. The skin is incised, and the incision is taken down through the subcutaneous 

tissue to the underlying thick TFL fascia. The fascia stays 

attached to the flap. 

6. Elevate the flap off the underlying tissues. You will see an obvious 

separation between the undersurface of the TFL fascia and the 

deeper tissues. It is useful to place a stitch in the distalmost part of 

the flap to connect the fascia to the skin so that you do not accidentally 

separate the skin/subcutaneous tissue from the TFL fascia 

during dissection. 

7. The flap is moved into the wound defect and loosely sutured in position. 

Place a few dermal sutures, and then do an interrupted skin 

closure. The skin closure should not be tight. It is better to have little 

gaps in the closure, which will heal, than to do a tight closure and 

lose part of the flap. 

8. The donor site is closed primarily with dermal sutures and interrupted 

skin sutures. A suction drain or a passive drain should be 

placed under the skin closure at the donor site as well as the site of 

the pressure sore. 

IIsscchhiiaall PPrreessssuurree SSoorreess 

Posterior Thigh Flap 

The posterior thigh flap is a V-Y advancement flap. It is quite useful for 

covering large ischial pressure sores (8–10 cm diameter). The pedicle of 

this flap is not a bridge of surrounding skin or subcutaneous tissue. 

The deep tissues underlying the flap supply the circulation. 



2. Mark the V with the widest area at the lower edge of the pressure 

sore, tapering gradually to a point. The V should go at least half way 

down the back of the thigh. 

3. Incise the skin edges going through the subcutaneous tissue down 

to (but not into) the underlying muscle.


Ischial pressure sore. A, B, and C, 

The back of the thigh is advanced as 

a V-Y flap for coverage of the open 

wound. 

4. You should be able to advance the flap superiorly into the wound 

defect. Place a drain at the base of the wound. 

5. Close the narrow part of the V flap defect primarily. This step creates 

the Y limb. 

6. Suture the flap loosely, under no tension. Place a few dermal sutures, 

and then do an interrupted skin closure. The skin closure 

should not be tight. It is better to have little gaps in the closure, 

which will heal, than to do a tight closure and lose part of the flap. 

GGeenneerraall PPoossttooppeerraattiivvee CCaarree ffoorr tthhee AAbboovvee PPrroocceedduurreess 

1. Cleanse and apply antibiotic ointment to the suture lines daily. 

2. If a suction drain was used, it should stay in place until the drainage 

is < 50 ml in 24 hours. Try to keep it in place at least 1 week. If you do 

not have a suction drain, remove the passive drain after 3–4 days.


3. In general, the patient should apply no pressure to the surgical site 

until the suture line has healed (usually 2–3 weeks). The patient 

then should be allowed to place weight over the area for limited periods 

(10–15 minutes 3 or 4 times daily). If the suture line stays intact 

(i.e., it does not start to separate), gradually decrease the restrictions 

on positioning. 

4. Leave the skin sutures in place for at least 14 days unless there are 

signs of irritation from the sutures. 


1. Cervo FA, Cruz AC, Posillico JA: Pressure ulcers: Analysis of guidelines for treatment 

and management. Geriatrics 55(3):55–60, 2000. 

2. Disa JJ, Carlton JM, Goldberg NH: Efficacy of operative cure in pressure sore patients. 


3. Hopkins A, Gooch S, Danks F: A programme for pressure sore prevention and management. 

J Wound Care 7:37–40, 1998.

Chapter 18 

CHRONIC WOUNDS 

KEY FIGURES: 

Open wound Wound covered with skin graft 

Chronic wounds are open wounds that for some reason simply will not 

heal. They may be present for months or even years. Often, especially 

in rural settings, the wounds have not received adequate care. The 

most important component of the overall treatment plan must be to 

identify and treat the underlying cause that interferes with normal 


Begin by taking a thorough history to find out about the patient’s medical 

status as well as information about the events that contributed to 

the development of the wound. Next, thoroughly examine the wound. 

From this information, the underlying cause for the nonhealing wound 

usually can be identified. 

Once the cause is identified and properly treated, the basic principle of 

chronic wound treatment is essentially the same as those of secondary 

wound healing: regular dressing changes. For large wounds, a skin 

graft or flap may be required for final closure. 

This chapter discusses the most common underlying causes (with 

treatments) for a nonhealing wound. In addition, a few specific, problematic 

chronic wounds are described. 

CCoommmmoonn CCaauusseess aanndd TTrreeaattmmeennttss 

Neglected Wound/Poor Wound Care 

Especially in the rural setting, many chronic wounds do not heal 

simply because of inadequate wound care. Without proper care, the 

wound becomes covered with dead (necrotic) tissue. To achieve 

wound closure, all necrotic tissue must be removed (debrided), either 

with wet-to-dry dressings or with surgical debridement. 

173


Surgical Debridement 

When a wound is covered with black, dead tissue or thick gray/green 

exudate, dressings alone may be inadequate. Surgical removal of a significant 

amount of necrotic tissue may allow successful wound closure 

with wet-to-dry dressings. 

Using a forceps, pick up an edge of the dead tissue and cut it off the 

wound with a scalpel or scissors. This procedure usually is not painful 

because the tissue that you are cutting into is already dead. If it hurts, 

you are near healthy tissue. 

Bleeding tissue is a good sign and indicates that you are in an area of 

healthy tissue. Dead tissue does not bleed. 

This procedure can be repeated as often as necessary. You do not have 

to remove all necrotic tissue with one procedure. 

Once the necrotic tissue has been removed, regular dressing changes 

should be started. Wet-to-dry dressings are the most appropriate 

choice. Dressings should be changed at least 2 times daily and optimally 

3 or 4 times (in areas where dressing supplies are plentiful) until 

the wound heals. See chapter 9, “Taking Care of Wounds,” for a detailed 

description of dressing options. 

Foreign Material in the Depths of the Wound 

A foreign body in the depths of a wound may prevent healing. Foreign 

material such as glass, wood, or metal fragments can cause an inflammatory 

reaction in the tissues that will not resolve until the foreign material 

is removed. 

The history often provides information that leads you to suspect that 

foreign materials may be the problem. An x-ray may be useful, but 

many foreign objects do not show up on x-rays. 

Often foreign material is removed with overlying dead tissue during 

surgical debridement, allowing the wound to heal with dressing changes. 

Infection 

If signs of surrounding soft tissue infection (redness, warmth, pain, 

swelling) are present, oral or intravenous antibiotics should be given. 

The presence of an open wound, in and of itself, does not necessitate 

oral or intravenous antibiotic administration. 

Infection of the underlying bone (chronic osteomyelitis) may cause a 

chronic nonhealing wound. An x-ray may show irregularity in the periosteum 

(the thin layer of connective tissue around the bone), and 

signs of bone destruction may be seen.

Chronic Wounds 175 

Infection of the bone often requires at least 6 weeks of antibiotics. In 

addition, orthopedic and reconstructive surgical expertise is usually 

required for successful treatment because bone debridement and coverage 

with a muscle flap may be required for control and resolution of 

the infection—especially when an infection develops after an open 

fracture. 

Tobacco 

Tobacco use interferes with wound healing through a combination of 

two mechanisms: 

1. The vasoconstrictive effects of nicotine decrease local blood circulation 

to the skin. Thus, less blood and oxygen (and other factors that 

promote healing) reach the wound. 

2. The carbon monoxide present in tobacco smoke further decreases 

oxygen delivery to the tissues because carbon monoxide decreases 

the ability of hemoglobin to release oxygen to the tissues. 

All patients should be counseled not to smoke, especially patients with 

open wounds. When the patient stops smoking, the improvement in 

the wound may be dramatic. 

Cancer 

In a long-standing wound that looks clean but still will not heal, the 

wound may be harboring an underlying cancer. Often such wounds 

look a little different from the usual chronic wound. The tissues around 

the wound edges may be raised and highly irregular, and irregular red 

patches may be seen in the surrounding skin. 

The concern about an underlying cancer is especially applicable in 

chronic wounds in elderly patients and on sun-exposed areas of the 

body. 

We tend to expect basal cell or squamous cell skin cancers to be relatively 

small (< 2–3 cm), but, if left untreated, they can grow to be quite large. 

Cancer of the breast and soft tissue sarcomas can erode through the skin 

to create a chronic open wound. Usually, these two types of cancer are 

associated with a large soft tissue mass underlying the wound. 

For such wounds to heal, the entire lesion—i.e., the entire area involved 

with cancer—must be excised. If the wound is small (< 1–2 cm), 

immediate excision is indicated. In larger wounds, an incisional biopsy 

should be done to get a preliminary diagnosis, which helps to plan the 

definitive resection. See chapter 22, “Skin Cancer,” for details.


Malnutrition 

For a wound to heal, the patient’s nutritional status must be sound. An 

adequate diet supplying the proper amount of calories and protein on 

a daily basis is very important. The importance of nutritional factors in 

wound healing is illustrated by the fact that elective surgery often is 

contraindicated in patients without adequate protein stores. 

How to Assess Nutritional Status 

The liver produces various proteins that have been found to correlate 

well with nutritional status. Examples include albumin, prealbumin, 

and transferrin. Although albumin does not correlate with nutritional 

status as well as the other two, measurement of serum albumin is helpful 

if the more expensive tests for prealbumin and transferrin are unavailable. 

Protein Normal Value 

Albumin 3.5–5.0 gm/dl 

Prealbumin 10–40 mg/dl 

Transferrin 200–400 mg/dl 

Vitamin C, vitamin A, iron, and zinc are also important nutrients for 

proper wound healing. In malnourished patients, vitamin/mineral 

supplements may be beneficial. In adequately nourished patients, however, 

extra doses of these nutrients are not necessarily useful. 

As stated below in the discussion of radiation, vitamin E may be useful 

in a wound exposed to radiation. However, high doses of vitamin E interfere 

with normal wound healing in patients without a deficiency. 

Although nutritional supplements may be required in severely malnourished 

patients, nutritional counseling may be all that is needed for 

most patients. Nutritional supplements, such as high protein/calorie 

drinks/puddings, are often quite expensive and unnecessary. See 

chapter 8, “Nutrition,” for more detailed information. 

Diabetes 

An elevated blood glucose level decreases the body’s natural ability to 

heal wounds. For this reason, patients with diabetes must watch their 

diet and regularly check glucose levels. High glucose levels should be 

treated with the appropriate medications (insulin or an oral agent) to 

maintain the best possible blood glucose control.

Medications 


Ask all patients about use of prescription and over-the-counter medications. 

Several classes of medications interfere with wound healing: 

Steroids 

Steroids significantly interfere with normal wound healing. Vitamin A 

may counteract the effects of steroids and promote healing. Try giving 

vitamin A orally (25,000 IU/day) or topically (200,000 IU/8 hours) for 

1–2 weeks, and see if the wound begins to heal. 

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) 

NSAIDs (e.g., aspirin, ibuprofen) interfere with wound healing by decreasing 

collagen production. The precise mechanism is not fully understood. 

If the patient has a chronic wound and is taking NSAIDs, see 

if switching to another type of medication (e.g., acetaminophen) results 

in improved wound healing. 

Radiation Injury 

The patient may give a history of previous radiation therapy to the area 

around the wound. Radiation damages the ability of the tissues to promote 

new blood vessel growth as well as interferes with cellular functions 

necessary for wound healing. These effects are not reversible once 

the radiation exposure has been completed and in fact may worsen with 

time. Because of these effects, a seemingly minor injury in an area that 

previously received radiation may result in a chronic, open wound. 

Vitamin E has been shown to improve wound strength in areas exposed 

to radiation. It may be useful to try a short course (1–2 weeks) of 

oral vitamin E supplementation (100–400 IU/day) to see whether the 

status of the wound improves. 

Often the entire wound may need to be excised to remove the damaged, 

radiated tissue. Especially if no reconstructive specialists are available, 

try local wound care for a few weeks after excision to see whether the 

wound begins to heal. If this treatment is unsuccessful, a split-thickness 

skin graft or, more likely, a flap may be required for wound closure. 

SSppeecciiffiicc PPrroobblleemmaattiicc WWoouunnddss 

Leg Ulcers 

Leg ulcers usually are caused by problems in either the arterial circulation 

or the venous circulation (or sometimes a combination of the two).


Arterial Insufficiency 

Leg ulcers due to blockages in the arterial circulation tend to develop 

over the medial aspect of the ankle. Compare the temperature of the 

patient’s feet: is one foot cooler than the other? Coolness is a sign of inadequate 

arterial blood flow. 

Check for the presence of palpable pulses in the foot and ankle. If you 

cannot feel the dorsalis pedis artery (on the top of the foot) or the posterior 

tibial artery (behind the medial malleolus), the patient probably 

has a problem in the arterial circulation. Even if you cannot feel a pulse 

in the foot vessels, blood flow to the foot may be sufficient to allow a 

properly treated wound to heal. Absence of a pulse, however, does indicate 

that the vessels are significantly diseased. 

There are many high-tech ways to examine the patency of the blood 

vessels of the legs. Some are invasive (e.g., arteriogram, in which dye is 

injected into the vessels and x-rays are taken), and some are not (e.g., 

Doppler studies using sound waves to examine the vessels). A simple 

test to measure blood flow to the foot is as follows: 

1. Measure the systolic blood pressure in the foot and divide this 

number by the systolic blood pressure in the arm (at the brachial 

artery, the usual place to check blood pressure). 

2. The result is the ankle/brachial index (ABI), which compares blood 

flow to the ankle with blood flow through the upper extremity. 

Because the upper extremity is rarely affected by vascular disease, 

the ABI allows you to determine the degree of diminution of blood 

flow to the foot. 

3. An ABI > 0.5 indicates that sufficient blood reaches the foot to allow 


4. An ABI < 0.4 indicates poor blood flow to the foot. Healing probably 

will not occur unless a vascular bypass is done to bring more blood 

into the lower extremity. 

Venous Insufficiency 

Ulcers due to problems with the venous circulation tend to be on the 

lateral side of the ankle or lower calf. Arterial pulses are usually 

normal. Such ulcers can become quite large (10–15-cm wounds are 

common). 

The foot, ankle, or calf around the wound is often chronically swollen, 

and obvious skin changes are present. Skin changes include woody induration 

(the skin feels very hard) and brawny discoloration. Enlarged 

varicose veins are usually present.

Combination Arterial and Venous Insufficiency 


Unfortunately, many patients with leg ulcers do not have purely arterial 

or purely venous problems. Often the disease involves both arteries 

and veins. 

Treatment 

Leg ulcers are often quite difficult to treat. Although we try to avoid 

amputation, sometimes it is the only successful treatment option. 

If the cause is inadequate arterial circulation: 

1. If the ABI is > 0.5, the wound has a high likelihood of healing with 

proper local care (dressings) or a skin graft. 

2. If the ABI is < 0.4, the chance of healing without vascular bypass to 

bring more blood to the area is low. 

3. If no one with vascular surgical expertise is available, it is worth 

trying local wound care to see if the wound improves. If this attempt 

is unsuccessful, amputation may be the only way to obtain a 

closed wound. 

If the cause is venous insufficiency: 

An important component of treatment is to decrease the swelling in the 

foot or calf: 

1. The patient should elevate the affected leg as much as possible. In 

bed the foot should be propped on a pillow. When the patient is 

seated, the foot should be propped on a stool so that it does not 

dangle dependently. 

2. The patient also should wrap the leg with Ace wraps or wear support 

stockings to improve blood flow through the veins and out the 

lower leg. This strategy also helps to decrease leg swelling. 

3. The Ace wraps should start at the toes and gradually go up to the calf. 

Be sure that the wrap is not too tight. It should be tighter at the toe than 

at the ankle and tighter at the ankle than at the calf. If the Ace wrap is 

not properly applied (i.e., if it is tighter at the ankle than the foot), it will 

cause constriction at the ankle and worsen the swelling in the foot. 

4. In patients with arterial and venous problems, take care that the Ace 

wraps and support stockings do not impede arterial circulation. 

Venous ulcers are notoriously difficult to treat. In some patients, especially 

those treated before the tissues of the leg become hard and 

woody, control of swelling and proper wound care allow venous ulcers 

to heal. For large venous ulcers, a split-thickness skin graft may be indicated, 

but there is a high chance that the graft will not work.


If the problem is a combination of arterial and venous insufficiency: 

Each problem must be addressed separately. However, if the arterial 

inflow is poor, no matter how aggressively the venous problems are 

treated, wound healing will not occur. 

Pressure Sores 

A pressure sore is a chronic wound caused by prolonged application of 

pressure to an area of soft tissue. Usually these wounds develop over 

a bony prominence. (See chapter 17, “Pressure Sores,” for detailed 

information.) 

OOvveerrvviieeww ooff TTrreeaattiinngg CChhrroonniicc OOppeenn WWoouunnddss 

The key strategies to promote healing of a chronic open wound can be 

summarized as follows: 

• Remove all dead tissues overlying the wound with either dressings 

or surgical debridement. 

• Remove any foreign material from the wound. 

• Treat with oral or intravenous antibiotics if signs of underlying or 

surrounding infection are present. The presence of an open wound in 

and of itself does not necessitate antibiotic administration. 

• Identify other underlying causes that may prevent wound healing. 

Provide appropriate treatment. 

• Because good nutrition is essential for wound healing, be sure that 

the patient gets enough calories and protein. A multivitamin may be 

helpful, but encourage the patient to eat a nutritious diet. 

• Stop smoking. 

• Adequate local wound care is essential. Dressings should be changed 

at least twice daily (3–4 times is optimal for a dirtier wound), and the 

wound should be cleansed with gentle soap and water or saline with 

each dressing change. Wet-to-dry dressings are often the method of 

choice. Wet-to-wet dressings or antibiotic ointment can be used once 

the wound is clean. 

It may take weeks or even months for a wound to heal in this manner, 

but you should see gradual improvement. It is a good idea to measure 

the dimensions of the wound at each visit to document how the wound 

is progressing. 

Large wounds (> 8–10 cm) may take many months to heal. Once the 

wound is clean and starting to heal, it may be useful to consider covering 

the wound with a split-thickness skin graft or a flap to hasten 

wound healing (see the appropriate chapters for more details).



A, Large (12 × 6 cm) chronic wound on the back of the calf. B, Wound covered 

with a split-thickness skin graft to promote closure. 

1. Nwomeh BC, Yager DR, Cohen IK: Physiology of the chronic wound. Clin Plast Surg 

25:407–414, 998. 

2. Stadelmann WK, Digenis AG, Tobin GR: Impediments to wound healing. Am J Surg 

176(Suppl 2A):39S–47S, 998.

Chapter 19 

SOFT TISSUE INFECTIONS 

Soft tissue infections can be difficult to treat. All health care providers, 

especially those practicing in rural settings, must be able to differentiate 

between infections that need treatment with antibiotics alone and 

infections that require incision and drainage or more radical debridement. 

Serious consequences can result when a severe infection requiring 

operative management is misdiagnosed as a minor infection. 

CCeelllluulliittiiss vvss.. AAbbsscceessss 

Cellulitis is a diffuse infection of the soft tissues with no localized area 

of pus amenable to drainage. The affected area is described as indurated 

(i.e., warm, red, and swollen). It is also painful. A component 

of lymphangitis (infection involving the lymphatics) is indicated by 

red streaking, progressing proximally from the affected area. 

An abscess is a localized collection of pus, often with a component of 

surrounding cellulitis (with the above signs). One sign of an abscess is 

an area of fluctuance; that is, when you apply gentle digital pressure 

over the area, you can push and feel a “give,” indicating the presence of 

fluid underneath. Another sign is that an abscess often seems to “point;” 

that is, the skin starts to thin from the pressure of the fluid underneath. 

The distinction between cellullitis and abscess is important. The main 

treatment for an abscess is incision and drainage (cutting into the abscess 

and widely opening the abscess cavity). Cellulitis does not warrant 

this intervention. 

GGaannggrreennee 

The term gangrene is used to describe tissues that are dead. There are 

two subtypes of gangrene: dry and wet. The distinction is important. 

Dry gangrene describes tissues that are generally black and dried out, 

with a distinct border between dead tissue and surrounding healthy 

tissue. Sometimes dry gangrenous tissues fall off on their own (dry 

gangrenous toes can fall off with minimal manipulation). However, 

183


debridement is usually required, but it is not emergent. Dry gangrene 

usually places the patient at no health risk as long as it does not become 

infected (see below). 

In contrast to dry gangrene, wet gangrene can be a significant health 

risk. It connotes active infection (noted by pain, swelling, redness, and 

drainage of pus) in the tissues surrounding the obviously dead tissue. 

Urgent debridement is required to prevent further tissue loss and 

worsening soft tissue infection. 

NNeeccrroottiizziinngg FFaasscciiiittiiss 

Necrotizing fasciitis is a serious, life-threatening infection of the fascia 

(the thin connective tissue overlying the muscle and under the skin 

and subcutaneous tissue). The popular press calls it the disease of 

“flesh-eating bacteria.” 

Necrotizing fasciitis is not common, but it must be considered in evaluating 

a patient with a soft tissue infection that seems to be progressing 

rapidly to surrounding tissues. This diagnosis should be considered 

when the patient is “sicker” than you would expect for simple cellulitis. 

The skin is swollen but often without many signs of cellulitis. The skin 

simply does not look “right.” You may be able to feel subcutaneous air 

in the soft tissues, or you may see air in the soft tissues on x-ray (no air 

is present in normal soft tissues on x-ray). 

The patient is often quite ill, with high fever, low blood pressure, general 

weakness, or even shock, and the infection spreads quickly. 

Radical debridement and even amputation may be necessary to save 

the patient’s life. 

Treatment requires aggressive operative debridement (opening the soft 

tissue spaces, as with an abscess) to remove affected tissue, intravenous 

antibiotics, close monitoring of the patient, and aggressive treatment of 

septicemia. Hyperbaric oxygen also may be indicated but does not replace 

aggressive operative treatment. Patients with necrotizing fasciitis 

should be treated by a surgeon with critical care expertise. 

EEvvaalluuaattiioonn ooff PPaattiieennttss wwiitthh SSoofftt TTiissssuuee IInnffeeccttiioonn 

History 

Antecedent Trauma 

Ask about traumatic injury to the area before the signs of infection 

developed.

Soft Tissue Infections 185 

Cuts from glass and punctures from metal objects should raise concern 

about the presence of a foreign body in the soft tissues. 

History of an animal bite should raise concern about specific bacterial 

organisms that may require a particular antibiotic (see discussion of 

specific treatments below). 

Medical Issues 

Infections in patients with diabetes are often worse than you expect, 

and more difficult to treat. You must treat these infections aggressively, 

and be sure to control the patient’s blood sugar. 

Ask about the patient’s tetanus immunization status, and give a 

booster as indicated. 

Physical Examination 

The classic signs of infection are redness, warmth, swelling, and pain. 

Look closely for puncture wounds or other signs of trauma. 

Try to distinguish between a localized collection of pus that needs 

drainage and diffuse infection. Check for fluctuance, as previously 

described. 

Determine whether the induration is spreading to surrounding areas. 

Do red streaks extend proximally from the affected area? 

Feel for crepitus (subcutaneous air) in the soft tissues, which is a sign 

of necrotizing fasciitis. Press on the soft tissues. If air is present under 

the skin, it will feel as if you are pressing on crinkled layers of cellophane 

or popping air bubbles beneath the skin. 

Assess the patient for fever, chills, low blood pressure, generalized 

weakness, and malaise. 

Check for enlarged lymph nodes in the surrounding area (groin or 

armpit, as appropriate). 

Determine whether a fluctuant area is present over a pulse point (e.g., 

in the groin over the femoral artery or on the volar aspect of the elbow 

over the brachial artery). 

Additional Studies 

Additional studies for all patients should include a complete blood 

count with a white blood cell count and X-ray evaluation of the infected 

area.


If the infectious process overlies a pulse point, the underlying artery 

may be involved, resulting in a pseudoaneurysm (an outpouching of 

the artery). Before any surgical intervention, you must evaluate the 

vessel with an ultrasound/duplex scan. 

If a pseudoaneurysm is present, a surgeon with vascular expertise 

must be involved in the patient’s care. If you incise and drain the abscess 

without proper equipment and expertise, you will open the blood 

vessel, which may result in massive blood loss and death of the patient. 

What to Look for on the X-ray 

• Foreign bodies 

• Unsuspected fractures/dislocations 

• Underlying bone infection (bone edges appear irregular because 

bone has been destroyed by infection) 

• Air in the soft tissues (when previous incision and drainage have not 

been done), which strongly indicates necrotizing fasciitis. Localized 

air may be present in the soft tissues in the immediate vicinity of an 

incision and drainage site, but diffuse air in the tissues is a sign of a 

necrotizing infection. 

GGeenneerraall TTrreeaattmmeenntt 

The patient must be evaluated carefully to distinguish among simple 

cellulitis, an abscess in need of incision and drainage (I & D), or necrotizing 

fasciitis in need of emergent radical debridement. 

If the patient is stable with normal blood pressure and has no fluctuance, 

the probable diagnosis is cellulitis. Treatment with antibiotics 

and warm compresses is indicated. Watch for signs of progression, 

which may indicate an underlying abscess or need for a change in antibiotic 

therapy. 

If the patient is stable but fluctuance is present, the abscess requires 

simple I & D. In addition, a short course of oral antibiotics may be useful. 

If the patient is quite ill, with evidence of an abscess or possible signs 

of necrotizing fasciitis or wet gangrene, he or she requires intravenous 

antibiotics, intravenous fluids, and urgent operative intervention. 

GGuuiiddee ttoo AAnnttiibbiioottiiccss 

Antibiotic administration is often the cornerstone of the treatment of 

soft tissue infections. The following are general guidelines:


1. Remind the patient that more than one dose of an antibiotic is 

needed to see any significant difference. 

2. Follow the patient closely because changes in antibiotic therapy 

may be needed. In addition, an area that you thought was merely 

cellulitis may show signs of an abscess at a later time. 

3. Whenever possible, send a specimen of any drainage from the area 

to the lab for aerobic and anaerobic culture and Gram stain. The results 

of these studies help to guide your choice of antibiotic therapy. 

Basic Skin Infections 

The infecting organisms are usually staphylococci or streptococci. Treat 

with an extended penicillin (a drug related to penicillin that covers 

penicillin-resistant organisms) or a first-generation cephalosporin. 

Animal Bites 

Pasteurella spp. are associated with cat and dog bites. Treatment requires 

an antipseudomonal antibiotic (e.g., amoxicillin/clavulanate or 

cefuroxime). On the hand, cat bites have a much higher incidence of 

subsequent infection than dog bites (80% vs. 5%, respectively). 

Human Bites 

Eikenella spp., other anaerobes, and streptococci are associated with 

human bite infections. If the patient is seen early after the injury 

before signs of infection have developed, treat with amoxicillin/ 

clavulanate. Once signs of infection are present, intravenous antibiotics 

such as amoxicillin/sulbactam or ticarcillin/clavulanate are indicated. 

The pathogens associated with human bites can cause serious 

infections that must be followed closely and treated aggressively, especially 

in bites to the hand (see chapter 36, “Hand Infections,” for 

specific information). 

Seawater and Shellfish Injury 

If the affected area has the typical signs of cellulitis, treatment should 

cover bacteria of the Vibrio species. Appropriate agents include tetracycline 

or an aminoglycoside. 

Freshwater Injury 

Aeromonas hydrophila is associated with freshwater infection. A fluoroquinolone 

or trimethoprim/sulfamethoxazole should be used.


Enlarged Lymph Nodes in the Affected Area 

The presence of enlarged lymph nodes may indicate cat-scratch disease, 

Mycobacterium marinum infection, sporotrichosis, or nocardial infection. 

An infectious disease specialist should be involved in the 

treatment of such patients. 

Concerns about Foreign Bodies 

If a foreign body is present in the infected tissues, the infection probably 

will not resolve until it is removed. However, a foreign body in soft 

tissues without cellulitis does not have to be removed unless it is causing 

symptoms. 

IInncciissiioonn aanndd DDrraaiinnaaggee ooff aann AAbbsscceessss 

1. Do not be timid. You want to open the abscess cavity fully to prevent 

the abscess from reforming. 

2. Local anesthetic often does not work well in infected tissues, but a 

block can be quite useful. Sometimes no anesthetic is required, or 

you may need only light sedation (see chapter 3, “Local Anesthesia,” 

for more details). 

3. Make a longitudinal incision through the most fluctuant part of the 

abscess. Do not make the incision too small. It is often useful to 

excise an ellipse of skin, because the opening must be large enough 

to drain the abscess completely and allow you to pack the cavity 

with gauze. 

4. Use the tips of a clamp to explore the abscess cavity gently and to 

ensure that it has been completely opened. 

5. Send a specimen to the microbiology lab for evaluation. 

6. Pack the wound with gauze. 


1. The gauze packing should remain in place for 1 day. 

2. Remove the gauze. Then repack the cavity with saline-moistened 

gauze and cover with dry gauze. The dressing should be changed 

2–3 times/day until the wound has healed. 

3. The patient may wash the area with gentle soap and water at each 

dressing change. Showering is permitted. 

4. Antibiotics should be continued until the surrounding cellulitis resolves 

(probably for a few days).


Temporizing Measure for an Abscess in Need of Drainage 

Sometimes you cannot perform the I & D without general anesthesia 

because of pain in the area and the extensive nature of the abscess. If 

you have to wait to get to the operating room for formal exploration, 

you can initiate treatment without anesthesia and prevent the patient 

from becoming more symptomatic. 

An abscess can be decompressed by placing a large needle (18 gauge is 

adequate) into the cavity and aspirating the pus with a syringe. This 

technique relieves some of the pressure building up in the abscess 

pocket and helps to prevent the infection from worsening before definitive 

I & D is performed. Send a small amount of the aspirated fluid to 

the microbiology lab for analysis. 



Therapy, 29th ed. Vermont, Antimicrobial Therapy Inc., 1999. 

2. Stevens DL: Cellulitis and abscesses. In Root RK (ed): Clinical Infectious Diseases. 

New York, Oxford University Press, 1999, pp 501–503. 

3. Swartz MN: Cellulitis and subcutaneous tissue infection. In Mandell GL, Bennett JE, 

Dolin R (eds): Principles and Practice of Infectious Diseases, 5th ed. New York, 

Churchill Livingstone, 2000, pp 1037–1057.

Chapter 20 

BURNS 

KEY FIGURES: 

Rule of 9’s adult, child 

Burns can be serious injuries and are a major cause of morbidity and 

disability worldwide. This chapter describes techniques that give the 

best chance of survival and reduce the risk of long-term disability. 

When treating patients with a severe burn, you must be prepared to 

provide extensive care over many days or even weeks. If you cannot 

meet this commitment, consider transferring the patient to a facility 

that specializes in the care of burns. 

IImmppoorrttaanntt FFuunnccttiioonnss ooff SSkkiinn 

Intact, uninjured skin plays a vital role in maintaining health. A burn 

causes significant damage that compromises the ability of the skin to 

perform its key functions (see table below). 

Table 1. The Physiologic Consequences of Burn injury 

Skin Function Consequence of Burn Injury and Required Intervention 

Contributes to tem- Patient is prone to lose body heat. You must keep patient 

perature regulation covered and warm at all times to prevent hypothermia. 

by preventing 

heat loss 

Keeps bacteria and Patient is at high risk for infection. Antibiotic ointments are 

microorganisms used on burn wound, but no systemic antibiotics are indifrom 

invading body cated unless signs of specific infection are present. 

Check tetanus immunization status; give booster if needed. 

Prevents water loss Patient loses tremendous amount of fluid into burned skin. 

Burn also causes release of factors that make all body 

tissues, not just skin, “leaky” to protein as well as water. 

Intravascular volume can be greatly depleted by large 

burn (> 20% body surface area) 

Common cause of death from large burn is renal failure due 

to inadequate fluid resuscitation during first 24–48 hrs 

after acute burn (see “Basic rules for fluid resuscitation” 

below for prevention strategies) 

191


MMeecchhaanniissmm ooff IInnjjuurryy 

A burn can be caused by thermal (heat) injury, electricity, or caustic 

chemicals. Aside from the resultant skin damage, each mechanism has 

associated complicating factors of which you should be aware. 

Thermal Injury 

Thermal injury is the most common cause of burns. In addition to 

damage to the skin, you must be alert for the possibility of inhalation 

injury—a burn to the patient’s airway (pharynx, trachea, even lungs). 

Failure to diagnose inhalation injury can result in airway swelling and 

obstruction, which, if untreated, can lead to death. 

Signs that may indicate inhalation injury include singed nasal hairs, 

carbon particles in the sputum, hoarseness, and elevated carbon 

monoxide (CO) levels in the blood. If you can test for CO, do so. 

Another way to tell whether the blood contains a significant amount of 

CO is to look at its color. Blood is bright red when CO is present. 

Optimally, bronchoscopy is used to assess edema of the airways and 

signs of burns in the oropharynx, pharynx, or lower airways. 

If signs of airway swelling or burns are present, an endotracheal tube should 

be placed to protect the airway. Because the swelling worsens over the 

first 24–48 hours after acute injury, it is best to intubate early. It may be 

impossible to get the endotracheal tube in place once significant 

airway swelling has occurred. 

Electrical Injury 

Electrical burns cause injury by a combination of thermal injury and 

direct effects of the electrical current (cell membrane instability and denaturation 

of cell proteins). 

It is often difficult to assess the magnitude of injury because the only 

visible indication may be damaged skin at the entrance and exit sites. 

Significant deep tissue injury often is present along the course of the electrical 

current through the body. 

Muscle is often the most seriously injured tissue. You must be on the 

alert for compartment syndrome (swelling of muscle groups that can 

lead to muscle necrosis). In patients with significant muscle damage, 

myoglobin is present in the urine, which appears purplish or red. 

Myoglobinuria requires aggressive treatment to prevent renal failure. 

The patient should be given sodium bicarbonate in intravenous fluids 

to make the urine more alkaline, and urine output should be maintained 

at over 50 ml/hr by giving intravenous fluids as well as intravenous 

furosemide or mannitol.

Burns 193 

Because the heart is a muscle, be alert for cardiac dysfunction. 

Arrhythmias are common. Patients should be monitored closely and 

arrhythmias treated appropriately. 

Chemical Injury 

Chemicals cause damage by reacting with the tissue proteins in a 

manner that leads to tissue death. Chemical injury is different from 

thermal injury in that chemicals can continue to cause damage until they are 

removed or neutralized. 

In general, the chemical agents are either acids or bases. Basic solutions 

tend to penetrate deeper into the tissues and thus cause more damage 

than acidic solutions. 

The key to initial treatment is to remove all clothing that may have contacted 

the chemical and to irrigate the injured area continuously with 

water for at least 2 hours or longer. 

Try to find out the exact chemical that caused the injury. Poison control 

centers located in almost every state are useful sources of information 

about the best way to treat various chemical injuries. A useful web address 

is: 

www.medwebplus.com/subject/Poison_Control_Centers.html 

It is difficult to estimate the depth of injury from a chemical at initial 

presentation. Close observation and daily examination of the burn 

wound are vital for proper treatment. 

No matter what the inciting incident, patients with a burn are evaluated 

and treated in the same manner as outlined below. 

IInniittiiaall TTrreeaattmmeenntt 

1. Remove all clothing from the affected area. 

2. Immediately cover the burned areas with saline-moistened gauze. 

Use saline that is lukewarm—not too cool. 

Special Considerations 

If the patient has been injured by hot tar: Tar is not absorbed; do not 

try to remove it by scraping and pulling. Such actions serve only to 

worsen the burn and injure additional skin. Simply apply petrolatumbased 

antibiotic ointments to the area (Neosporin or Bacitracin), and 

the tar will separate as the burns heal. 

If grease is present on the burned tissues: Grease often can be removed 

by gently rubbing with the same petrolatum-based antibiotic ointments.


For chemical burns, the area should be rinsed continuously with water 

for several hours instead of merely applying saline-moistened gauze. 

Intravenous access should be obtained for delivering fluids. 

Check the tetanus immunization status, and give a booster if needed. 

The patient should not be given intravenous antibiotics initially. They are 

used only in the presence of signs that the burn wound has become infected 

or for treatment of other diagnosed infections (e.g., pneumonia). 

Once you have evaluated the extent of the injury, apply a topical agent 

to the burned areas and cover with sterile gauze. For large burns 

(> 20% BSA), consider transfer to a burn unit if available (see below). 

Table 2. Commonly Used Agents for Burn Wounds 

Applications 

Agent Per Day Indications/Precautions 

Bacitracin, Neo- 1–2 Useful for face burns* or burns over relatively small 

sporin, or triple areas. Do not come in large enough containers for 

antibiotic ointment use on large burns. 

Silver sulfadiazene 1–2 Most commonly used agent for burn wounds. Comes in 

(Silvadene) large containers for use on large burns and can be 

used on all parts of body except face. Does not cause 

pain upon application. Major side effect is decrease in 

white blood cell count, which necessitates stopping its 

use. Do not use in patients allergic to sulfa drugs. 

Mafenide acetate 1–2 Comes in large containers. Better burn wound penetra- 

(Sulfamylon) tion than Silvadene, but painful when applied to burn. 

Also may cause electrolyte disturbances. Best used 

for small areas only. Especially indicated for burns on 

ears to protect cartilage from getting infected. Do not 

use in patients allergic to sulfa drugs. 

Silver nitrate (0.5%) Several Can be used on large burns and is not painful to apply. 

(at least Should be applied in wet, bulky dressings. Does not 

4 times/ penetrate burn wound as well as Silvadene and may 

day) cause severe drop in serum sodium concentration; you 

must monitor electrolytes closely. Annoying problem 

is that silver nitrate turns everything it contacts black 

(e.g., skin, clothing, bedding). 

* Keep out of the eyes. Use only ophthalmic preparations for the eyes or areas immediately around 

the eyes. 

DDeetteerrmmiinniinngg PPeerrcceenntt ooff TToottaall BBooddyy 

SSuurrffaaccee AArreeaa ((BBSSAA)) BBuurrnneedd 

Adults 

The rule of nines 

• Each entire arm: 9% • Posterior trunk: 18% 

• Each entire lower extremity: 18% • Head/neck: 9% 

• Anterior trunk: 18% • Genital area: 1%

Children 

Modification of the rule of nines 

The adult proportions are slightly different in children because of the 

relatively large size of a child’s head in relation to the rest of the body: 

• Infant head: ~20% 

• Each lower extremity decreased to ~10% 

• Other areas remain essentially the same 

DDeetteerrmmiinniinngg DDeepptthh ooff BBuurrnn 

Burns 195 

Rule of nines in adults and children. Modification of Lund and Browder chart for 

determining body surface area. (From Jurkiewicz MJ et al (eds): Plastic 

Surgery: Principles and Practice. St. Louis, Mosby, 1990, with permission.) 

It is often difficult to determine the exact severity of the burn at the initial 

examination. Therefore, reevaluation of the patient once the burns 

have been cleansed and again 24 hours later is vital.


Burns are classified as first-, second-, or third-degree, depending on the 

depth of injury. A first-degree burn implies injury to the superficial surface 

of the skin; it is similar to a sunburn. A second-degree burn involves 

varying levels of the dermis, and a third-degree burn completely destroys 

the dermis and may injure even the underlying subcutaneous tissue. 

The burn injury is often not uniform. There may be areas of first-, 

second-, and third-degree burn on different parts of the body. This 

variation should be noted in your examination. The distinction among 

burn types is important. In general, the deeper the burn, the greater the 

amount of intravascular fluid that is lost into the burned tissues and 

the greater the overall physiologic injury. 

Table 3. Burn Wound Classification 

Burn Depth Appearance Pain Sensation 

Superficial 

(first-degree) 

Erythema + Yes 

Partial-thickness Blisters, hairs (if present) stay +++ Yes 

(second-degree)* attached 

Full-thickness Thick, leathery feel 0 No 

(third-degree) Pale color (nerve endings 

Hairs, if present, do not stay 

attached 

May see thrombosed veins 

are destroyed) 

* Partial-thickness burns can be superficial or deep. A superficial partial-thickness burn may have a 

thin blister, and the skin is soft and pink. A deep partial-thickness burn appears white but some hair 

follicles are still attached. It feels softer than a full-thickness burn. A deep partial-thickness burn 

often behaves like a full-thickness burn. 

BBaassiicc RRuulleess ffoorr FFlluuiidd RReessuusscciittaattiioonn 

A burn injury results in dramatic loss of fluids from the intravascular 

space. To prevent kidney damage or failure, the patient requires a large 

amount of fluids compared with the baseline state. In patients with 

second- and third-degree burns affecting > 15–20% BSA, proper fluid 

resuscitation is vital for survival. 

Estimating Fluid Needs for the First 24 Hours after Injury 

The Parkland Formula is a good way to estimate fluid needs. The patient 

must be monitored closely for blood pressure, heart rate, and 

urine output. Adjustments in fluid rate should be based on these parameters. 

If necessary and if available, central venous pressure or Swan- 

Ganz catheter monitoring should be used because they provide more 

precise measurements of circulatory status. Urine output should be at 

least 20–30 ml/hr for adults and 1–2 ml/kg/hr for infants or children. 

Increase output by giving additional intravenous fluids, not diuretics.

Burns 197 

Parkland Formula 

4 ml × patient wt (kg) × %BSA = fluids for first 24 hr 

One-half of this amount is given over the first 8 hours after injury; the 

rest is given over the next 16 hours. 

The intravenous fluid of choice in adults is Ringer’s lactate. Normal 

saline is the next best option. Do not use dextrose solutions for the initial 

fluids. In children, use Ringer’s lactate, but also administer 5% dextrose 

in one-fourth normal saline solution (D 1 

5 ⁄4NS) for maintenance 

glucose needs. 

Example: A 70-kg man has sustained a 55% BSA burn, of which 10% is 

first-degree, 20% is second-degree, and 10% is third-degree. Fluids required 

for the first 24 hours: 

4 ml × 70 kg × (20 + 10)%BSA = 8400 ml 

(I told you that we were talking a lot of fluid!) The total BSA that you 

calculate includes second- and third-degree burns; first-degree burns 

are not included. 

Give 4200 ml over the first 8 hours, then 4200 ml over the next 16 

hours. The amount of fluid given per hour is also an important point: 

• If the patient presents immediately after the burn, give 4200/8 = 525 

ml/hr for the first 8 hours, then 4200/16 = 262 ml/hr for the next 16 

hours. 

• If the patient presents 2 hours after the injury, give 4200/6 (fluid 

must be given over 8 hours after injury, not after presentation) = 700 

ml/hr over the next 6 hours, then 4200/16 = 262 ml/hr for the next 

16 hours. 

PPaaiinn CCoonnttrrooll 

Few injuries are more painful than a burn. Thus, an important part of 

the management is adequate pain control. Everything related to a burn 

injury and its treatment is painful. Keep this in mind, and do not skimp 

on pain medications. Morphine is often the medication of choice. For 

patients with large burns, intravenous injection is the best way to administer 

the medication. Absorption of subcutaneous or intramuscular injections 

is not reliable. Oral pain medications may be indicated with a small burn 

wound, but they are not useful in patients with significant burn injury. 

Morphine 

Intravenous morphine is the pain medication of choice. An adult can 

be given 2–3 mg at a time, titrated to pain control. Do not give too


much, because excessive morphine can cause the patient to stop 

breathing. 

Guideline for dosing: do not administer more than 0.1 mg of morphine 

per kg of patient weight (0.1 mg/kg) over a 1–2-hour period. 

This rule applies to both children and adults. 

Sedation 

Intravenous sedation can be given along with pain medication. It is especially 

useful during the initial evaluation and before dressing 

changes. Sedation may decrease the need for pain medication and alleviates 

the anxiety often associated with painful procedures. Be cautious, 

and monitor the patient closely because sedatives also can 

depress the respiratory drive. 

A short-acting agent such as midazolam (Versed) is quite useful. If 

none is available, diazepam (Valium) is another option. See chapter 3, 

“Local Anesthesia,” for detailed dosing information. 

SSuubbsseeqquueenntt CCaarree ooff BBuurrnn WWoouunnddss 

Patients with a large burn have difficulty in maintaining body temperature. 

During dressing changes, the patient may become quite hypothermic 

if precautions are not taken. If possible, warm the room, use 

warming lights, uncover parts of the wound individually instead of removing 

all of the dressings at the same time, and use lukewarm, not 

cold saline. 

Examine the burns daily to look for signs of infection (e.g., induration, 

blanching erythema, increased redness/warmth). 

First-degree Burns 

Clean daily with gentle soap and water. 

Apply a gentle moisturizer (aloe, cocoa butter, something without perfumes) 

or antibiotic ointment once or twice daily. 

First-degree burns require several days to heal. 

Second-degree Burns 

If the blisters are intact, it is usually best to leave them alone. The area 

under the blister essentially represents a sterile environment and promotes 

healing. An exception is the blister that is so tight that it interferes 

with the circulation of surrounding tissues. Such blisters should 

be opened and the loose skin removed.

Burns 199 

If the blisters have opened, the skin should be removed gently. This 

procedure usually requires a pair of forceps and a pair of scissors. 

Removing the skin should not hurt. 

Apply antibiotic ointment—usually Silvadene on the body, Bacitracin 

on the face—twice daily, and cover with dry gauze. 

Clean the burn wound with saline, and remove the old ointment before 

applying new ointment. 

Dressing and cleansing the wound are often quite painful. Be sure to 

give pain medication before changing the dressings. 

Superficial second-degree burns usually heal within 10–14 days, 

whereas deep second-degree burns often take 3–4 weeks. Deeper burns 

are also prone to thick, hypertrophic scarring. Therefore, unless the area 

is very small (< 4–5 cm in diameter), tangential excision (see below) is 

often recommended for deep second-degree burns. 

Third-degree Burns 

Apply antibiotic ointment—usually Silvadene on the body, Baci-tracin 

on the face—twice daily, and cover with dry gauze. 

Clean the burn wound with saline and remove the old ointment before 

applying new ointment. 

Full-thickness burns take at least 4 weeks to heal and often heal with a 

hypertrophic scar. Except for small (< 4–5 cm in diameter) thirddegree 

burns, tangential excision and split-thickness skin grafting usually 

are recommended 

FFlluuiiddss aafftteerr tthhee FFiirrsstt 2244 HHoouurrss 

Because the capillaries are no longer as “leaky” after the first 24 hours, 

the fluids are changed from crystalloid (Ringer’s lactate) to proteincontaining 

solutions (colloids). Colloids provide improved intravascular 

volume expansion. 

In general, give 0.3–0.5 ml/kg/%BSA over 24 hours. 

In addition, 5% dextrose in water or 5% dextrose in 0.45 saline is given 

to maintain urine output of at least 20 ml/hr. 

After this regimen, fluids should be administered according to the patient’s 

overall condition.


NNuuttrriittiioonnaall CCoonncceerrnnss 

A severe burn injury causes severe metabolic disturbances and a concomitant 

increase in caloric requirements. Chapter 8, “Nutrition,” explains 

how to estimate caloric needs; for a severe burn injury (> 40% 

BSA), the basal metabolic rate is multiplied by a factor of 2–2.5, a 

larger factor than for any other injury. Depletion of nutritional stores 

is a distinct risk. Caloric requirements reach their peak at approximately 

7–10 days after injury and do not return to normal until all 

burns have healed. 

Nutritional support is vital for the treatment of a severely burned patient. 

If the patient cannot ingest enough calories orally, a nasogastric 

or other type of enteral feeding tube must be placed to supply calories. 

If the patient cannot tolerate feedings through the gastrointestinal 

tract, central intravenous nutritional support should be started. 

TTaannggeennttiiaall EExxcciissiioonn 

For deep second- and third-degree burns larger than a few centimeters, 

tangential excision followed by split-thickness skin grafting is recommended. 

It leads to faster healing, with more stable skin coverage. In 

tangential excision, only the burned tissue is removed; uninjured tissue 

is left alone. 

Careful tangential excision of the burn and split thickness skin grafting 

should be done relatively early (within days of the injury) if possible. 

Usually the procedure is done in the operating room under general 

anesthesia. A special knife or dermatome (see chapter 12, “Skin 

Grafts”) is used. Be sure to excise only the tissue that is burned. You 

will know when you have reached healthy tissue because it will bleed. 

In general, dead tissue does not bleed. 

This procedure can cause significant blood loss. Usually only small 

areas (< 10% BSA) are done at any one time, and blood should be available 

for transfusion. Patients always lose more blood than you expect. 

Hemostasis usually can be obtained by holding a gauze pad over the 

area and applying pressure for a few minutes. Sometimes topical 

thrombin or epinephrine solutions can be applied as well. 

The wound is then ready for split-thickness skin grafting (see chapter 

12, “Skin Grafts,” for details). 

Caution: Tangential excision should be done only by a practitioner 

with special surgical skills who is comfortable performing skin grafting. 

Unless only a small area (e.g., part of the arm) is involved, this procedure 

can be quite difficult to perform safely.

SSppeecciiffiicc IInnjjuurriieess 

Hand Burns 

Burns 201 

See chapter 34, “Hand Burns,” for detailed information. Simple techniques 

can prevent permanent loss of hand function. 

Electrical Burns of the Mouth in Children 

Electrical burns of the mouth usually occur when the child bites down 

on an electrical cord. Such injuries usually involve a burn of the lip 

commissure (where the upper lip meets the lower lip). 

The eschar (scab) that forms at the commissure separates after 10–14 

days. Separation may be accompanied by significant bleeding from the 

labial artery. You should warn parents about this potential event. They 

can control the bleeding by holding gauze over the area and pinching 

the lip at the commissure. The bleeding should stop after 5–10 minutes 

of pressure, but medical treatment may be needed. 

Burns on the Dorsum of the Foot 

Second-degree burns on the top of the foot initially may seem insignificant 

and, in fact, often heal with local care alone. However, improper 

management may result in a more extensive tissue loss than you 

expect. Exposure or injury to the underlying tendons may result and 

can be quite problematic to treat. 

Proper Treatment 

1. Apply the usual antibiotic ointment and dressings, as described 

above. 

2. The patient should wear no shoes or boots on the injured foot until 

the burn is healing well. 

3. The foot should be kept elevated at all times. 

4. The patient should not put weight on the affected foot until you are 

sure that the burn is healing properly. 

RReeffeerrrraall ttoo BBuurrnn CCeenntteerr 

A burn center is a tertiary care center that specializes in the multidisciplinary 

care of patients with acute burn injuries. Burn centers serve an 

important purpose and are responsible for improved outcomes in severely 

injured burn patients. Only second- or third-degree burns 

should be referred. If you are lucky enough to have one available, the 

following criteria may be applied for referral:


1. Burns of the genitalia, face, hands, and feet 

2. Burns involving over 10% BSA in patients younger than 10 years or 

older than 50 years 

3. Burns involving over 20% BSA in patients of any age 

4. Inhalation injury 

5. Other significant trauma 

6. Third-degree burns involving over 5–10% BSA 

7. Multiple medical problems as well as significant burn injury 

Do not be reluctant to transfer. Burn patients are seriously ill and have 

the potential for developing many complications. They are best treated 

at centers that specialize in burn care. 

Even if you decide to transfer the patient to a burn center, you should not hesitate 

to start the appropriate treatment. The first few hours after an injury 

are critical, and measures such as fluid resuscitation, burn dressings, 

and pain control must be initiated and implemented appropriately 

while awaiting transfer. 

FFrroossttbbiittee 

Frostbite is an injury caused by prolonged exposure to cold temperature 

that results in freezing of soft tissues and formation of ice crystals. 

Ice crystals form not only inside cells but also inside the smallest 

of blood vessels, causing occlusion. Occlusion ultimately leads to 

tissue loss. 

Initial Treatment 

This information applies to patients who present at the time of injury. 

Some patients do not seek treatment for several days or weeks after 

injury. The treatment that follows is not for delayed presentation (see 

next section for treatment after the acute thermal process has resolved). 

Rapid Rewarming 

1. The first line of treatment for patients with acute frostbite injury is 

rapid rewarming of the tissue. Rewarming should be done only 

when you are certain that the tissue will not again be exposed to 

cold. 

2. Immerse the affected part in warm water (104–108°F or 40–42°C). 

Use of hotter water may cause a burn injury, whereas use of cooler 

water may not provide the benefits of rewarming. It usually takes 

about 20–30 minutes to rewarm the tissues.

Burns 203 

3. Rewarming hurts. Give the patient pain medication, preferably intravenous 

morphine. 

4. Do not massage the affected tissue. 

After Tissues are Rewarmed or 

if Patient Presents Days after Injury 

1. Unroof only those blisters with clear fluid. 

2. Blisters filled with blood should be left alone. They are signs of 

deeper tissue injury. 

3. Gently elevate the affected area to decrease swelling. 

4. Apply aloe vera to the affected areas, and cover with a gauze 

dressing. 

5. Antiplatelet medications may be useful (e.g., aspirin, 80–325 mg/ 

day). 

6. Use gentle range-of-motion exercises to prevent joint stiffness. 

7. For hand injuries, remember to splint the hand in neutral position. 

8. Change the dressing daily, or prescribe whirlpool treatments, if 

available. 

9. Check the patient’s tetanus toxoid status, and treat appropriately. 

10. Antibiotics are used only if signs of infection are present in the surrounding 

soft tissue. 

Note: The cornerstone of treatment of a frostbite injury is to allow the 

injured tissues to demarcate. The dead tissue turns black, gradually 

shrivels, and eventually falls off. After dermarcation, you will debride 

only the tissue that does not survive the injury. 

During the first few days or even weeks after the initial injury, tissue 

that at first appeared unlikely to survive may actually heal. By waiting 

for the tissues to demarcate, you can tell definitively which tissue is 

dead, and you will not remove more tissue than necessary. Another indication 

for surgical debridement of injured tissue is development of 

an infection that does not resolve with antibiotic therapy. 

Long-term Effects 

1. Joint stiffness and arthritis are common. 

2. The affected area may be permanently sensitive to cold temperatures. 

3. In children, frostbite injures the growth plate of the bones and may 

result in diminution of bone growth.



1. Luce EA: Electrical injuries. In McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. 

Saunders, 1990, pp 814–830. 

2. Robson MC, Smith DJ: Cold injuries. In McCarthy JG (ed): Plastic Surgery. 

Philadelphia, W.B. Saunders, 1990, pp 849–866. 

3. Salisbury RE: Thermal burns. In McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. 

Saunders, 1990, pp 787–813.

Chapter 21 

FRACTURES OF THE 

TIBIA AND FIBULA 

KEY FIGURES: 

Calf anatomy Longstanding open 

How to do fasciotomy fracture 

Gastrocnemius and Gastrocnemius flap 

neighboring structures 

Fractures of the tibia and fibula are a special concern because missing 

early warning signs can result in a useless leg. 

The tibia and the fibula are the two long bones of the calf. Fractures of 

these bones often result from a sport-related injury or motor vehicle accident. 

Most fractures of the tibia and fibula (tib-fib fractures) heal 

without complication, and the patient is able to resume his or her 

normal activities. 

However, potentially serious complications can develop, and you must 

be aware of their early warning signs. With this knowledge, you can 

intervene before permanent tissue damage develops. Early intervention 

may make the difference between a normally functioning patient 

with a well-healed fracture and disaster. 

CCaassee EExxaammppllee 

An 18-year-old boy was playing football and collided with another 

player, injuring his right leg. He tried to keep playing, but because the 

pain was so intense he could not place any weight on the leg. He sat 

out the rest of the game and then came in for evaluation. 

The calf was swollen and tender, and the x-ray showed a minimally 

displaced mid-shaft tib-fib fracture. No orthopedic surgeon was available. 

After finding the fracture in Campbell’s Orthopaedics, you placed 

him in a cast, gave him crutches and pain medications, and sent him 

home. 

205


He returns a few days later in horrible pain. You remove the cast. His 

calf is very tight and swollen, and except for the lateral aspect he has 

no sensation in his foot. When you move his ankle, the pain intensifies 

in his calf. You check for pulses in his feet, and they are present. 

A general surgeon takes one look at the patient, and immediately sends 

him to the operating room. Incisions are made in the calf, and much of 

the calf muscle is dead. 

The boy’s leg will never function as it did before the injury. He will 

have a life-long disability. 

What happened? First you need some basic background information. 

CClloosseedd vvss.. OOppeenn FFrraaccttuurreess 

Fractures are usually classified as closed or open. 

A closed fracture means that the skin around the fracture site is intact. 

In terms of bone healing, closed fractures have a favorable prognosis 

because of the low risk for infection of the bone (osteomyelitis) at the 

fracture site. However, complications may arise, as illustrated by the 

case example. 

In an open fracture, also called a compound fracture, the skin around 

the fracture site has been punctured. Open fractures are more serious 

injuries because it generally takes greater forces to disrupt the skin and 

fracture the bones. An open fracture greatly increases the risk for the 

development of osteomyelitis, and osteomyelitis increases the risk for 

poor healing. 

The quality of the soft tissue around the fractured bones plays a role in 

fracture healing. Feel your own calf. The anterior surface of the tibia is 

covered only by skin; there is not much padding around this bone. 

Significant injury to the skin around the tibia can result in exposure of 

the bone and thus a greater risk for poor healing of the fracture. 

The higher the energy of the injury, the more significant the injury to 

the soft tissue and the greater the potential for problems. Falling off a 

step results in a low-energy injury; being hit by a car results in a highenergy 

injury. 

EEsssseennttiiaall EElleemmeennttss ooff tthhee PPhhyyssiiccaall EExxaammiinnaattiioonn 

1. Is the skin intact? (open vs. closed fracture) 

2. If the skin is punctured, what can you see in the wound? Foreign material 

must be removed, and dead muscle or skin should be cut out. 

If the fracture site is exposed, soft tissue coverage may be needed.

Fractures of the Tibia and Fibula 207 

3. What is the vascular status of the leg? Check capillary refill. Check 

the pulses on the top of the foot (dorsalis pedis) and behind the 

medial malleolus (posterior tibial artery). If capillary refill or pulses 

are not present, the patient may have a serious arterial injury. 

4. What is the neurologic status of the leg? Evaluate the patient for evidence 

of nerve dysfunction or injury. Check sensation in the following 

areas: 

• The first web space on the dorsum of the foot between the great 

toe and the second toe: deep peroneal nerve 

• The plantar surface of the foot: posterior tibial nerve 

• The lateral aspect of the foot: sural nerve 

Check active ankle motion and toe motion: 

• Plantarflexion of the ankle and toes (pointing of toes and foot): 

posterior tibial nerve 

• Dorsiflexion of the ankle and toes (bringing the toes and foot 

upward toward the front of the calf): anterior tibial nerve 

• Eversion (elevating the lateral side of the foot): peroneal nerve 

5. What are the radiographic findings? A single break in each of the 

bones usually heals with fewer complications than when the bones 

are broken into many pieces (a comminuted fracture). A large 

number of fragments indicates a higher-energy injury, which is associated 

with a higher rate of complications. 

6. Evaluate the patient for signs and symptoms of compartment syndrome. 

If they are present, you have a surgical emergency on your 

hands (see below). 

CCoommppaarrttmmeenntt SSyynnddrroommee 

A compartment syndrome develops when pressure builds up within a 

fixed, well-defined space. The increase in pressure prevents venous 

and lymphatic outflow, and fluid build-up leads to a further increase 

in pressure in the tissues. High pressures can cause tissue injury and 

death. 

High pressures also prevent blood and nutrients from reaching the tissues, 

causing further injury. Without appropriate intervention to relieve 

pressure build-up, a vicious cycle develops. This is essentially the 

definition of a compartment syndrome. 

Muscle and nerve are the tissues most prone to injury. If a compartment 

syndrome remains untreated even for a few hours, the result is muscle 

death, which translates into tissue loss and permanent disability. 

The death of muscle tissue can also be a very serious problem for the 

patient’s overall health. A muscle breakdown byproduct, myoglobin,


is released into the bloodstream and can cause permanent kidney 

damage. Thus a compartment syndrome not only endangers normal 

function; it can also threaten the patient’s life. For these reasons, the 

treatment of a compartment syndrome is a surgical emergency. 

Anatomy of the Calf 

The anatomy of the calf puts it at increased risk for the development of 

a compartment syndrome. The muscles of the calf are segregated into 

four well-defined compartments, surrounded by tight, unyielding 

fascia. Build-up of pressure in one compartment cannot decompress 

into another uninjured compartment. In the thigh, on the other hand, 

the separation of the muscle compartments is not as tight and well defined. 

An increase in pressure of the anterior thigh muscle compartment 

can be absorbed by the posterior compartment. This dissipation 

of pressure does not occur in the calf. 

Understanding the nerves and muscles in each of the four compartments 

of the calf facilitates examination of an injured leg. 

Table 1. Compartments of the Calf 

Compartment Nerve Motor Function Sensory Distribution 

Anterior Deep peroneal Dorsiflexion of foot Dorsal first web 

and toes space 

Lateral Superficial Eversion of foot Dorsal aspect of foot 

peroneal except for area 

noted above 

Posterior * Plantarflexion of foot * 

Deep Posterior tibial Inversion of foot, Plantar surface 

posterior plantarflexion of toes of foot 

* The sural nerve runs in the subcutaneous tissue of the posterior calf skin; it does not run in the posterior 

compartment of the calf. The sural nerve provides sensation to the lateral aspect of the foot. 

This is often spared in the patient with a pending compartment syndrome. 

In patients with a tib/fib fracture, the force of the injury leads to bleeding 

at the fracture site and in the muscle, along with additional 

swelling of the muscle and soft tissues in the calf. Swelling may impair 

venous return, which can start the vicious cycle leading to the development 

of a compartment syndrome.

Signs and Symptoms 


Axial section through the middle third of the calf showing the four compartments. 

(From Jurkiewicz MJ, et al (eds): Plastic Surgery: Principles and 

Practice. St. Louis, Mosby, 1990, with permission.) 

It is important to be aware of the potential development of compartment 

syndrome and to warn patients about the early warning signs. 

The key is to catch the problem early so that intervention can prevent 

permanent damage. An untreated compartment syndrome can lead to 

severe morbidity, extremity loss, and potentially life-threatening complications. 

The following signs and symptoms should be kept in mind: 

• Severe pain in the calf, out of proportion to that expected from the 

injury 

• Significant calf tightness 

• Pain with passive stretch of a muscle group; for example, pain in the 

front of the calf with pointing of the toes and plantarflexing the 

ankle, or pain in the back of the calf with dorsiflexion of the ankle. 

• Tingling or numbness in the foot, along the peroneal and posterior 

tibial distribution, but not necessarily along the lateral aspect of the 

foot. 

Note: Pulses in the foot and ankle may be completely normal even with 

a significant build-up of pressure in the calf compartments.


Prevention 

It is vital that the patient keep the leg elevated and not let it dangle in a 

dependent position. If you have any concerns about the patient’s ability 

to follow these recommendations, the patient should be admitted to 

the hospital for leg elevation and close observation. 

Be careful not to cast the leg too tightly. A tight cast can increase tissue 

pressure. If swelling in the calf is significant or if you do not have much 

experience making a cast, consider putting the leg in a splint for the 

first few days. A splint (sometimes called a backslab in rural areas) is a 

plaster half-cast placed over padding on the posterior aspect of the calf 

onto the foot. It is held in place by a loosely applied Ace wrap. 

If the patient complains at all that the cast seems too tight, bivalve the 

cast. Make cuts in the cast along the medial and lateral sides, and separate 

the underlying padding. This technique may relieve symptoms of 

pressure. If bivalving the cast does not relieve the symptoms, remove 

the cast and reevaluate the leg to be sure that a compartment syndrome 

has not developed. 

In patients with an open fracture, do not close the skin if it seems tight. 

It is better to have an open wound in need of coverage than to risk the 

development of a compartment syndrome by tightly closing the skin. 

Have a high index of suspicion. Remember: a compartment syndrome 

can occur even with an open fracture and even when the patient has 

normal pulses. 

Treatment 

The key to treatment is to open the involved compartments before permanent 

tissue damage has occurred. Treatment is emergent. You 

should not wait for many hours or days for a specialist to be available. 

Each compartment must be individually opened (see diagrams and descriptions). 

Often, when you open the compartment, the bulging muscle initially 

looks purple and dead. Give the tissue a few minutes; it often becomes 

pinker and healthier-looking. Muscle that remains dark and purple, 

however, is dead and should be excised. 

The incisions should be left open. Saline dressings are a good choice 

for wound care. 

Further surgery is needed for wound closure. Wait at least 3–4 days for 

the swelling to lessen. A split-thickness skin graft (STSG) is almost 

always required for wound closure. If you attempt to close one of the 

incisions primarily, be sure that there is no tension on the skin closure.


Adequate stabilization of the fracture is also required. Usually temporary 

stabilization can be attained with a posterior splint. If an orthopedic 

surgeon is available, more definitive stabilization should be done. 

Adequate treatment of a compartment syndrome requires two incisions on the 

calf. One incision is made along the medial aspect of the calf, 2–3 cm posterior 

to the medial edge of the tibia. This incision allows access to the two posterior 

compartments. The second incision—on the lateral aspect of the calf, immediately 

in front of the fibula—allows access to the anterior and lateral compartments. 

(From Cameron JL (ed): Current Surgical Therapy, 4th ed. St. Louis, 

Mosby, 1992, with permission.) 

Back to our case example. As you may have guessed, he developed a 

compartment syndrome that was not recognized. 

OOppeenn FFrraaccttuurreess 

The ultimate treatment of open fractures requires specialists, but as a 

nonspecialist you can take steps to improve the patient’s chances for a 

good outcome until specialty care is available. 

Open fractures of the lower leg are a major cause of morbidity because 

of the high propensity for development of osteomyelitis and inadequate 

bone healing.


Leg of a patient who sustained an open tib-fib fracture 1 year earlier. No soft 

tissue coverage was provided at the time of injury. The soft tissue never healed 

over the bone, and the exposed bone is dead. The patient is in constant pain 

and cannot walk without assistance. 

With poor healing of the fracture, the patient may not be able to walk 

without assist devices (cane or crutches), may have chronic pain, and 

often is unable to work. Amputation may become necessary to control 

infection and improve overall function. 

The underlying fracture must be anatomically reduced in a stable position 

to allow healing of the soft tissues. Healthy soft tissue coverage is 

vital to healing of the fracture. 

Basic Treatment 

The goal is to achieve a healed bone, surrounded by healthy soft tissue. 

Intravenous antibiotics should be started immediately. Both gentamicin 

and a first-generation cephalosporin (e.g., cephalexin) should be given. 

Thoroughly wash out the wound under anesthesia as soon as possible 

after injury. Be sure to remove all foreign material and dead tissue, and 

copiously irrigate the wound with saline. 

In patients with significant contamination or soft tissue injury, it is best 

to pack the wound with gauze moistened with antibiotic solution or 

saline and to immobilize the leg in a splint. Return the patient to the 

operating room in 24–48 hours to wash out and debride the wound 

again and to stabilize the fracture. 

The patient should keep the leg slightly elevated to minimize swelling. 

Be sure to watch out for signs and symptoms of compartment syndrome. 

If soft tissue can be closed over the bone, do so very loosely. Because of 

swelling, a tight closure actually increases the chances for further


tissue loss, making the wound more difficult to manage. If muscle 

around the fracture can be sutured together to cover the bone, do so. If 

the skin cannot be closed, place a STSG over the muscle. This technique 

is much preferable to tight skin closure. 

If only a small area of bone (< 1–11 ⁄2 cm in diameter) is exposed, the 

wound may heal secondarily with dressing changes. For larger 

wounds, a local muscle flap or distant flap is required to cover the fracture 

and promote proper healing. Flaps require surgical expertise (see 

below). Optimally, the fracture site should be covered within the first 

week after injury. 

LLooccaall MMuussccllee FFllaappss 

Local muscle flaps should be undertaken only by someone with surgical 

skills. Several muscles in the calf can be used as a local flap to cover 

an exposed tib-fib fracture site. Muscle flaps also bring robust circulation 

to the fracture site and thereby improve healing of the injured bone. 

The use of muscle flaps has markedly decreased the morbidity associated 

with open fractures. Studies have shown that muscle flaps promote 

fracture healing; the average time for proper healing decreases 

from 9 to 5 months. The risk of developing osteomyelitis also decreases 

from 40% to 5%, and the amputation rate decreases from almost 30% to 

5% when muscle flap coverage of an exposed bone or fracture is done 

within the first week after injury. 

Proximal and Middle Third of the Calf: 

Gastrocnemius Flap 

The gastrocnemius muscle is the most superficial muscle of the posterior 

aspect of the calf. It accounts for most of the muscle mass at the top 

of the calf. The gastrocnemius muscle originates from the distal femur 

and joins the underlying soleus muscle to form the Achilles tendon. 

The main vascular supply enters the gastrocnemius muscle proximally 

near the knee joint. The muscle can be divided from the Achilles 

tendon and underlying soleus muscle without interfering with its 

blood supply. It should be divided longitudinally at its midline so that 

you take only one-half of the muscle. 

The gastrocnemius muscle then can be easily moved to cover wounds 

in the middle and proximal third of the calf. Sometimes the origin of 

the muscle has to be divided to allow increased movement into the 

wound. Usually the medial gastrocnemius is used. If the lateral 

muscle is used, it must swing around the fibula, which decreases the 

range of the flap.


The gastrocnemius muscle and neighboring structures are depicted in posterior 

and medial views of the leg. The tendon of the gastrocnemius muscle joins 

with the tendon of the soleus muscle to form the Achilles tendon. (From 

Strauch B, et al (eds): Grabb’s Encyclopedia of Flaps. Boston, Little, Brown, 


Operation 

1. General or spinal anesthesia is required. 

2. Use a tourniquet, if available, for the dissection. 

3. Be sure that the wound is adequately debrided and that all dead 

tissue or bone is completely removed. 

4. Do not take overlying skin with the muscle. An STSG is placed 

over the muscle at the end of the procedure. 

5. Extend the open wound onto the medial calf skin to visualize the 

underlying muscle. Try not to leave skin bridges because they have 

diminished circulation and may become necrotic. 

6. Identify the gastrocnemius muscle. It is the most superficial muscle 

(closest to the calf skin).


Patient with an exposed, open tib-fib fracture. The injury is less than 48 hours 

old, and the bone is being covered with a gastrocnemius flap. Note the external 

fixator, which is stabilizing the fracture. 

7. Separate the gastrocnemius muscle from the overlying skin and 

underlying soleus muscle. This procedure often can be done 

bluntly or with electrocautery. Be gentle. 

8. You will see the vascular pedicle coming into the deep surface of 

the muscle around the knee. Do not divide or injure these vessels. 

9. In the back of the calf, the medial and lateral parts of the muscle 

come together in the midline. The muscle fibers form a V, whose 

point marks a natural plane between the two halves of the muscle. 

The muscle can be divided along this line and then detached from 

the Achilles tendon using electrocautery. 

10. Try to bring the muscle around to the defect. The proximal 

muscle may need to be freed to allow sufficient length. This procedure 

can be done safely, but be careful not to injure the vascular 

pedicle.


11. Once the muscle is freed and seems to reach the wound, remove 

the tourniquet and ensure hemostasis. 

12. The muscle should turn pink and look healthy when the tourniquet 

is removed. If it remains dark purple, the vascular pedicle has been 

injured and you are in trouble. Another flap option, perhaps a soleus 

flap (see below under mid-calf injury) or a distant flap, is necessary. 

13. The muscle should be sutured loosely to the wound edges with absorbable 

sutures. Avoid a tight closure, which may interfere with 

the circulation to the muscle. Make sure that the blood vessels to 

the muscle are not kinked. 

14. Place a suction drain (if available) or a Penrose drain under the 

muscle flap and at the donor area. These drains should be brought 

out through the incisions. They prevent blood and other fluids 

from accumulating under the muscle flap and under the skin flap 

that was created when the muscle was dissected free. 

15. Place an STSG over the muscle. 

16. Place the leg in a posterior splint, and keep it gently elevated. 


1. The leg should remain elevated and immobilized in either a splint 

or, if an orthopedic surgeon is available, some type of internal or 

external fixation device. The leg should not be in a dependent position 

for at least 7 days after surgery. 

2. The dressing should be changed daily. Antibiotic ointment and 

saline-moistened gauze or a wet-to-wet dressing is best to use over 

the skin graft. 

3. Remove the drains after 2–3 days. 

4. The flap initially will be quite swollen. Swelling improves dramatically 

over the first 2–3 weeks and continues to improve over the 

next several months. 

5. After 7 days, when the wounds are healing well, the patient can 

gradually let the leg dangle for increasing amounts of time. Start 

with 15 minutes 2 times/day. When the leg is dependent, it should 

be gently wrapped with an Ace wrap to prevent swelling. 

Middle and Possibly Distal Third of the Calf: 

Soleus Flap 

The soleus muscle lies immediately deep to the gastrocnemius muscle 

and joins with the gastrocnemius distally to form the Achilles tendon.


The soleus flap is most useful for wounds in the middle of the calf. 

Although sometimes it can be used for wounds of the lower third, it is 

not as reliable in the lower leg. 

The soleus muscle has a somewhat segmental blood supply without 

one dominant vessel (as seen in the gastrocnemius muscle). The vessel 

that enters the top half of the muscle can nourish the whole muscle. In 

addition, a few smaller vessels in the distal portion of the muscle can 

nourish the entire soleus if the proximal vessel is divided. 

The flap is based most commonly and reliably on its proximal, main 

blood supply, but at times it can be based on the smaller, distal vessels. 

Judge which vessel to use by looking at the surrounding damage in the 

leg. In patients with proximal calf soft tissue damage, it may be prudent 

to base the flap on the distal vessels. If the injury has injured the 

distal tissues, base the flap on the proximal vessel. 

Operation 

1. General anesthesia or spinal anesthesia is required. 

2. Use a tourniquet, if available, for the dissection. 

3. Be sure that the wound is adequately debrided and that all dead 

tissue or bone is completely removed. 

4. Extend the open wound onto the medial calf skin to visualize the 

underlying muscles. Try not to leave skin bridges, which have diminished 

circulation and may become necrotic. 

5. Identify the gastrocnemius muscle, which is the most superficial 

muscle (closest to the skin). The plane of dissection is between the 

gastrocnemius muscle and underlying soleus muscle. Keep the 

gastrocnemius muscle attached to the overlying skin as you separate 

it from the underlying soleus. This procedure often can be 

done bluntly or with electrocautery. Be gentle to avoid tearing of 

blood vessels. 

6. Bluntly separate the soleus muscle from the muscles of the deep 

posterior compartment, taking care to avoid damage to blood vessels 

coming off the posterior tibial artery. Determine which way the 

flap will be based and divide the vessels that are unnecessary. 

7. Determine whether the blood vessel on which you want to base the 

flap is sufficient to supply circulation to the flap. Place a small vascular 

(noncrushing) clamp across the vessels that you plan to 

divide before doing so. If the muscle turns purple with the clamp 

in place, the blood vessel you are basing the flap on will not supply 

enough circulation to the flap.


8. Divide the muscle from the Achilles tendon (if basing the muscle 

proximally) or near its origin (if based on distal vessels). 

9. Bring the muscle to the exposed fracture site. The muscle may need 

to be freed from the tissues around the pedicle to allow sufficient 

length. This procedure can be done safely, but you must be careful 

not to injure the vascular pedicle. 

10. Once the muscle is freed and seems to reach the wound, remove 

the tourniquet and ensure hemostasis. 

11. The muscle should turn pink and look healthy when the tourniquet 

is removed. If it remains dark purple, the vascular pedicle has been 

injured and you are in trouble. A distant flap is required to cover 

the wound. 

12. The muscle should be sutured loosely to the wound edges using an 

absorbable suture. Tight closure may interfere with the circulation 

to the muscle. Make sure that the blood vessels are not kinked. 

13. Place a suction drain (if available) or a Penrose drain under the 

muscle flap and in the area from which the muscle was taken. 

These drains should be brought out through the incisions. They 

prevent blood and other fluids from accumulating under the flap 

or at the donor site. 

14. Place an STSG over the muscle. 

15. Place the leg in a splint, and keep the leg gently elevated. 


Follow the steps described above for the gastrocnemius flap. 

Distant Flaps 

In high-energy wounds, the muscles in the calf may be too damaged to 

use for coverage of the fracture site. In this case, a distant flap is required 

to achieve healing of the fracture and soft tissues. 

Although cumbersome for the patient, a cross-leg flap can be quite 

useful if you have no access to a reconstructive specialist (see chapter 

14, “Distant Flaps,” for details). 

The other option is a free flap, which is preferred if specialist help is 

available. Free flaps, however, are beyond the ability of clinicians without 

microsurgical skills. Transfer of the patient is required.



1. Byrd HS, Spicer TE, Cierney G: Management of open tibial fractures. Plast Reconstr 

Surg 76:719–730, 1985. 

2. Cohen BE: Gastrocnemius muscle and musculocutaneous flap. In Strauch B, Vasconez 

LO, Hall-Findlay EJ (eds): Grabb’s Encyclopedia of Flaps. Boston, Little, Brown, 1990, 

pp 1695–1702. 

3. Hertel R, Lambert SM, Muller S, et al: On the timing of soft-tissue reconstruction for 

open fractures of the lower leg. Arch Orthop Trauma Surg 119: 7–12, 1999. 

4. McBryde AM, Mays JT: Compartment syndrome. In Cameron JL (ed): Current 

Surgical Therapy, 6th ed. St. Louis, Mosby, 1998, pp 974–979. 

5. Tobin GR: Soleus flaps. In Strauch B, Vasconez LO, Hall-Findlay EJ (eds): Grabb’s 

Encyclopedia of Flaps. Boston, Little, Brown, 1990, pp 1706–1711. 

6. Yaremchuk MJ, Gan BS: Soft tissue management of open tibia fractures. Acta Orthop 

Belg 62(Suppl 1):188–192, 1996.

Chapter 22 

SKIN CANCER 

KEY FIGURES: 

Typical melanoma Incisional biopsy 

Basal cell carcinoma Excisional biopsy 

Squamous cell carcinoma Shave biopsy 

Punch equipment 

Punch biopsy 

Lazy S incision 

The most commonly performed plastic surgical procedures involve the 

removal of suspicious, possibly cancerous skin lesions. This undertaking 

usually is not highly technical and, particularly for lesions located 

on areas other than the face, often does not require special surgical expertise. 

In areas where few or no specialists are available, it is reasonable 

for a clinician with basic surgical skills to initiate treatment. 

However, you should have certain important background knowledge 

before removing a suspicious lesion. Lack of this knowledge may have 

negative consequences for your patient. 

This chapter presents the basics concerning the most commonly encountered 

skin cancers and the proper techniques for excising a suspicious 

skin lesion. In addition, a brief explanation of what to do for the 

patient diagnosed with a specific type of skin cancer is included. 

WWhhaatt MMaakkeess aa SSkkiinn LLeessiioonn SSuussppiicciioouuss 

Several characteristics should make you suspect cancer may be present. 

An open wound that, despite proper care, just will not heal or one that 

temporarily heals and then opens again warrants further investigation. 

Red, raised lesions that do not go away, increase in size, or have small 

blood vessels at their base should raise suspicion. Skin cancer may develop 

at the site of a preexisting mole, but not all moles are precancerous. 

When to be Concerned about a Mole 

If a patient reports a change in what had been a stable mole (i.e., one 

that has not changed in appearance for many years), biopsy/excision 

should be done. These changes include but are not limited to: 

221


• Increase in size • Ulceration/bleeding 

• Change in color • Irritation 

CCoommmmoonnllyy EEnnccoouunntteerreedd SSkkiinn CCaanncceerrss 

Melanoma 

Appearance of a typical melanoma. (From Fitzpatrick JE, Aeling JL (eds): 

Dermatology Secrets. Philadelphia, Hanley & Belfus, 1996, with permission.) 

Melanoma is potentially the most serious of all skin cancers because of 

its propensity for metastatic spread. There is still no successful adjuvant 

therapy (such as chemotherapy or radiation treatment); surgery 

remains the primary mode of treatment. The incidence of melanoma is 

increasing worldwide. 

The thickness of the lesion and the depth of skin penetration determine 

the need for subsequent surgery as well as the patient’s prognosis. This 

is why proper excision is important and should not be taken lightly. 

Etiology 

The risk for developing melanoma is related to the patient’s history of 

sun exposure and genetic background. People with fair skin, who sunburn 

easily, have a higher incidence of melanoma than darker-skinned 

people, who rarely sunburn. 

What It Looks Like 

Although sun exposure is a causative factor for the development of 

melanoma, the lesions are not necessarily found on sun-exposed 

areas. Melanoma can occur anywhere on the body, including the 

palms of the hands, soles of the feet, perineal area, and under fingernails 

or toenails.

Skin Cancer 223 

Most melanomas arise from preexisting moles. Classically, a melanoma 

is described as looking like a very dark brown or black mole, but color 

is not the only characteristic that should raise suspicion. Other characteristics 

of a pigmented mole that are considered to be worrisome (but 

not diagnostic) for melanoma include: 

• Asymmetry 

• Irregular shape 

• Border irregularity—the edges of the mole are ragged instead of 

smooth 

• Color variability—a benign mole tends to have a uniform color. A 

worrisome mole will have some portions lighter or darker than the 

predominant color. Also, a dark mole that has lost some of its pigmentation 

is worrisome. 

• Diameter > 6 mm—moles > 6 mm are at a significant risk for melanoma 

and should be excised. (However, if a mole of this size has 

been present for years, is light brown in color, and has not changed at 

all in appearance, it probably does not have to be removed.) 

Note: Many elderly people develop very dark brown/black moles that 

appear to be “stuck on” or glued to the skin surface. They do not look 

like typical moles, which are embedded in the skin. These lesions, 

known as seborrheic keratoses, are benign despite their dark pigmentation. 

However, if any of the above mentioned signs is associated with 

one of these lesions, it should be removed. 

Basal Cell Carcinoma 

Appearance of a typical basal cell carcinoma.


Basal cell carcinoma (BCC) is the most common type of skin cancer. It 

occurs primarily on sun-exposed skin and often looks like a small ulcer 

or nonhealing area with raised edges and a red base. BCCs usually do 

not metastasize, but they can recur if not adequately excised. They also 

have a propensity to burrow into deeper tissues, which can make complete 

excision difficult. 

Squamous Cell Carcinoma 

Appearance of a typical squamous cell carcinoma. 

Squamous cell carcinoma (SCC) is less common than BCC but more 

common than melanoma. SCC almost always arises on sun-exposed 

areas, often in an area with previous skin damage. It usually appears 

as an ulcerative lesion with crusting, but it can be a raised, solid, reddish 

lesion. SCC can metastasize to lymph nodes, but metastasis is not 

as common as with melanoma. 

SCC can develop in a chronic wound (i.e., a longstanding pressure sore 

or a burn that never achieved a stable scar). Such lesions involve a 

higher incidence of metastatic spread than usually is associated with 

SCC. They are more aggressive tumors. 

WWhhaatt ttoo DDoo WWhheenn SSoommeeoonnee PPrreesseennttss 

wwiitthh aa SSuussppiicciioouuss LLeessiioonn 

Start with a Good History 

History of skin cancer, either personally or in the family. Melanoma 

and even some forms of BCC may run in families. Patients with a personal 

history of skin cancer are at a higher-than-normal risk for developing 

another similar skin cancer.


History of sun exposure. This question is not aimed only at finding 

out whether the patient spends hours in the sun trying to tan, but also 

applies to patients whose work or hobbies keeps them outdoors in the 

sun. As noted above, sun exposure is a causative factor for most primary 

skin cancers. 

History of the lesion. How long has the lesion been present? Has it 

changed recently? A longstanding, stable lesion (i.e., one that has not 

changed for several years) is less worrisome than a lesion of short duration 

that has changed in appearance. 

Weight change or other change in overall medical status. Weight loss, 

general fatigue, or simply not feeling well can be signs of metastatic 

spread if no other reasons can be found. 


Note the specific characteristics of the lesion, such as size, color, and 

ulceration. 

Examine the entire patient for other suspicious lesions. It is vital to 

do a thorough examination so that other lesions are not missed. With 

melanoma on an extremity, you should be particularly concerned 

about lesions proximal to the one under suspicion. Proximal lesions indicate 

a more aggressive stage of disease. 

Check for enlargement of lymph nodes in the area where the lesion 

would drain. Enlargement may imply lymphatic spread of cancer. 

Table 1. Lymph Node Drainage Areas 

Location of Suspicious Lesion Area to Check for Enlargement of Draining Lymph Nodes 

Hand/arm Axilla (armpit) 

Foot/leg Groin/inguinal area 

Face Cervical (neck) area 

Trunk Axilla and inguinal areas; these lesions have 

multiple drainage sites 

Check for enlargement of the liver, which also can be a sign of 

metastatic spread. 

HHooww ttoo MMaakkee tthhee DDiiaaggnnoossiiss:: BBiiooppssyy 

A definitive diagnosis requires removing the entire lesion (or just a 

representative portion) and sending it to a pathologist for formal 

evaluation.


Incisional Biopsy 

Biopsy Techniques 

An incisional biopsy removes a small, representative sample of the 

lesion, not the entire lesion. It should include the full thickness of skin 

into the underlying subcutaneous tissue. 

Excisional Biopsy 

The entire lesion with a rim of surrounding, normal-appearing tissue 

is removed with an excisional biopsy. Again, the full thickness of the 

involved skin is removed. The resultant defect is larger than with an 

incisional biopsy and usually is closed primarily. However, depending 

on the size of the lesion, other choices for wound closure may be 

more appropriate. 

Shave Biopsy/Excision 

A shave biopsy removes the lesion with only the top layers of skin, 

which seem to be grossly involved with the lesion. This is more correctly 

called a shave excision. Because only the top layers of skin are removed 

rather than the full thickness of skin, the defect will heal well 

with local wound care alone. 

When to Do Which Biopsy Technique 

Table 2. Indications for Each Type of Biopsy Technique 

Technique 

Lesion 

Characteristics Reasoning Behind Biopsy Choice 

Excisional biopsy < 1–2 cm Wounds of this size usually are easy to close 

and may allow treatment with one procedure. 

Incisional biopsy Large lesions: Large wounds may be difficult to close. In- 

> 3 cm on body cisional biopsy allows you to make the diagor 

> 2 cm on nosis and plan further treatment. It is often 

face good to make the diagnosis before making 

a large wound, especially on the face. 

Shave biopsy/ Only for obviously Unless you are well trained in recognizing skin 

excision benign lesions, cancers, you probably should not perform 

seborrheic shave excisions. Especially on a pigmented 

keratitis lesion with any chance of being melanoma, 

shave excision is not recommended because 

it makes thickness measurements 

(important for staging and treatment decisions) 

impossible.

How to Do the Biopsy 


General procedures common to all techniques: 

• The excision can be done using clean technique for gloves and 

gauze, but the instruments and suture material should be sterile. 

• Place the patient in as comfortable a position as possible, sitting or 

reclining as appropriate. Because some patients faint or feel lightheaded 

during the procedure, it is best for them to be reclining. 

• Administer local anesthetic (usually lidocaine; see chapter 3, “Local 

Anesthesia”). Use as small a needle as possible, and inject slowly. 

Injection of local anesthetics hurts. If bicarbonate is available, add it 

to the solution before injection. 

• Do not inject directly into the lesion; inject into the surrounding 

normal tissues. 

• “Paint” the area, i.e., apply an antimicrobial solution to the lesion 

and surrounding skin before making any incisions. 

• The biopsy specimen should be taken to the pathologist in a small 

container with formalin. There should be at least enough formalin 

in the container to cover the lesion. 

Incisional Biopsy 

An incisional biopsy needs to be only a few mm in width and should be 

taken from an area representative of the entire lesion. Stay away from 

areas with a lot of crusting. It is usually best to take the biopsy toward 

the periphery of the lesion, because the center of a large lesion is often 

necrotic tissue, which may not yield a diagnosis on pathologic evaluation. 

It is useful to include a rim of normal-appearing skin at the margin 

to aid the pathologist. The biopsy specimen should be full-thickness 

skin, including the upper portion of the underlying subcutaneous tissue. 

Punch biopsy procedure. If you have access to a punch biopsy instrument, 

use it. This instrument has a sharp, hollow, circular end that 

easily takes the biopsy for you. 

1. The skin around the lesion should be held under some tension. 

2. Hold the instrument perpendicular to the lesion. 

3. Push the sharp end gently into the lesion; then twist 180°. 

4. Remove the instrument. 

5. The specimen can be removed by gently grasping the skin surface 

with a forceps, pulling it upwards, and cutting the subcutaneous 

tissue attachment on the undersurface of the specimen.


Left, Punch biopsy instrument. (Photo courtesy of 

Moore Medical Corporation.) 

Above, Punch biopsy procedure. The punch should 

be introduced through the dermis and into the fat. 

(From Habif TB (ed): Clinical Dermatology, 3rd ed. 

St. Louis, Mosby, 1996, with permission.) 

If you do not have access to punch biopsy instruments, use a scalpel and 

forceps. Excise a piece of tissue that is a few mm wide by 1 cm (or longer 

if the lesion is large) in an elliptical fashion (see figure below). An ellipse 

is the easiest shape to suture closed, but other shapes may be chosen, depending 

on the characteristics of the lesion. Because the biopsy site is 

small, the defect can be allowed to heal on its own (with antibiotic ointment 

and a dry dressing daily) or closed primarily with 1 or 2 sutures. 

Excisional Biopsy 

Incisional biopsy. The white 

ellipse is an example of how 

to orient an incisional biopsy 

to include abnormal skin as 

well as a normal-appearing 

skin margin. The pathology 

report showed this lesion to 

be a BCC. 

Whenever possible, primary closure of the excision site is usually best. 

However, on some areas (e.g., the calf), even small 1–2-cm excisions 

can result in a wound that is difficult to close because little redundant 

surrounding skin is available. If such is the case, you often can treat 

the wound with local dressings and allow it to heal secondarily. This


approach is especially useful on the forehead or lateral cheek (in front 

of the ear), behind the ear, and on the calf. 

If you believe that primary closure is possible, remove the lesion as an 

ellipse to facilitate closure (see figure below). If you have a marking 

pen, it is helpful to draw the ellipse or whatever shape you intend to 

use before making the incision. Usually you should draw the ellipse in 

the direction of the lesion if one dimension is larger than the other or in 

the direction of the most redundant skin. If you cannot determine the 

best direction, excise the lesion as it appears. Once the lesion is removed, 

the surrounding skin tension will open the wound and show 

you the best way to finish the ellipse to facilitate closure. 

Remember: you want to include a 1–2-mm rim of normal-appearing 

tissue around the lesion. In general, the length of the ellipse should be 

3 times its width. 

Excisional biopsy. The most common way to excise a lesion is in the form of an 

ellipse. The long axis should be approximately 2–3 times the diameter of the 

lesion so that the closure will be smooth. Undermining may be required to 

obtain wound closure. 

Make the incision. If the markings have one limb of the ellipse above 

the other, do the bottom limb first. This will prevent any bleeding from 

the top limb from dripping down and obscuring your ability to easily 

make the lower incision (a lesson learned the hard way by many). 

Cut through the skin and dermis and into the subcutaneous tissue. 

This should be a full-thickness skin biopsy. The thickness of the skin 

varies over different areas of the body. The back has very thick skin


(which is often a surprise to the inexperienced surgeon), whereas the 

skin of the dorsum of the hand or face is much thinner. 

If you have access to an electrodesiccator, use it to treat the resultant 

wound. This technique stops the bleeding and also treats any remaining 

abnormal cells if the lession is a BCC. 

If you can almost but not quite suture the wound closed, you can try 

undermining the surrounding skin (see chapter 2, “Surgical Skills”). I 

do not recommend more than a few centimeters of undermining. 

If you choose primary closure, follow the instructions in the chapter 

11, “Primary Wound Closure.” Wash the excision site and the surrounding 

skin with saline. Apply antibiotic ointment and cover with a 

dry gauze. The gauze can be removed after 24 hours; the suture line 

should be cleaned and dressed daily. After 2–3 days the suture line can 

be left open. 

If you choose secondary closure, apply antibiotic ointment to the 

wound and cover with dry gauze. The wound should be dressed and 

cleansed daily. Wet-to-dry dressings also may be used. Once the 

wound has formed an eschar (dry scab), no dressings are required. 

Reassure the patient that leaving the wound open to heal secondarily 

will not necessarily lead to an increased risk of infection, but it may 

leave a somewhat larger scar than primary closure. However, because 

closing a wound under tension involves far higher risks for infection 

and wound-healing problems, secondary closure is more appropriate. 

Shave Excision 

Shave excision. The curved surgical blade is laid flat on the skin surface and 

drawn smoothly through the base of the lesion. (From Habif TP: Clinical 

Dermatology, 3rd ed. St. Louis, Mosby, 1996, with permission.)


Performing a shave excision requires a scalpel and forceps. Place the 

scalpel so that it is flat against the skin with the sharp edge parallel to 

the skin. Using a back-and-forth sawing motion, pass the knife under 

the lesion, taking only the top layers of skin. Dermis should remain at 

the excision site when the lesion is removed. 

The resultant defect should be treated with an electrodessicator if possible. 

The electrodessicator heats the tissues and kills superficial cancer 

cells if the lesion is BCC. Apply antibiotic ointment to the wound and 

cover with a dry gauze. Repeat daily until a dry scab forms. The 

wound can then be left open. 

Marking the Tissue Specimen 

For all excisions, it is helpful to mark the specimen so that the pathologist 

can orient the lesion. Place a nonabsorbable stitch at the superior 

edge of the specimen, and tie it in place. Cut the ends, and note on the 

specimen slip what the marking stitch represents (i.e., superior 

margin). Another stitch can be placed along the medial or lateral 

margin. Cut the suture ends longer than the stitch on the superior 

margin. Again, be sure to explain what you have done on the pathology 

slip (i.e., long stitch = lateral margin). 

If the lesion is malignant and goes to the edge of the specimen, the 

pathologist can report which edge of the specimen is involved. This information 

simplifies the repeat excision. 

WWhhaatt tthhee PPaatthhoollooggyy RReeppoorrtt MMeeaannss 

iinn TTeerrmmss ooff FFuurrtthheerr TTrreeaattmmeenntt 

If the lesion is benign: 

You are done. Remove the sutures when appropriate. If you did an incisional 

biopsy and part of the lesion remains, you can remove the remainder 

by using the shave biopsy technique, if the patient so desires. 

If the lesion is fully excised BCC or SCC: 

You are done. Remove the sutures when appropriate. The patient 

should be seen again in 3–6 months and then yearly. Look for new lesions, 

and check the excision site for recurrence. 

If the lesion is BCC that was not fully excised: 

If you have a close margin (< 0.1 mm) and treated the area with the 

electrodessicator at the time of the excision, you can either watch 

closely (see the patient every 3 months for the first year and then semiannually) 

or re-excise. Repeat excision is recommended if you expect


follow-up to be difficult or impossible or if you did not have access to 

an electrodessicator. 

If the lesion is SCC that has not been fully excised: 

Re-excise. You should take a bit more grossly “normal” tissue with reexcision 

of SCC than with re-excision of BCC. 

Re-excision of BCC or SCC 

The re-excision can be done at the time of diagnosis or after a few 

weeks when the tissues have begun to heal. 

If the defect was closed primarily, the portion of the suture line containing 

the positive margin should be excised as an ellipse. Remember 

to take a few mm margin around the suture line to ensure a clear 

margin (i.e., no residual tumor). 

If the biopsy site is healing secondarily, excise the involved margin, 

making sure to take at least a few mm of grossly normal surrounding 

skin. 

If the positive margin is the deep margin: make sure that you go 

deeper into the subcutaneous tissues than on the first excision. 

IIff MMeellaannoommaa iiss DDiiaaggnnoosseedd 

Patients diagnosed with melanoma should see a specialist. However, if 

no specialist is accessible, further excision is required. The extent of the 

re-excision is determined by the depth of the primary lesion. The following 

is a basic guide to further treatment. 

A lesion < 1.0 mm is considered a very thin melanoma, but it still 

needs to be re-excised with a 1-cm margin all the way around the scar. 

Often such re-excision is curative. 

A lesion of 1.0–4.0 mm is considered an intermediate-thickness melanoma. 

Re-excision is required with 1.5–2-cm margins. Often you will 

not be able to close the resultant defect primarily. A split-thickness skin 

graft or a local flap may be the best option for closure. In the presence 

of clinically palpable lymph nodes, lymphadenectomy is recommended. 

This procedure is beyond the abilities of a nonsurgeon; refer 

the patient to a specialist. 

A lesion > 4 mm is considered a thick melanoma and is associated 

with a high likelihood of metastatic spread at the time of diagnosis. To 

control local disease, re-excision with 2–3-cm margins is recommended. 

Split-thickness skin grafting or a local flap often is required. 

In the presence of clinically palpable lymph nodes, lymphadenectomy 

is recommended.

Re-excision for Melanoma 


A re-excision for melanoma is a more extensive procedure than re-excision 

for BCC or SCC. It is also more extensive than the initial biopsy. 

The melanoma re-excision includes skin and subcutaneous tissue 

down to, but not including, the fascia of the underlying muscle group. 

This is a much larger chunk of tissue than the initial biopsy. Unless the 

lesion is in an area with a great deal of redundant tissue (e.g., on the 

abdomen), a split-thickness skin graft or local flap may be required for 

closure. 

One technique that may facilitate primary wound closure is to perform 

the re-excision making a “lazy S” incision instead of the usual ellipse 

(see figure below). With limited undermining of the surrounding skin 

edges, the lazy S incision often can be closed primarily. 

To perform a wide excision for melanoma, it is often useful to use the lazy S 

technique instead of the usual ellipse. 

Reasons for Specialist Intervention 

In an attempt to improve overall survival rates, a new technique called 

sentinel lymph node biopsy is recommended for patients with thin 

and intermediate-thickness melanoma and no clinically palpable 

draining lymph nodes in an attempt to identify microscopic metastatic 

lymph node spread. It is hoped that removal of diseased lymph nodes 

before they become clinically palpable can prevent melanoma cells 

from metastasizing to a distant site. 

Essentially the surgeon injects dye or a radioactive isotope into the 

area of the primary lesion. The draining lymph node basin is then surgically 

explored, and the specific lymph node that first takes up the 

dye/isotope is identified. If a radioactive isotope is used, a Geiger


counter-like device is used to find the lymph node; if dye is used, the 

surgeon looks for a blue lymph node. The lymph node is then removed, 

and the pathologist examines it thoroughly for melanoma. If 

no cancer is found, no further treatment is performed. If cancer is present, 

a formal lymph node dissection is performed. So far this approach 

shows promise for catching the cancer at the earliest possible 

stage with the least amount of patient morbidity. 

For All Patients with Melanoma 

Check for enlargement of draining lymph nodes, and order a chest radiograph 

to look for signs of metastases. The patient should be followed 

every 3–6 months for several years to look for recurrence at the 

excision site, new satellite lesions in the skin heading toward the draining 

lymph area, enlargement of draining lymph nodes, and enlargement 

of the liver. 

IImmppoorrttaanntt PPoosstteexxcciissiioonn IInnssttrruuccttiioonnss ffoorr AAllll PPaattiieennttss 

Remind all patients that sun exposure is a causative factor in most primary 

skin cancers. All patients who have been seen for a suspicious 

skin lesion should be counseled about the importance of staying out of 

the sun as much as possible. The regular use of a good sunscreen (SPF 

> 15) must be emphasized. 


1. Balch C, Houghton A, Sober A, Soong S (eds): Cutaneous Melanoma, 3rd ed. St. Louis, 

Quality Medical Publishing, 1998. 

2. Goldberg DP: Assessment and surgical treatment of basal cell skin cancer. Clin Plast 

Surg 24:673–686, 1997. 

3. Roth JJ, Granick MS: Squamous cell and adnexal carcinomas of the skin. Clin Plast 

Surg 24:687–700, 1997. 

4. Wagner JD, Gordon MS, Chuang TY, Coleman JJ: Current therapy of cutaneous 

melanoma. Plast Reconstr Surg 105:1774–1799, 2000. 

5. www.skin-cancer.com 

6. www.melanoma.net

Chapter 23 

CLEFT LIP/PALATE 

KEY FIGURES: 

Unilateral cleft lip Cleft lip: preoperative 

Bilateral cleft lip and postoperative 

Cleft palate Pierre Robin syndrome 

Also known as “harelip,” cleft lip with or without a cleft palate is the 

most common craniofacial birth defect. It is beyond the scope of this 

text to describe the specific surgical procedures used to correct this 

anomaly. In fact, the treatment of cleft lip/palate remains a challenging 

problem even for plastic and reconstructive surgeons. 

All health care providers, especially those in rural settings, should have 

an understanding of basic background information so that they can educate 

parents and ensure that the child receives proper treatment. 


Cleft Lip 

A cleft lip results when the developing tissues of the lip do not completely 

fuse. The lip is divided into two parts, and an incorrect alignment 

of the lip muscles (orbicularis oris) results. 

A cleft lip primarily involves the upper lip, although rare forms of 

facial clefting can involve the lower lip. The typical cleft lip often 

involves the nose, with resultant distortion of the nostrils and nasal 

sill. 

Cleft Palate 

The palate is essentially the roof of the mouth. It is composed of two 

parts, the hard palate and the soft palate. The teeth erupt in the anterior 

hard palate (called the alveolar ridge), and the posterior hard 

palate serves as the base of the nasal cavity. 

235


Unilateral cleft lip. The upper lip is twisted and shortened vertically. Cupid’s 

bow is incomplete, the vermilion tapers cephalad, and the white line extends 

into the vestibule. In this case an alveolar cleft is present, creating a defect in 

the nasal floor. The alar rim is significantly distorted. (From Jurkiewicz MJ, et al 

(eds): Plastic Surgery: Principles and Practice. St. Louis, Mosby, 1990, with 

permission.) 

Bilateral cleft lip. Severely shortened columella, wide flattened alae, and jutting, 

often rotated premaxilla are hallmarks of the deformity. (From Jurkiewicz 

MJ, et al (eds): Plastic Surgery: Principles and Practice. St. Louis, Mosby, 


The soft palate is the posterior portion of the roof of the mouth. The 

soft palate is mobile and is composed of several muscles important for 

normal speech and proper function of the eustachian tubes (associated 

with the middle ear).

PPrreesseennttaattiioonn aanndd IInncciiddeennccee 

Presentation varies widely. The child may be born with a unilateral or bilateral 

cleft lip with a normal palate, a cleft palate (soft only or hard and 

soft) with a normal lip, or a unilateral/bilateral cleft lip with a cleft palate. 

The most common presentation is left-sided unilateral cleft lip with cleft 

palate. Male infants are affected more often than female infants. 

The majority of affected infants are otherwise healthy and normal intellectually. 

However, there is a 25% incidence of additional anomalies, 

including neurologic and cardiac abnormalities as well as club foot. 

Evaluate the child closely so that other problems are not missed. 

Cleft lip/palate is the most common congenital facial abnormality. The 

incidence in Caucasian populations is 1–1.5/1000 live births; in African 

and African-American populations, < 0.5/1000 live births; and in 

Asian and Hispanic populations, 2–3/1000 live births. 

EEmmbbrryyoollooggiicc DDeevveellooppmmeenntt aanndd EEttiioollooggyy 

Cleft Lip/Palate 237 

Unilateral complete cleft lip and palate. (From Jurkiewicz MJ, et al (eds): 

Plastic Surgery: Principles and Practice. St. Louis, Mosby, 1990, with permis- 

During fetal development the lip and palate are formed during the first 

trimester (days 30–60 of gestation). A cleft develops when something 

interferes with the normal processes of fusion and mesodermal penetration 

of the frontonasal processes and maxillary processes of the face 

of the embryo. Essentially, instead of growing together to form a 

normal lip and palate, the embryonic tissues remain separate, causing 

the cleft to develop.


Parents without clefts who have one child with a cleft lip/palate have 

a 5% chance of having another child with a cleft lip/palate (compared 

with the usual 0.14% risk in parents with no family history of cleft). If 

both one parent and one child have a cleft or if two normal parents 

have two children with clefts, the likelihood of a cleft in another child 

increases to 15–20%. These data seem to suggest a genetic component. 

The development of cleft lip/palate, however, probably is due to a 

combination of multiple factors—for example, folic acid deficiency, advanced 

maternal/paternal age, use of anticonvulsants (phenytoin or 

phenobarbital), alcohol intake, and possibly smoking. A viral etiology 

also has been suggested. 

It is quite common for the parents of a child with a cleft to give a history 

that includes none of the above factors. In some rural cultures, a 

cleft palate is thought to represent a sign of evil or wrong-doing on the 

part of the family. Parents are often quite guilt-ridden, thinking that 

they did something to cause the defect. Therefore, it is important to assure 

parents that they did nothing wrong to cause the child’s abnormality. 

IImmmmeeddiiaattee CCoonncceerrnnss 

Adequate Nutrition 

The initial concern for an infant with cleft lip/palate is ingestion of 

adequate calories and fluids to maintain health and allow proper 

growth. 

An infant’s ability to suck is related to two factors: the ability of the external 

lips to perform the necessary sucking movements and the ability 

of the palate to allow the necessary build-up of pressure inside the 

mouth so that foodstuff can be propelled into the mouth. 

Infants with cleft lip/palate have sufficient external lip muscle movements. 

Therefore, an isolated cleft lip usually does not interfere with 

the child’s ability to suck, although it may take some practice not to 

lose a lot of milk out of the cleft lip defect. 

In contrast, a child with a cleft palate with or without a cleft lip has difficulty 

sucking properly. The cleft in the palate impedes the proper 

build-up of pressure inside the mouth. For the same amount of effort, 

the infant with a cleft palate does not ingest as much milk as a normal 

infant. This increase in the work of feeding may lead to insufficient 

intake of calories for proper growth and health.

Helpful Strategies 


The child should be fed with the head upright at about a 45° angle. 

Usually bottle feeding is needed. If possible, use a nipple made for premature 

infants because it has a larger opening than normal. An alternative 

is to cut an X in the tip of a regular nipple to enlarge the opening. 

The larger-than-normal opening allows more liquid to flow out of the 

nipple with less suction. 

A squeezable bottle also facilitates getting the milk into the infant’s 

mouth. 

If you are in an area with access to a pediatric orthodontist, an appliance 

can be made to fit into the infant’s mouth and cover the cleft 

defect. This appliance, called an obturator, greatly improves the infant’s 

ability to suck and ingest calories with less energy expenditure. 

Do not be alarmed when milk comes out of the infant’s nose. The 

palate serves to separate the nasal cavity from the oral cavity. The 

presence of a cleft in the palate removes this separation so that food 

and liquids easily pass from the mouth and come out of the nose. 

IInniittiiaall CCoorrrreeccttiivvee OOppeerraattiioonnss 

Correction of the cleft lip/palate deformity is not a life-preserving 

medical necessity. However, nontreatment often results from lack of 

access to specialists rather than a conscious decision to leave the child 

untreated. 

A cleft lip/palate is a challenging deformity to repair. Usually, the lip is 

repaired at around 3 months of age. In full-term, healthy infants, however, 

repair may be undertaken at an earlier age. 

In utero repair of the cleft lip defect is a subject of ongoing research. 

Clefts usually can be seen on prenatal ultrasound, and it has been 

shown that fetal tissues heal without the scars usually seen in infants 

and adults. 

The palate is repaired at a separate operation, usually when the infant 

is around 12 months of age. In areas with limited access to specialists, 

however, the lip and palate can be repaired at the same time. In fact, 

even in the developed world where plastic surgeons are abundant, 

some authorites believe that simultaneous repair of the lip and palate 

may yield better results than separate repairs. 

Often, if the infant has recurring ear infections, pressure-equalizing 

(PE) tubes are needed. Usually they are inserted at the time of palate 

repair.


Infant with an incomplete bilateral cleft lip. A, Preoperative appearance. 

B, Appearance after one operation. 

Other Possible Operations 

Unfortunately, even under the best of circumstances, further operations, 

available primarily to patients in the developed world, may be 

required for definitive treatment. The combination of cleft lip and cleft 

palate requires additional surgery more often than cleft lip or cleft 

palate alone. 

Even if the palate is properly repaired, the child may have significant 

speech difficulties. Often they can be corrected with speech therapy, 

but approximately 20% of children with a repaired cleft palate require 

an additional operation to improve palatal function, usually between 

the ages of 4 and 6 years. 

Irregularities of the lip often are noticeable even after repair. Some irregularities 

that are present when the child is 1–2 years of age are due 

to tight scarring and improve with time. Revisions usually are delayed 

until the child is 4–6 years of age. 

In addition, significant deformity of the nostrils may require correction, 

usually when the child is 4–6 years of age. Surgery on the nose 

can be done at the same time as lip revisions. 

Most clefts of the anterior hard palate (alveolar ridge) are repaired 

when the canine tooth on the side of the cleft begins to erupt, usually 

around age 7–8 years.

Optimally, a pediatric dentist or orthodontist should be continually involved 

with the care of children with cleft palate to get the teeth in as 

normal a position as possible. 

If the maxilla (upper jaw) does not grow normally, corrective surgery 

may be indicated. The procedure, called a Le Fort I osteotomy, usually 

is delayed until the child is much older, often in the later teen 

years. 

Table 1. Overview of Operations that May be Required for Cleft Lip/Palate 

PE = pressure-equalizing. 

VViissiittiinngg SSuurrggeeoonn PPrrooggrraammss 


Approximate 

Age Operation Comments 

3 mo Cleft lip repair Should be delayed for small children (< 10 lb or 

4 kg) to decrease risks from anesthesia. 

12 mo Cleft palate repair Can be delayed to 18 mo because of airway concerns, 

but should be done before infant starts 

to talk. 

3–12 mo PE tubes Depending on number of ear infections, PE tubes 

can be placed at time of lip repair or palate 

repair. 

4–6 yr Improvement of Improves child’s speech; about 20% of children 

palatal function with cleft palate repair require additional surgery. 

4–6 yr Lip revision, minor 

nostril corrections 

These procedures can be done at the same time. 

7–8 yr Repair of anterior Usually done when canine tooth begins to erupt; 

(alveolar) hard can be done successfully in older child (10–12 

palate yr old). 

> 17–18 yr Le Fort I osteotomy: Maxilla usually does not grow normally in child born 

upper jaw surgery with cleft palate and may need to be cut and repositioned 

to correct relationship of upper jaw 

to lower jaw (mandible). 

> 17–18 yr Rhinoplasty; more Nose may need significant work to achieve more 

complex nose normal appearance and function. Procedure 

surgery than may include cartilage grafts, bone repositioning, 

performed before and correction of deviated septum. 

Skilled plastic surgeons and other health professionals in several international 

programs travel to remote areas and perform cleft lip/palate 

repair and other reconstructive procedures. These high-volume initiatives 

serve tens of thousands of patients. There is no need for rural 

families to lose hope for their child. 

Listed on the following page are just a few organizations that you can 

contact to gain more information or to arrange a visit to your area.


Table 2. Visiting Surgeon Programs 

Organization Contact Information Background Information 

Operation Smile (757) 321-7645 Operating since 1982 

Fax: (757) 321-7660 Members travel in 

6435 Tidewater Drive U.S. and through- 

Norfolk, VA 23509 

www.operationsmile.org 

out world 

Interplast (650) 962-0123 Operating since 1969 

Fax: (650) 962-1619 Members travel 

300-B Pioneer Way 

Mountain View, CA 94041 

www.interplast.org 

e-mail: DirMedServcs 

@Interplast.org 

throughout world 

American Society (847) 228-9900 Formed in 1988 

of Plastic Surgery- Fax: (847) 228-9131 Clearinghouse that offers 

Reconstructive 444 E. Algonquin Rd information about many 

Surgeons Volun- Arlington Heights, IL 60005 organizations that 

teers Program www.plasticsurgery.org volunteer time and 

skills worldwide 

PPiieerrrree RRoobbiinn SSyynnddrroommee 

Pierre Robin syndrome is another congenital anomaly to be aware of. 

These patients may also have a cleft palate, so be sure to evaluate all 

neonates with a cleft palate for signs of this syndrome. 

Pierre Robin syndrome describes an infant with a small, posteriorly 

displaced mandible that causes the tongue to seem too large for the 

mouth. During fetal development a cleft palate or a highly arched 

Pierre Robin syndrome. Note the 

small lower jaw and the resultant 

position of the tongue in 

the back of the throat. The 

tongue can cause potentially 

life-threatening airway obstruction. 

(From McCarthy J (ed): 

Plastic Surgery. Philadelphia, 

W.B. Saunders, 1990, with permission.)


palate forms to accommodate the relatively large tongue. Early recognition 

of newborns with Pierre Robin syndrome is mandatory to avoid 

serious complications. 

Immediate Concerns 

Affected infants may present with episodes of severe respiratory distress. 

When the infant is in an upright position or with the head forward, 

the tongue falls forward and the airway opens. If the infant is 

placed in the supine position (lying down, face up—the usual position 

in which an infant is placed to sleep), the tongue falls backward and 

blocks the airway, causing severe respiratory distress. If unrecognized, 

this syndrome can result in death. 

Treatment 

• The infant must be monitored closely and kept in the prone (facedown) 

position for sleep. 

• The child should sit upright in a somewhat forward position when 

eating. 

• Occasionally the tongue needs to be stitched to the lower lip to prevent 

the tongue from falling backward. 

• Rarely, in very severe cases, the infant may require a tracheotomy to 

maintain an adequate airway. 

• If the infant has a cleft palate, repair is usually delayed until the child 

is a few years old because of airway concerns. 

• As the infant grows, the mandible grows. Respiratory concerns 

become less problematic. Usually, no other treatment is required. 


1. Mackool RJ, Gittes GK, Longaker MT: Scarless healing. Clin Plast Surg 25:357–366, 

1998. 

2. Stal S, Klebuc M, et al: Algorithms for the treatment of cleft lip and palate. Clin Plast 

Surg 25:493–507, 1998.

Chapter 24 

BREAST SURGERY 

KEY FIGURES: 

Saline implant reconstruction 

Latissimus dorsi reconstruction 

Free TRAM reconstruction 

In the developed world, breast reconstruction after mastectomy and 

breast reduction (reduction mammaplasty) are common reconstructive 

procedures. They require a combination of artistic and technical skills, 

which can be obtained only through many years of surgical training. 

Because of their highly technical nature, no specific procedures are discussed 

in detail. Instead, this chapter offers basic information. 

BBrreeaasstt RReeccoonnssttrruuccttiioonn 

Evolution of Procedures 

Over the past 25 years, because of advances in plastic surgical techniques, 

the esthetic quality of breast reconstruction has improved greatly. Before 

the early 1970s, breast reconstruction was a multistaged procedure in 

which a distant random flap was transferred to the chest in a series of operations. 

The results were not always successful, nor were the reconstructed 

breasts consistently cosmetically pleasing. 

Snyderman and Guthrie reported the use of a silicone implant for 

breast reconstruction in 1971. Their achievement was remarkable because 

for the first time a breast was reconstructed in a single procedure. 

Although it was not necessarily a cosmetic triumph, patients were so 

pleased to have a breast after one operation that they considered the 

procedure worthwhile. 

Implant reconstruction is still a popular option for breast reconstruction, 

although now saline implants are used. To achieve the best aesthetic 

result, implant reconstruction is often not a single procedure. 

Initially, a tissue expander (a modified implant to which the surgeon 

245

246 Basic Surgical Procedures for the Nonsurgeon 

Breast reconstruction with a saline 

implant. Nipple-areolar reconstruction 

also has been completed. (Photo 

courtesy of Nelson Goldberg, M.D.) 

can add saline in the office) is placed under the chest wall muscles and 

skin. The expander is then gradually filled with saline to stretch the tissues 

of the chest. Thus, an implant large enough to match the opposite 

breast eventually can be placed. Expansion usually takes several 

months to complete, and a second operation is required to replace the 

expander with the permanent implant. 

Implant breast reconstruction has its drawbacks. Because the implant 

is a foreign body, risks include infection, implant deflation, and distortion 

of the reconstructed breast. It is also difficult to create a droopy 

breast with an implant. Because of these limitations, other reconstructive 

options were developed. 

In the late 1970s, axial musculocutaneous flaps enhanced a patient’s reconstructive 

options. These flaps (composed of muscle and overlying 

skin and subcutaneous tissue) could be designed for use in breast reconstruction. 

The use of a muscle flap allows creation of the reconstructed 

breast from the patient’s own tissues. 

The latissimus dorsi flap (a flap using tissue from the back) became a 

popular reconstructive option. However, only a relatively small sized 

breast can be reconstructed with this flap, so an implant may still be 

needed to attain symmetry in a large-breasted woman. The advantage 

of this procedure is that even if an implant is needed, the breast can be 

reconstructed in one operation. The latissimus dorsi flap with or without 

an implant remains a viable reconstructive option. 

In the mid 1980s, Carl Hartrampf popularized the pedicle TRAM flap 

for breast reconstruction. TRAM stands for transverse rectus abdominis 

(the paired muscles that are vertically oriented on the abdomen 

and run on either side of the umbilicus) myocutaneous flap. This procedure 

often is called the “tummy tuck” breast reconstruction.

Breast Surgery 247 

Latissimus dorsi flap. A, Patient with 

Paget’s disease of the right breast. 

B, The patient underwent a skinsparing 

mastectomy; only the nipple 

and areolar skin were removed with 

the underlying breast tissue. The 

breast was reconstructed immediately 

with a latissimus dorsi musculocutaneous 

flap. The flap is drawn 

on the patient’s back. C, Final result 

before nipple reconstruction. 

The pedicle TRAM flap is composed of the lower abdominal skin and 

subcutaneous tissue, which remains attached to the rectus abdominis 

muscle. The blood supply comes from the superior portion of the 

muscle. The TRAM flap allows creation of a larger breast (compared 

with the latissimus dorsi flap) without the need for an implant. 

The pedicle TRAM flap is still a popular reconstructive technique, but 

the procedure does have limitations. Under some circumstances and in 

some patient populations (diabetics, smokers, and obese patients), an 

unacceptably high rate of partial flap loss has been noted. 

Because of these limitations, researchers performed cadaver dissections 

to more fully evaluate the blood supply to the TRAM flap. These 

studies demonstrated that the tissues making up the TRAM flap are 

better supplied by the deep inferior epigastric artery and inferior 

rectus muscle (as opposed to the deep superior epigastric artery and 

superior rectus muscle used in the pedicle TRAM technique). 

Microsurgeons now perform breast reconstruction using the TRAM as 

a free flap based on the deep inferior epigastric vascular circulation. 

Because of its better blood supply, the free TRAM flap overcomes most 

of the limitations of the pedicle TRAM.


Currently free TRAM breast reconstruction offers the best way to make 

a large breast in one operation using the patient’s own tissues. The 

drawback is that not all plastic surgeons have the technical skills required 

to perform microsurgery. 

Free TRAM breast reconstruction. A, 

Preoperative markings show the 

amount of abdominal wall tissue to be 

removed. The rectus muscles and vascular 

pedicle also are drawn to show the 

underlying anatomy. B, Completed re- 

RReeccoonnssttrruuccttiioonn ooff tthhee NNiippppllee aanndd AArreeoollaarr CCoommpplleexx 

The above procedures describe the creation of the breast mound. The 

nipple and areolar complex usually are reconstructed in a second, relatively 

minor procedure. 

Small flaps of tissue from the breast mound are used to create a nipple. 

Sometimes a full-thickness skin graft is required as well. A tattoo machine 

is used to add pigment to the nipple and surrounding skin to 

complete the reconstruction of the nipple and areolar complex. This 

procedure often can be done in the surgeon’s office. 

TTiimmiinngg ooff BBrreeaasstt RReeccoonnssttrruuccttiioonn 

Breast reconstruction can be done at the time of mastectomy (immediate 

reconstruction) or at almost any time after the mastectomy (delayed 

reconstruction). The advantage of an immediate reconstruction is that 

the patient awakens from the mastectomy with a reconstructed breast. 

Avoidance of an extended period with a flat, scarred chest is an important 

psychological boost for some patients.

Breast Surgery 249 

Because of concerns that reconstruction may interfere with surveillance 

for recurrent breast cancer, general surgeons initially were hesitant 

to refer patients for immediate breast reconstruction. Studies have 

shown that these concerns are unwarranted. Immediate breast reconstruction 

does not interfere with surveillance or mask evidence of recurrent 

disease. 

Some patients may not be appropriate candidates for immediate reconstruction 

because of the extent of disease or concerns that postoperative 

radiation or chemotherapy may affect the reconstruction. Delayed 

reconstruction is always an option and can be performed months or 

even years after cancer treatments have been completed. The timing of 

breast reconstruction is ultimately decided on an individual basis after 

thorough discussion between the patient and her doctors. 

Currently, women with breast cancer have many options for breast reconstruction. 

Depending on the patient’s reconstructive needs and expectations, 

the prognosis for obtaining a matched pair of breasts after 

mastectomy is excellent. 

BBrreeaasstt RReedduuccttiioonn 

Large, pendulous breasts (D–DDD or even larger cup sizes) can be a 

source of embarrassment for some women and also may cause significant 

neck, upper back, and shoulder pain. These symptoms can significantly 

interfere with their ability to work. 

Breast reduction (reduction mammaplasty) decreases the size of the 

breasts, so that they are more appropriately proportioned to the patient’s 

body habitus. Attaining an aesthetically pleasing result is a high priority. 

Classically, this procedure involves large incisions to remove excessive 

breast tissue and to reposition the nipple and areolar complex. 

These incisions result in long scars (around the areola, from the 

areola to the inframammary fold, and along the inframammary fold). 

These scars can be problematic as well as noticeable. Other complications 

of breast reduction include loss of nipple sensation, inability to 

breast feed, and loss of the nipple/areolar complex. Despite these 

risks, most women who undergo breast reduction are quite pleased 

with the results. 

To obviate the need for such large incisions and to decrease the risks 

for other complications, liposuction is beginning to be included in the 

operative technique. Currently, plastic surgeons are developing other 

modifications to decrease the risks inherent in breast reduction.


GGyynneeccoommaassttiiaa 

Gynecomastia is the term for abnormal enlargement of the male breast. 

It is commonly encountered in pubescent males or older men because 

of hormonal considerations. Gynecomastia associated with puberty 

usually resolves within a few years; no surgery should be considered 

until the patient is at least 19 or 20 years of age. 

When evaluating a patient with gynecomastia, be sure to get a thorough 

medical history. Medications associated with gynecomastia include 

cimetidine, spironolactone, digitalis, and reserpine. Be sure to inquire 

about recreational drug use because marijuana also has been implicated. 

You must examine the patient’s testicles to rule out the presence of a 

testicular tumor, which may produce hormones responsible for breast 

enlargement. Especially with unilateral enlargement or when a a discrete 

breast mass is palpable, you must rule out the possibility of an 

underlying breast cancer. (Yes, men can get breast cancer). Blood tests 

to evaluate the levels of various hormones also should be done. 

Gynecomastia is quite challenging to treat. Simple mastectomy used to be 

the treatment of choice, but esthetic considerations make it a poor option. 

Currently, liposuction with or without additional formal excision of 

breast tissue (using a small incision along the areola) is the treatment of 

choice and has resulted in a markedly improved esthetic outcome. 


Breast reconstruction 

1. Hartrampf CR, Scheflan M, Black PW: Breast reconstruction with a transverse abdominal 

island flap. Plast Reconstr Surg 69:216–225, 1982. 

2. Maxwell GP: Latissimus dorsi breast reconstruction: An aesthetic assessment. Clin 

Plast Surg 8:373–387, 1981. 

3. Schusterman MA: The free TRAM flap. Clin Plast Surg 25:191–195, 1998. 

4. Slavin SA, Schnitt SJ, Duda RB, et al: Skin-sparing mastectomy and immediate reconstruction: 

Oncologic risks and aesthetic results in patients with early-stage breast 

cancer. Plast Reconstr Surg 102:49–62, 1998. 

5. Snyderman RK Guthrie RH: Reconstruction of the female breast following radical 

mastectomy. Plast Reconstr Surg 47:565, 1971. 

6. Spear SL, Majidian A: Immediate breast reconstruction in two stages using textured, integrated 

valve tissue expanders and breast implants: A retrospective review of 171 consecutive 

breast reconstructions from 1989–1996. Plast Reconstr Surg 101: 53–63, 1998. 

Breast reduction/Gynecomastia 

7. Hammond DC: Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. 


8. Hidalgo DA: Improving safety and aesthetic results in inverted T scar breast reduction. 


9. Lejour M: Vertical mammaplasty: Update and appraisal of late results. Plast Reconstr 

Surg 104:771–781, 1999. 

10. Rosenberg GJ: Gynecomastia. In Spear SL (ed): Surgery of the Breast: Principles and 

Art. Philadelphia, Lippincott Williams and Wilkins, 1998, pp 831–841.

Chapter 25 

FACIAL FRACTURES 

KEY FIGURE: 

Ivy loops 

Definitive treatment for most facial fractures requires advanced surgical 

skills and special equipment. However, certain interventions that 

may improve patient outcome do not require special skills. This chapter 

provides basic information about the initial evaluation and treatment 

of patients with a facial fracture. In addition, an easy-to-perform 

procedure specifically for the treatment of a mandible (lower jaw) fracture 

is described to assist the provider with no access to specialty care. 

IInniittiiaall PPaattiieenntt EEvvaalluuaattiioonn 

The type of injury that results in a facial fracture can cause other significant 

injuries. When examining a patient with a possible facial fracture, 

you must be vigilant not to overlook a potentially life-threatening 

injury. 

If the patient was reported to have lost consciousness or if the patient 

has any signs of altered level of consciousness, you must rule-out a 

cerebral injury. 

Patients with a facial fracture also may have a cervical spine injury. Be 

careful with positioning of the patient’s head and neck until you are 

sure that the cervical spine is not injured. 

Be sure the patient is breathing easily and has a stable airway. Patients 

with a fractured lower jaw or severe fracture of the midface (cheekbones, 

nose, and/or upper jaw) may have difficulty with breathing. 

Difficulty with breathing can result from blockage of the airway by 

bleeding from the fracture site or by displaced bones. 

Patients with injury around the eye, should have a thorough eye exam. 

See chapter 5, “Evaluation of the Acutely Injured Patient,” for more 

specific information. 

251


DDiiaaggnnoossiiss 

Physical Exam 

Most patients who sustain any type of facial trauma have significant 

soft tissue swelling. However, swelling alone does not signify a fracture. 

Feel along the jaws, cheeks, orbital rim, and base of the nose. You 

are looking for bony instability or a “step-off” irregularity of the bones, 

which indicates a fracture. 

If the fracture involves tooth-bearing bone, patients often report that 

their teeth do not seem to meet correctly or that the teeth do not feel 

“right” during biting down. Check to see whether the patient can adequately 

open and close his or her mouth. 

Examining the Patient’s Bite 

• Use a tongue depressor to pull each cheek away from the teeth. 

• Have the patient gently close the mouth and bring the teeth together. 

• Examine the vertical midline between the upper and lower central 

incisors. Does it line up? 

• Look along the lateral side of the molars. Are the molars lined up 

equally, or do you see space between the upper and lower teeth on 

one side but not the other? 

• Ask the patient whether any findings you note are new or old. New 

changes probably represent the result of a fracture involving toothbearing 

bone. 

• If the jaw is fractured, look inside the mouth for a laceration of the 

gum overlying the fracture. If the gum is torn, the fracture is an open 

fracture that requires treatment with antibiotics. 

Patients with a fracture of the cheek bone or orbit often report numbness 

of the inner cheek and upper lip on the side of the fracture. The 

numbness is due to injury of the infraorbital nerve (V2) as it emerges 

from the bone under the inferior orbital rim. Normal sensation often 

returns within 1–2 months of injury. The eyelids on the side of the 

injury show significant swelling, and the conjunctiva may be bloodstained. 

Radiologic Studies 

The best way to evaluate the mandible is with a Panorex radiograph 

that shows the entire upper and lower jaws.

Facial Fractures 253 

If you have access to a computed tomography (CT) scanner, order a 

face scan with axial and coronal views. CT is the best way to diagnose 

a fracture of the other facial bones. Note: To allow coronal views, the 

patient must hyperextend at the neck or lie prone with the neck bent. 

The cervical spine must be cleared of injury before obtaining coronal 

views on a CT scan of the face. 

Plain radiographs of the face should be obtained if you cannot get a 

CT scan. When interpreting the radiographs, begin by looking at the 

maxillary sinuses (the large paired sinuses on either side of the nose). 

Usually, the sinuses are areas of black (air), surrounded by white bone 

and located on either side of the nose. If fluid is present in the sinus, it 

looks white instead of black. The presence of fluid may be due to a 

fracture and should alert you to check the radiographs carefully for a 

fracture on the same side of the face. 

BBaassiicc IInniittiiaall TTrreeaattmmeenntt 

If the patient has a fracture of the jaw with laceration of the overlying 

mucosa, start antibiotics—usually penicillin. The patient also should 

rinse the mouth with salt water several times each day to decrease bacterial 

content. These interventions are necessary to decrease the chance 

for infection of the bone. 

To decrease swelling: When the patient is lying in bed, the head 

should be elevated with pillows or by raising the head of the bed. The 

patient should avoid bending and heavy lifting, which can worsen 

facial swelling. The application of cool compresses to the face also 

helps to decrease swelling. 

If the patient has a significant facial fracture, especially with involvement 

of tooth-bearing bone, it is best to transfer the patient to a facility 

where specialty help is available. If transfer is impossible, most midface 

fractures will heal, although the patient’s appearance may be altered 

significantly. 

Patients with a mandibular fracture and reasonably aligned teeth 

who can open and close the mouth easily can be treated with a soft diet 

for 4–6 weeks. 

In contrast, patients with an unstable mandibular fracture (i.e., with 

mobile bone segments or inablity to open and close the mouth effectively) 

have a significant amount of pain and are unable to eat. This 

type of injury heals poorly without reduction of the fracture and immobilization 

of the jaws. Without proper treatment, the patient may be 

left with permanent pain and difficulty in eating.


SSppeecciiffiicc TTrreeaattmmeenntt ffoorr MMaannddiibbuullaarr FFrraaccttuurree 

WWhheenn NNoo SSppeecciiaallttyy CCaarree IIss AAvvaaiillaabbllee 

If there is a dead or decayed tooth at the fracture site, remove it. 

To decrease pain and infection risk and to improve the chance for bone 

healing, the jaws should be wired together. Intermaxillary fixation stabilizes 

the fracture(s), brings the bones into proper alignment, and promotes 

healing. 

Placement of Ivy loops is a relatively easy way to achieve intermaxillary 

fixation and requires little special equipment. 

Ivy Loops Procedure 

Placement of Ivy loops for intermaxillary fixation. (From McCarthy JG (ed): 

Plastic Surgery. Philadelphia, W.B. Saunders, 1990, with permission.) 

1. General anesthesia with nasal intubation is the best choice. 

2. Cut a 24-gauge wire (or whatever you have) into at least 6 pieces, 

each 6 inches (15 cm) in length. Be careful, because the ends of the 

wire can easily pierce through the glove into your finger. 

3. Bend the piece of wire in half. Grasp the midsection of the wire with 

a needle holder, and twist the wire 2–3 times, making a small loop at 

the bend in the wire. 

4. Pass both ends of the wire between two teeth that seem to be stable 

and are located distal to the fracture. Be sure that matching stable 

teeth are available on the opposite upper or lower jaw. The wire 

goes through the gum from outside (the side nearest the cheek) to 

inside (the side nearest the tongue). The loop should be along the 

outer surface of the teeth.

Facial Fractures 255 

5. Take one end of the wire and wrap it around the tooth in front by 

passing it through the gum, going from inside to outside. 

6. Wrap the other end of the wire around the tooth behind in the 

same manner. Both wire ends should be on the outside of the teeth. 

7. Pull on the ends to keep the wire snug along the teeth. 

8. Pass one wire end through the loop. 

9. Bring the wire ends together, and manually twist them in clockwise 

direction once or twice. 

10. Use a needle holder to grasp the twisted wire a few centimeters away 

from the gum. Pull up on the needle holder, and twist the wire in a 

clockwise fashion until the wire seems snug. Look closely at the wire 

while doing so. If the appearance of the wire changes from shiny to 

dull, stop—or you will break the wire and have to start again. 

11. Repeat this process on the corresponding teeth on the opposite jaw 

and on teeth on the other side of the fracture. You will need to place 

the wires around at least 4 pairs of teeth. 

12. Use a wire cutter to shorten the twisted wire ends to a length of 1 

cm. Bend the wire into the surface of the gum so that the wire ends 

do not cut into the cheek mucosa. 

13. When all of the wires have been placed, bring the patient’s jaws together 

and try to line up the teeth. Be sure that the tongue is not 

caught between the teeth. 

14. Use additional wire to connect each pair of loops and thereby bring 

the top and bottom jaws together. This technique immobilizes the 

jaws and fracture sites. Twist the wire (as previously described) in 

place. 

15. The jaws should stay wired together for approximately 6 weeks. 

To ensure adequate nutrition, the patient should eat pureed foods 

and drink lots of liquids. Most patients lose weight. Encourage patients 

to ingest sufficient calories. Be sure to discourage smoking. 

Poor nutrition and tobacco use impair fracture healing. 

16. The teeth should be carefully brushed at least 1–2 times each day, 

and the mouth should be rinsed with salt water after meals and 

before going to bed. 

17. When pain is no longer present at the fracture site (usually after 

4–6 weeks), remove the connecting wires and allow the patient to 

eat nothing harder than soft foods for an additional 2–3 weeks. 

18. If the patient develops pain at the fracture site, reconnect the jaws 

for another 2–3 weeks.


19. If, after removing the connecting wires, the patient can eat and the 

fracture site remains pain-free, remove the wires from the teeth. 

Note: When the connecting wires are first removed, the patient’s ability 

to open the mouth will be limited. This problem will improve over 

the subsequent days and weeks. 


1. Manson PN: Facial Injuries. In McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. 

Saunders, 1990, pp 867–1141. 

2. Markowitz BL, Sinow JD, Kawamoto HK Jr, et al: Prospective comparison of axial 

computed tomography and standard and panoramic radiographs in the diagnosis of 

mandibular fractures. Ann Plast Surg 42:163–169, 1999. 

3. Plaiser BR, Punjabi AP, Super DM, Haug RH: The relationship between facial fractures 

and death from neurologic injury. J Oral Maxillofac Surg 58:708–712, 2000. 

4. Sinclair D, Schwartz M, Gruss J, McLellan B: A retrospective review of the relationship 

between facial fractures, head injuries, and cervical spine injuries. J Emerg Med 

6:109–112, 1988.

Chapter 26 

THE NORMAL HAND EXAM 

KEY FIGURES: 

Volar landmarks Intrinsic muscles 

Sensory innervation Vascular supply 

FDS motor function Finger rotational 

FDP tendon function 

Thumb opposition 

deformity 

For most people, good hand function is essential for day-to-day living, 

as well as the ability to support a family. Especially in areas that have a 

weak economic safety net, even minor hand injuries can have a disproportionately 

devastating effect on individual well-being. 

Effective, early treatment of hand injuries can produce dramatic benefits 

in the final outcome of hand function. Conversely, lack of proper 

early treatment may cause a seemingly trivial injury to result in severe 

limitation of hand function and permanent disability. 

The first step in providing optimal care of a hand injury is to know the 

basic principles of normal hand function, which are described in this 

chapter. The following chapters explain how to evaluate an injured 

hand and detail the treatment of specific hand injuries. 

AAnnaattoommiicc DDeeffiinniittiioonnss 

It is important to describe the hand in anatomic position: the arms are 

at the patient’s sides with the palms facing forward so that the little 

finger is medial (also described as ulnar), next to the body, and the 

thumb is lateral (also described as radial), away from the body. The 

dorsal surface is the back of the hand, where the extensor tendons are 

located, and the volar surface is the palmar/front surface of the hand, 

where the flexor tendons are located. 

Proximal means closer to the heart, and distal means farther away. 

The thenar eminence represents the soft tissue bulk on the volar surface 

of the hand just proximal to the thumb; it includes the intrinsic 

muscles to the thumb. 

257


The volar (palmar) surface of the hand. IP = interphalangeal, DIP = distal interphalangeal, 

PIP = proximal interphalangeal. 

The hypothenar eminence represents the soft tissue bulk on the volar 

surface of the hand just proximal to the little finger. 

The phalanges are the bones of the fingers. 

The metacarpophalangeal (MCP) joint is the joint where the fingers 

and thumb join the hand (essentially, the knuckles). 

The proximal interphalangeal (PIP) joint is the finger joint closest to 

the MCP joint. 

The distal interphalangeal (DIP) joint is the finger joint farthest from 

the MCP joint. 

The thumb has only the interphalangeal (IP) joint. 

The carpal tunnel is the space in the center of the proximal palm between 

the thenar eminence and hypothenar eminence. The nine flexor 

tendons to the fingers and thumb and the median nerve traverse this 

tunnel into the hand. The boundaries of the carpal tunnel are bone on 

the deep, medial, and lateral sides; the roof is the strong transverse 

carpal ligament (a fascial layer of the hand). 

Skin creases are landmarks that help to describe where to place an incision 

or where a lesion on the volar surface of the hand is located. 

Location often is described in relation to the various skin creases on the 

volar surface of the hand.

TThhee NNoorrmmaall HHaanndd 

The Normal Hand Exam 259 

A good understanding of the normally functioning hand is necessary 

for adequate evaluation of a hand injury. Seemingly insignificant injuries, 

such as a simple laceration, may involve damage to more tissue 

than just the skin. If this additional tissue damage is missed, significant 

morbidity can result, with a devastating effect on the patient. 

If you identify an abnormality that may not make sense in light of the 

injury, there may be another explanation besides trauma. An abnormality 

may be a normal variant. For example, a patient without a palpable 

radial pulse may have congenital absence of the radial artery 

rather than an arterial injury. When these variants occur, they often involve 

the other hand as well. It is always a good idea to check the other 

hand for comparison. 

Sensory Exam 

Three major nerves are responsible for sensation to the hand: the 

radial, ulnar, and median nerves. 

Sensory innervation of the hand. (From Jurkiewicz MJ, et al (eds): Plastic 

Surgery: Principles and Practice. St. Louis, Mosby, 1990, with permission.)


Radial Nerve 

Sensory distribution: dorsal aspect of the radial two-thirds of the hand 

and thumb; dorsal aspect of the thumb, index, middle, and radial half 

of the ring finger to the PIP joint. 

Course in the forearm: the radial nerve runs in the muscles of the 

dorsal aspect of the forearm and becomes superficial (near the skin) 

approximately 4–5 cm proximal to the wrist on the lateral border of the 

forearm. At this site the nerve is especially prone to injury. 

Ulnar Nerve 

Sensory distribution: dorsal and volar aspects of the ulnar side of the 

hand; dorsal and volar sides of the medial half of the ring finger and 

the entire little finger. 

Course in the forearm: the ulnar nerve runs deep to the muscles on the 

medial side of the forearm, adjacent to the ulnar artery in the distal half 

of the forearm. An injury to the ulnar artery should alert you to test 

specifically for an ulnar nerve injury. Approximately 8 cm proximal to 

the wrist, the nerve sends off a sensory branch that travels under the 

dorsal skin and supplies the dorsal aspect of the hand. Just distal to the 

wrist, in the hypothenar muscles, it divides into motor and sensory 

branches. The sensory branches innervate the ulnar side of the volar 

surface of the hand and become the digital nerves to the little finger 

and the ulnar half of the ring finger. 

An injury to the ulnar nerve at the wrist should not result in diminished 

sensation to the dorsal aspect of the hand. The sensory branch 

comes off the main nerve proximal to the injured area. If all ulnar sensation 

is missing, look for an additional, more proximal injury. 

Median Nerve 

Sensory distribution: volar aspect of hand and fingers from the thumb 

to the radial half of the ring finger; dorsal aspect of index, middle, and 

radial half of the ring finger from the PIP joint to the tip of the finger. 

Course in the forearm: at the elbow, the median nerve is next to the 

brachial artery. It then runs deep to the volar forearm muscles in the 

upper part of the forearm but becomes quite superficial in the distal 

third of the forearm. The palmaris longus tendon, if present (it is 

absent in 10–15% of people), is just overtop of the nerve and offers 

some protection near the wrist. The nerve then goes through the carpal 

tunnel to give off its sensory and motor branches in the hand. The sensory 

branches become the digital nerves to the thumb, index finger, 

long finger, and radial half of the ring finger.

Motor Exam 


Many people do not realize that a large part of hand and finger movement 

is governed by muscles and tendons originating in the forearm. 

To move the hand and fingers requires proper functioning of both 

muscles originating in the forearm (extrinsic muscles) and muscles 

originating in the hand itself (intrinsic muscles). 

If limitation in movement is due to dysfunction of an extrinsic muscle, 

you must determine whether the injury involves the distal tendon or 

the nerve supply. Dysfunction of the intrinsic muscles usually is due to 

an injury to the nerve supply. 

If the hand or fingers do not flex (bend) or extend (straighten) appropriately 

and with adequate strength compared with the noninjured 

hand or fingers, you must determine the precise cause so that appropriate 

treatment can be given. This process is detailed and methodical. 

However, with practice and an understanding of what you are testing, 

the motor exam takes only a few minutes to complete. 

Extrinsic Muscle/Tendon Evaluation 

The flexor digitorum superficialis (FDS) inserts into the middle 

phalanx of each finger. It is tested by blocking the finger MCP joint 

and asking the patient to flex the PIP joint. To block the MCP joint, 

hold the proximal phalanx in extension just distal to the MCP joint, 

so that the MCP joint is unable to bend when the patient tries to flex 

the finger. 

Testing flexor digitorum superficialis function.


The flexor digitorum profundus (FDP) inserts into the distal phalanx 

of each finger. It is tested by blocking the finger PIP joint and asking 

the patient to flex the DIP joint. To block the PIP joint, hold the middle 

phalanx in extension just distal to the PIP joint, so that the PIP joint is 

unable to bend when the patient tries to flex the finger. 

Testing flexor digitorum profundus 

function. 

The flexor pollicis longus (FPL) is the primary flexor of the thumb interphalangeal 

(IP) joint. It is tested by holding the thumb MCP joint in 

extension and asking the patient to flex the thumb IP joint. 

The wrist flexors include the flexor carpi radialis, flexor carpi ulnaris, 

and palmaris longus (PL; weak effect). When the patient flexes the 

wrist, you should be able to feel these tendons under the skin. In a 

small percentage of the population, the PL is absent. Compare with the 

uninjured hand. 

The extensor pollicis longus (EPL) is the primary extensor of the 

thumb IP joint. Test the patient’s ability to extend the thumb IP joint. 

The finger extensors are responsible for extension of the MCP joints of 

the fingers (not thumb). Please note: the finger extensors are not responsible 

for extension of the the finger IP joints, which is the function 

of the intrinsic muscles (see ulnar nerve below). 

The wrist extensors are the extensor carpi radialis and extensor carpi 

ulnaris. Check function by testing for wrist extension.

Evaluation of Extrinsic Muscle/Intrinsic Muscle Nerve Supply 

Radial Nerve 


Hand: no motor innervation to the intrinsic muscles. 

Forearm: innervates the forearm muscles that provide extension of the 

wrist, thumb, and all finger MCP joints. 

Median Nerve 

Hand: primarily thumb opposition (bringing the thumb tip to meet the 

tip of each finger). 

Forearm: innervates the muscles that flex the thumb, wrist (FCR), all 

PIP joints, and DIP joints of the index and middle fingers. 

To test function of the motor branch of the median nerve, bring the thumb and 

little finger together in opposition. Keep the thumb IP joint at 0° so that you do 

not confuse action of the flexor pollicis longus with action of the thenar muscles. 

Ulnar Nerve 

Hand: the ulnar nerve provides the dominant innervation to the intrinsic 

muscles of the hand: flexion of the MCP joints and extension of the 

IP joints of the fingers and adduction of the thumb. It is best to check 

the first dorsal interossei (the muscle along the index metacarpal bone 

in the thumb web). Ask the patient to abduct the index finger against 

resistance. Alternatively, you may ask the patient to hold a piece of 

paper between adjacent fingers that are fully extended. 

Forearm: innervates the muscles that flex the wrist (flexor carpi ulnaris) 

and DIP joints of the ring and little fingers.


Vascular Evaluation 

Metacarpophalangeal joint flexion 

and interphalangeal joint 

extension. The intrinsic muscles 

are innervated primarily 

by the ulnar nerve. 

Two main arteries supply the hand: the radial artery and the ulnar 

artery. Both are branches of the brachial artery. In the hand the radial 

artery and ulnar artery come together and meet, forming the palmar 

arch. The digital arteries come off the palmar arch to supply circulation 

to the fingers. 

Radial Artery 

Most people are familiar with the radial artery, which health care 

providers palpate to check heart rate. The radial artery usually can be 

felt on the lateral aspect of the volar surface of the wrist, just below the 

thenar eminence. Check for presence of a pulse, and compare with the 

other side. In some patients anatomy varies from the norm, and this 

variance is often symmetrical. Always check the opposite hand. 

Ulnar Artery 

The ulnar artery is actually the more important of the two arteries supplying 

circulation to the hand. It usually supplies most of the blood to 

the hand. The ulnar artery can be felt on the medial aspect of the volar 

surface of the wrist, just below the hypothenar eminence. It is often 

more difficult to feel than the radial artery pulse. Check for presence of 

a pulse, and compare with the other hand.

Capillary Refill 


Blood supply to the hand. The superficial arch and the deep arch are separated 

by tendinous structures. The superficial arch is formed primarily by the 

ulnar artery, the deep arch by the radial artery. This arrangement is seen in 

most, but not all dissections. (From Jurkiewicz MJ, et al (eds): Plastic Surgery: 

Principles and Practice. St. Louis, Mosby, 1990, with permission.) 

A well-vascularized finger generally has a pink hue under the nail. If 

the area under the nail is blue or very pale, circulation may be impaired. 

These findings also may be a sign that the patient is very cold 

or hypovolemic; be sure to compare with the uninjured hand. To test 

capillary refill, pinch the fingertip, which should blanch (i.e., turn 

pale). Then release the pressure. The color should return to normal within 

2–3 seconds. A period longer than 2–3 seconds may imply an arterial 

injury (i.e., difficulty with getting blood to the finger). A period shorter


than 2–3 seconds may imply a problem with the venous circulation 

(i.e., difficulty with draining blood from the finger). 

Alignment of the Fingers with Movement 

You should evaluate the patient for a rotational deformity of the finger, 

which indicates significant bone or joint injury. When the patient actively 

flexes the finger IP joints in tandem, the nails and fingertips 

should be well aligned. When MCP flexion is added, the fingers should 

not criss-cross; they should point gently toward the thenar eminence. 

As always, compare with the other hand because some people may 

have mild rotational deformities in the uninjured state. 

Left, Normally all fingers point toward the region of the scaphoid when a fist is 

made. Right, Malrotation at fracture site causes the affected finger to deviate. 

(From Crenshaw AH (ed): Campbell’s Operative Orthopedics, 7th ed. St. Louis, 

Mosby, 1994, with permission.) 

This evaluation is important in examining a patient with a phalangeal or 

metacarpal fracture. At rest, with the fingers straight, the fingers may 

look well positioned. However, when their alignment is checked with 

motion, the fingers may criss-cross, which suggests that the fracture requires 

greater reduction. If the fracture is not reduced properly and the 

rotational deformity becomes permanent, hand function may be limited. 


1. Ariyan S: The Hand Book. New York, McGraw-Hill, 1989. 

2. Lampe EW: Clinical Symposia: Surgical Anatomy of the Hand. 40th anniversary issue 

40(3), 1988.

Chapter 27 

EVALUATING THE INJURED HAND 

KEY FIGURES: 

Normal posture 

Forearm injury involving flexor tendons 

Flexor tendon injury in the hand 

Patients with hand injuries have many different presentations, ranging 

from a swollen, tender finger or a small laceration on the palm of the 

hand to a severely mangled hand. This chapter explains how to evaluate 

patients with a hand injury. It is important to do a complete exam 

of every injured hand so that no important injuries are missed. 

As usual, the first priority is to control life-threatening hemorrhage. 

Apply point pressure over the wound. This does not mean to place 

gauze in the wound and wrap the area with an Ace bandage. It means 

to place a wad of gauze over the injured area and to apply firm point 

pressure to the injured site with two fingers. The pressure may need to 

be maintained for several minutes before the bleeding stops. In patients 

with arterial bleeding, exploration is required. 

If the patient has a rapid, exsanguinating hemorrhage that cannot be 

controlled with point pressure, place a tourniquet or blood pressure 

cuff proximal (closer to the heart) to the injury. If a blood pressure cuff 

is used, it must be inflated to at least 50 mmHg above the patient’s systolic 

pressure. 

Caution: Tourniquets hurt and place the tissues at risk for ischemic 

injury. Optimally, the tourniquet should not be left in place for more 

than 15–20 minutes. If a tourniquet is needed, so is urgent operative 

exploration. 

For patients with a non–life-threatening injury, the following elements 

are crucial to the evaluation of an injured hand. 

IImmppoorrttaanntt EElleemmeennttss ooff tthhee HHiissttoorryy 

As discussed more thoroughly in chapter 6, “Evaluation of an Acute 

Wound,” it is important to obtain a good history from the patient. 

267


Information about what caused the injury may have important implications 

for treatment. 

Nature of Injury 

Human bites are very dirty wounds. Never close a human bite to the 

hand. Such injuries require specific antibiotics, and surgical exploration 

and wash-out in the operating room may be necessary. 

Animal bites. About 80% of cat bites become infected compared with 

5% of dog bite wounds. Remember to ask about the animal’s rabies 

vaccination status. 

Glass wound. Did the glass shatter? Are foreign bodies retained in the 

wound? 

Knife/sharp object wound. The object may have penetrated more 

deeply than you think. 

Dirty wound. Worry about particulate matter in the wound, and check 

tetanus immunization status. 

Burn. Is injury due to thermal, chemical, or electrical burn? Each has 

different implications. See chapters 20, “Burns,” and 34, “Hand Burns.” 

Component of a crush injury. Crush mechanisms involve a more extensive 

injury than you may initially expect. See chapter 35, “Hand 

Crush Injury and Compartment Syndrome.” 

Other Important Questions 

1. Is the injured hand the dominant hand? If the injury involves the 

dominant hand, treatment outcome is especially important. This 

consideration may affect which treatment modalities you select. 

2. What is the patient’s tetanus immunization status? Update as needed. 

See chapter 6, “Evaluation of an Acute Wound,” for tetanus booster 

recommendations. 

3. Did pulsatile bleeding occur at the time of injury? Pulsatile bleeding 

(blood squirting out with some force as opposed to a continuous ooze) 

implies an arterial injury and usually mandates surgical exploration. 

4. Was any deformity noted immediately after injury? Ask about an 

immediate deformity that has since disappeared. Many patients are 

able to reduce (realign) a dislocated joint right after the injury so 

that it appears normal at the time of exam. However, the injured 

finger may still require protective splinting even if it appears to be 

in its normal position.

Evaluating the Injured Hand 269 

5. Does the patient have a history of previous trauma to the hand? A 

previous injury may be the cause of an abnormal exam instead of 

the acute injury. Be sure to ask whether the functional deficit or contour 

abnormality identified on the exam was present before the current 

trauma. 

PPhhyyssiiccaall EExxaammiinnaattiioonn ooff tthhee IInnjjuurreedd HHaanndd 

Remove immediately all rings that the patient is wearing. Injury to a 

hand often leads to significant swelling. The rings may become quite 

tight, possibly to the point that they cut off circulation to the finger. If 

the ring is tight, lubricating jelly or antibiotic ointment is often useful. 

If this strategy is unsuccessful, the ring may need to be cut off with a 

ring cutter or strong wire cutter. 

Full evaluation of the injured hand may necessitate anesthesia to control 

the pain so that the patient can cooperate with the exam. See chapter 

3, “Local Anesthesia,” for specific information. Be sure to test 

sensation distal to the injury before administering local anesthetic. Once you 

have given the anesthetic, it is too late to test for sensory function. 

Vascular Exam 

Active Bleeding 

Is the wound actively bleeding during the exam? If so, is the bleeding 

pulsatile, with bright red blood (probable arterial injury), or continuous, 

with darker blood (probable venous injury)? 

Capillary Refill 

Check for capillary refill of the digits distal to the injury. Is the tissue 

pink, indicating sufficient circulation, or is it bluish or pale, indicating 

inadequate circulation to the distal tissue? 

Radial and Ulnar Pulses 

Make sure that the radial and ulnar pulses are intact, even if capillary 

refill of the hand seems normal. Missing an arterial injury can have 

serious consequences (see chapter 33, “Nerve and Vascular Injuries of 

the Hand”). 

Note what happens when you press on either the radial or ulnar artery. 

Does the pulse of the other artery disappear? In patients with an injury 

to the radial artery in the mid-forearm, for example, you may still feel a 

pulse in the radial artery at the wrist. In most people the radial and ulnar 

arteries come together in the hand to form the palmar arch. Because of


this anatomic arrangement, blood from the ulnar artery flows through 

the palmar arch. From the palmar arch blood travels into the digital 

vessels and into the distal radial artery. Thus patients with injury to the 

proximal radial artery may still have a palpable radial pulse at the 

wrist. If you press on the ulnar artery to occlude its flow and the radial 

pulse also disappears, injury to the radial artery is indicated. 

Sensory Exam 

Test sensation distal to the injury. It is best to determine whether the 

patient can differentiate between a sharp stimulus (pinprick) and a 

dull stimulus (light touch of a dry cotton swab). Patients who cannot 

feel the sharp stimulus probably have a nerve injury. 

Motor Exam 

Unless you see an obvious muscle injury, the purpose of testing the 

function of a specific muscle group is to evaluate for a specific underlying 

nerve injury or tendon injury (see below). 

IP = interphalangeal. 

Table 1. Muscle Functions and Associated Nerves 

Muscle Function Associated Nerve 

Extension of finger IP joints, finger adduction/ 

abduction, or abduction of the first dorsal 

interosseous muscle 

Ulnar nerve 

Thumb opposition Median nerve 

Wrist flexion Median nerve primarily; some contribution 

from ulnar nerve 

Wrist extension Radial nerve 

Tendon Exam 

1. Depending on the site of injury, make sure that nearby flexor and 

extensor tendons are intact. Remember that there are two flexor tendons 

to the fingers. 

2. Flexion of the metacarpophalangeal (MCP) joints and extension of 

the interphalangeal (IP) joints are under intrinsic muscle control; 

they are not controlled by flexor or extensor tendons. 

3. Note whether you can see cut tendon ends in the wound.

Obvious Deformity 

Exam for Fracture or Dislocation 


Most finger dislocations and fractures are quite obvious, but this is not 

always the case. Sometimes the finger is just slightly swollen. The patient 

may report that right after the injury the finger looked “funny,” 

but the patient was able to “pop it back” into position. 

Rotational deformity when the patient flexes the fingers strongly implies 

a fracture or dislocation in need of reduction. 

Open Wound 

Is the joint visible in the wound? Is the capsule intact? Is a fracture visible? 

An open fracture (fracture associated with skin laceration) has a 

higher rate of infection and improper healing than a closed fracture. 

Whenever you have any doubt about the possibility of a fracture or dislocation, 

order a radiograph. 

Soft Tissue Coverage 

Is there enough healthy tissue to allow wound closure or at least to 

cover exposed tendons, bones, nerves, or blood vessels? 

Foreign Bodies 

Check to be sure that no pieces of foreign material are present in the 

wound (e.g., grass, glass, metal, dirt). Some foreign materials can be 

seen on a radiograph. Foreign debris should be removed before the 

wound is closed to prevent infection. 

PPhhyyssiiccaall EExxaamm ooff aann UUnnccoonnsscciioouuss PPaattiieenntt 

Although it is impossible to do a complete hand exam on an unconscious 

patient, certain parts of the exam can be performed: 

1. Examine the wound, and evaluate the hand’s vascular status, as described 

above. 

2. For a gross estimate of the status of the flexor tendons, grab the patient’s 

forearm and shake the hand gently. Then allow the hand to fall 

backward so that the palm faces up. The fingers should assume a 

gently flexed posture, with the little finger slightly more flexed than 

the ring finger, the ring finger more flexed than the middle finger, and 

the middle finger more flexed than the index finger. The thumb also 

should assume a slightly flexed position. If any finger assumes a more 

extended posture than expected, flexor tendon injury is indicated.


The resting posture of an uninjured hand in an unconscious patient. Note that 

all of the fingers are in a slightly flexed position. 

An unconscious patient with a forearm injury involving the flexor tendons to the 

index and middle fingers. Note the difference in hand posture compared with 

the uninjured hand (above). The affected middle and index fingers are in an extended 

position.



Same process as in the two previous photographs, but the tendon injury is 

located in the hand. (From Crenshaw AH (ed): Campbell’s Operative 

Orthopaedics, 7th ed. St. Louis, Mosby, 1994, with permission.) 

1. Ariyan S: The Hand Book. New York, McGraw-Hill, 1989, pp 91–172. 

2. Walton RL, Chick LR, Petry J, Borah G: Hand injuries: General principles. In 

Jurkiewicz MJ, Krizek TJ, Mathes SJ, Ariyan S (eds): Plastic Surgery: Principles and 

Practice. St. Louis, Mosby, 1990, pp 605–643.

Chapter 28 

HAND SPLINTING AND 

GENERAL AFTERCARE 

KEY FIGURES: 

Neutral position for basic Thumb spica splint 

splinting Ulnar gutter splint 

Neutral position splint Finger immobilization 

Splint for flexor tendon injury Proper elevation of 

Splint for extensor tendon 

injury 

injured hand 

SSpplliinnttiinngg 

The hand and fingers often need a period of immobilization after 

injury to allow the tissues to heal properly. For most hand injuries, a 

splint rather than a cast is the method of choice. 

Splint vs. Cast 

A cast immobilizes the injured hand by completely surrounding it with 

hard, inflexible materials (plaster or fiberglass). The inflexibility of a cast 

can cause serious problems if the injured tissues swell or if the cast is 

placed too tightly. Potential problems include skin loss due to pressure on 

the skin from the tight cast or possibly development of a compartment 

syndrome (see chapter 55, “Hand Crush Injury and Compartment Syndrome”) 

if the tightness compromises blood circulation to the extremity. 

A splint is essentially a half cast used for immobilization. The extremity 

is not completely bound by inflexible materials. Therefore, a splint 

is safer than a cast because it usually can accommodate tissue swelling 

without becoming too tight. 

Materials 

Place cotton gauze between each finger to absorb perspiration. 

Rolls or sheets of plaster of Paris are used to make the splint. Fiberglass 

rolls also can be used but are much more expensive than plaster rolls. 

Fiberglass is used in the same way as plaster for creating a splint. 

275


Padding is important. You need cotton padding to protect the hand and 

forearm from the heat of the plaster (splint materials become quite warm 

as they dry and can burn unprotected skin). The padding also prevents 

the splint from rubbing or putting too much pressure on the skin. 

An Ace or other soft wrap is needed to hold the splint in place. 

How to Make the Splint 

1. Measure the required length of the splint. To immobilize the hand 

and fingers adequately, the splint should be long enough to cover 

from the mid-forearm to the fingertips. 

2. Place four layers of cotton padding between the patient’s skin and 

the plaster. 

3. Cut another layer of cotton padding to place on the outer side of the 

plaster. This outer layer makes it easier to remove the splint to reexamine 

the hand and allows the splint to be reused. 

4. Use approximately 12 layers of plaster of Paris of a width appropriate 

for the extremity. The splint should be a bit wider than the extremity; 

cut it if necessary. 

5. Wet the plaster with lukewarm water, and squeeze out the excess 

water. The plaster should be damp, not soaking wet. Do not use hot 

water. Because the plaster heats as it dries, hot water increases the 

risk of burning the patient. 

6. Place the four layers of cotton padding on the plaster, and place the 

splint on the patient’s extremity. Be sure that the cotton padding is 

directly against the patient’s skin. This rule sounds simple, but it is 

easy to make a mistake. 

7. Place the single layer of cotton padding on the outside of the plaster. 

8. Secure the splint in position with an Ace or other soft wrap. Do not 

wrap tightly. If the Ace wrap is tight, it will become inflexible, 

making the splint as potentially dangerous as a cast. Wrap the extremity 

lightly—just tight enough to secure the splint in position. 

9. Hold the splint in the appropriate position (see below) until it dries. 

It will take a few minutes for the plaster to cool and dry. 

Position and Contour of the Splint 

The contour of the splint is determined by the hand injury. 

Neutral Position 

The neutral position is used for basic splinting of an injured or infected 

hand. The purpose of the splint is to allow the hand to rest in a

Hand Splinting and General Aftercare 277 

safe position—that is, a position that will not lead to hand dysfunction 

if stiffness results. The wrist is placed in 20° of extension, the metacarpophalangeal 

(MCP) joints are positioned in 70° of flexion, and the interphalangeal 

(IP) joints should be straight. The splint usually is placed 

on the volar side of the hand. Exception: a burn on the volar surface of 

the hand may require a dorsal splint. 

The neutral position is a safe position for immobilization of an injured hand. 

The IP joints are straight, the MCP joints are flexed, and the wrist is slightly ex- 

Splinting the hand in neutral position. The splint usually is placed on the palmar 

surface of the hand and forearm. 

For a Flexor Tendon Injury 

The splint should hold the hand in a position that prevents extension 

of the hand and finger. For this reason, the splint is placed on the 

dorsal side of the hand. The wrist is flexed 20–30°, the MCP joints 

are positioned in 70° of flexion, and the IP joints are flexed slightly at


10–20°. Do not put anything rigid (anything that prevents passive flexion 

of the fingers) on the volar side of the hand or fingers. 

Splinting the hand with a flexor 

tendon injury. The splint is on the 

dorsal surface of the hand. The 

wrist and MCP joints are flexed. 

For an Extensor Tendon Injury 

The splint is used to prevent flexion of the hand and fingers. For this 

reason, the splint is placed on the volar side of the hand. The wrist 

should be placed in 20° of extension, the MCP joints are positioned in 

10–15° of flexion (they should not be completely straight), and the IP 

joints should be straight. (See figure on following page.) 

For an Injury to the Thumb 

If the thumb is the only injured part of the hand, it is possible to immobilize 

the wrist and thumb with a thumb spica splint and leave the fingers 

free. The patient thus can use the hand for light activities. The 

splint is placed on the radial side of the forearm and brought over the 

thumb, all the way out to the tip. The thumb should be slightly abducted 

(positioned away from the rest of the hand). Mold the plaster 

so that it wraps half-way around the thumb to keep it immobilized. 

(See figure on following page.) 

For a flexor tendon injury, the wrist should be slightly flexed; for an extensor 

tendon injury, the wrist should be slightly extended, as described 

above. The thumb IP joint should be held straight for either injury.

Splinting the hand with an extensor 

tendon injury. The splint is on the palmar 

surface of the hand. The wrist is extended, 

and the MCP joints are almost, 

but not quite, at 10–15° of flexion. 

For an Injury to the Little Finger 


Thumb spica splint. The thumb and wrist are immobilized, but the rest of the 

fingers are free. 

If the little finger is the only involved finger, it is possible to immobilize 

the wrist and little finger with an ulnar gutter splint and leave the 

rest of the hand free. The patient thus has more use of the hand. The 

splint is placed on the ulnar side of the forearm and hand and then extended 

just beyond the little finger. Mold the plaster so that it partially


wraps around the little and ring fingers. The ring finger is included to 

add extra protection to prevent accidental movement of the little 

finger. The wrist, MCP joints, and IP joints should be positioned as 

with flexor or extensor tendon injury, depending on the exact nature of 

the injury to the little finger. 

Ulnar gutter splint for the little finger. The little and ring fingers as well as the 

wrist are immobilized. The thumb and index and middle fingers are free. 

For Injury to a Single Finger 

Commercially available aluminum splints with foam rubber padding 

can be shaped to the proper position to immobilize a single digit. This 

type of splint is indicated for immobilization of a phalangeal fracture 

or dislocation. If such splints are not available, plaster with padding or 

a tongue depressor cut to the appropriate size also can be used. 

When only one finger needs to be immobilized, an aluminum splint is quite 

useful.


GGeenneerraall AAfftteerrccaarree 

Basic aftercare recommendations should be explained thoroughly to all 

patients, no matter what their injury. More specific instructions, tailored 

to each injury, are given in subsequent chapters. 

Elevation of the Extremity 

Elevation is the cornerstone of the treatment of hand injuries. Hand 

elevation decreases swelling and thus improves wound healing. Hand 

elevation also significantly decreases pain. 

When the patient is resting or reclining, elevating the affected hand by 

placing it on a pillow is usually sufficient. Be sure that the hand is 

higher than the elbow. 

When the patient is walking, the hand should be held up and not allowed 

to dangle by the side. I generally do not recommend arm slings, 

because patients tend to become too dependent on them and do not 

move their shoulder. This tendency can lead to shoulder stiffness, 

which may become problematic. 

Proper elevation of the injured hand at rest. The hand should be higher than 

the elbow to promote drainage and decrease swelling. 

Dressings 

The specific type of dressing depends on the injury. (See chapter 9, 

“Wound Care,” for specific details.)


Motion 

It is your responsibility to tell the patient when it is permissible to start 

moving the hand and fingers. Specific information is given for different 

hand injuries in subsequent chapters. Once patients are allowed to 

start moving the injured hand and fingers they should be given instructions 

for various ways to exercise the hands. 

Passive Range-of-motion Exercises 

The patient (or another person) gently moves the finger joints passively 

( i.e., without use of the patient’s own muscle contractions). 

Active Range-of-motion Exercises 

The patient should actively flex and extend the entire finger by using 

the muscles of the forearm and hand. To exercise the distal IP joint and 

prevent stiffness, the patient should hold the finger straight at the 

proximal IP joint and actively move the distal IP joint. 

The above exercises can be easier to do if the patient places his or her hand 

in warm water for a few minutes before attempting the exercises. Warmth 

allows the fingers to move more easily by making the tissues more supple. 

The patient can even do the exercises while the hand is soaking. 

Duration of Splinting 

Unless you tell the patient to remove the splint to clean the hand or to 

do gentle range-of-motion exercises, the splint should be removed only 

under your supervision. However, be sure to show the patient how to 

wrap the splint in place so that it can be loosened if the patient feels 

that the splint is tight. 

Specific information about how long to splint the hand after various 

hand injuries is discussed in subsequent chapters. 

Smoking 

Vigorously counsel the patient not to smoke during the healing 

process. Smoking considerably reduces blood circulation in the hand 

and thus may lead to unnecessary tissue loss, delayed bone and tendon 

healing, and poor functional outcome. 


1. Coppard BM, Lohman H: Introduction to Splinting: A Critical-Thinking and Problem- 

Solving Approach. St. Louis, Mosby, 1996. 

2. Falkenstein N, Weiss-Lessard S: Hand Rehabilitation: A Quick Reference Guide and 

Review. St. Louis, Mosby, 1999.

Chapter 29 

FINGERTIP AND NAIL BED INJURIES 

KEY FIGURES: 

Digital tourniquet Thenar flap 

Bone rongeur Repair of nail bed 

Fingernail with hematoma 

Hand injuries are commonly encountered by health care providers 

throughout the world. In the United States alone, the hand is involved 

in approximately 10% of all accident cases seen in the emergency 

department. 

Hand injuries are particularly important to treat, because good hand 

function frequently is necessary to hold a job and support a family. 

Specific injuries and their basic evaluation and treatment are discussed 

in this and subsequent chapters. 

Although specialists are required for optimal final treatment of some 

injuries, often the care given by the first-line provider has a dramatic 

effect on the ultimate outcome. Accurate evaluation and proper initial 

basic care can significantly improve outcome and decrease disability. 

You should be aware of the basics of treatment in case you find yourself 

the only health care provider around. 

FFiinnggeerrttiipp IInnjjuurriieess 

Fingertip injuries are probably the most commonly encountered hand 

injury. The best treatment is usually the simplest. A fingertip injury can 

cause short-term disability but generally should not affect long-term 

hand function. Improper treatment, however, can result in a stiff finger 

and reduce long-term hand function. 

Initial Care 

It is often useful to start by giving a digital block with either lidocaine 

or bupivacaine (see chapter 3, “Local Anesthesia”). The block allows 

you to examine and evaluate the finger completely. Although the 

283


wounds may not be large, fingertip injuries are often quite painful. It 

may be necessary to place a digital tourniquet to control slow bleeding 

from the wound, which prevents a thorough examination. 

Digital Tourniquet 

A digital tourniquet is easy to create and makes exam and repair much 

simpler. Do not keep the tourniquet in place for more than 25–30 minutes. 

The tourniquet can be made from a surgical glove that is one size 

smaller than the patient’s hand: 

1. Cut off the ring or little finger from the glove; then cut off its tip. 

2. Put the piece of glove on the injured finger. 

3. Roll the cut end of the glove from distal to proximal to force the 

blood out of the finger and to control bleeding. 

Digital tourniquet. Left, Cut off the finger from a glove and place it on the injured 

finger. Right, Roll the glove proximally to create the tourniquet. 

Clean the wound with gentle soap and water, and irrigate it with 

saline. 

Remove all foreign material and dead tissue. To remove grease, 

Bacitracin or another petrolatum-based antibiotic ointment is often 

useful.

Treatment 

Fingertip and Nail Bed Injuries 285 

If the skin can be sutured together, use a few loose, simple sutures. A 

tight closure can lead to further tissue loss. 

If no skin is available for closure and no bone or tendon is exposed, 

the wound can be left open and treated with dressings. 

If only a few millimeters of bone are exposed, try to shorten the bone, 

using a bone rongeur (see figure below) or other instrument. Shorten 

the bone enough that it can be covered by soft tissue. Because the profundus 

flexor tendon inserts on the proximal half of the bone, do not 

be too aggressive. 

Bone rongeur. (Photo courtesy of Moore Medical Corporation.) 

4. If a segment of the fingertip has been amputated, the skin can be 

defatted and used to cover the soft tissue as a full-thickness skin 

graft. To defat the skin, take a pair of scissors and cut away the fat 

on the undersurface of the skin. See chapter 12, “Skin Grafts,” for a 

more detailed description of this technique. Although the graft may 

not survive, it will serve as a biologic dressing and may decrease 

pain and hasten healing. 

5. If more than a few millimeters of bone have been exposed, see 

“Complicated Fingertip Injuries” later in this chapter. 

General Aftercare 

Apply antibiotic ointment and a simple dry dressing 1–2 times/day. 

Clean with gentle soap and water with each dressing change. 

If the wound was closed with sutures, after a few days the dressings 

can be stopped.


If the wound was left open, continue the dressing changes until the 

wound has healed. If the wound becomes covered with a grayish material, 

change to a wet-to-dry saline dressing for a few days, until 

wound appearance improves. 

Encourage the patient to use the finger and hand to prevent joint stiffness. 

Active and passive range-of-motion exercises also should be encouraged. 

Initially, acetaminophen alone may be insufficient to control pain. 

Fingertip injuries can be quite painful for the first several days. 

Strongly encourage the patient not to smoke. The use of tobacco products 

significantly slows the healing process of fingertip wounds. 

The patient should keep the affected hand elevated to decrease 

swelling and pain and to promote healing. 

More Complicated Fingertip Injuries 

Open Fracture of the Distal Phalanx 

Open fractures involve a soft tissue wound around the fracture site. 

They are more serious than closed fractures because of the higher risk 

for infection. 

When the fracture does not involve the distal interphalangeal (DIP) 

joint, it usually can be treated by manipulating the fracture into alignment 

and closing the soft tissues. Closing the soft tissues serves to 

splint the bone. 

If the fracture involves the joint surface, full reduction (proper alignment 

of the pieces) is necessary to preserve joint motion. Full reduction 

requires special skills and equipment (often K-wires or screws) that 

belong to the realm of the hand surgeon. Without the intervention of a 

hand surgeon, the wound will heal, but the patient probably will be 

left with a very stiff joint and little normal motion. 

The wound should be cleansed thoroughly, and the patient should be 

given oral antibiotics for several days. The antibiotics prevent bone infection 

(osteomyelitis), which can become a chronic problem and may 

be quite difficult to treat. 

The finger should be immobilized in a splint that prevents the patient 

from moving only the DIP joint. The DIP joint should be in an extended 

position. The proximal interphalangeal (PIP) and metacarpophalangeal 

(MCP) joints should be free. The splint should be used until the 

fingertip is no longer tender (probably 7–10 days). No other stabilization 

of the bone usually is required.

Subungual Hematoma 


Many injuries, especially those with a crush component (as when the 

patient hits a finger with a hammer), result in a subungual hematoma 

(blood clot under the nail). Treatment depends on the size of the 

hematoma. 

A small subungual hematoma (< 50% of the nail surface) usually 

heals on its own, but the pressure of the blood under the nail can be extremely 

painful. Heat the tip of a needle or the end of a paper clip until 

it is red hot. Then use it to puncture the nail, and let the accumulated 

blood escape. Alternatively, an electrocautery unit can be used to make 

the drainage hole in the nail. 

Drainage of a subungual hematoma. 

(From Simon RR, Brenner EE (eds): Emergency 

Procedures and Techniques, 3rd 

ed. Baltimore, Williams & Wilkins, 1994, 


In patients with a large hematoma (≥ 50% of the nail surface), the 

usual recommendation is to remove the nail. Often there is a significant 

laceration in the nail bed, which can be repaired once the nail is removed. 

See “Nail Bed Injuries” later in this chapter for further details. 

Fracture of the Bone with Nail Bed Injury 

Fracture of the bone with nail bed injury is considered an open fracture. 

The patient should be given oral antibiotics for a few days. 

If more than just a few mm of bone is exposed: 

A skin graft will not heal over exposed bone, and in the finger, little 

local tissue is available to cover the bone reliably. A distant flap, such 

as a chest flap or cross-arm flap, may be required to cover the bone. 

Another useful flap for a small wound (1–2 cm at most) is the thenar 

flap.


Thenar Flap 

A thenar flap involves bending the injured finger to the thenar eminence 

at the base of the thumb (by the MCP flexion crease). The injured 

finger is essentially sutured into the palm so that the finger and the 

skin flap from the thenar eminence grow together. Later, the finger is 

separated with its newly acquired tissue. 

Thenar flap for coverage of fingertip injury. 

(Illustration by Elizabeth Roselius © 1998. 

From Green DP, et al (eds): Operative Hand 

Surgery, 4th ed. New York, Churchill Livingstone, 


Indications. A thenar flap is used to cover a fingertip injury when 

bone is exposed and preservation of finger length is important. Thenar 

flaps should be done only in patients younger than 30 years. Significant 

joint stiffness may result if they are used in older patients. 

The thenar flap is best used to provide coverage for the index and 

middle fingers. The ring and little fingers do not reach the thenar area 

very well. A similar type of flap can be designed over the hypothenar 

eminence for coverage of injuries of the ring and little fingers. 

Procedure. A thenar flap can be done under local anesthesia using a 

wrist block. The following steps are essential: 

1. Observe where the injured finger makes contact with the thenar eminence 

just proximal to the MCP joint of the thumb.


2. Mark the three sides of a proximally based flap (i.e., the skin should 

stay attached at the side closest to the wrist). The flap should be 

slightly longer and wider than the defect. 

3. Incise the three sides of the flap, and raise the flap with subcutaneous 

tissue attached to the skin. Do not go too deeply; you may 

injure the digital nerves of the thumb. 

4. Suture the flap loosely to the fingertip. 

5. A full–thickness skin graft can be sutured to the donor site, or the 

donor area can be allowed to heal on its own with dressings. 

6. Apply a dorsal splint to keep the affected finger flexed into the 

palm. The splint prevents the patient from accidentally extending 

the finger and thereby pulling the finger off the flap. 

7. Divide the flap (i.e., cut through area where the skin remains attached 

to the palm) after 10–14 days. Sew the edge of the flap to the 

open wound of the finger very loosely. Do not worry about achieving 

perfect skin closure; small gaps between the flap and fingertip 

will heal with dressings. 

8. Antibiotic ointment and dry dressings should be used as needed 

postoperatively. 

NNaaiill BBeedd IInnjjuurriieess 

The nail bed is often involved with injuries to the fingertips. Unfortunately, 

even with the most precise repair, the nail may not grow back 

with a completely normal appearance. Be sure to warn the patient 

about this risk. 

Nails grow slowly. A normal, uninjured nail takes approximately 100 

days to reach full length (to the end of the finger). With injury to the 

nail bed or fingertip, growth is delayed by almost 1 month. 

As noted above, if a nail bed injury is associated with a fracture of the 

distal phalanx, treat the injury as an open fracture. 

If a subungual hematoma is > 50% of the nail surface, a significant laceration 

usually is found in the nail bed. Repair of the laceration warrants 

removal of the nail for formal exploration. 

Repair of an injured nail bed can be quite difficult because the tissues 

are very delicate and friable. Recent studies have shown that if the nail 

and surrounding nail margin are intact, removal of the nail and repair 

of nail bed lacerations are unnecessary in both children and adults. But 

you must still drain the hematoma.


If a subungual hematoma is accompanied by injury to the margin of the 

nail, the nail should be removed to allow proper repair of the nail bed 

and its surrounding tissues. A digital block and a digital tourniquet 

make the procedure much easier. Nail bed tissue is highly vascular. 

Removing the Nail 

1. Use a digital block. This procedure hurts! 

2. Place the digital tourniquet once the finger is anesthetized. Alternatively, 

you can wait to place the tourniquet until the nail has been 

removed. 

3. Place a small hemostat clamp just beneath the nail (between the nail 

and nail bed). 

4. Gradually spread the clamp (open its jaws) to free the nail completely 

from the underlying nailbed. 

5. Gradually advance the clamp proximally, until it is under the proximal 

portion of the nail (where it emerges from under the skin). 

6. Grab the nail with the clamp, and pull. It may take some effort. 

7. Clean the nail, and save it in saline-moistened gauze or a cleansing 

solution (e.g., Betadine). The nail may be useful for splinting the nail 

bed repair. 

Repair 

1. Use as small an absorbable suture as you can find (6-0 chromic is 

best) to repair the nail bed. Some type of magnification often is helpful. 

(See figure on following page.) 

2. Nail bed tissue is highly friable and difficult to sew—much like suturing 

wet toilet paper. Take small amounts of tissue, and do not 

pull up on the needle as you pass through the tissue. Take your 

time. This procedure can be frustrating. 

3. Once the repair has been completed, place the nail back on the nail 

bed to serve as a splint. Be sure to slide the proximal part of the nail 

under the skin fold at the base of the nail. This technqiue prevents 

the skin fold from scarring down to the nail bed. 

4. If necessary, place a single stitch through the nail and the distal fingertip 

skin to hold it in place. Remove this stitch after a few days. 

5. The injured nail will be pushed off by the growth of the new nail.

Nail bed lacerations are often multiple 

and uneven. (From Foucher G 

(ed): Fingertip and Nail Bed Injuries. 

London, Churchill Livingstone, 1991, 


Aftercare 


Place a small amount of antibiotic ointment around the nail, and cover 

the fingertip with light gauze. 

After 1 or 2 days the fingertip can be left open without a dressing. 

The hand should be kept elevated at all times. The finger will start to 

throb if the hand is dependent. 

Encourage the patient to move all the joints of the finger to prevent 

stiffness. 

Remember pain medication. Fingertip and nail bed injuries are quite 

painful. 

Strongly encourage the patient to refrain from using tobacco products, 

which significantly delay healing. 


1. Hart R, Kleinert H: Fingertip and nail bed injuries. Emerg Med Clin North Am 11: 

755–765, 1993. 

2. Lee L: A simple and efficient treatment for fingertip injuries. J Hand Surg 20B:63–71, 

1995. 

3. Roser SE, Gellman H: Comparison of nail bed repair versus nail trephination for subungual 

hematomas in children. J Hand Surg 24A:1166–1170, 1999. 

4. Seaberg DC, Angelos WJ, Paris PM: Treatment of subungual hematomas with nail 

trephination: A prospective study. Am J Emerg Med 9:290–310, 1991.

Chapter 30 

FINGER FRACTURES AND DISLOCATIONS 

KEY FIGURES: 

Rotational deformity 

Buddy taping 

Reduction of metacarpal fracture 

Because we use our hands for so many things, finger fractures and dislocations 

are common injuries. Unless they are associated with significant 

soft tissue injury, definitive treatment is not emergent. Often the initial 

evaluation and necessary splinting can be done by a nonspecialist. 

This chapter describes basic treatments for finger fractures and dislocations 

that can be done by all health care providers. For the best possible 

outcome, however, more highly technical procedures may be required. 

Whenever possible, patients with all but the simplest injuries should 

be referred to a hand specialist for definitive treatment. 

An occupational therapist also should be consulted to help with rehabilitation 

once the fracture or dislocation has been properly treated. 

In areas where specialists are not available, the basic interventions discussed 

in this chapter can help the patient attain an acceptable functional 

outcome. 


To reduce a fracture or dislocation means to restore the proper anatomic 

and functional alignment of the bone or joint. For most hand injuries, 

functional status is most important to the patient. 

An open fracture or dislocation implies a wound in the soft tissues 

overlying the bone injury. In a closed injury the surrounding skin is 

intact. This distinction is important. An open fracture or dislocation 

has a high risk for infection. To prevent this complication, careful and 

thorough wash-out of the wound is required. The patient also should 

be given antibiotics (the oral route is usually sufficient, but extent of 

injury is the determining factor) for at least 48 hours after the repair. A 

293


closed fracture or dislocation is not associated with a high risk of infection; 

thus, the patient does not require treatment with antibiotics. 

FFiinnggeerr FFrraaccttuurreess 

Compared with leg fractures, finger fractures may seem to be insignificant 

injuries. However, finger fractures can be quite problematic. 

Without proper treatment, a finger fracture can lead to significant limitation 

in hand function and disability. 

Anesthesia 

Administer a digital block before attempting to reduce a fracture. Use a 

combination of lidocaine and bupivacaine whenever possible to help 

with postprocedure pain control. 

Distal Phalangeal Fractures 

The distal phalanx is the most commonly fractured bone of the finger. 

Distal phalangeal fractures are classified into three types: tuft fractures, 

shaft fractures, and intraarticular fractures. 

Tuft Fractures 

A tuft fracture involves the most distal portion of the bone. It usually is 

caused by a crush mechanism, such as hitting the tip of the finger with 

a hammer. A tuft fracture is often an open fracture because of its 

common association with injury to the surrounding soft tissues and/or 

nail bed. Even without injury to surrounding soft tissue, the fracture is 

considered open in the presence of nail bed injury. 

Treatment 

1. The soft tissue wound should be cleansed thoroughly, and all foreign 

material should be removed. 

2. In patients with a subungual hematoma > 50% of the nail surface, 

consider removing the nail to allow repair of the nail bed (see chapter 

29, “Fingertip and Nail Bed Injuries”). 

3. Soft tissues should be sutured loosely in an interrupted fashion. Use 

4-0 nylon or chromic material. Repair the nail bed with 5-0 or 6-0 

chromic sutures. Repair of soft tissues usually leads to adequate reduction 

of the fracture. 

4. Cover the suture line with antibiotic ointment and dry gauze. The 

dressing should be changed daily. 

5. Keep the finger elevated as much as possible.

Finger Fractures and Dislocations 295 

6. Strongly advise the patient to avoid smoking. Tobacco products 

slow the healing process. 

7. Provide pain medication. Tuft fractures are often quite painful and 

tender for several days. 

8. The patient may wear a protective splint or bulky dressing over the 

fingertip and distal interphalangeal (DIP) joint to prevent movement. 

The splint also protects the finger from accidental reinjury. 

However, do not immobilize the entire finger with the dressing or 

splint. Complete immoblization leads to unnecessary finger stiffness. 

9. Once the finger is less tender (usually within 10–14 days), encourage 

the patient to gradually resume normal use of the finger. 

Shaft Fractures 

Shaft fractures involve the central portion of the distal phalanx. They 

also are associated often with soft tissue or nail bed injuries. As described 

above, repair of any soft tissue usually leads to adequate reduction 

of the fracture. 

For further bone stabilization, a 20-gauge needle can be passed manually 

from the end of the fingertip into the bone segments. This procedure 

should be done before repair of any soft tissue injury (if present). The 

needle easily passes through the soft tissues into the bone if it is pushed 

firmly with a twisting motion. Bend the top part of the needle (the hub) 

so that it does not protrude too far from the end of the fingertip. 

Basically, shaft fractures are treated like tuft fractures. If a needle is used 

to stabilize the fracture, remove it when the fingertip is no longer tender. 

Intraarticular Fractures 

Intraarticular fractures involve the joint surface of the distal phalanx at 

the DIP joint. The patient may present with a mallet deformity (inability 

to extend the DIP joint fully) if the fracture involves the bony insertion 

of the extensor tendon. In this setting, treat the finger like a mallet 

finger, as described in chapter 32, “Tendon Injuries of the Hand.” 

If there is no evidence of mallet deformity, the joint surface should be 

aligned as meticulously as possible to ensure optimal function. Such injuries 

are best referred to a hand specialist. If no specialist is available: 

1. Manipulate the finger to align the bone pieces as precisely as possible. 

2. Immobilize the DIP joint in 0–10° of flexion for 10–14 days. You can 

use a plaster splint or make a splint from a tongue depressor. Alternatively, 

the 20-gauge needle technique (described above) can be 

used to immobilize the DIP joint.


3. However you immobilize the joint, be sure to allow motion of the 

proximal interphalangeal (PIP) joint. 

4. When the finger is no longer tender, the patient should start moving 

the joint both passively and actively in hope of regaining functional 

range of motion at the DIP joint. 

Middle and Proximal Phalangeal Fractures 

Middle and proximal phalangeal fractures are classified according to 

whether they involve the joint surface. 

Extraarticular Fractures 

Extraarticular fractures affect the part of the bone that is not involved 

with the joint surface. The main concern is whether a rotational deformity 

is present when the patient attempts to bend the fingers. See chapter 26, 

“Normal Hand Exam,” for discussion of rotational finger alignment. 

Any malrotation associated with metacarpal or phalangeal fractures must be 

corrected. Left, Normally all fingers point toward the region of the scaphoid 

when a fist is made. Right, Malrotation at the fracture site causes the affected 

finger to deviate. (From Crenshaw AH (ed): Campbell’s Operative 

Orthopaedics, 7th ed. St. Louis, Mosby, 1987, with permission.) 

If no rotational deformity is present, the finger can be treated by 

buddy taping for 2–3 weeks until the finger is no longer tender. Buddy 

taping is used to initiate gentle movement of the injured finger while 

maintaining proper bone alignment. The injured finger is taped to the 

adjacent finger, and the patient is instructed to use the hand as normally 

as possible.


Table 1. Which Fingers to Use for Buddy Taping 

Injured Finger Finger Used for Buddy Taping 

Index Long 

Long Index 

Ring Long 

Little Ring 

Buddy taping. To promote protected 

motion of the injured finger, secure it to an 

adjacent noninjured finger. 

If a rotational deformity is present, give a digital block, and try to 

align the bone by manipulating the finger. Then place the finger in a 

volar splint. 

If the fracture involves the proximal phalanx, the splint should immobilize 

the PIP joint in 0° of flexion and the metacarpophalangeal (MCP) 

joints in 70° of flexion. If the fracture involves the middle phalanx, the 

splint should immobilize both the DIP and PIP joints in 0° of flexion. 

The splint should be worn for 2–3 weeks until the tenderness over the 

fracture site has resolved. 

After removing the splint, buddy-tape the finger for an additional 1–2 

weeks. This approach initiates gentle movement of the affected finger 

and improves motion of the joints. 

Fractures with a rotational deformity should be treated by a hand specialist 

if one is available.


Intraarticular Fractures 

Intraarticular fractures involve the portion of bone that makes up the 

joint surface. Proper reduction is required to obtain adequate range of 

motion and finger function once the bone has healed. Intraarticular 

fractures usually require operative exploration for proper bony stabilization 

(with pins or screws) and thus should be treated by a hand 

specialist if one is available. If no hand specialist is available, try the 

treatment described for extraarticular fractures. 

Metacarpal Fractures 

Metacarpal fractures are included in this chapter because they can 

affect the position and function of the affected finger. A poorly aligned 

metacarpal fracture can cause a rotational deformity. 

Metacarpal fractures may occur anywhere along the bone. Many require 

some type of pin fixation or stabilization for optimal treatment. 

Therefore, you should consult a hand specialist whenever possible. 

If no specialist is available, begin by checking finger rotation. If the fingers 

maintain proper alignment and the fracture looks reasonably well 

positioned on radiographs, a short period (2–4 weeks until the fracture 

site is no longer tender) of cast or splint immobilization may be all that 

is required. 

If a rotational deformity is present, reduction and manipulation must 

be performed before immobilization. 

Fracture Reduction 

Before the fracture is reduced a wrist block or a hematoma block 

should be given for pain control. 

Hematoma Block 

1. Draw up 3–5 ml of lidocaine in a syringe. 

2. Clean the area overlying the fracture with alcohol or povidoneiodine 

solution. This procedure must be done under sterile conditions 

so that you do not contaminate the area around the fracture 

site and cause an infection. 

3. Insert the needle into the tissues overlying the fracture until the tip 

of the needle contacts bone. Then back up the needle a few millimeters 

and inject 1–2 ml of solution. 

4. Without completely removing it from the skin, back up the needle 

and reposition the tip by a centimeter or so. Then inject the rest of 

the solution.


Reduction Procedure 

1. Start by flexing the MCP joint. 

2. Apply downward pressure on the dorsal side of the fracture and 

exert upward pressure at the MCP joint until you feel the bone fragments 

move into the proper position. 

3. Recheck finger alignment to ensure that the rotational deformity 

has been corrected. Repeat this procedure until proper alignment is 

achieved. 

Reduction of a metacarpal fracture. Arrows indicate the direction of pressure 

application for fracture reduction. (From Green DP, et al (eds): Operative Hand 

Surgery, 4th ed. New York, Churchill Livingstone, 1999, with permission.) 

4. Immobilize the hand with a cast or splint that includes the wrist 

(20–30° of extension) and MCP joints (60° of flexion). The interphalangeal 

joints can be left free so that you can monitor for rotational 

changes in the fingertips. 

5. If you place the hand in a cast, be sure to use several layers of 

padding to protect the skin, and do not wrap the plaster too tightly. 

6. The initial swelling from the injury should decrease after a few 

days. Therefore, the cast may need to be changed 5–7 days after 

injury to ensure adequate immobilization of the fracture site. 

7. The hand should be immobilized for 3–4 weeks. Watch for changes in 

the position of the fingertips, which may be a sign that the reduction 

has slipped. If so, repeat manipulation of the fracture is required. 

8. When the fracture site is no longer tender, the patient can begin to 

use the hand for light activity. Gradually increase activity over the 

next few months, as tolerated by the patient.


JJooiinntt DDiissllooccaattiioonnss 

For treatment purposes, finger joint dislocations can be classified as 

either simple or complex. A simple dislocation involves no fracture of 

the bone and can be reduced easily. A complex dislocation is not reducible 

or is associated with fracture of one of the involved bones. The 

main concern is whether the dislocation is reducible. 

Simple MCP Joint Dislocations 

Reduction of an MCP joint dislocation demands particular care. An incorrect 

reduction can change a simple dislocation into a complex one. 

Reduction Technique 

1. You may need to give a wrist block or gentle sedation for pain 

control. 

2. Flex the wrist to keep the flexor tendons slack. 

3. Avoid pulling on the finger and placing extension forces onto the 

joint. 

4. Apply direct digital pressure on the dorsal side of the base of the 

proximal phalanx, and push the proximal phalanx in a volar direction 

to reposition the proximal phalanx above the metacarpal head. 

After Reduction 

The joint will slide into a flexed position once the dislocation has been 

reduced. The patient is allowed to use the finger, but a splint should be 

placed on the dorsal surface of the hand (onto the finger) to prevent extension 

of the MCP joint beyond 0°. The patient should wear the splint 

until the joint is completely non-tender, usually for 2–3 weeks. 

Active and passive range-of-motion exercises should be done for several 

months to attain full motion in the joint. 

Simple Interphalangeal Joint Dislocations 

Often the patient presents after the dislocation is reduced. If reduction 

is required, use the following technique. 

Reduction Technique 

1. A digital block may be required for pain control. 

2. Apply gentle traction to the finger by grasping the finger distal to 

the affected joint. Gently pull on the finger, and the dislocation 

should reduce.

After Reduction 


The affected joint(s) should be immobilized with a dorsal splint, keeping 

the joint in 20–30° of flexion for 5–7 days until the tenderness significantly 

decreases. 

The finger then should be buddy-taped for another 2–3 weeks. When 

the affected joint is completely pain-free, the taping can be stopped. 

Joint stiffness may remain for months. The patient should continue 

range-of-motion exercises until the finger moves normally. 

Complex Dislocations 

The treatment of a complex dislocation requires operative exploration, 

the description of which is beyond the scope of this text. Complex dislocations 

require referral to a hand specialist. 


1. Glickel SZ, Barron OA, Eaton RG: Dislocations and ligament injuries in the digits. In 

Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, 4th 

ed. New York, Churchill Livingstone, 1999, pp 772–808. 

2. Kiefhaber TR, Stern PJ: Fracture dislocations of the proximal interphalangeal joint. J 

Hand Surg 23A:368–380, 1998. 

3. Stern PJ: Fractures of the metacarpals and phalanges. In Green DP, Hotchkiss RN, 

Pederson WC (eds): Green’s Operative Hand Surgery, 4th ed. New York, Churchill 

Livingstone, 1999, pp 711–771.

Chapter 31 

TRAUMATIC HAND AND FINGER 

AMPUTATIONS 

KEY FIGURES: 

Care of amputated segment 

Amputation of the middle finger 

Successful replantation 

This chapter outlines the basic principles for the evaluation and treatment 

of traumatic hand and finger amputations proximal to the distal interphalangeal 

(DIP) joint. Amputations distal to the DIP joint can be treated 

as a fingertip injury (see chapter 29, “Fingertip and Nail Bed Injuries”). 

The procedure to reattach an amputated part is highly technical and tedious. 

It includes reconnecting blood vessels (both an artery and at 

least one vein), nerves, and lacerated tendons as well as realigning and 

stabilizing the bones. A highly trained microsurgeon with access to 

specialized equipment is required. 

IIff NNoo PPrrooppeerrllyy EEqquuiippppeedd MMiiccrroossuurrggeeoonn iiss AAvvaaiillaabbllee 

Your best strategy is to help the wound heal with as little functional 

disability as possible. You can take steps to prevent, for example, a 

painful stump, which will interfere with use of the hand. 

Basic Wound Treatment 

After administering a digital block or wrist block, as indicated by the 

level of amputation, completely clean and examine both the stump and 

the amputated part (see chapter 6, “Evaluation of an Acute Wound”). 

Exposed tendons that have lost their distal insertion sites should be cut 

off so that the ends of the tendons are covered by soft tissue. 

Do not discard the amputated part until you have thoroughly examined 

the wound. You may be able to use some of the skin from the amputated 

segment as a skin graft to cover the open wound. 

303


Options for Wound Closure 

If enough skin is available, close the wound with a few loose sutures. A 

tight closure can lead to further tissue loss. 

If no skin is available, no bone or tendon is exposed, and the wound is 

relatively small (< 2 cm), the wound can be left open and treated with 

local care. An alternative is to use noninjured skin from the amputated 

segment as a full-thickness skin graft to cover the wound. 

If the wound is large and cannot be closed primarily or if bones or 

intact tendons are exposed, a distant flap (e.g., chest flap, groin flap) is 

needed for wound closure. (See chapter 14, “Distant Flaps.”) 

If a nerve is exposed at the end of the stump, place a clamp on the 

nerve and pull gently. Then cut the nerve back to the point where it 

exits the soft tissues. This maneuver allows the nerve to retract under 

healthy skin or soft tissue and thus prevents development of a sensitive 

or painful stump. 

Wound Care 

Clean with gentle soap and water or sterile saline daily. 

Strongly urge the patient not to smoke. 

The patient should keep the affected hand elevated to decrease 

swelling and pain and to promote healing. 

Remember pain medication. Acetaminophen alone may not be enough 

for the first few days after injury. Amputations can be quite painful. 

Apply antibiotic ointment and a simple, dry dressing 1–2 times/day. 

Wet-to-dry dressings also can be useful. 

• If the wound was sutured closed, after a few days the dressings can 

be discontinued. 

• If the wound was left open, continue the dressing changes until the 

wound is healed. 

Encourage the patient to move the finger and hand to prevent joint 

stiffness. Active and passive range-of-motion exercises also should be 

encouraged. 

IIff aa PPrrooppeerrllyy EEqquuiippppeedd MMiiccrroossuurrggeeoonn iiss AAvvaaiillaabbllee 

You can take several important steps before the patient is transferred to 

the microsurgeon’s care. An amputated hand or finger(s) can be replanted 

even many hours after the injury, but the amputated part must 

receive proper care.

Traumatic Hand and Finger Amputations 305 

In addition, the patient must be informed that he or she will not 

awaken from surgery with a normally functioning hand. Replantation 

of the amputated segment commits the patient to a long and tedious 

rehabilitation program to obtain maximal hand function. Be sure to explain 

this prolonged process to the patient. 

Patient Preparation 

1. Administer intravenous (IV) fluids (normal saline or Ringer’s lactate) 

to keep the patient hydrated. While awaiting surgery, the patient 

should not be allowed to eat or drink anything except required 

medications. 

2. Give aspirin (not acetaminophen) at a dose of 80–160 mg, which is 

equivalent to one baby aspirin or one-half of an adult aspirin. It can 

be given by mouth or as a rectal suppository. The antiplatelet properties 

of aspirin may help to prevent clotting of the vessels after the 

reattachment has been completed. 

3. Give a dose of IV antibiotics. A first-generation cephalosporin is 

most appropriate. 

4. Control pain with IV morphine or a digital block. Give the nerve 

block only after consultation with the surgeon. 

5. Clean and dress the stump with saline-moistened gauze (damp, not 

soaking wet), and wrap the stump lightly with dry gauze to control 

oozing and to keep the wound clean. 

6. Gently elevate the affected hand. 

7. Get a radiograph of the stump as well as the amputated segment. 

Care of the Amputated Part 

1. Remove any foreign material from the exposed soft tissues. 

2. Clean the amputated part with saline, and wrap it in saline moistened 

gauze (damp, not soaking wet). 

3. Place the wrapped segment in a plastic bag. 

4. Place the bag into a container filled with ice mixed with saline. Do 

not place the amputated part directly on ice. 

5. Do not forget to get a radiograph of the amputated part. 

The patient is now ready for transfer. 


Merle M, Dautel G: Advances in digital replantation. Clin Plast Surg 24:87–106, 1997.


Care of the amputated segment. The amputated 

segment should be cooled immediately 

by wrapping it in a moist saline 

gauze, placing it in a sealed plastic bag, 

and immersing it in an iced saline container. 

(From McCarthy J (ed): Plastic 

Surgery. Philadelphia, W.B. Saunders, 


Traumatic amputation of the middle finger. A, Hand with missing finger. 

B, Amputated segment. 

One year after successful replantation. A and B, Patient has regained excellent 

function of her hand.

Chapter 32 

TENDON INJURIES OF THE HAND 

KEY FIGURES: 

Extensor surface of hand Injured finger in 

Mallet finger stack splint 

Mallet splints Repair of open mallet 

Most hand specialists believe that the earlier a tendon injury is repaired, 

the better the final result. However, repair of a lacerated flexor 

tendon is not a surgical emergency mandating immediate repair. 

If the tendon ends are easily identifiable in the wound, you should 

repair the tendon when you first see the patient. However, if immediate 

repair is not possible or if you do not have the necessary surgical skills, 

the tendon can be repaired at a later time when a specialist is available. 

The overall outcome will not be adversely affected by delayed repair. 

The most important point is to thoroughly wash out the wound and loosely 

close the skin as soon as possible after injury. This treatment prevents wound 

infection and allows safe performance of definitive repair at a later time 

(preferably within 7–10 days). 

FFlleexxoorr TTeennddoonn IInnjjuurriieess 

Suspect a flexor tendon injury if the patient is unable to actively flex 

the distal (DIP) or proximal interphalangeal (PIP) joint of a finger, the 

interphalangeal (IP) joint of the thumb, or the wrist. 

Partial and complete flexor tendon lacerations should be repaired to 

prevent disability. Repair requires careful exploration in the operating 

room (the proximal end of the cut tendon almost always retracts and is 

therefore difficult to locate) and advanced surgical skills. A clinician 

with technical expertise in hand surgery should repair flexor tendon 

injuries; the procedure can be quite challenging. 

An important part of the initial treatment after repair of the overlying 

open wound is to place the hand in a splint. For injury to the flexor 

tendon of the thumb, use a thumb spica splint. For injury to the flexor 

307


tendon of the finger or wrist, immobilize the entire hand by applying a 

dorsal splint that covers the forearm, hand, and fingers. For more detailed 

information about splinting, see chapter 28, “Hand Splinting and 

General Aftercare.” The patient should wear the splint until he or she 

is evaluated by a specialist. 

EExxtteennssoorr TTeennddoonn IInnjjuurriieess 

An extensor tendon injury should be suspected when the patient 

cannot extend the metacarpophalangeal (MCP) joint of a finger or the 

thumb, the IP joint of the thumb, or the wrist. 

Injury to the extensor tendon mechanism on the dorsal surface of the 

finger is evidenced by an inability to extend the PIP and DIP joints. 

Unless the patient has lacerations over each finger, generalized inability 

to extend the PIP and DIP joints of all fingers probably represents 

an ulnar nerve injury rather than a tendon injury. 

In wounds over the dorsal surface of the hand or a finger, the cut ends 

of the tendon often can be identified with minimal wound exploration. 

Therefore, an extensor tendon injury often can be repaired on initial 

evaluation without taking the patient to the operating room. 

Dorsal view of the hand 

showing extensor tendons, 

accessory communicating 

tendons (vincular accessorium), 

and extensor expansions. 

(From Crenshaw AH 

(ed): Campbell’s Operative 

Orthopaedics, 7th ed. St. 

Louis, Mosby, 1987, with 

permission.)

Repair of the Extensor Tendon 

Tendon Injuries of the Hand 309 

Administer local anesthetic either by direct infiltration of the wound or 

by digital block. Be sure to clean the wound thoroughly. 

If you see the tendon ends in the wound, repair the tendon (see below). 

If you cannot identify the proximal end (usually the harder end to 

locate), try to extend the involved finger and wrist. If this maneuver is 

unsuccessful, try to enlarge the wound with a knife by an additional 

1–2 cm. Keep the involved part in extension, and see if this maneuver 

brings the tendon end into view. 

If you are unable to locate the tendon ends, surgical exploration by a 

clinician with hand expertise is needed. Loosely close the skin so that 

the repair can be done at a later date. 

If the tendon ends are identified, sew them together using a nonabsorbable 

suture such as 4-0 nylon. The tendon can be repaired with a 

single figure-of-eight suture. Alternatively, place one or two simple sutures 

in the tendon ends to bring them together. 

Caution: When tying the suture(s), do not pull too tightly. You may rip 

the suture out of the tendon. 

Repair the overlying skin laceration with a few simple sutures. Apply 

antibiotic ointment and dry gauze over the repaired skin. A splint is required 

to protect the repair. 

Table 1. Splinting of Extensor Tendon Injury* 

Location of Injury Type of Splint 

On finger Volar splint of finger that extends onto palm of hand. 

It is best to use an aluminum splint or to make a 

splint from plaster. Finger should be immobilized 

with MCP joint in 10–15° of flexion and IP joints 

straight. 

On thumb Thumb spica splint. 

Extensor tendon to finger(s) Volar splint from forearm to fingertips. Wrist 

on dorsum of hand or should be placed in 20° of extension, MCP joints 

wrist in 10–15° of flexion, and IP joints straight. 

Extensor tendon to thumb Thumb spica splint. 

on dorsum of hand or wrist 

*See chapter 28 for more information about splinting. 

If the extensor tendon is repaired, the patient should wear the splint 

for 4–6 weeks. An occupational therapist (if available) should see the 

patient to promote proper tendon healing and hand function. 

If the tendon is not repaired, the splint should be worn until the patient 

can be evaluated by a hand specialist.


MMaalllleett FFiinnggeerr 

Mallet finger results from injury of the extensor tendon at its insertion 

into the distal phalanx. The patient cannot fully extend the finger at the 

DIP joint. Without adequate treatment, the finger will not completely 

straighten, which can be quite bothersome. For example, patients will not 

be able to get objects out of their pocket, a common everyday activity. 

Mallet finger. The patient cannot actively extend the DIP joint. 

In contrast to most tendon injuries, a mallet finger can result from a 

closed injury (no cut to the overlying skin that also injured the tendon) as 

well as an injury with an overlying skin laceration. A closed mallet injury 

is caused by sudden, forced flexion of an extended finger. The tendon 

is torn off the distal phalanx, and sometimes the bone is fractured. 

Closed Mallet Deformity 

With No Underlying Fracture or a Fracture of < 50% 

of the Articular Joint Surface 

The best treatment is a volar splint—either the commercially available 

splint (Stack finger splint) or an aluminum foam splint. If neither is 

available, a splint can be made from plaster or from a piece of a tongue 

depressor (with cotton padding). The splint should be long enough to 

immobilize only the DIP joint. The PIP joint should not be immobilized. 

Position the DIP joint in slight hyperextension. Caution: Be careful not 

to hyperextend the joint too much because skin necrosis may result. 

Look at your own finger—you can see the skin blanch (indicating diminished 

blood circulation) when you overly hyperextend the DIP 

joint. This effect should be avoided. 

If you are unable to get the joint into proper hyperextension with a 

volar splint, a dorsal splint can be used. Again, immobilize only the DIP 

joint. You must be careful because of the higher incidence of skin breakdown 

when the splint is placed over the dorsal surface of the joint.

Tendon Injuries of the Hand 311 

Splints for treatment of mallet finger. (Illustration by Elizabeth Roselius © 1998. 

From Green DP, et al (eds): Operative Hand Surgery, 4th ed. New York, 

Churchill Livingstone, 1999, with permission.) 

Tape is used to keep the splint in place. The splint is removed only to 

cleanse the finger (once daily). The patient should keep the joint in extension 

while the splint is off. The splint stays in place continuously for 

at least 6 weeks. 

After 6 weeks, if the finger is nontender and the patient can actively 

hold the finger in full extension, the splint can be removed during the 

day, but only light activity should be allowed. The patient should wear 

the splint at night for another 4 weeks and when doing strenuous work 

with the hand. 

If after 6 weeks the patient cannot actively hold the finger in full extension, 

the splint should remain in place continuously for another 4 

weeks. 

If at any time after the splint is removed the patient notices loss or 

weakness of full active extension of the DIP joint, the splint should be 

replaced and worn continuously for another 4–6 weeks. 

This treatment regimen can be successful even if the patient does not 

seek treatment until several months after the initial injury. 

Injured finger in a Stack splint.


With a Facture of > 50% of the Articular Joint Surface 

To optimize functional outcome, the fracture should be meticulously 

reduced and stabilized. This procedure requires operative treatment by 

a hand specialist. However, if none is available, try the treatment described 

above. It may be successful. 

Open Mallet Deformity 

In open mallet deformities, the overlying skin is lacerated as well as 

the tendon. 

Once the finger has been thoroughly cleansed, the skin and tendon can 

be repaired together with one or two nonabsorbable figure-of-eight sutures 

(4-0 or 3-0 nylon). Alternatively, if you can see the tendon ends, 

the tendon can be repaired separately from the skin, but often this approach 

is not possible. A nonabsorbable suture should be used to 

repair the tendon. 

The splinting regimen is the same as for closed mallet deformity. The 

skin sutures are removed after 10–14 days, regardless of how the repair 

was performed. 


Repair of an open mallet deformity. 

The extensor tendon and 

overlying skin are lacerated 

(A). The skin and tendon can 

be repaired together with one 

or two nonabsorbable figureof-eight 

sutures (B), which are 

removed after 10–14 days. 

The finger must remain 

splinted for at least 6 weeks. 


Roselius © 1998. From Green 

DP, et al (eds): Operative 

Hand Surgery, 4th ed. New 

York, Churchill Livingstone, 


1. Doyle JR: Extensor tendons: Acute injuries. In Green DP, Hotchkiss RN, Pederson WC 

(eds): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 

1999, pp 1950–1987. 

2. Ingari JV, Pederson WC: Update on tendon repair. Clin Plast Surg 24:161–174, 1997. 

3. Strickland JW: Flexor tendons: Acute injuries. In Green DP, Hotchkiss RN, Pederson 

WC (eds): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 

1999, pp 1851–1897.

Chapter 33 

NERVE AND VASCULAR INJURIES 

OF THE HAND 

KEY FIGURES: 

Digital nerve location on finger 

Epineurial repair 

Nerves and blood vessels of the hand and fingers usually are quite delicate, 

and some are quite small. Optimal repair of injuries often requires 

the microsurgical expertise of a reconstructive surgeon. However, 

an understanding of basic principles is useful when you find yourself 

without specialist support. 

NNeerrvvee IInnjjuurriieess 

Nerve Physiology 

When a nerve is cut, the distal part of the nerve slowly dies and 

cannot regrow. The proximal part of the nerve will regenerate. 

However, without proper treatment, there is no guarantee that the 

nerve will grow correctly or that function (sensory or motor) will be 

restored. 

The nerve laceration should be repaired by sewing the cut ends together. 

Repair increases the likelihood that the living proximal part 

will grow in the proper direction, along the path left by the disintegrating 

distal part. 

Nerves grow at a rate of 1 mm/day once the reparative process begins 

(usually within a few weeks of injury). 

Remind the patient that even if the nerve is repaired, normal sensation 

and movement will not be apparent immediately after the procedure. 

It will take many months to know the final outcome. 

313


General Nerve Anatomy 

Nerves are made up of axonal fibers running in parallel. These fibers 

are surrounded by loose connective tissue, called epineurium. In 

larger nerves that have many different axons (some sensory, some 

motor in function), the connective tissue between the individual axons 

is called perineurium. Sutures should be placed in the loose connective 

tissue around the axons, not in the axonal substance itself. 

Digital Nerves 

Digital nerves are approximately 2–3 mm in diameter. They run with 

the digital arteries along the sides of each finger. If you look at your 

Determining the position of the digital nerve. A, Flex the finger and mark the 

most dorsal aspect of both PIP and DIP flexion creases with a dot. Connect the 

dots in a straight line. B, The course of the digital nerve is illustrated by the 

dashed line.

Nerve and Vascular Injuries of the Hand 315 

finger from the side and completely flex the distal (DIP) and proximal 

interphalangeal (PIP) joints, the neurovascular bundle runs along a 

line that connects the flexion creases of these joints. 

Digital nerves are purely sensory. If a digital nerve is cut, the patient 

feels numbness on the corresponding side of the finger. Motor function 

in the finger should be normal, because it is controlled by the tendons, 

whose muscles are innervated more proximally in the forearm. 

Impairment of motor function (other than pain with movement) suggests 

that tendon injury also is present. 

Injury to a digital nerve at any point proximal to the DIP flexion crease 

should be repaired. In the fingertip (distal to the DIP flexion crease), 

the nerve divides into its terminal branches, which are too small to 

repair. With distal nerve injuries, sensation may return without formal 

nerve repair. 

Larger Nerves 

Nerves in the forearm and wrist (e.g., median and ulnar nerves at the 

wrist) are much larger than digital nerves; their diameters range from 

5–10 mm. Most have both motor and sensory functions. When you 

look at the cut ends of the nerve, especially under magnification, you 

can see that the inner nerve fibers are of various diameters and that 

some fibers seem to be grouped together within the nerve. 

For optimal outcome, the proximal sensory fibers should be sutured 

to the distal sensory fibers and the proximal motor fibers to the distal 

motor fibers. Specialists sometimes repair larger nerves with electophysiologic 

guidance. This technique uses electric stimulators to identify 

which fibers are sensory and which are motor. Thus, the surgeon 

can determine exactly which fibers should go together. However, this 

specialized equipment usually is found only in high-technology hand 

centers. 

Your best strategy is to try to align the nerve, using whatever landmarks 

you can discern. For example, try to line up the tiny blood vessels 

in the connective tissue around the nerve and fibers of similar size. 

Nerve Repair 

For optimal results, use at least twofold magnification (glasses or microscope). 

The more magnification, the better. Twofold magnification 

glasses make the image appear twice as large as with the naked eye. 

Use the most delicate instruments you have—jewelers forceps, fine 

needle holders, fine scissors—and the smallest needle you can find (8-0 

or 9-0 nylon is best).


Epineurial repair. Sutures are placed in the connective tissue surrounding the 

nerve fibers. (From McCarthy JV (ed): Plastic Surgery. Philadelphia, W.B. 

Saunders, 1990, with permission.) 

Place your sutures in the epineurium, not in the nerve fibers. This approach 

aligns the nerve fibers and allows proper growth. 

There should be no tension on the repair. You may need to free the 

nerve from the surrounding soft tissues to remove tension. You also 

can change the position of the patient's fingers or wrist to allow the 

ends to meet more easily. Caution: if you bend the finger or wrist 

during surgery to bring the nerve ends together, it must stay in this position 

for 10–14 days. If you accidentally straighten the hand in the operating 

room, you will disrupt the repair. 

If you have no magnification and minimal instruments: For a digital 

nerve, place a single simple suture to bring the ends together. For a 

larger nerve, 3–4 sutures should be placed. 

If you have magnification and very small sutures (8-0 or 9-0): For a 

digital nerve, place 2–4 simple sutures to bring the ends together. For 

larger nerves, place as many as you need to get a smooth repair (i.e., 

nerve fibers should not protrude from the epineurium). 

If there is too much tension on the nerve repair despite different positioning 

techniques, a nerve graft is required. This technically challenging 

procedure requires referral to a specialist for optimal outcome. 

Even so, there is no guarantee that a nerve graft will work. To facilitate 

future exploration and nerve grafting, mark the ends of the nerve by 

placing a 4-0 or 5-0 nylon or prolene simple suture in the epineurium. 

Be sure to use a nonabsorbable material, which helps to locate the 

nerve ends at the next operation. The surgeon performing the subsequent 

procedure will be grateful.



The repair should be immobilized by splinting the hand or finger for a 

minimum of 10–14 days. 

If the finger or hand required special positioning to get the nerve 

ends to meet during the operation, the patient should begin to open 

the finger or hand slowly (over the subsequent 1–2 weeks) to avoid disruption 

of the repair. 

If a motor nerve is injured, the patient should move the joints of the 

hand regularly to prevent stiffness. It takes months for the nerve to 

start working again. Even if the nerve repair is successful, the patient 

may not regain function if the joints have become stiff from disuse. 

If a sensory nerve is injured, remind the patient to be careful around 

very hot, very cold, or sharp objects to prevent accidental injury to the 

insensate area. 

VVaassccuullaarr IInnjjuurriieess 

First, address the risk of exsanguination (bleeding to death), which is a 

real danger with arterial injuries. 

If serious bleeding persists: Apply point pressure over the wound. 

This does not mean placing gauze in the wound and wrapping the 

area with an Ace bandage. It means placing a wad of gauze over the 

injured area and using two fingers to apply firm point pressure to the 

injured site. You may need to hold the pressure for several minutes 

before the bleeding stops. If the bleeding is arterial, exploration is 

needed. 

If you cannot control an exsanguinating hemorrhage, place a tourniquet 

or blood pressure cuff proximal to the injury (closer to the heart). 

If you use a blood pressure cuff, it must be inflated to at least 50 mmHg 

above systolic arterial pressure (usually to at least 200–250 mmHg). 

Tourniquets hurt and place the tissues at risk for ischemic injury. The 

tourniquet should not be left in place for more than 15–20 minutes. If a 

tourniquet is needed, urgent operative exploration is required. 

Patients with a history of pulsatile bleeding (blood squirting out 

from a hand or forearm wound) must be explored surgically, even in 

the absence of active bleeding at the time of exam. Failure to tie off or 

repair the vessel is associated with a high incidence of pseudoaneurysm 

(outpouching of the vessel). A pseudoaneurysm can be dangerous because 

of its propensity for rupture in the future.


Digital Artery 

Bleeding from a digital artery usually can be controlled by repairing 

the skin laceration and applying pressure over the injured area. In the 

rare instance when this approach fails, the vessel can be tied off with a 

very small suture (5-0 or 6-0 silk or chromic). 

Caution: The digital nerve is adjacent to the artery. Do not accidentally 

place the suture around the nerve as well as the artery. If you accidentally 

tie off a digital nerve, the patient will have considerable postoperative pain. 

Radial Artery 

Although we palpate the radial artery to check heart rate, it is not the 

dominant source of circulation to the hand. Many patients with a radial 

artery injury still have adequate circulation in the injured hand, as evidenced 

by good capillary refill and normal hand temperature (compared 

with the other hand). The artery does not necessarily need to be 

repaired or reconstructed. The vessel can be tied off with minimal morbidity. 

Remember to tie off both ends of the vessel. 

Because a significant amount of pressure pushes blood through an 

artery, a preferable and more secure way to tie off a larger artery is to 

use a “stick tie.” Both techniques are discussed in the chapter 2, “Basic 

Surgical Skills.” 

However, if circulation to the hand is insufficient, as evidenced by poor 

capillary refill and cold skin, the vessel should be repaired. Repair of 

the blood vessel involves joining together the two severed parts of the 

artery so that blood can flow as it did before the injury. Blood vessels in 

the distal forearm are quite small, and repair requires microsurgical 

equipment and expertise. Transfer to a specialist is vital to save the 

hand. 

Ulnar Artery 

The ulnar artery is the dominant artery to the hand in most people. 

Thus, if it is injured, it should be repaired or reconstructed. Repair requires 

microsurgical expertise, because the ulnar artery is even smaller 

than the radial artery. 

The vessel should be tied off only if no one with microsurgical skills is 

available or if the patient is actively bleeding. In addition, some patients 

have sufficient circulation to the hand even if the ulnar artery is 

injured. In these few patients, the vessel can be safely tied off. In general, 

however, it is not recommended to tie off the ulnar artery permanently 

if specialists are available for referral.



1. Modrall JG, Weaver FA, Yellin AE: Diagnosis and management of penetrating vascular 

trauma and the injured extremity. Emerg Med Clin North Am 16:129–144, 1998. 

2. Watchmaker GP, Mackinnon SE: Advances in peripheral nerve repair. Clin Plast Surg 

24:63-73, 1997.

Chapter 34 

HAND BURNS 

KEY FIGURES: 

Neglected hand 

Escharotomy 

Severe hand burns are especially problematic injuries because of their 

propensity for causing long-term disability. Proper treatment of the 

burned hand may mean that the patient can return to work and a 

normal lifestyle. 

Unfortunately, if a large portion of the body is burned, the importance of 

the hands in terms of overall functional outcome is often overlooked. 

But if not properly treated, burns of the hand can result in severe dysfunction 

and significant morbidity. Simple interventions can make a 

huge difference in final outcome. 

This chapter discusses specific interventions for treatment of a hand 

burn. A thorough discussion of the treatment of the “whole patient” 

with a burn injury is found in chapter 20, “Burns.” 

IInniittiiaall TTrreeaattmmeenntt 

• Cleanse the burned hand with a gentle soap and cool water. Salinemoistened 

gauze also may be used for cleansing. Remove any clothing 

or other material attached to the burned tissues. 

• Grease embedded in burned tissues often can be removed by gently 

wiping with a petrolatum ointment. If tar is stuck onto the skin, leave 

it alone; it will separate as the tissues heal. If you pull the tar off, you 

probably will remove healthy skin, making the injury worse than it 

needed to be. 

• Make sure that the patient’s tetanus immunizations are up to date. 

• Pain medication is important; intravenous administration of morphine 

is the most useful approach. 

321


• Apply an antibiotic ointment, such as silver sulfadiazine, to the 

burned areas, and cover lightly with gauze. 

• Gentle cleansing with saline and application of antibiotic ointment 

optimally should be done twice each day, but daily is acceptable. 

• The hand should be kept elevated (on a pillow or folded sheet) to 

minimize swelling. 

• Oral or intravenous antibiotics should be used only if signs of infection 

are present. 

Severely burned hand of a child who did not receive proper care. The hand is 

essentially nonfunctional and will not grow properly. A, Dorsal surface. B, Volar 

surface.

Blisters 

Hand Burns 323 

A blister is a collection of fluid beneath a layer of burned skin. It represents 

a partial-thickness injury (see discussion of depth of burn on the 

following page). In general, a blister serves as a useful biologic dressing 

because it allows the deeper tissues to remain in a sterile environment. 

Blisters promote healing and decrease pain. 

Leaving the blister alone is often the best initial treatment. However, 

some blisters become very tight, to the point that blood flow to the hand 

is diminished. Ischemia can lead to further, unnecessary tissue loss. 

Tight blisters also interfere with hand and finger motion. Therefore, 

when a blister feels very tight, it should be opened and the outer skin 

layer should be removed. The top skin layer also should be removed 

from blisters that have burst or look as if they are about to burst. 

How to Debride a Blister 

Debridement of blisters is not a painful procedure if done properly: 

1. Clean the area with Betadine or some other cleansing solution. 

2. Use a knife or scissors to make an opening in the outer layer of the 

blister. 

3. Remove the outer layer of the blister by cutting it off a few millimeters 

from the point where it attaches to the surrounding nonblistered 

skin. 

4. The fluid in the blister has a high protein content and may be almost 

gelatinous. Completely remove the fluid and gel-like material, and 

gently wipe the area with saline-moistened gauze. 

5. Apply antibiotic ointment to the area, and cover with gauze. 

Prevention of a Stiff and Useless Hand 

A severe burn to the hand poses significant risk for long-term morbidity. 

The injured hand tends to assume a flexed posture, which can lead 

to stiffness of the interphalangeal (IP) and metacarpophalangeal 

(MCP) joint ligaments. Without aggressive treatment during the time 

required for the burn to heal, the hand may become permanently stiff 

with limited function. 

• Occupational therapy is a vital component in the treatment of severe 

hand burns. If a therapist is available, make the referral. 

• Encourage the patient to move his or her hands and fingers often, 

especially at dressing changes. The nurse or family can move the fingers 

and hand for the patient if the patient is unable to do so. Active 

and passive range-of-motion exercises should be done.


• Pain control is important because movement hurts. 

• Place the hand in a splint to prevent it from assuming the flexed position 

that ultimately may limit function. The splint should keep the 

wrist in 20° of extension, the MCP joints in 70° of flexion, and the IP 

joints as straight as possible. The padding for the splint should be 

changed if it becomes soiled. At a minimum, the patient should wear 

the splint at night; critically injured patients should wear the splint at 

all times until the burns have healed. 

• Careful tangential excision of the burn and split-thickness skin 

grafting should be done relatively early (within days of the injury if 

possible) for full-thickness burns. This will prevent the development of 

tight scars, which can lead to severe movement limitations. Only health 

care providers with surgical expertise should undertake these procedures. 

See the discussion of surgical treatments for more information. 

DDeetteerrmmiinniinngg DDeepptthh ooff BBuurrnn 

As explained in chapter 20, “Burns,” it is often difficult to determine 

the severity of the burn at the first examination. Reevaluate the burn 

once it has been cleansed and regularly thereafter. Burns are described 

as first degree (superficial), second degree (partial thickness), and third 

degree (full thickness). 

Table 1. Burn Wound Classification 

Burn Depth Appearance Pain Sensation 

Superficial (first-degree) Erythema + Yes 

Partial thickness* (second Blisters, hairs (if present) stay +++ Yes 

degree) attached 

Full thickness (third Thick, leathery feel 0 No 

degree) Pale color 

Hairs (if present) do not stay 

attached 

Thombosed veins may be seen 

* Partial-thickness burns can be superficial or deep. A superficial partial-thickness burn may have a 

thin blister, and the skin will be soft and pink. A deep partial-thickness burn appears white and feels 

softer than a full-thickness burn; some hair follicles are still attached. A deep partial-thickness burn 

often behaves like a full-thickness burn. 

The skin of the hand has a wide range of thickness. The skin over the 

dorsum of the hand is much thinner than the skin over the palmar surface. 

A more severe burn injury is required to cause a full-thickness 

burn to the palmar vs. the dorsal surface. Because the extensor tendons 

are so close to the surface, full-thickness burns to the dorsal surface of 

the hand can be especially problematic.


Estimating the depth of the burn is important to approximate time to 

healing. First- and superficial second-degree burns should heal within 

2 weeks, whereas deep second- and third-degree burns can take 3–4 

weeks or longer to heal. 

If the burns do not show significant evidence of healing after 7–10 days 

or if a full-thickness burn occurs in an area where tight scarring is 

likely, consideration should be given to early surgical intervention (see 

Tangential Excision). 

SSuurrggiiccaall TTrreeaattmmeennttss 

Escharotomy 

Severe, circumferential full-thickness burns of the hand and fingers 

require extra precautions. The burned skin becomes leathery and loses 

all elasticity. As the underlying tissues swell (from a combination of 

the burn injury and from the fluid that the patient receives), the 

burned skin cannot “give,” and pressure builds up in the tissues. 

Pressure build-up can lead to decreased circulation, which can result 

in further loss of tissue. 

In all patients with severe burns, check for palpable pulses at the wrist. 

If they are not present, blood circulation to the tissues probably is inadequate 

because of the tightness of the burned tissues. An escharotomy 

must be done emergently to prevent further tissue loss. 

Escharotomy is the placing of incisions into the burned tissues to release 

the tightness. Do not extend the incisions into the deeper tissues; cut 

through the burned tissue only. Incisions must be placed with care to prevent 

injury to the important underlying nerves, tendons, and vessels. 

Escharotomy can be done at the bedside. Caution: Escharotomy can be 

a bloody procedure. Be sure that blood is available, along with gauze, 

clamps, and an electrocautery device. 

Although the eschar itself has no sensation, the procedure can be quite 

painful. Intravenous morphine or intravenous sedation/general anesthesia 

is required. 

To Treat the Fingers 

An incision is made along the side of the finger. Usually only one incision 

is needed on each finger. Try to avoid placing the incisions on the 

radial borders of the fingers. Placing the incisions along the ulnar surfaces 

of the fingers will prevent future problems with scar sensitivity 

when the patient attempts to grasp objects.


To Treat the Hand 

Four dorsal, longitudinal incisions should be made between the metacarpal 

bones. Place a clamp into the deeper tissues, and spread open 

the jaws of the clamp to relieve the pressure over the underlying interosseous 

muscles. 

To Treat the Forearm 

The incision starts at the radial side of the wrist and proceeds proximally 

along the radial side of the forearm. The incision should be extended 

onto the upper arm (staying along the radial border of the arm) 

until the tight burn has been released completely. 

If the above incision does not completely relieve the pressure in the 

arm, an incision along the ulnar aspect of the arm and forearm should 

be made. Take care around the elbow. Keep the incision anterior to the 

medial epicondyle at the elbow to prevent accidental injury to the 

ulnar nerve. 

Incisions should be left open; do not try to close them. The purpose of escharotomy 

is to relieve pressure and prevent further tissue loss. Perform 

the same type of dressing changes in these open areas as you 

Escharotomy incisions should be placed to minimize risk for injury to nearby 

nerves, tendons, and vessels. (From Achauer BM: Burn Reconstruction. New 

York, Thieme Medical Publishers, 1991, with permission.)


perform to the burned skin. Alternatively, you may apply saline-moistened 

gauze to the incisions. 

Be sure to keep the hand elevated and in a splint to minimize swelling. Splitthickness 

skin grafts will be required for final wound healing. 

Tangential Excision 

Tangential excision is a method to remove burned tissue. See chapter 

20, “Burns,” for specific details. Care must be taken to avoid removing 

uninjured tissue. To perform this procedure you must have technical 

expertise to avoid injury to underlying tendons, nerves, and blood 

vessels. 

The excision should be done with a tourniquet on the extremity. The 

tourniquet allows you to excise more accurately only the burned 

tissue. It is important to leave the thin layer of tissue surrounding the 

tendons (peritenon) intact, if it is not burned. This tissue is vital for successful 

skin grafting. If the peritenon is burned, skin grafting is not 

possible. A distant flap is required for wound closure. 

When the tourniquet is released, the area will bleed uniformly, letting 

you know that all burned tissue has been removed. 

The wound is then ready for split-thickness skin grafting. See chapter 

12, “Skin Grafts,” for details. 

Postoperative Care after Tangential Excision and Skin Grafting 

Keep the hand elevated (on a pillow or folded sheet) to minimize 

swelling. 

Keep the hand in a splint, as previously described. 

The splint should be worn at all times for the first 2 weeks. As the 

grafts heal, the patient can wear the splint only at night. Critically injured 

patients should wear the splint at all times. 

Once the grafts have begun to “stick” (5–6 days), start gentle active and 

passive range-of-motion exercises of the hand and fingers. 

After a few weeks, as the grafts heal and the patient begins to use the 

hand more, the splint can be worn only at night. The splint should be 

used at night for at least 1–2 months. 

CCaarree aafftteerr BBuurrnnss oorr SSkkiinn GGrraaffttss hhaavvee HHeeaalleedd 

Once the tissues have healed, it is important to start treatment to prevent 

the scars from becoming thick and tight: 

Scar massage is a useful modality that requires no special equipment.


Gently rub the fingers and hand with a mild moisturizing cream 2–3 

times/day to soften scars, diminish itching, and improve functional 

outcome. 

The best way to prevent hypertrophic scarring is to fit the patient with 

a pressure garment (if available). The pressure garment should be 

worn for as many hours of the day as the patient tolerates for several 

months. 

For further discussion of these and other useful treatments, see chapter 

15, “Scar Formation.” 


1. Achauer BM: The burned hand. In Green DP, Hotchkiss RN, Pederson WC (eds): 

Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp 

2045–2060. 

2. Robson MC, Smith DJ: Burned hand. In Jurkiewicz MJ, Krizek TJ, Mathes SJ, Aryian S 

(eds): Plastic Surgery: Principles and Practice. St. Louis, Mosby, 1990, pp 781–802.

Chapter 35 

HAND CRUSH INJURY AND 

COMPARTMENT SYNDROME 

KEY FIGURES: 

Volar forearm fasciotomy incisions 

Hand/dorsal forearm fasciotomy incisions 

Finger fasciotomy incisions 

The previous chapters about the hand have discussed easily identifiable, 

individual injuries to the upper extremity. A crush injury is more 

complex and may affect all of the tissues of the hand and forearm. It is, 

therefore, more difficult to treat. The risk of long-term disability after a 

crush injury is quite high. 

Initially, the affected hand and forearm may appear to have suffered 

only minor damage because external wounds are few. Significant 

damage to the skin and underlying tissues may not become appreciable 

for hours or even days after the injury. Initial care plays an important 

role in final functional outcome. 

Most of the necessary interventions require surgical expertise. However, 

the initial examiner must be aware of all of the potential problems 

that may develop so that proper specialty help can be obtained. This 

chapter outlines such problems and discusses specific treatment for 

compartment syndrome (the most severe complication of crush injury) 

if specialty help is not available. It may save not only hand function 

but also the patient’s life. 

CCrruusshh IInnjjuurryy:: DDeeffiinniittiioonn aanndd EExxaammpplleess 

A crush injury occurs when a compressive type of force is applied to 

the tissues. At the site of injury the tissues experience several forces simultaneously, 

including shearing, contusion, and stretching in addition 

to pressure. This scenario is much different from what the tissues 

experience when injured, for example, with a knife. 

Examples of crush injuries include the following: 

329


• Getting the fingers, hand, or forearm caught in a wringer or roller 

machine. 

• A motor vehicle accident that occurs as the patient is resting an arm 

along the window sill on the outside of the car. The car flips over 

onto that side, crushing the extremity. 

• Getting the hand or forearm caught between two heavy objects that 

are compressed together. 

Skin and Subcutaneous Tissue 

EEffffeeccttss oonn tthhee TTiissssuueess 

The skin may be seriously injured with multiple lacerations and contusions. 

Foreign material may be embedded in the wounds. Alternatively, 

the skin may look largely intact. However, large flaps of skin 

may have been created by the injury. If the skin is detached from the 

underlying fascia and muscle (degloving injury), the circulation to the 

skin is greatly compromised. The result can be significant skin loss. 

In addition, blood and serum may collect in the tissue plains between 

skin and muscle. Build-up of pressure may cause further tissue 

damage and possibly a compartment syndrome (see below). 

Muscle 

Direct pressure injury and shearing forces lead to overstretching and 

tearing of the muscle. The results are bleeding and swelling within the 

muscle itself. A compartment syndrome with potentially devastating 

consequences may develop (see below). In addition, disruption of 

muscle-tendon connections may result in loss of function. 

Tendons 

Although a crush injury probably will not tear a tendon completely, 

the stretching forces may create small, partial tears. During the healing 

process, scar tissue forms to heal such tears and may cause the tendons 

to adhere to surrounding tissues. Adhesions may interfere significantly 

with the tendon’s ability to glide smoothly, resulting in loss of joint 

motion and hand function. 

Nerves 

Usually, nerves are not torn by a crush injury. However, the nerve’s 

ability to conduct electrical impulses may be temporarily or possibly 

permanently disrupted. It may take weeks to even months to determine 

whether the loss of nerve activity is permanent.

Hand Crush Injury and Compartment Syndrome 331 

With damage to sensory nerves, the patient may experience tingling 

and numbness (paresthesias) or even painful hypersensitivity to touch. 

With damage to motor nerves, weakness or complete loss of function 

may result. 

Blood Vessels 

Blood vessels can be injured by direct compression (depending on how 

long the extremity was crushed) or shearing forces, which may injure the 

inner layer (the intima). Either mechanism can cause the vessel to clot. 

If the injured vessel is an artery, the surrounding tissues lose their 

blood supply and ischemia results. If the injured vessels are veins, 

diminution of venous outflow from the damaged area leads to a buildup 

of pressure in the tissues. This pressure may contribute to the formation 

of compartment syndrome (see below). 

Injury to a major artery or to the veins of the extremity can result in 

devastating tissue loss if appropriate intervention is not forthcoming. 

Bone and Joints 

Joint capsules and surrounding ligaments may rupture, resulting in 

joint dislocation or joint instability. Fractures may occur, and often the 

bone is broken into several pieces (comminuted fracture). 

In children, the growth plates of the bones may be disrupted. 

Disruption of growth plates interferes with subsequent bone growth, 

and the bone may not grow to its proper length. 

IInniittiiaall AApppprrooaacchh ttoo PPaattiieennttss 

wwiitthh aa CCrruusshheedd HHaanndd oorr FFoorreeaarrmm 

The key is to get a good history and do a thorough exam. You should 

have a high index of suspicion so that you do not miss a potentially 

devastating underlying injury. 

History 

It is important to know the nature of the injury as well as background 

information about the patient to guide your physical exam and treatment 

options. Information that you should obtain includes: 

• Extent of injury (e.g., fingers, hands, forearms) 

• Mechanism of injury 

• Force of crush (some pieces of equipment have known compression 

forces)


• Duration of crush forces (seconds, minutes?) 

• History of previous injury or chronic hand problems (e.g., symptoms 

compatible with carpal tunnel syndrome) 

• Smoking history (encourage patients not to smoke because smoking 

may worsen the injury to the tissues) 

• Tetanus toxoid status (be sure tetanus immunizations are up to date) 

Physical Exam 

The injured extremity must be thoroughly examined. Particular attention 

should be paid to the following factors. An asterisk indicates that 

positive findings may indicate a compartment syndrome. 

• Appearance of skin (look for blisters, open wounds, elevated areas, 

foreign material, other abnormalities) 

• Circulation to the hand (palpable pulses in the radial and ulnar arteries, 

capillary refill in the fingers) 

• Palpation of forearm and hand (significant swelling, tissue tightness)* 

• Neurologic exam (e.g., complaints of tingling or numbness, ability to 

differentiate between sharp and dull objects, ability to move fingers)* 

• Pain out of proportion to injury (e.g., additional pain when you passively 

move fingers or wrist)* 

• Deformity indicating possible bone or joint injury 

• Radiographic studies to document a fracture 

* Finding may indicate the presence of a compartment syndrome. 

WWhhaatt ttoo DDoo NNeexxtt 

1. If you find evidence of arterial compromise, exploration and vascular 

reconstruction are needed. A specialist is required. 

2. Fractures or dislocations should be reduced and treated appropriately. 

See chapter 30 for specific information. 

3. If the patient has no evidence of a compartment syndrome (see 

below) but reports numbness and tingling of the hand consistent 

with compression of the median nerve, a carpal tunnel release 

should be done. This procedure decreases the pressure on the 

median nerve and may prevent permanent neural damage. See 

chapter 38 for details about surgical release of the median nerve. 

4. Lacerations to the skin should be cleansed thoroughly and examined 

carefully. If the tissues are soft and the skin is still attached to 

the underlying muscle, the wounds may be loosely closed. If you


are concerned about swelling in the tissues, leave the wounds open. 

You do not want to do anything that may increase pressure in the 

tissues. Once the swelling resolves, you may want to close the 

wounds or leave them to heal secondarily. 

5. If you note evidence of a degloving injury, a plastic surgeon (if 

available) should evaluate the patient. It is quite likely that much of 

the degloved skin will die, even if it looks viable at the initial examination. 

If no specialist is available, wash out the wound to ensure 

that no blood has collected under the skin. Then reposition the skin 

on top of the muscle. Do not try to suture the skin together, because 

sutures place added tension on the skin flaps and may further compromise 

the circulation. The skin will demarcate gradually over the 

next several days. Skin that turns purple and dies should be excised. 

6. If the patient has a swollen and somewhat painful extremity but 

the forearm and hand tissues still feel soft, the patient should be 

watched closely. Splint the hand in neutral position, and gently elevate 

the hand. Give pain medication (avoid aspirin and nonsteroidal 

anti-inflammatory agents), and reexamine the patient several times 

over the next 48 hours for evidence of a compartment syndrome. 

After a few days of splinting, as the swelling and pain resolve, the 

patient should start moving the hand and fingers to prevent stiffness. 

7. If the patient has signs and symptoms of a compartment syndrome, 

urgent surgical intervention is required. 

CCoommppaarrttmmeenntt SSyynnddrroommee 

A compartment syndrome develops when increased pressure builds 

up within a fixed, well-defined space (such as the tissues of the forearm). 

The increase in pressure prevents venous and lymphatic outflow, 

which leads to a further increase in tissue pressure. Without appropriate 

intervention to relieve the pressure, a vicious cycle develops. High 

tissue pressures also prevent oxygen and nutrients from getting to the 

tissues. Muscle and nerve are the tissues most prone to injury. 

If a compartment syndrome remains untreated, even for a few hours, 

the result is tissue death. For the patient, tissue death translates into 

tissue loss and permanent disability. 

Muscle death can be a serious problem from more than just the functional 

standpoint. A byproduct of the dead muscle, myoglobin, can 

injure the kidneys and lead to permanent kidney damage. Compartment 

syndrome endangers not only the normal functioning of the 

hand but also the patient’s life.


Signs and Symptoms 

It is important to be aware of the potential for development of compartment 

syndrome and to educate the patient about the early warning signs. 

The key is early diagnosis so that you can intervene before permanent 

damage has occurred. An untreated compartment syndrome can lead to 

severe morbidity and extremity loss and even endanger the patient’s life. 

• Severe pain in the affected extremity, out of proportion to the injury 

• Significant swelling and tightness in the forearm or hand tissues 

• Pain with passive stretch of a muscle group (e.g., passive extension 

of the fingers or wrist stretches the flexor muscles and causes pain in 

the volar forearm, whereas passive flexion of the fingers or wrist 

stretches the extensor muscles and causes pain in the dorsal forearm) 

• Tingling or numbness in the hand, along the median, ulnar, and 

radial nerve distributions 

Note: Pulses at the elbow and wrist may be completely normal even 

with a significant build-up of pressure in the forearm and hand. 

Compartment pressure can be measured, but results are highly unreliable 

without proper equipment and an experienced clinician. In general, 

if the patient has the above signs and symptoms, treatment should 

be instituted. 

Treatment of compartment syndrome is a true surgical emergency. You 

must get help early. If you have no access to a provider with surgical 

expertise, the following information will be useful. 

Treatment 

Fasciotomy 

The key to treating a compartment syndrome is to open the involved 

tissue compartments to relieve the pressure before permanent tissue 

damage has occurred. This procedure is done in the operating room 

under general anesthesia. 

Skin incisions are made to access the underlying muscle fascia. The 

fascia must be opened (hence the term fasciotomy) to relieve the pressure 

in the muscles; opening the skin alone is not sufficient. 

The need for this procedure is emergent. It should not be delayed for 

days until a specialist is available. 

Forearm 

The forearm has three compartments: volar (flexor), dorsal (extensor), 

and mobile wad (upper forearm muscles on the radial side). The


compartments of the forearm are somewhat interconnected. Opening 

(i.e., releasing) the volar compartment may relieve the pressure in the 

other two compartments. However, if the forearm still feels tight after 

release of the volar compartment, an additional incision should be 

made to release the dorsal compartment. When making the incisions, 

take care to avoid injury to the superficial veins. 

The volar compartment is opened by making a curvilinear incision 

that starts in the palm (to release the carpal tunnel), then crosses the 

wrist transversely to the ulnar side of the forearm. The incision then is 

extended up the center of the forearm in a large arc. 

The dorsal compartment and mobile wad are released by a straight, 

longitudinal incision on the dorsal surface of the forearm (see figure on 

next page). 

Markings for an incision to decompress the volar forearm. The incision begins 

in the hand for full decompression of the carpal tunnel. 

Hand 

On the volar surface of the hand, the carpal tunnel should be opened 

to relieve the pressure, which can injure the median nerve. 

On the dorsal surface, the interosseous muscles are released by placing 

the first longitudinal incision over the index metacarpal and another 

over the ring finger metacarpal. Slide to either side of the underlying 

bone to release the fascia around the surrounding muscles. 

The thenar muscles are released through an incision along the radial 

side of the thumb metacarpal. 

The hypothenar muscles are released through an incision along the 

ulnar side of the little finger metacarpal.


Markings for the incisions needed to decompress the dorsum of the hand and 

the dorsum of the forearm. 

Fingers 

If the fingers are very swollen and tight, they must be opened. A midaxial, 

lateral incision is used to release each finger. The incisions are 

positioned along the ulnar side of the index, middle, and ring fingers 

and are made along the radial side of the thumb and little finger. Be 

careful to avoid injury to the underlying neurovascular bundle. 

When the fascia around the muscle is opened, the muscle “bulges out” 

dramatically. Initially, the muscle may look purple and nonviable. Wait 

several minutes; often the muscle becomes redder and healthier looking. 

Only muscle that remains dusky and purple and obviously looks 

dead should be excised. 

Proper incision for decompression of a finger. The 

course of the digital nerve is illustrated by the dashed 

line.


Postfasciotomy Care 

1. The incisions should be left open. Saline dressings or antibiotic 

gauze may be placed over the open wounds. Be sure that the dressings 

are applied loosely. Daily dressing changes can be started 24–48 

hours after the operation. The patient may require anesthesia for the 

initial dressing change. 

2. A splint should be used to keep the hand in neutral position. 

3. The hand should be gently elevated (higher than the elbow) to promote 

venous return and decrease swelling. 

4. Further surgery is needed for wound closure. In general, wait at 

least 3–4 days for the swelling to decrease. A split-thickness skin 

graft is almost always required for wound closure. If you attempt to 

close any of the incisions primarily, make certain that there is no tension 

on the skin. 

5. Adequate stabilization is required for all fractures. Usually, temporary 

stabilization can be attained with a splint. If an orthopedic surgeon 

is available, more definitive bone stabilization can be performed 

at the time of fasciotomy or wound closure. 

Prevention of the Vicious Cycle the Leads 

to a Compartment Syndrome 

Elevate the hand and forearm. The patient must keep the injured hand 

and forearm gently elevated and not let them dangle in a dependent 

position The dependent position promotes swelling of injured tissues. 

The hand should be higher than the elbow. 

Use a splint instead of a cast for immobilization of broken bones 

until the swelling has decreased. A tight cast can contribute to an increase 

in tissue pressure. If there is a fair amount of swelling in the 

forearm or hand or if you do not have much experience making a cast, 

consider putting the extremity in a splint for the first few days. 

Although a splint does not immobilize the fracture as well as a cast, it 

is worth taking this precaution initially to prevent the development of 

a compartment syndrome. 

Be sure that the splint is held loosely in place. It is possible to secure the 

splint too tightly with an Ace wrap—be careful. 

If you have placed the patient in a cast: If the patient complains that 

the cast seems too tight or reports numbness in the fingers, bivalve the 

cast immediately. Make cuts in the cast along the medial and lateral 

sides, and separate the underlying padding. If this maneuver does not


relieve the symptoms, the cast should be removed and the extremity examined 

closely for signs of a compartment syndrome. 

If an open wound is present: Do not close the skin if it seems at all 

tight. It is better to have an open wound that heals with an ugly scar 

than to risk the development of a compartment syndrome by closing 

the skin tightly. 

Keep a high index of suspicion. A compartment syndrome can occur 

even with an open wound and even when the patient has normal 

pulses. 


1. Buchler U, Hastings H: Combined injuries. In Green DP, Hotchkiss RN, Pederson WC 

(eds): Green’s Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 

1999, pp 1631–1650. 

2. Rowland SA: Fasciotomy: The treatment of compartment syndrome. In Green DP, 

Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, 4th ed. New 

York, Churchill Livingstone, 1999, pp 689–710.

Chapter 36 

HAND INFECTIONS: 

GENERAL INFORMATION 

KEY FIGURE: 

Elevation and splinting 

Hand infections are relatively common problems. Seemingly minor injuries 

can sometimes lead to significant infections. Proper treatment is 

vital to prevent long-term disability. 

CCeelllluulliittiiss vvss.. AAbbsscceessss 

Cellulitis is a diffuse infection of the soft tissues. No localized area of 

pus can be drained. The affected area is described as indurated (i.e., 

warm, red, and swollen). The hand is also painful. A component of 

lymphangitis (infection involving the lymphatics) may be indicated by 

red streaking in the tissues, progressing proximally up the arm. The 

treatment of cellulitis centers on the administration of the appropriate 

antibiotic regimen. 

An abscess is a localized collection of pus, often with a component of 

cellulitis in the surrounding soft tissues (with the above signs). One 

sign of an abscess is an area of fluctuance. When you apply gentle digital 

pressure over the area of the presumed abscess, you feel a “give,” 

indicating the presence of fluid beneath the skin. Another sign is that an 

abscess often seems to “point”; that is, the skin starts to thin from the pressure 

of the fluid underneath. The primary treatment of an abscess is incision 

and drainage (I & D)—cutting open the roof of the abscess to 

allow the pus to drain. Antibiotic therapy may be needed, but the infectious 

process will not resolve with antibiotics alone. 

From the above information, you can see that the distinction between 

the two entities is important because their treatments are different. I & D 

is indicated for an abscess, whereas cellulitis does not warrant this 

intervention. 

339


GGaannggrreennee 

The term gangrene is used to describe tissues that are dead. There are 

two subtypes of gangrene, wet and dry. The distinction is important. 

Dry gangrene describes tissues that are generally black and dried out. 

There is a distinct border between the dead tissue and surrounding 

healthy tissue. Sometimes the dead tissues fall off on their own; dry 

gangrenous fingertips can fall off with minimal manipulation. However, 

debridement usually is required, but it is not emergent. Dry gangrene 

usually places the patient at no health risk as long as it does not 

become infected (see below). 

In contrast to dry gangrene, wet gangrene can be a significant health 

risk. Wet gangrene connotes active infection (noted by pain, swelling, 

redness, and drainage of pus) in the tissues surrounding the obviously 

dead tissue. Urgent debridement is required to prevent further tissue 

loss and worsening of soft tissue infection. 

NNeeccrroottiizziinngg FFaasscciiiittiiss 

Necrotizing fasciitis is a serious, potentially life-threatening infection 

of the fascia (the thin connective tissue overlying the muscle under the 

skin and subcutaneous tissue). The popular press calls it the disease of 

flesh-eating bacteria. 

Necrotizing fasciitis is not common. However, it must be considered in 

the evaluation of patients with a hand infection that seems to be 

rapidly progressing proximally up the forearm. Necrotizing fasciitis 

should also be considered when the patient is sicker than you would 

expect for simple cellulitis. 

The skin is swollen, but often without the typical signs of cellulitis. The 

skin simply does not look “right.” You may be able to feel subcutaneous 

air in the soft tissues of the arm, or you may see air in the soft 

tissues on x-rays (normally, no air is present in soft tissues on x-ray). 

The patient is often quite ill (high fever, low blood pressure, general 

weakness, and even shock may be present). The infection can spread 

quickly up the arm and into the chest. Radical debridement and even 

amputation may be necessary to save the patient’s life. 

Treatment requires aggressive operative debridement (opening up the 

soft tissue spaces, as with an abscess) to remove diseased tissue, intravenous 

antibiotics, and close monitoring for aggressive treatment of 

septicemia. Hyperbaric oxygen also may be indicated but does not replace 

aggressive operative treatment. Patients with necrotizing fasciitis 

should be treated by a surgeon with critical care expertise.

Hand Infections: General Information 341 

EEvvaalluuaattiioonn ooff aann IInnffeecctteedd HHaanndd 

History 

Ask the patient about events that may have led to the development of 

the infection. This information may help to guide your treatment. 

Antecedent Trauma 

A history of being cut by glass or sustaining a puncture wound should 

raise concern about the presence of a foreign body in the soft tissues. 

Ask whether the patient was bitten by an animal. An animal’s canine 

teeth, especially those of a cat, may penetrate much deeper into the underlying 

tissues than you expect. Find out what type of animal was involved; 

different animals have specific bacterial organisms that may 

require a particular antibiotic. Ask about the possibility of rabies exposure 

(see chapter 6, “Evaluation of an Acute Wound,” for information 

about rabies prevention). 

If the patient has a wound over a metacarpophalangeal knuckle, you 

must ask specifically whether the wound is due to human teeth. People 

are often embarrassed to admit that they have been in a fight. Ask 

point-blank: Did you punch someone in the mouth? Did someone bite 

you? This information is important because the human mouth has 

strong pathogens that can lead to significant soft tissue destruction. 

Choice of specific antibiotics is based on the usual organisms found in 

the human mouth. 

Recent History of Swimming 

Well-managed swimming pools usually are treated adequately with 

chemicals, and the ocean has such a high salt content that neither 

venue is associated with specific organisms that cause infection. 

However, streams, ponds, lakes, and aquariums are associated with 

specific bacteria that can cause significant infections. In addition, ask 

whether the injury occurred while the patient was working on a boat 

or fishing. 

Medical Issues 

Patients with diabetes often develop infections that are unexpectedly 

difficult to treat. You must treat such infections aggressively and 

ensure that blood sugar is well controlled. 

Ask about the patient’s tetanus immunization status.



1. The classic signs of a hand infection are redness, warmth, swelling, 

and pain. The swelling associated with a hand infection is often 

quite pronounced. 

2. Look closely for puncture wounds and other signs of trauma. 

3. Determine whether the patient has a localized collection of pus that 

requires drainage or diffuse soft tissue infection. 

4. Look for induration extending proximally up the forearm. 

5. Look for red streaks extending up the arm. 

6. If the forearm is involved, palpate for crepitus or subcutaneous air 

in the forearm tissues (signs of necrotizing fasciitis). To test for crepitus, 

press on the soft tissues. If air is present under the skin, it will 

feel as if you are pressing on crinkled layers of cellophane or popping 

air bubbles beneath the skin. 

7. Look for signs of systemic illness (fever, chills, low blood pressure, 

generalized weakness, and malaise). 

8. Look for evidence of enlarged lymph nodes in the armpit or back of 

the elbow. 

Additional Studies 

The basic studies include complete blood count with a white blood cell 

count and x-ray evaluation of the infected area. Include the forearm if 

the induration extends proximally up the forearm. Blood cultures 

should be done if the patient is febrile or looks ill. If there is an open 

wound present, culture it. 

What to Assess on X-rays 

1. Foreign bodies 

2. Unsuspected fractures or dislocations 

3. Evidence of joint contamination: air in the joint, destruction of joint 

surfaces, foreign material in the joint. Any of these findings warrants 

operative exploration. 

4. Underlying bone infection: the bone edges appear irregular if bone 

is involved with the infectious process. If bone is involved, 4–6 

weeks of antibiotic therapy are needed. 

5. Air in the soft tissues strongly indicates necrotizing fasciitis. 

Localized air may be present in the soft tissues at the immediate 

vicinity of an I & D site, but diffuse air in the tissues is a sign of 

necrotizing infection.


IImmppoorrttaannccee ooff KKeeyy EElleemmeennttss iinn tthhee HHiissttoorryy 

aanndd PPhhyyssiiccaall EExxaammiinnaattiioonn 

Foreign Bodies 

If a foreign body is located in the infected tissues, the infection will not 

resolve unless it is removed. However, a foreign body in soft tissues without 

cellulitis does not have to be removed unless it is causing symptoms. 

Animal Bites 

Pasteurella multocida and Staphylococcus aureus are associated with cat 

and dog bites. Treatment with an antipseudomonal and antistaphylococcal 

antibiotic (amoxicillin/clavulanate, cefuroxime) is required. Cat 

bites often penetrate more deeply than you expect and may involve 

underlying joints or tendons. Exploration and washout of the joint and 

tendon may be required. Cat bites have a much higher incidence of 

subsequent infection than dog bites (80% vs. 5%, respectively). 

Human Bites 

Eikenella corrodens, other anaerobes, and Streptococcus viridans are associated 

with infections caused by a human bite. If the patient is seen 

early after the injury, before signs of infection have developed, treat 

with amoxicillin/clavulanate. Once signs of infection are present, intravenous 

antibiotics, such as amoxicillin/sulbactam or ticarcillin/ 

clavulanate, are indicated. Operative exploration also may be required 

if the underlying joint is affected. In addition, abscess formation is 

common after a human bite. 

Seawater and Shellfish-related Injury 

If the infected tissues are swollen and red but not particularly hot or 

tender, the causative organism may be Mycobacterium marinum. Treatment 

requires long-term (3 months) administration of doxycycline or 

rifampin/ethambutol. An infectious disease specialist should be involved 

in the treatment of such patients. 

If the infected area has all of the typical signs of cellulitis, treatment 

should cover bacteria of the Vibrio species; tetracycline or an aminoglycoside 

may be used. 

Freshwater Injury 

Aeromonas hydrophila is associated with freshwater infection. A fluoroquinolone 

or trimethoprim/sulfamethoxazole should be used for 

treatment.


Red Streaking 

Red streaking is a sign of lymphangitis, which means that the infection 

is traveling through the lymphatic system. Staphylococcal infections 

are most commonly associated with this physical finding. 

Enlarged Lymph Nodes Around the Elbow or Armpit 

The presence of enlarged lymph nodes may indicate cat-scratch disease, 

a Mycobacterium marinum infection, sporotrichosis or nocardial infection. 

An infectious disease specialist should be consulted because 

these unusual infections can be difficult to treat. 

GGeenneerraall IInniittiiaall TTrreeaattmmeenntt 

The infected hand is often diffusely swollen. Initially it may be difficult 

to determine whether the patient has an abscess in need of drainage. If 

the patient otherwise looks well and has no signs of flexor tenosynovitis 

(see chapter 37, “Specific Types of Hand Abscesses”), underlying joint 

infection, or necrotizing fasciitis, treat conservatively. Do not make cuts 

in the skin looking for an abscess; you may well find nothing. 

Conservative Approach 

1. Start the appropriate antibiotics. 

2. Splint the hand in neutral position (see chapter 28, “Hand Splinting 

and General Aftercare”), and elevate the hand. These two interventions 

are the cornerstone of treatment for all hand infections. 

Splinting and elevation significantly reduce swelling, thus making 

it easier to determine whether an abscess is present. 

The proper way to elevate an injured hand. The hand should be higher than the 

elbow to promote drainage and decrease swelling in the hand.


3. Warm (not hot) compresses applied to the inflamed area of the hand 

may be useful. 

4. After 24 hours reevaluate the hand. 

• Significant improvement may be seen. If there is no evidence of an 

abscess, continue splinting, elevation, and antibiotics. The splint 

should be removed once pain and swelling have resolved. 

Regular exercise then becomes important to prevent stiffness. 

Continue the antibiotics for 7–10 days until the infectious process 

has resolved completely. 

• Alternatively, a localized collection of pus in need of drainage 

may be identifiable. The following chapter discusses specific types 

of hand abscesses and their treatment. 



Therapy, 29th ed. Vermont, Antimicrobial Therapy, Inc., 1999. 

2. Lampe EW: Clinical Symposia: Surgical Anatomy of the Hand. 40th anniversary issue 

40(3):31–36, 1988.

Chapter 37 

SPECIFIC TYPES OF HAND INFECTIONS 

KEY FIGURES: 

Felon 

Paronychia 

Collar button abscess 

FFeelloonn 

A felon is an abscess of the fingertip along the volar skin pad. The fingertip 

is swollen and quite painful. Without proper treatment, the infection 

can progress and cause serious complications. Necrosis of the fingertip 

skin, osteomyelitis (infection of the underlying bone), and even flexor 

tenosynovitis (see description later in this chapter) may result. 

If the infectious process is caught before abscess formation, it can be 

treated with antibiotics alone. If no improvement is observed with antibiotics 

or if fluctuance is present, incision and drainage are necessary. 

Incision and Drainage 

1. Anesthetize the finger with a digital block using lidocaine, bupivacaine, 

or a mixture of the two. 

2. Clean the fingertip with some type of antibacterial agent. 

3A. If the “point” (i.e., area of maximal tenderness and fluctuance) is 

on the volar fingertip pad, make a longitudinal incision over this 

point. Take care to keep the incision distal to the distal interphalangeal 

(DIP) flexion crease. 

B. If the “point” is on the lateral surface, make a longitudinal incision 

on the ulnar side of the digit (radial side for the thumb or 

little finger) parallel to the expected position of the digital nerve. 

Take care to keep distal and dorsal to the DIP flexion crease to prevent 

injury to the digital nerve and artery. 

4. Use a clamp to open the incision and thoroughly drain the space. 

347


5. If you have access to a microbiology lab, send a specimen of the pus 

for culture to identify the causative organism. 

6. Irrigate the abscess cavity with sterile saline. 

7. Pack a small piece of gauze into the cavity, and cover the fingertip 

with dry gauze. 

Two ways to drain a felon. A, Midline vertical 

incision. B, Lateral incision. (From 

Crenshaw AH (ed): Campbell’s Operative 

Orthopaedics, 7th ed. St. Louis, Mosby, 


Aftercare 

• Keep the hand elevated. 

• Remove the packing the next day, and clean the finger with gentle 

soap and water or saline. 

• If possible, repack the cavity with saline-moistened gauze. Change 

this dressing 1 or 2 times each day. 

• Once you cannot pack the cavity with gauze, simply apply antibiotic 

ointment to the area and cover with a dry gauze 1 or 2 times each day. 

• Be sure to wash the finger with gentle soap and water or saline twice 

daily.

Specific Types of Hand Infections 349 

• Encourage active and passive range-of-motion exercises to prevent 

the finger from becoming stiff. 

• Continue the oral antibiotics for several days, until the tenderness 

and redness resolve. 

PPaarroonnyycchhiiaa 

A paronychia is an infection around the fingernail, in the surrounding 

skin fold (eponychial fold). It usually is caused by Staphylococcus 

aureus. The skin around the proximal portion of the fingernail is 

swollen, and the finger is quite tender. 

If the infection is caught early, the finger can be successfully treated by 

soaking it in warm, soapy water several times a day and giving oral antibiotics. 

If pus is present around the base of the nail, drainage is needed. 

Drainage 

1. Anesthetize the finger with a digital block using lidocaine, bupivacaine, 

or a mixture of the two. 

2. Soak the finger in warm, soapy water for 5–10 minutes. 

3. Place the tips of a closed clamp under the skin fold around the nail 

to open the abscess. Wash the space out with saline, and then pack it 

with a small piece of gauze. 

4. Remove the gauze the next day. Instruct the patient to continue the 

warm soaks and cover with antibiotic ointment and dry gauze 2 or 3 

times/day. 

Treatment of a paronychia. A, Elevation 

and removal of one-fourth 

of the nail to decompress the 

paronychium. B, Incision of the 

paronychial fold with the blade directed 

away from the nail bed and 

matrix. (Illustration by Elizabeth 

Roselius © 1998. From Green 

DP, et al (eds): Operative Hand 

Surgery, 4th ed. New York, 

Churchill Livingstone, 1999, with 

permission.)


5. If this approach does not lead to resolution of the infection, the skin 

fold may need to be incised and formally opened. The proximal part 

of the nail may need to be removed as well. 

Caution: Be wary when a patient presents with an infection around the 

fingernail that does not seem like a “typical” infection. The finger may 

be swollen but not very tender, and small vesicles (blisters that are not 

pus-filled) are around the base of the nail. This presentation indicates a 

herpetic (viral) infection, which is seen most commonly in medical and 

dental personnel and people whose hands are often in water. 

Do not incise and drain. Leave the vesicles alone. Incision and drainage 

carry a high risk for secondary bacterial infection, which can be quite 

difficult to treat. Herpetic infection is self-limiting and resolves in 3–4 

weeks. If you have access to anti-herpes medications, oral treatment 

(acyclovir, 400 mg 3 times/day for 10 days) may relieve symptoms. 

AAccuuttee SSuuppppuurraattiivvee FFlleexxoorr TTeennoossyynnoovviittiiss 

The flexor tendons of the fingers travel within the confines of the surrounding 

flexor sheath. This anatomic arrangement allows the smooth 

gliding action of the flexor tendons, which is responsible for optimal 

finger flexion and hand function. The sheath around the flexor tendons of 

the fingers runs from the distal palmar skin crease of each finger to just 

proximal to the DIP joint flexion crease. It is essentially a closed space. 

Acute suppurative flexor tenosynovitis is an infection within the confines 

of the flexor sheath. It is similar to an abscess and often requires 

drainage for resolution. Acute suppurative flexor tenosynovitis is potentially 

a serious infection and must be treated expeditiously. It can 

lead to the destruction of the gliding mechanism necessary for normal 

tendon function. If not treated appropriately, it can result in significant 

permanent limitation in finger and hand function. 

History and Physical Exam 

This infection is often associated with penetrating trauma to the finger. 

However, some patients cannot recall any significant antecedent injury. 

Cardinal Signs 

• Flexed posture of affected finger 

• Diffuse swelling of the entire finger, which may extend to the dorsal 

surface of the metacarpophalangeal (MCP) area 

• Significant tenderness along the volar aspect of the finger (where the 

tendon sheath is located) 

• Pain with passive extension of the affected finger


The main area of tenderness, especially when the patient presents early 

in the course of the process, is over the A1 pulley. The A1 pulley represents 

the beginning of the flexor sheath, near the volar, distal palmar 

crease. Tenderness in this area is the most sensitive sign of acute flexor 

tenosynovitis and may help to differentiate it from other infectious 

processes involving the finger. For example, a felon or simple cellulitis 

of the finger does not have tenderness over this area. 

If you are unsure of the diagnosis, you can treat conservatively with a 

splint, hand elevation, and antibiotics for 24 hours. You should splint 

the entire hand in neutral position. If symptoms improve, continue 

conservative management; if symptoms progress or do not improve 

significantly, operative exploration is necessary. 

Operative Treatment 

Because of the potential for long-term disability if treatment is not 

prompt, drainage should be attempted if no specialist is available. If a 

specialist is available, refer the patient. 

1. General anesthesia is best, but a wrist block may be used. 

2. Use a tourniquet to keep blood out of the operating field and facilitate 

exploration of the finger. The tourniquet also helps to prevent 

accidental injury to digital nerves and vessels. With general anesthesia, 

place an upper arm tourniquet. With a wrist block, use a forearm 

tourniquet. Do not exsanguinate the arm. 

3. Keep in mind that digital nerves and vessels run along the sides of 

the fingers. 

4. Make a traverse incision in the DIP flexion crease. Use a clamp or 

blunt scissors to separate the soft tissues gently so that you can identify 

the distal portion of the flexor sheath. It is grayish and much 

thicker than normal (a few millimeters vs. < 1 mm). 

5. Open this portion of the sheath. 

6. Make a transverse counterincision in the palm over the distal palmar 

skin crease of the finger. It should not be too large (about 1.5 cm). 

7. Carefully spread the soft tissues until you identify the sheath. It may 

appear gray and thick. Take care not to damage the digital arteries 

and nerves on either side of the sheath. Use blunt dissection, and do 

not cut anything until you are sure of what you are cutting. 

8. If you have difficulty in identifying the sheath, extend the incision distally 

in a zig-zag fashion to improve access to the underlying tissues. 

9. Open the sheath. Send a swab of the fluid from the sheath to the 

microbiology lab for analysis.


10. Place a catheter (20 gauge is best) similar to what you use for intravenous 

access into the sheath. Wash out the sheath by attaching a 

syringe with saline to the catheter and irrigating the sheath until 

the fluid that comes out is clear and no longer cloudy (cloudiness 

is due to the presence of pus in the canal). Irrigation fluid should 

come out of the distal incision by the DIP flexion crease. 

11. If you had to extend the palm incision beyond the simple transverse 

incision, close the additional incision very loosely with one 

or two nonabsorbable sutures. Otherwise do not close either incision; 

the incisions will heal on their own. 

12. The catheter should be left in place to allow irrigation of the sheath 

every few hours for the first 24 hours after surgery. If possible, 

attach the catheter to IV extension tubing so that a syringe can be 

attached outside the dressing. 

13. Place a piece of gauze in each open wound. 

14. Release the tourniquet, and apply gentle pressure over the incisions 

to control bleeding. 

15. Place dry gauze between all fingers and around the affected finger. 

16. Wrap the hand with soft gauze. 

17. Splint the hand in neutral position. 

18. Secure the IV tubing attached to the catheter in the flexor sheath to 

the outside of the splint so that it does not dislodge. 


1. The hand should be kept elevated in a splint. 

2. Continue intravenous antibiotics. When the symptoms and signs 

of infection improve, change to oral antibiotics, and complete a 

7–10 day course. 

3. Irrigate the sheath with 3–5 ml of saline every 3–4 hours. Pain medication 

should be given before beginning irrigation. 

4. Change the dressing after 24 hours, and remove the gauze packing 

and catheter at this time. 

5. The patient should continue to wear the splint until the swelling 

and tenderness improve. 

6. The patient should start passive and active motion once the 

swelling and tenderness improve. 

7. The incisions heal on their own. The patient can apply antibiotic 

ointment after a few days and cover each incision with a bandage.


Note: There is no such thing as acute suppurative extensor tenosynovitis 

because there is no sheath around the extensor tendons of the fingers. 

Patients with rheumatoid arthritis may develop a noninfectious tenosynovitis, 

which essentially is inflammation of the tendons caused by 

the underlying rheumatic disease. Often the tendons are involved 

more proximally at the wrist, and flexor or extensor tendons may be affected. 

This inflammatory disorder is quite different from an acute infectious 

process and does not require antibiotics or urgent surgical 

intervention. The symptoms are more chronic, and the physical findings 

are not as dramatic as those due to an infectious process. 

AAbbsscceessss oonn tthhee DDoorrssaall SSuurrffaaccee ooff tthhee HHaanndd 

The patient often presents with a very swollen hand and fingers. At first 

it may be difficult to appreciate the abscess cavity because of the diffuse 

nature of the swelling. In the presence of an obvious abscess, proceed 

to incision and drainage. If you are not certain whether or not an abscess 

is present, and the patient does not appear ill, treat conservatively 

at first with splint, hand elevation, and antibiotics for 1 day. Often after 

24 hours of conservative treatment, the swelling decreases in areas not 

involved with the abscess. The abscess cavity is then identifiable. 

Incision and Drainage 

1. If the skin overlying the abscess is very thin (i.e., the abscess is 

“pointing”), no anesthetic may be required. 

2. If the patient is in too much pain, local anesthetics may not be very 

useful because they do not work well in infected tissues. However, a 

block may work, or, if indicated by the extent of the abscess, general 

anesthesia may be required. 

3. Make a longitudinal incision through the most fluctuant part of the 

abscess. Do not be timid when making the incision. Excise an ellipse 

of skin so that the opening is large enough to drain the abscess completely 

and to allow packing of the cavity with gauze. 

4. Use the tips of a clamp to explore the abscess cavity. Make sure that 

the cavity does not extend to the volar side of the hand. If it does, a 

counterincision should be made over the volar extension of the 

cavity. This extension allows better drainage of the entire abscess. If 

you need to make a counterincision on the volar surface, first inject 

some anesthetic into the area. 

5. Pack the wound with gauze. 

6. Use a splint to keep the hand in neutral position.


A collar button abscess extends from the volar to the dorsal surfaces of the 

hand. Both sides of the hand must be drained individually because the two 

areas are connected by a narrow path. (From Chase RA: Atlas of Hand 

Surgery. Philadelphia, W.B. Saunders, 1973, with permission.) 


1. Keep the hand elevated and in the splint until the swelling and 

other signs of infection have improved. 

2. The gauze packing should remain in place for 1 day. Then remove 

the gauze, and repack the cavity with saline-moistened gauze. 

Cover with dry gauze. This entire procedure should be done 2 or 3 

times/day until the wound has healed. 

3. The patient may wash the hand with gentle soap and water at each 

dressing change. 

4. Antibiotics should be continued until the surrounding cellulitis resolves 

(probably only a few days). 

5. Once the infection has resolved, the patient must start regular (several 

times per day) active and passive range-of-motion exercises to 

prevent permanent hand stiffness and limitation of hand function. 


Neviaser RJ: Acute infections. In Green DP, Hotchkiss RN, Pederson WC (eds): Green’s 

Operative Hand Surgery, 4th ed. New York, Churchill Livingstone, 1999, pp 1033–1047.

Chapter 38 

CHRONIC HAND CONDITIONS 

KEY FIGURES: 

Pulley system of fingers Carpal tunnel anatomy 

Trigger finger release Carpal tunnel release 

A1 pulley opening incision 

Chronic hand pain is a common complaint, especially among people 

who work with their hands. What initially may seem to be only an annoying 

pain can turn into significant disability without adequate 

treatment. This chapter discusses several of the most commonly encountered 

chronic hand disorders. 

TTrriiggggeerr FFiinnggeerr 

Anatomic Background 

The flexor tendons travel through a connective tissue, synovial-lined 

tube as they course through the fingers. This tube runs from the 

metacarpophalangeal (MCP) joint (just proximal to the MCP flexion 

crease as you look at the palm of the hand) to a point immediately 

proximal to the distal interphalangeal (DIP) joint. 

This tube is highly pliable and thin. The tissue is slightly thicker in 

several areas, called pulleys. The purpose of the pulleys is to prevent 

the tendons from bowstringing during finger flexion. This action is 

important for adequate grip strength and proper hand function. The 

most important pulleys are A1, A2, and A3, which overlie the MCP 

joint, the proximal phalanx, and the proximal interphalangeal (PIP) 

joint, respectively. 

The digital neurovascular bundles (digital nerve and vessels) run 

along either side of the tube in the soft tissue. 

355


Anatomy of the flexor tendon pulley system. Top inset illustrates flexor digitorum 

profundus nodular thickening. Bottom inset illustrates flexor digitorum superficialis 

decussation fraying. (From Zelouf DS (ed): Atlas of the Hand Clinics. 

Philadelphia, W.B. Saunders, 1999, with permission.) 

Definition of Trigger Finger 

The technical name for trigger finger is stenosing tenosynovitis. It is 

postulated that repetitive use of the fingers or thumb causes the A1 

pulley to become thick and unyielding. Pathologic thickening in the 

tendon near the pulley also may occur. As a result of such changes, the 

tendon is unable to glide properly through the pulley. In extreme cases, 

the tendon may become stuck outside the entrance of the pulley (just 

proximal to the MCP flexion crease). 

The clinical result is triggering of the affected finger or thumb. Triggering 

means that the digit assumes a flexed posture. Active straightening 

of the affected digit is often difficult. Massage of the tissues of the 

distal palm and passive extension of the finger or thumb may be required. 

Sometimes the digit cannot be fully extended even with these 

measures. 

Before the development of triggering, patients often complain of 

chronic pain not only in the area of the MCP joint but also in the area 

around the PIP joint. 

Congenital trigger finger may be seen in infants. Because of the small size 

of the tissues, this problem should be treated only by a hand specialist. 

Diagnosis 

The history of triggering is usually the most important finding. 

Sometimes patients simply complain of a dull pain in the distal palm 

or the PIP joint of the affected digit(s).

Chronic Hand Conditions 357 

On physical exam, feel the tissue just proximal to the MCP joint at the 

distal palmar skin crease. This is the location of the A1 pulley. Gently 

flex and extend the affected digit, and you may feel a small “knot” 

moving back and forth. This “knot” clinches the diagnosis in a patient 

with the above clinical symptoms. 

Nonoperative Treatment 

Steroid injection around the A1 pulley may provide symptomatic relief, 

which can delay the need for surgery for many months. Betamethasone 

is commonly used; inject 0.25–0.50 ml around the A1 pulley. Warn the 

patient that it will take a few weeks to see whether the injection is successful. 

A second steroid injection can be given 6 weeks after the initial 

injection if no improvement has been noted. Sometimes the second injection 

is successful even if the first resulted in little improvement. 

How to Inject the A1 Pulley 

1. Draw the steroid solution into a syringe. Use a small needle (≤ 21 

gauge) for the injection. 

2. The landmark for the A1 pulley is the distal palmar skin crease of 

the affected digit. 

3. Starting with an injection of a local anesthetic is not necessary because 

it will hurt just as much as the steroid injection. But give the 

patient a choice. 

4. Alternatively, 1 ml of lidocaine can be added to the steroid solution 

to help alleviate the chronic pain temporarily. 

5. Stick the needle into the tissues. You need to go deeper than the superficial 

skin. If the patient reports feeling pins and needles, you are 

probably in the digital nerve. Back out a few millimeters, and reposition 

the needle. 

6. Draw back on the syringe to ensure that you are not in a blood 

vessel. 

7. Ask the patient to flex and extend the finger with the needle in 

place. If the needle moves with the tendon, it may be lodged in the 

substance of the tendon. Back out the needle a few millimeters, and 

ask the patient to move the finger again. Keep adjusting the needle 

until the needle tip is no longer in the tendon. 

8. Once the needle is in the correct position, inject one-half of the solution 

in the syringe. Move the needle a few millimeters to another 

position near the A1 pulley, check for the above positioning concerns, 

and inject the remainder of the steroid solution.


9. Remove the needle, place a Band-Aid over the injection site, and 

gently massage the tissues for a few minutes. 


Operative treatment should be considered when two steroid injections 

are unsuccessful in alleviating symptoms or when symptoms argue 

against waiting 4–6 weeks for improvement. 

A patient whose finger is locked in flexion also should undergo surgical 

treatment. Waiting for a steroid injection to work is impractical because 

of concerns about subsequent joint stiffness due to inability to 

move the finger for so long a period. 

How to Release a Trigger Finger 

Incisions for release of trigger 

fingers and thumb. The index 

is released through an incision 

in the proximal palmar 

crease, the ring and little fingers 

in the distal crease, and 

the middle finger midway between 

the two palmar creases. 

The thumb is approached 

through its metaphalangeal 

crease. (Illustration by 

Elizabeth Roselius © 1998. 

From Green DP, et al (eds): 

Operative Hand Surgery, 4th 

ed. New York, Churchill Livingstone, 


1. Trigger finger release can be done with a wrist block or Bier block. 

General anesthesia is used less commonly. 

2. The hand should be exsanguinated, and a tourniquet should be 

used on the forearm or upper arm. It is important to have a bloodless 

field to prevent injury to the nearby neurovascular bundles. 

3. The incision (1–1.5 cm) should be centered over the distal palmar 

skin crease of the affected digit. It can be made with a vertical or horizontal 

orientation. The vertical orientation may be more protective


of the neurovascular bundle, but it is somewhat more difficult from 

an exposure perspective. 

4. Using blunt dissection—that is, using the scissors to spread the tissues, 

not to cut them (see chapter 2, “Surgical Techniques”)—separate 

the soft tissues until you see the underlying tendon and A1 

pulley. Do not cut anything until you are certain that the neurovascular 

bundles are protected. Use retractors to keep the tissues to the side of 

the your working area once the A1 pulley has been identified. 

5. Use sharp scissors or the tip of your knife to open the pulley. Then open 

the entire pulley with a scissors. You will know you are at the end of the 

pulley when the tissue becomes thin and pliable compared with the 

thickened A1 pulley. The pulley is approximately 1 cm in length. 

6. Flex and extend the finger to ensure that the tendon moves back and 

forth easily and that the entire pulley has been opened. 

7. For postoperative pain control, inject a few milliliters of bupivacaine 

into the tissues that you have been dissecting. 

8. Release the tourniquet, and apply pressure to control bleeding. 

Close the skin incision with a few interrupted sutures. Apply antibiotic 

ointment over the suture line, and cover with gauze dressing. 

9. Alternatively, close the incision with a few interrupted sutures. 

Apply antibiotic ointment over the suture line, cover with gauze, 

and gently wrap the hand with an Ace wrap. Once the hand is 

dressed, release the tourniquet. Continue to hold pressure over the 

area around the incision for several minutes. 

Trigger finger release. The A1 pulley is divided carefully with either scissors or 

knife. (From McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. Saunders, 




1. Acetaminophen or nonsteroidal anti-inflammatory agents should 

be adequate for postoperative pain control. 

2. Keep the hand elevated to decrease swelling and decrease pain. 

3. The patient should be encouraged to use the hand for light activities 

within 1–2 days after surgery. 

4. Remove the dressing the day after surgery, and clean with gentle 

soap and water daily. 

5. Apply antibiotic ointment to the suture line daily for the first few 

days. Cover with dry gauze as needed. 

6. After 10–14 days, remove the sutures. Instruct the patient to increase 

gradually the activities performed with the hand until the patient 

has resumed regular activities. 

CCaarrppaall TTuunnnneell SSyynnddrroommee 

Anatomic Background 

Anatomy of the carpal tunnel. The median nerve and flexor tendons transverse 

the carpal tunnel, lying beneath the transverse carpal ligament. (Illustration by 

Elizabeth Roselius © 1998. From Green DP, et al (eds): Operative Hand 

Surgery, 4th ed. New York, Churchill Livingstone, 1999, with permission.)


The carpal tunnel is essentially the space in the center of the palm just 

distal to the wrist. The carpal tunnel is bound by bone on three sides, 

and the transverse carpal ligament is the roof (i.e., the most superficial 

boundary). It is a relatively tight, fixed space. 

The median nerve travels through the enclosed space of the carpal 

tunnel with the nine flexor tendons to the fingers and thumb. Anything 

that decreases the size of the tunnel, such as tissue swelling from repetitive 

hand and wrist movements, can place pressure on the median 

nerve. Pressure on the nerve causes dysfunction and clinical symptoms. 

Although the median nerve at the wrist is primarily sensory, it gives 

off a motor branch to the thenar muscles responsible for opposition. 

The motor branch of the median nerve can originate from the main 

nerve before going under the transverse carpal ligament, in the carpal 

tunnel, or, most commonly, after leaving the confines of the carpal 

tunnel. The motor branch also can pierce through the ligament to innervate 

the muscles. It is important to have a thorough understanding 

of this anatomy to prevent injury to the motor branch if operative intervention 

is undertaken. 

Definition of Carpal Tunnel Syndrome 

The symptoms of carpal tunnel syndrome (CTS) include pain and tingling 

in the hand and distal forearm as well as numbness along the 

median nerve distribution of the hand. Hand clumsiness may occur, 

and the symptoms often are aggravated when the hands are in extension 

or grasping objects. Examples include reading the newspaper or 

grasping the steering wheel while driving. 

Night awakenings with hand numbness, and pain in the hand or distal 

forearm are also common complaints. Significant weakness and muscle 

wasting are late symptoms. 

Diagnosis 

Gentle tapping on the median nerve at the wrist causes tingling or the feeling 

of electric shocks. This phenomenon is called a positive Tinel’s sign. 

Development of numbness in the median nerve distribution with flexion 

of the wrist, called a positive Phalen’s sign, is also indicative of CTS. 

Special electrophysiologic tests can be done to measure the nerve conduction 

velocity and the status of the muscles supplied by the median 

nerve. Although the physical signs and symptoms are often enough to 

diagnose CTS, these studies are useful when the diagnosis is in doubt. 

Electrophysiologic studies are also useful for documentation and 

medicolegal purposes.


Nonoperative Treatment 

Often stopping or at least decreasing the amount of time in which the 

hand performs repetitive movements is necessary for symptom relief. 

In addition, splinting the hand in neutral position (immobilizing only 

the wrist in 10–20° of flexion) during work and sleep may alleviate the 

symptoms. It often takes several weeks to see improvement. The splint 

should be used for at least 6–8 weeks before determining that it is not 

helpful. If symptoms improve, the splint should be worn an additional 

1–2 months. 

The use of nonsteroidal anti-inflammatory agents (e.g., ibuprofen, 

naproxen sodium), may help to relieve pain and decrease swelling. 

A cornerstone of therapy is evaluation by an occupational or other 

movement therapist, who can teach the patient how to use the entire 

upper extremity in a more efficient manner. By incorporating use of the 

entire arm instead of just the hand or wrist, the patient distributes the 

strain of work more evenly. This approach should remove some of the 

stresses on the wrist and hand and may alleviate symptoms. 

Another option, which should be used with caution, is to inject steroids 

around the median nerve. Betamethasone, 0.75–1.0 ml, can be injected 

in a manner similar to performing a median nerve block (see chapter 3, 

“Local Anesthesia”). You must take care to avoid injection into the 

median nerve, which can cause nerve injury and further problems. 


Carpal tunnel release (CTR) involves dividing the transverse carpal 

ligament to relieve the tightness in the carpal tunnel and thereby decrease 

pressure on the median nerve. Worldwide, CTR is performed 

most often by making a longitudinal incision in the palm and dividing 

the transverse carpal ligament under direct vision. Alternatively, in 

areas with access to endoscopic technology, CTR can be done with a 

small incision near the wrist or in the palm, with use of an endoscope 

to visualize and divide the ligament. 

Although this operation is considered by many to be relatively minor, 

this writer does not agree. Complications, including injury to the 

median nerve or its motor branch and incomplete release of the transverse 

carpal ligament, may occur even when the operation is performed 

by a clinician with extensive hand surgical training. This 

procedure should be undertaken only if you have surgical expertise 

and a thorough understanding of the anatomy in the area. The patient 

should have significant signs and symptoms of CTS , including denervation 

of the thenar muscles.


Also, unless there are signs of muscle denervation, conservative treatment, 

especially movement therapies to teach the patient to use the 

upper extremity more efficiently, should be fully explored before turning 

to surgery. Not all hand surgeons agree. 

How to Perform Carpal Tunnel Release 

1. CTR can be done using a wrist block, Bier block, upper extremity 

regional block, or general anesthesia. 

2. The hand should be exsanguinated, and a tourniquet should be 

used on the forearm or upper arm. It is important to have a bloodless 

field to prevent injury to the median nerve and surrounding 

structures. 

3. The hand should be held in a fully supinated position for the operation. 

It is useful to wrap gauze around the thumb and clamp it to the 

operating drapes to help hold the hand in position. 

4. A slightly curved incision, approximately 3–4 cm in length, is made 

in the distal palm over the ray of the fourth metacarpal. The incision 

is immediately ulnar to the vertically oriented palmar skin crease. If 

the incision needs to be elongated for better exposure, cross the 

wrist in a zig-zag fashion. 

Carpal tunnel release. The skin incision should be made along a line over the 

fourth metacarpal bone to prevent injury to the motor branch of the median 

nerve. If the incision needs to be elongated for better exposure, cross the wrist 

in a zig-zag fashion.


5. If you are not experienced with this procedure, do not try to be 

slick by using a small incision. Make an incision that allows you to 

see clearly what you are doing. 

6. Gently separate the tissues using blunt dissection. You need small 

self-retaining retractors or assistants who can hold retractors to 

keep the soft tissues out of the way. 

7. You will encounter a muscle, the little known palmaris brevis. 

Gently tease the fibers to get them out of the way. 

8. Beneath this muscle layer is the gray/white transverse carpal 

ligament. 

9. Make a small opening in this layer with the tip of the knife or 

scissors. 

10. Carefully extend the opening a few millimeters until you can see 

the underlying median nerve (it is a smooth, cream-colored structure). 

Then place a clamp into the opening in the ligament to protect 

the nerve, and use the tips of the scissors to divide fully the 

transverse carpal ligament. Dividing the transverse carpal ligament 

opens the carpal tunnel. 

11. The distal extent of the ligament ends just before the palmar arch (an 

important vascular structure). Take care not to injure this vessel. 

12. The ligament extends proximally onto the distal forearm as a fascial 

layer. Open the distal part of this layer by gently pushing the 

the barely open scissors from the leading edge of the fascia in the 

palm toward the distal forearm. You will know that you have divided 

the fascia thoroughly when you can easily pass your finger 

into the distal forearm without feeling any tightness. (This step is 

necessary only if the surgical incision has not crossed the wrist. If 

the incision has crossed the wrist, the fascial layer will be opened 

during normal dissection.) 

13. For completeness, feel for a mass in the carpal tunnel. A mass is a 

rare cause of CTS. 

14. For postoperative pain control, inject a few milliliters of bupivacaine 

into the tissues that you have dissected. 

15. Release the tourniquet before closing the incision, and be sure that 

hemostasis is adequate. Close the wound with a few interrupted 

sutures, and cover with antibiotic ointment and dry fluffed gauze. 

Wrap the hand gently with an Ace wrap. 

16. Alternatively, place a few interrupted sutures to close the incision. 

Apply antibiotic ointment over the suture line, and cover with 

fluffed gauze. Wrap the hand gently with an Ace wrap, and apply


gentle pressure to the area around the incision. Then release the 

tourniquet. 


1. Acetaminophen or a nonsteroidal anti-inflammatory agent should 

be sufficient for pain control. 

2. Keep the hand elevated as much as possible. 

3. An ice pack placed on the volar aspect of the hand helps to alleviate 

some of the pain and swelling. 

4. The soft dressing can be removed the day after surgery. The suture 

line should be cleansed with gentle soap and water each day. Keep 

the suture line covered with a gauze, and wrap the hand gently with 

an Ace wrap. The hand can be used for light activities, and gentle 

range-of-motion exercises should be done with the fingers. 

5. Remove the sutures after 14 days. 

6. Once the sutures are removed, gently massage the scar for several 

months to keep it from getting tight. 

7. Gradually increase the use of the affected hand until the patient has 

resumed regular activities. 

8. Occupational therapy is quite useful in the postoperative period. 

OOsstteeooaarrtthhrriittiiss 

The most common joint disease of the upper extremity is osteoarthritis 

(OA). Although there are several other types of arthritis, OA is the only 

form discussed because of its high prevalence. Approximately 70% of 

people over 65 years of age have changes consistent with OA. 

OA is caused by loss of joint cartilage and growth of new bone at the 

joint edges. The joints primarily affected are the finger DIP joints and 

the thumb carpometacarpal joint. The PIP and MCP joints are involved 

less often. 

Symptoms include pain with hand use, joint enlargement and deformity, 

and joint stiffness with loss of motion. 

The primary goals of treatment are relief of pain and maintenance of 

adequate hand function. Acetaminophen and nonsteroidal anti-inflammatory 

agents are the most useful medications. Several homeopathic 

remedies (e.g., arnica) also can be quite useful. 

Occupational therapy or other movement therapy to encourage efficient 

use of the entire upper extremity is an important adjunct to treatment.


Surgery usually is done only for intractable pain and joint destruction 

that leads to significant loss of hand function. The most common procedure 

is fusion (arthrodesis) of the affected DIP joint. Arthrodesis or 

arthroplasty (joint replacement) may be indicated for a severely symptomatic 

PIP joint. These highly technical procedures should be done 

only by a hand specialist. 


1. Kozin SH: The anatomy of the recurrent branch of the median nerve. J Hand Surg 

23A:852–858, 1998. 

2. Palmer AK, Toivonen DA: Complications of endoscopic and open carpal tunnel release. 

J Hand Surg 24A:561–565, 1999. 

3. Taras JS, Miskovsky C: Nonoperative management of trigger digits. Atlas Hand Clin 

4:1–8, 1999.

Chapter 39 

EXPLORATION OF AN INJURED 

HAND OR FOREARM 

KEY FIGURES: 

Tourniquet Dorsal incisions 

Midlateral finger incisions Proximal and distal 

Brunner zigzag incisions extension of wound 

Volar surface incisions 

When exploring an injured forearm or hand, you must be aware of the 

surrounding tendons, nerves, and blood vessels. You do not want to 

injure one of these structures accidentally. This chapter explains basic 

principles about how to operate safely on an injured hand or forearm. 

It is not intended to qualify you as a hand specialist; it is intended for 

rural health care providers who have no access to hand or reconstructive 

specialists. The chapter also provides important background information 

for all health care providers. 

AAnneesstthheessiiaa 

To operate on an upper extremity properly, you must provide adequate 

anesthesia. Either general anesthesia or some type of nerve block must 

be given so that the patient feels no pain and is able to stay completely 

still during the operation. (See chapter 3, “Local Anesthesia.”) 

TToouurrnniiqquueett UUssee 

The hand has an excellent blood supply. Thus, any incision into the tissues 

will ooze blood continuously throughout the procedure, making it 

difficult to see exactly what you are doing. To prevent inadvertent injury 

to the important nearby structures (tendons, nerves, and blood vessels), 

it is best to operate in a bloodless field. This means that the circulation to 

the hand must be temporarily interrupted while you operate. 

To interrupt the vascular supply to the hand, a tourniquet is placed 

proximal to the site where you are working to compress the blood vessels 

supplying the extremity. 

367


Equipment and Supplies 

Before placing the tourniquet, be sure to pad the area where the tourniquet 

will be placed with two layers of web roll (soft cotton wrap). 

A pneumatic tourniquet is the best equipment to use because you can 

accurately set the inflation pressure as well as a time limit. An alarm 

will sound when the time limit has been reached. 

A regular blood pressure cuff also can be used as a tourniquet. It is best 

used for short procedures because the pressure in the cuff often gradually 

decreases, and the bloodless field is lost. It is helpful to have someone 

available to monitor the cuff pressure and pump up the cuff before 

the pressure decreases too much. 

An alternative is to wrap an Esmarch (wide rubber wrap) tightly 

around the upper arm 4–5 times and tape it in place. This technique is 

effective, but should be used only as a last resort. 

Placement of the Tourniquet 

For procedures that will take longer than 30 minutes to complete, it is 

best to place the tourniquet on the upper arm. Because such procedures 

usually are done with a Bier block, an axillary block, or general 

anesthesia, pain control should not be an issue. 

For short procedures (less than 20 minutes) that involve the hand or 

wrist, a forearm tourniquet can be used with a digital or wrist block as 

appropriate. For this short period, most patients can tolerate the discomfort 

associated with the inflated tourniquet on the forearm. 

When you are working on a simple, isolated finger injury, a digital tourniquet 

can be used. (See chapter 29, “Fingertip and Nail Bed Injuries.”) 

A blood pressure cuff can serve as a tourniquet to allow the procedure to be done 

in a bloodless field. Note the padding beneath the tourniquet. A, Upper arm. 

(Figure continued on next page.)

Exploration of an Injured Hand or Forearm 369 

A blood pressure cuff can serve as a tourniquet to allow the procedure to be 

done in a bloodless field. Note the padding beneath the tourniquet. B, Forearm. 

Exsanguination of the Extremity 

Before the tourniquet is inflated, the extremity should be exsanguinated 

(i.e., all blood should be removed from the extremity). For 

this purpose, a large rubber wrap (Esmarch) can be wrapped around 

the extremity before the tourniquet is inflated. Start at the fingertips, 

and proceed proximally. The Esmarch should be stretched as you 

wrap it around the extremity to squeeze blood out of the tissues. You 

should allow a few centimeters of overlap with each turn of the wrap. 

Once you have reached the tourniquet, inflate the tourniquet and 

remove the wrap. 

An alternative method is to have several assistants use their hands to 

apply pressure to the patient’s elevated extremity. In this way, they 

manually squeeze the blood from the tissues. Inflate the tourniquet 

while their hands are still in place. This method requires several assistants. 

You should not exsanguinate the hand if infection is present. Exsanguinating 

an infected extremity may spread the infection proximally 

and have serious consequences. 

Inflation Pressure 

Amount 

The tourniquet should be inflated to a pressure approximately 100 mmHg 

higher than the patient’s systolic blood pressure—usually 250–300 

mmHg. This pressure level applies to the pneumatic tourniquet and blood 

pressure cuff. The pressure of a rubber wrap cannot be measured.


Duration 

A pneumatic tourniquet can stay in place for 2 hours before it is necessary 

to let down the tourniquet (release the pressure). 

If you are using an Esmarch wrap as a tourniquet, I recommend removal 

after 1–11 ⁄2 hours. 

If necessary, the tourniquet can be reinflated after the extremity is 

given a few minutes of uninterrupted blood flow. 

Tourniquet Release 

When the tourniquet is released, circulation returns to the extremity. 

For the first 5–10 minutes, the blood flow is greater than usual and 

the hand becomes very red. This increase in blood flow is due to the 

effects of ischemia on the tissues. The vessels dilate for the first few 

minutes after blood flow returns. The initial effect is increased bleeding 

from the incision, which can be a little scary if you are not expecting 

it. 

To prevent blood loss, place saline-moistened gauze in the wound 

before deflating the tourniquet and apply gentle pressure while the 

tourniquet comes off. Continue the pressure for several minutes. 

Of course, the bleeding may be due to an injured vessel. If it is particularly 

brisk and does not decrease after several minutes of direct pressure, 

the wound should be checked thoroughly to rule out vascular 

injury. If you have any concern that you may have accidentally injured 

a blood vessel during the procedure, the tourniquet should be deflated 

before the incision is closed. 

Make sure that all pulses are intact after the tourniquet is released. The 

tourniquet can cause a blood vessel to clot, although clotting is unusual 

and occurs only in severely diseased blood vessels. 

If you are reasonably sure that you have not accidentally injured a 

blood vessel during the procedure, you may close the wound before releasing 

the tourniquet. Be sure to use a secure dressing and to apply 

gentle pressure to the area before deflating the tourniquet. 

IInncciissiioonnss 

Depending on the reason for exploration, you may not have much 

choice about where to place the incision. If the patient has a laceration 

or an abscess, its location dictates the placement of the incision. Even 

in these situations, however, you may need to extend the incision for 

adequate exploration and treatment. Thus you should know the basics 

about proper placement of incisions on the hand.

Proper placement of incisions is important for several reasons. One 

reason is to prevent injury to underlying structures. Another is that improperly 

placed incisions can result in poor wound healing, tight scarring, 

and, ultimately, limitation in hand function. You do not want to 

worsen the problem because of a lack of understanding about the 

proper way to position an incision. 

It is always best to draw out your planned incisions before cutting the 

skin. This technique allows you to think carefully about the design and 

to make changes before you create the incision. 

Volar Surface 


Fingers 

An incision that crosses the joint flexion crease incorrectly often heals 

with a tight scar. A tight scar on the volar surface of the finger can result 

in permanent flexion of the finger and limitation of finger movement. 

There are two correct ways to make incisions for access to the volar tissues 

of the fingers. Both avoid crossing the joint flexion creases incorrectly. 

The choice depends on the area in which you need access to 

underlying tissues. 

Midlateral incisions can be placed on either side of the finger, volar to 

the digital vessels. They can extend from the metacarpophalangeal 

flexion crease to the distal phalanx. 

The midlateral incision is one approach to the volar 

side of the finger. Note the position of the digital 

nerve (dashed line) in relation to the planned incision 

(solid line).


Brunner zigzag incisions go on a diagonal from the lateral edge of the 

joint crease to the opposite lateral edge of the next crease. They give 

the best exposure to the central aspect of the digits. 

Brunner zigzag incisions provide another approach to the volar side of the 

finger and allow access to the center of each finger. To prevent tight scarring, 

the volar skin creases should not be crossed at a 90° angle (as would occur 

with a straight longitudinal incision through the central volar aspect of the digit.) 

Dorsal Surface 

On the dorsal surface of the finger, there is less concern about crossing 

the skin creases. Simple longitudinal incisions usually provide the best 

exposure and heal well. 

Hand 

Volar Surface 

Straight incisions on the volar surface of the hand often result in tight 

scars that may prevent full opening of the hand and thus lead to decreased 

function. For this reason, diagonal incisions that zigzag across 

the palm are recommended. 

Brunner zigzag incisions. Using a nearby flexion crease as a starting 

point and guide, make incisions that follow a diagonal and zigzag 

across the palm. On the average, each incision should only be 2–21 ⁄2 

cm in length. The incisions should be placed at a > 30° angle to one 

another.

Dorsal Surface 


Incision for the volar surface of the hand. The palmar skin creases should be 

incorporated into the incisions. The incisions then should be extended in a 

zigzag fashion. 

As on the fingers, a tight scar on the dorsal surface of the hand may interfere 

with hand function. Longitudinal incisions usually provide the 

best exposure. 

Alternatively, to prevent the need for multiple longitudinal incisions if 

you need access to a large area of the dorsal surface, a transverse incision 

is acceptable. 

Incisions on the dorsal surface of the hand and fingers. Multiple choices are 

available depending on where exposure is needed. Placement is not as critical 

as on the volar surface.


Volar and Dorsal Surfaces 

Forearm 

Longitudinal incisions can be used on the volar and dorsal surfaces. If 

a wound from an injury is already present, simply extend it in a curvilinear 

manner parallel to the long axis of the forearm. 

At the Elbow 

Do not cross the flexion crease of the elbow (the antecubital fossa) in a 

straight line. Such incisions can lead to tightness about the elbow when 

the wound heals. It is best to use a zigzag technique. 

Alternatively, make a transverse incision at the antecubital crease and 

then extend the ends of the incision in a curvilinear fashion down the 

forearm or up the upper arm as needed. 

When a Laceration is Present 

Often the patient with a hand injury in need of surgical exploration already 

has an open wound. It is best to incorporate the wound into your 

incision by extending the edges of the wound, using the above mentioned 

principles for proper incision placement. 

When exploring a hand with a traumatic 

laceration, use the wound incision 

whenever possible. If more exposure is 

needed, try to extend the traumatic 

wounds in a zigzag fashion. The original 

wound should be entended only as 

far as necessary, using proper incisions. 


Roselius © 1998. From Green DP, et 

al (eds): Operative Hand Surgery, 4th 

ed. New York, Churchill Livingstone, 



Conolly WB: Atlas of Hand Surgery. New York, Churchill Livingstone, 1997, pp 29–32.

Index 

Page numbers in boldface type indicate complete chapters. 

ABCs (airway, breathing, circulation), of 

trauma care, 49–53 

Abdomen, stab wounds to, 64 

Abscess 

aspiration of, 189 

“collar button,” 354 

decompression of, 189 

definition of, 339 

differentiated from cellulitis, 183, 339 

fluctuance of, 183, 185, 186, 339 

of the hand, 347–354 

acute suppurative flexor 

tenosynovitis, 347, 350–353 

on dorsal surface, 353–354 

felon, 347–349, 351 

paronychia, 349–350 

human bite wound-related, 343 

incision and drainage of, 188–189, 339, 

353–354 

Adhesives, as suturing alternative, 17–18 

Adhesive tape, as suturing alternative, 

18–19 

Aeromonas hydrophila infections, 187, 343 

Air, subcutaneous. See Crepitus 

Airway management, in trauma patients, 

49–51 

Airway obstruction, facial fracturerelated, 

251 

Airways, thermal injury to, 192 

Albumin, serum levels of 

as nutritional status indicator, 74, 176 

in pressure sore patients, 167 

Alcohol abuse, maternal, as cleft 

lip/palate cause, 238 

Altered level of consciousness, as 

indication for supplemental oxygen 

therapy, 52 

American Society of Plastic Surgery, 

Reconstructive Surgeons Volunteer 

Program of, 242 

Amputated parts, care of, 305 

Amputation 

necrotizing fasciitis-related, 340 

traumatic, of finger, 303–306 

of fingertip, 285 

Anesthesia. See also Local anesthesia 

in facial laceration care, 146–147 

Anesthesia (cont.) 

in surgical exploration of upperextremity 

injuries, 367 

Animal bite wounds, 59, 185, 187, 268, 

341, 343 

Ankle/brachial index (ABI), 178, 179 

Ankle fractures, free flap coverage of, 

133–134 

Anterosuperior iliac spine, as groin flap 

anatomic landmark, 130, 131 

Antibacterial solutions 

as eye injury cause, 146 

for facial laceration care, 146 

Antibiotic ointment 

as burn treatment, 82, 197, 198, 199, 321 

for grease removal from wounds, 284 

ophthalmic, 153 

for pressure sore treatment, 165 

for primary wound closure, 95 

as wet-to-wet dressing alternative, 

83–84 

Aquatic bacteria, as infection cause, 187, 

341, 343 

Areola, reconstruction of, 248 

Arrhythmia, electrical injury-related, 193 

Arterial injuries 

acute, 62 

crush injury-related, 331, 332 

hand injury-related, 268 

Arterial insufficiency 

capillary refill in, 265–266 

as leg ulcer cause, 177, 178, 179, 180 

Arthritis. See also Osteoarthritis; 

Rheumatoid arthritis 

frostbite-related, 204 

Arthrodesis, 366 

Arthroplasty, 366 

Ascorbic acid. See Vitamin C 

Aspirin 

use by traumatic amputation patients, 

305 

Axial groin flap, 129–133 

Axial musculocutaneous flaps, 246 

Axillary nerve block, 43 

Bacitracin 

as burn treatment, 82, 198, 199 

375

376 Index 

Bacitracin (cont.) 

for grease removal from wounds, 284 

as open wound treatment, 82 

Backslab, 210 

Bacteria, “flesh-eating.” See Fasciitis, 

necrotizing 

Bacterial infections 

aquatic bacteria-related, 187, 341, 343 

suture-related, 3 

Basal cell carcinoma, 223–224 

as chronic wound cause, 175 

re-excision of, 231–232 

treatment of, 231 

Basal metabolic requirements (BMR), 

74–75 

Betadine 

as wound cleanser, 81 

Bicarbonate, as local anesthesia additive, 

31, 39, 146 

Bier block, 42–43 

in carpal tunnel release, 363 

in trigger finger release, 358 

Biopsy 

sentinel lymph node, 233–234 

of skin lesions, 225–231 

excisional, 226, 228–230 

incisional, 226, 227–228 

punch, 227–228 

shave biopsy/excision, 226, 230–231 

Bite wounds, 89 

animal, 59, 185, 187, 268, 341, 343 

human, 59, 187, 268, 341 

Blisters, 323 

burn-related, 324 

pus-filled, 350 

Blood, dried 

human immunodeficiency virus 

survival time in, 47 

removal from acute wounds, 62 

Blood-borne pathogen exposure, safety 

precautions for, 45–48 

Blood flow, in foot, 178 

Blood glucose. See also Diabetic patients 

effect on wound healing, 58, 176 

Blood pressure cuff, use as tourniquet, 64, 

267, 317, 368, 369 

Blood pressure measurement, without 

blood pressure cuff, 52 

Blood vessels 

crush injuries to, 331 

suturing of, 24–26 

tying off of, 24–25 

Blunt dissection, 26–27 

Body fluids exposure, safety precautions 

for, 45–48 

Body surface area (BSA), of burns, 

193–194, 196, 198, 202 

Bone 

exposure of, in fingertip injuries, 285, 

287 

infection of. See Osteomyelitis 

Bone growth, frostbite-related impairment 

of, 204 

Bone rongeur, 285 

Brain injury, facial fracture-associated, 251 

Breast surgery, 245–250 

breast mound reconstruction, 245–248 

with free flaps, 133–134 

with implants, 245–246 

with latissimus dorsi flap, 246 

nipple and areolar reconstruction in, 

246, 248 

with pedicle transverse rectus 

abdominis muscle flap, 246–248 

timing of, 248–249 

breast reduction, 245, 249 

in gynecomastia, 250 

Bronchoscopy, for airway thermal injury 

evaluation, 192 

Buckshot injuries, 71 

Buddy taping, of phalangeal fractures, 

296, 297 

Bullets 

embedded in tissue, 61 

radiographic evaluation of, 68 

removal from wounds, 71 

Bupivacaine, as local anesthetic, 30–31, 32 

in digital nerve blocks, 283 

in facial nerve blocks, 39, 146 

in primary wound closure, 92 

Burns, 59, 191–204 

antibiotic ointments for, 82, 197, 198, 

199, 321 

body surface area (BSA) of, 194–195, 

196, 198, 202 

depth of, 195–196 

first-degree, 196, 198, 324, 325 

fluid resuscitation in, 196–197, 199 

of the hand, 201, 268, 321–328 

aftercare for, 327–328 

care during healing, 323–324 

determination of depth of, 324–325 

escharotomy of, 325–326 

initial treatment of, 321–324 

surgical treatment of, 325–327 

tangential excision of, 324, 327 

initial treatment of, 193–194, 321–324 

nutritional concerns associated with, 

200 

pain control for, 197–198 

physiologic consequences of, 191 

as pressure sore risk factor, 162 

second-degree, 86, 196, 198–199, 201, 

324, 325

Burns (cont.) 

subsequent care for, 198–199 

tangential excision of, 199, 200, 324, 

327 

third-degree, 196, 199, 202, 324, 325 

Calcaneus, pressure sores of, 163 

Calcium, 77 

Calf 

compartments of, 208, 209 

compartment syndrome of, 207–211 

Caloric requirements 

of burn patients, 200 

estimation of, 74–75 

Cancer. See also specific types of cancer 


as impaired wound healing cause, 58 

Capillary refill 

evaluation of, 62 

in hand injuries, 265–266, 269 

in radial artery injury, 318 

in tibial and fibular fractures, 207 

Carbon monoxide, blood content of, 192 

Carpal tunnel 

anatomy of, 360–361 


Carpal tunnel release, 332, 335, 362–365 

Carpal tunnel syndrome, 360–365 


diagnosis of, 361 

nonoperative treatment of, 362 

operative treatment (release) of, 332, 

335, 362–365 

Casts 

for hand injuries, 275 

for metacarpal fractures, 299 

tight, as compartment syndrome cause, 

210 

Cat-bite wounds, 59, 187, 268, 341 

Catgut sutures, 4 

Cat-scratch disease, 344 

“Cauliflower ear,” 157 

Cellulitis, 187 

chronic wound-related, 80 

definition of, 79, 183, 339 

differentiated from abscess, 183, 339 

of the finger, 351 

pressure sore-related, 165 


Cervical spine injury, facial fractureassociated, 

251 

Cheek 

fractures of, 252 

lacerations of 

full-thickness, 152 

intraoral, 151–152 

Chemical burns, 193, 197 

Index 377 

Chest, stab wounds to, 64 

Chest flaps, 121, 122–124 

for fingertip fracture with nail bed 

injury coverage, 287 

Children 

absorbable suture use in, 93, 147 

burns in, 194 

frostbite in, 204 

local anesthesia injections in, 30 

oral electrical burns in, 201 

scarring in, 137 

suture removal from, 3 

Circumflex scapular artery, as axial flap 

blood supply source, 112 

Cleansing 

of acute wounds, 60–61 

of burned hands, 321, 322 

of facial lacerations, 146 

of gunshot wounds, 70 

of local flap placement sites, 114 

of nerve injuries, 62 

of skin graft donor sites, 100 

of tendon injuries, 63, 307 

Clean techniques, 81 

Cleft lip/palate, 235–243 

definition of, 235–237 

embryologic development and etiology 

of, 237–238 

incidence of, 237 

in utero repair of, 239 

initial corrective operations for, 239–241 

nutritional concerns in, 238–239 

Pierre Robin syndrome-associated, 

242–243 

presentation of, 237 

visiting surgeon programs for, 241–242 

Clothing 

penetration of, by foreign objects, 59 

removal from patients 

from gunshot wound patients, 67 

from trauma patients, 54 

Cold, anesthetic effect of, 30 

Collagen 

in scar healing, 137 

synthesis of, nutrient requirements for, 

76 

Colloid resuscitation, of burn patients, 200 

Compartment syndromes, 192, 207–211, 

330, 331, 333–338 


etiology of, 333 

prevention of, 210 

signs and symptoms of, 209 

treatment of, 210–211, 334–335 

“vicious cycle” of, 333, 337–338 

Computed tomography, of facial 

fractures, 253

378 Index 

Conjunctivitis, antibiotic ointmentrelated, 

153 

Copper, dietary intake of, 77 

Crepitus, 185, 186, 340, 342 

Cricothyroidotomy, surgical, 50–51 

Cross-arm flaps, 125–126 

for fingertip injury coverage, 287 

Cross-leg flaps, 126–129 

for open tibial-fibular fracture coverage, 

218 

Crush injury, 59, 268, 329–333 


as disability cause, 329 

effects on tissues, 330–331 

Dakin’s solution, 81, 89 

Debridement 

of blisters, 323 

of chronic wounds, 173, 174, 180 


of facial lacerations, 146 

of frostbitten tissue, 203–204 

of gangrene, 340 

of necrotizing fasciitis, 184, 340 

of pressure sores, 161, 165–166, 167 

Decompression. See also Fasciotomy 

of abscess, 189 

of paronychia, 349 

Defatting, of skin grafts, 107–108 

in fingertip injuries, 285 

Degloving injury, 330, 333 

Delay procedure, for local flap formation, 

113–114 

Dermatome, 101, 102, 200 

Dermis, anatomy of, 97–98 

Diabetic patients 

hand infections in, 341 

impaired wound healing in, 58, 176 

soft-tissue infections in, 185 

steroid injections in, 142 

Diazepam, 42 

use in burn patients, 197 

Digital arteries, injuries to, 318 

Digital nerve blocks, 34–35, 41 

as contraindication to epinephrine 

administration, 32 

in finger fracture reduction, 294 

in fingertip injury repair, 283–284 

in joint dislocation reduction, 300 

in nail removal, 290 

Digital nerves 

accidental suturing of, 318 

anatomy of, 314 

injuries to, 315 

location of, 34 

repair of, 315–317 

DIP. See Distal interphalangeal joints 

Direct infiltration, of local anesthetics, 33 

Disinfection, of contaminated surfaces, 47 

Dislocations 

acute wound-related, 63, 64 

crush injury-related, 332 

of finger joints, 271, 280 

complex, 300, 301 

interphalangeal, 300–301 

metacarpal, 300 

simple, 300–301 

Dissection 

blunt, 26–27 

sharp, 27 

Distal interphalangeal joints (DIP) 


osteoarthritis of, 365, 366 

Distal phalanges, fractures of, 286, 289, 

294–296 

intraarticular, 295–296 

mallet deformity of, 310 

open, 286 

shaft, 295 

tuft, 294–295 

Dog-bite wounds, 187, 268 

Donor sites 

for flaps, 111 

chest flaps, 121, 123 

distant flaps, 121, 123, 126, 127, 132 

for skin grafts 

full-thickness grafts, 107, 109 

split-thickness grafts, 100, 106 

Drainage. See also Incision and drainage 

of abscess, 188–189 

of acute suppurative flexor 

tenosynovitis, 351–352 

of hand infections, 344, 345 

of paronychia, 349 

of pus from wounds, 89 

of subungual hematoma, 287, 289 

Dressings. See also Gauze dressings 

for amputation stumps, 305 

for burns, 197 

for ear lacerations, 157 

for fasciotomy sites, 337 

for fingertip injuries, 285, 286 

for gunshot wounds, 70, 80–83 

for hand injuries, 281 

for pressure sores, 165 

for secondary wound closure sites, 89, 91 

for skin grafts, 105, 108–109 

solutions for, 81 

wet-to-dry, 82–83 

for chronic wounds, 173, 174, 180 

for delayed primary wound closure, 

96 

for secondary wound closure sites, 89 

for traumatic amputations, 304

Dressings (cont.) 

wet-to-wet, 83 

antibiotic ointment as alternative to, 

83–84 

for pressure sores, 165 

DuoDERM, as pressure sore dressing, 165 

Ear, full-thickness external lacerations of, 

156–157 

Ear piercing, as keloid cause, 142–143 

Ectropion, 158 

Eikenella infections, of bite wounds, 187, 

343 

Electrical burns, 192–193 

oral, in children, 201 

Electric stimulation, as nerve injury repair 

technique, 315 

Electrocautery devices, 23, 24 

use in skin lesion biopsy, 230, 231–232 

Electrodiagnostic studies, of carpal tunnel 

syndrome, 361 

Elevation 

of burned hand, 322, 326 

of forearm, in compartment syndrome, 

337 

of hand, in compartment syndrome, 337 

of infected hand, 344, 345 

of injured hand, 281 

Endotracheal intubation 

for airway patency, 50 

in inhalation injury patients, 192 

Epidermis, anatomy of, 97 

Epinephrine, as local anesthesia additive, 

31–32 

Epineurium, 313–314 

suture placement in, 315, 316–317 

Escharotomy, of burns to the hand, 

325–326 

Esmarch, 368, 369, 370 

Ethyl chloride, anesthetic action of, 30 

Exposure, of trauma patients, 54 

Extensor pollicis longus tendon, motor 

examination of, 262 

Extensor tendons, of the hand 

motor examination of, 262 

splinting of, 278, 279 

Extraarticular fractures, of middle or 

proximal phalanges, 296–297 

Extrinsic muscles, of hand, evaluation of, 

261–262, 263 

Exudate 


Eyebrows, lacerations of, 154–155 

Eyelids 

lacerations of, 153–154 

lower, involvement in facial wound 

closure, 88 

Index 379 

Facial injuries 

fractures, 251–256 

basic initial treatment of, 253 

diagnosis of, 252–253 

initial evaluation of, 251 

mandibular fractures, 253–256 

gunshot wounds, 70–71 

lacerations, 145–159 

anesthesia for, 146–147 

initial care for, 146 

jaw fracture-related, 253 

soft-tissue loss associated with, 

158–159 

specific types of, 149–159 


unique properties of, 145 

near lower eyelid, 88 

nerve blocks for, 38–41, 147 


wound closure of, 58 

local anesthesia for, 92 

suture sizes for, 2 

suturing techniques for, 93 

Fasciitis, necrotizing, 184, 186, 340, 342, 344 

Fasciotomy 

of calf, 210–211 

of fingers, 336 

of forearm, 334–335 

of hand, 335–336 

Felon, 347–349, 351 

Femur, closed fractures of, as blood loss 

cause, 52 

Fingers. See also Distal phalanges; Middle 

phalanges; Proximal phalanges 

amputated, replantation of, 304–305 

digital nerves of, 34 

digital tourniquet use in, 368 

escharotomy of, 325 

exploratory incisions in, 371–372 

fasciotomy of, 336 

fractures of, 63, 271, 293–299 

anesthesia for, 294 

definitions related to, 293–294 

distal phalangeal, 294–296 

metacarpal, 298–299 

middle and proximal phalangeal, 

296–298 

shaft, 295 

joint dislocations of, 300–301 

lacerations of, mallet deformity 

associated with, 312 

little, splinting of, 279–280 

nerve blocks of, 34–35, 41 

as contraindication to epinephrine 

administration, 32 

rotational deformities of, 266, 268, 271, 

296, 297

380 Index 

Fingers (cont.) 

splinting of, 268, 279–280 

trigger, 355–360 

Fingertips 

felon of, 347–349, 351 

injuries to, 283–289 


complicated injuries, 286–289 

digital tourniquet for, 284 

initial care for, 283–284 


traumatic amputation of, 285 

Flaps 

classification of, 111 


distant, 121–135 

for acute wound coverage, 65 

attached, 121–133 

axial, 129–133 

chest flap, 122–124 

cross-arm, 121, 125–126, 287 

cross-leg, 126–129, 218 


free, 121, 122, 133–134 

groin, 129–133 

random, 121–129 

for tibia and fibula fracture coverage, 

218 

local, 27, 111–120 

for acute wound coverage, 65 

axial, 112–113, 120 

classification of, 112–113 

delay procedure for, 113–114 

for melanoma excision site coverage, 

232 

muscle flaps, 111, 120, 212–218 

for pressure sore coverage, 166–172 

random, 113, 114–119 

rhomboid, 115–116 

rotation, 117–118 

V-Y advancement, 114, 118–119, 

170–171 

rotation buttock, for pressure sore 

coverage, 168–169 

3:1 rule for, 114, 122 

tensor fascia lata, for pressure sore 

coverage, 169–170 

Flexor carpi radialis tendon, anatomic 

relationship with median nerve, 36 

Flexor carpi ulnaris tendon, anatomic 

relationship with ulnar nerve, 37 

Flexor digitorum profundus tendon, 


Flexor digitorum superficialis tendon, 


Flexor pollicis longus tendon, motor 


Flexor sheath, acute suppurative 

tenosynovitis of, 350–352 

Flexor tendons 

anatomic relationship with carpal 

tunnel, 360 

course of, 355 

injuries to, 270, 271–273 

splinting of, 277–278 


Fluctuance, of abscess, 183, 185, 186, 339 

Fluid resuscitation, of burn patients, 

195–196 

Foot 

burns of, 201–202 

pseudomonal infections of, 59 

Forceps, use in suturing, 5, 6–7 

Forearm 

crush injury to, 331–333 

escharotomy of, 325 

fasciotomy of, 334–335 

infections of, 342 

lacerations of, 374 

surgical exploration of, 367–374 

anesthesia in, 367 

incisions in, 367, 370–374 

tourniquet use in, 367–370 

Forehead, lacerations of, 155 

Foreign material 

as chronic wound cause, 174, 180 

embedded in acute wounds, 59, 60, 

61–62, 64 

embedded in crush injury wounds, 

330 

embedded in gunshot wounds, 70, 71 

embedded in hand wounds, 268, 271 

as hand infection cause, 341, 342, 343 

as infection cause, 61 

as primary wound closure 

contraindication, 91 

removal from traumatically-amputated 

parts, 305 

as soft-tissue infection cause, 185, 186 

Fractures 

closed 


of tibia and fibula, 206 

comminuted 


of tibia and fibula, 207 

compartment syndrome-associated, 

337 

crush injury-related, 331, 332 

facial, 251–256 

basic initial treatment of, 253 

diagnosis of, 252–253 

initial evaluation of, 251 

mandibular fractures, 254–255

Fractures (cont.) 

of fingers, 63, 266, 280, 271, 293–299 

anesthesia for, 294 

definitions related to, 293–294 

distal phalangeal, 286, 289, 294–296 

mallet deformity-associated, 310, 

312 

metacarpal, 266, 298–299 

middle and proximal phalangeal 

fractures, 296–298 

shaft fractures, 295 

frontal sinus, 155 

gunshot wound-related, 68 

hand infection-related, 342 

open (compound), 63, 64 


of distal phalanx, 286 

of the fingertips, 287, 289 

hand injury-associated, 271 

muscle flap coverage for, 120 

of tibia and fibula, 206, 210, 211–218 

with overlying wounds, 88 

of tibia and fibula, 205–219 

case example of, 205–206 

closed fractures, 206 

comminuted, 207 

compartment syndrome associated 

with, 207–211 

distant flap coverage for, 218 

free flap coverage for, 218 

local muscle flap coverage for, 

212–218 

open (compound) fractures, 206, 210, 

211–218 

Free flaps, 133–134 

for tibia and fibula fracture coverage, 

218 

Freshwater-associated bacterial infections, 

187, 341 

Frostbite, 202–204 

Gangrene 

dry, 183–184, 340 

wet, 184, 186, 340 

Gastrocnemius flaps, 213–216 

Gastrocnemius muscle, anatomy of, 

213–214 

Gauze dressings, 80, 81 

saline-moistened, for burns, 197 

for skin grafts, 105 

as wet-to-dry dressings, 82–83 

as wet-to-wet dressings, 83 

Glasgow Coma Scale, 53–54 

Gloves 

nonsterile, 81 

protective, 46 

sterile, 80–81 

Index 381 

Goggles, protective, 47 

Granulation tissue, definition of, 79 

Grease 

removal from burned tissues, 197, 321 

removal from fingertip wounds, 284 

Groin flap, 129–133 

Gunshot wounds, 59, 67–71 

bullet removal from, 71 

entrance and exit sites of, 69, 70 

external wound care for, 69–70 

initial treatment of, in stable patients, 

67–69 

Gynecomastia, 250 

Hand. See also Fingers 

abscesses of, 347–354 

acute suppurative flexor 

tenosynovitis, 347, 350–353 

on dorsal surface, 353–354 

felon, 347–349, 351 

paronychia, 349–350 

amputated, replantation of, 304–305 

anatomic positions of, 257–258 

blood supply to, 264–265, 318 

chronic conditions of, 355–366 

carpal tunnel syndrome, 360–365 

osteoarthritis, 365–366 

trigger finger, 355–360 

finger alignment of, 266 

infections of, 339–345 

bite wound-related, 59 

evaluation of, 341–342 

general initial treatment of, 344–345 

normal, examination of, 257–266 

extrinsic muscle/intrinsic muscle 

nerve supply evaluation in, 

263–264 

motor examination, 261–262 

sensory examination, 259–260 

vascular evaluation in, 264–266 

Hand injuries 

bite wounds, 59, 187, 268, 341, 343 

burns, 201, 268, 321–328 


care during healing, 323–324 

determination of depth of, 324–325 

escharotomy of, 325–326 

initial treatment of, 321–324 


tangential excision of, 324, 327 

crush injuries, 59, 268, 331–333 

dressings for, 281 


motor examination in, 270 

patient history in, 267–269 

physical examination in, 269–271 

sensory examination in, 270

382 Index 

Hand injuries (cont.) 

evaluation of (cont.) 

tendon examination in, 270 

in unconscious patient, 271–273 

vascular examination in, 269–270 

general aftercare for, 281–282 

nerve blocks for, 34–38 

digital blocks, 34–35, 41 

wrist blocks, 35–38, 41 

splinting of, 275–280 

versus casting, 275 

duration of, 282 

materials for, 275–276 

splint construction for, 276 

splint position and contour in, 

276–280 

surgical exploration of, 367–374 

anesthesia in, 367 

incisions in, 367, 370–374 

tourniquet use in, 367–370 


to the tendons, 307–312 

extensor tendon injuries, 308–312 

flexor tendon injuries, 307–308 

mallet finger, 310–312 

Handwashing, for infectious disease 

prevention, 46 

Harelip. See Cleft lip/palate 

Harris-Benedict equation, 74–75 

Head injury 

Glasgow Coma Scale evaluation of, 

53–54 

as pressure sore risk factor, 162 

supplemental oxygen therapy in, 52 

Hematoma, 87 

ear laceration-related, 157 

subungual, 287, 289 

Hematoma block, in metacarpal fracture 

reduction, 298 

Hemorrhage 

acute wound-related, 57, 58, 63–64 

exsanguinating/pulsatile, 64, 317 

hand injury-related, 267, 268, 269 

as pseudoaneurysm cause, 317–318 

gunshot wound-related, 68 

lip laceration-related, 151 

management of, 24–26 

scalp wound-related, 156 

from skin edges, 23–24 

after tourniquet release, 370 

in trauma patients, 52 

Hepatitis, transmission by needlestick 

injury, 5 

Hepatitis B virus 

contagiousness of, 45 

postexposure treatment for, 48 

prevalence of, 46 

Hepatitis B virus vaccination, 47, 48 

Hepatitis C virus 

contagiousness of, 45 



Hepatitis D (delta) virus, 46 

Herpetic infections, of the fingers, 350 

Human bite wounds, 59, 187, 268, 341 

Human immunodeficiency virus infection 

(HIV) 

as impaired wound healing cause, 58 



transmission by needlestick injury, 5 

Humby knife, 101, 102–103 

Hyperbaric oxygen therapy, for 

necrotizing fasciitis, 184, 340 

Hypotension, trauma-related, 52–53 

Hypothenar eminence, 258 

Hypothenar muscles, fasciotomy of, 335 

Incision and drainage, 342 

of abscess, 188–189, 339, 353–354 

contraindication in herpetic infections, 

350 

of felon, 347–348 

Incisions, 21–23 

Brunner zigzag, 372, 373 

for compartment syndrome treatment. 

See Fasciotomy 

for escharotomy, 325–326 

for surgical exploration of upperextremity 

injuries, 367, 370–374 

in fingers, 371–372 

in forearm, 374 

in hand, 371–372 

for trigger finger release, 358–359 

Incontinence, as pressure sore cause, 

163 

Infants 

congenital trigger finger in, 356 

protein requirements of, 76 

Infections 

as chronic wound cause, 174–175 

foreign body-related, 61, 185, 186, 341, 

342, 343 



general initial treatment of, 344–345 

after secondary wound closure, 89 

signs of, 89 

Infectious disease exposure, safety 

precautions for, 45–48 

Infraorbital nerve, facial fractureassociated 

injury to, 252 

Inhalation injury, 192, 202 

Injection, of local anesthetics, 30–33

Instruments 

sharp 

disposal of, 47 

safety precautions for use of, 46, 47 

sterile, 80–81 

for suturing, 5–7 

Interferon therapy, for hepatitis C 

patients, 48 

Intermaxillary fixation, Ivy loops 

procedure for, 254–256 

Interosseous muscles, fasciotomy of, 335 

Interphalangeal joints (IP) 

burn-related stiffness of, 323 


extension of, 264, 270 

Interplast, 242 

Intravenous access, in trauma patients, 52 

Intrinsic muscles 

dysfunction of, 261 

evaluation of, 263 

Intubation. See also Endotracheal 

intubation 

for airway patency, 50 

IP. See Interphalangeal joints 

Iron, dietary intake of, 77 

Iron supplementation, for wound healing, 

176 

Irrigation 

of acute wounds, 60–61 

of chemical injuries, 193 

of flexor sheath, 352 

Ischial pressure sores, 161, 163, 170–171 

Ivy loops procedure, for intermaxillary 

fixation, 254–256 

Jaw 

fractures of, 253, 254–256 

Joints 

crush injuries to, 331 

dislocations of. See Dislocations 

frostbite-related stiffness of, 204 

hand infection-associated 

contamination of, 342 

Keloids, 138, 139, 142 

ear piercing-related, 142–143 

secondary wound closure-related, 86 

Keratoses, seborrheic, 223 

Knife, skin-graft (Humby), 101, 102–103 

Knife blades, for incisions, 21–23 

Knife wounds, 58, 64, 268 

Kwashiorkor, 73 

marasmic, 74 

Labial artery 

hemorrhage from, lip burn-related, 201 


Index 383 

Lacerations 

of the cheek 

as ectropion cause, 158 

full-thickness, 152 

intraoral, 151–152 

crush injury-related, 332–333 

of the face, 145–159 

anesthesia for, 146–147 

initial care for, 146 

jaw fracture-related, 253 

soft-tissue loss associated with, 

158–159 

specific types of, 149–159 


unique properties of, 145 

of the forearm, 374 

Latissimus dorsi flaps, 246 

Leg, ulcers of, 177–180 

Lidocaine 

as local anesthetic, 30–31, 32 

in axillary blocks, 43 

in Bier blocks, 42–43 

in digital nerve blocks, 283 

in facial lacerations, 146 

in facial nerve blocks, 39 


in scalp lacerations, 156 

in wound cleansing, 60 

Lignocaine. See Lidocaine 

Lip 

burn injuries of, 201 

lacerations of, 149–151 

Local anesthesia, 29–44 

action mechanism of, 29 

additives to, 31–32 

direct infiltration of, 33 

dosage of, 30–31, 32, 33 

duration of action of, 32 

for facial lacerations, 146–147 

in gunshot wound treatment, 71 

injection of, 30–33 

safety precautions for, 33 

as nerve blocks, 30, 34–42 

axillary blocks, 43 

Bier blocks, 39–43 

in facial injury repair, 39–41, 147 

in hand injury repair, 34–39, 41 

with sedation, 41–42 

in wound cleansing, 60, 92 

overdose of, 33 

topical agents, 29–30 

Lymphadenectomy, in melanoma 

patients, 232 

Lymphangitis, 183, 339, 344 

Lymph nodes, enlarged 

hand injury-related, 342, 344 

skin cancer-related, 225

384 Index 

Mafenide acetate, as burn treatment, 198 

Magnesium, dietary intake of, 77 

Mallet finger, 310–312 

closed, 310–312 

distal phalangeal fracture-related, 295 

open, 312 

Malnutrition, 73–74 


as impaired wound healing cause, 58, 

73 

Mammaplasty, reduction, 245, 249 

Mandible, fractures of, 253, 254–256 

Marasmus, 73, 74 

Marcaine. See Bupivacaine 

Massage, of scar tissue, 140, 142 

Mastectomy 

breast reconstruction after. See Breast 

reconstruction 

as gynecomastia treatment, 250 

MCP. See Metacarpophalangeal joints 

Median nerve 

anatomic relationship with carpal 

tunnel, 360, 361 

anatomy of, 36 

compression of. See Carpal tunnel 

syndrome 

function testing of, 263, 270 

sensory distribution of, 259, 260 

Median nerve block, 35–37 

Melanoma 

appearance of, 222–223 


genetic factors in, 224 

physical examination of, 225 


sentinel lymph node biopsy of, 233–234 

Mental nerve blocks, 41, 147 

Mesher, 103, 104 

Metacarpal fractures, 266, 298–299 

Metacarpophalangeal joints (MCP) 

burn-related stiffness of, 323 


human bite wounds to, 341 

osteoarthritis of, 365 

Midazolam, 42 

use in burn patients, 197 

Middle phalanges, fractures of, 296–298 

extraarticular, 296–297 

intraarticular, 298 

Mole, cancerous, 221–222, 223 

Motion, of injured hand and fingers, 282 

Motor examination 

of injured hand, 270 

of normal hand, 261–262 

Motor nerves, of hand, injuries to, 317, 

331 

Mouth, lacerations of, 151–152 

Mucosa, oral, lacerations of, 150–152 

Mycobacterium marinum infections, of the 

hand, 343, 344 

Myoglobinuria, 192–193, 207–208, 333 

Nail bed injuries, 287, 289–291 

Nails 

growth rate of, 289 

paronychia of, 349–350 

removal of, 290 

Nasal airway tubes, 50 

Needles 

for injections, proper use and disposal 

of, 47 

for suturing, 1–2, 6 

holder for, 5, 6 

proper use and disposal of, 47 

Needlestick injuries, 5, 47–48 

Nerve blocks, 34–41 

in attached distant flap placement, 124 

in facial injury repair, 38–41, 147 

infraorbital, 38, 40–41 

mental nerve, 41 

supraorbital, 38, 39–40, 41 

supratrochlear, 38, 40, 41 

in hand injury repair, 34–38 

digital block, 34–35, 41 

wrist block, 35–38, 41 


in surgical exploration of upperextremity 

injuries, 367 

in wound cleansing, 60 

Nerve grafts, 316–317 

Nerve injuries, 62, 313–317 

crush injuries, 330 

repair of, 315–317 

Nerves, anatomy of, 313–314 

Neurovascular bundles, digital, 355 

Neurovascular examination, of gunshot 

wound patients, 68, 69 

Nipple, reconstruction of, 248 

Nonsteroidal anti-inflammatory drugs 

(NSAIDs) 

as carpal tunnel syndrome treatment, 

362 

deleterious effect on wound healing, 

177 

Nose, lacerations of, 153 

Numbness, in the hand 

carpal tunnel syndrome-related, 361 

compartment syndrome-related, 334 

Nutrition, 73–78 

Nutritional status 

assessment of, 74–75, 176 

of pressure sore patients, 167 

required for wound healing, 76–78, 176, 

180

Nutritional support, for burn patients, 200 

Nylon sutures, 4 

Occupational therapy 

for carpal tunnel syndrome patients, 

362, 365 

for hand burn patients, 323 

for osteoarthritis patients, 365 

Operation Smile, 242 

Oral airway tubes, 50 

Orbit, fractures of, 252 

Osteoarthritis, 365–366 

Osteomyelitis, 186 

chronic, 174–175 

felon-related, 347 

open fracture-related, 206, 211–212 

Overdose, of local anesthetics, 33 

Pain control 

in burn patients, 196–197, 321 

during dressing changes, 82 

in fingertip and nail bed injury patients, 

291 

in hand burn patients, 324 

in osteoarthritis patients, 365 

during rewarming of frostbitten tissue, 

203 

in traumatic amputation patients, 304, 

305 

Palate, anatomy of, 235, 236 

Palmar arch, 264, 269–270 

Palmaris longus tendon, anatomic 

relationship with median nerve, 36 

Paraplegic patients, pressure sores in, 

162 

Parkland formula, for fluid resuscitation 

of burn patients, 195–196 

Paronychia, 349–350 

Parotid duct, in mouth laceration repair, 

151 

Pasteurella infections, of bite wounds, 187, 

343 

Pedicle 


of distant flaps, 121 

of local flaps, 113, 114, 115, 116, 117, 

118 

Perineurium, 313–314 

Phalanges. See also Distal phalanges; 

Fingers; Middle phalanges; Proximal 

phalanges 


fractures or dislocations of, 280 

Phalen’s sign, 361 

Pierre Robin syndrome, 242–243 

PIP. See Proximal interphalangeal joints 

Pneumothorax, tension, 52–53, 54 

needle thoracostomy for, 54–56 

Index 385 

Poison control centers, 193 

Polydioxanone sutures, 4 

Popliteal artery pulse, in gunshot wound 

patients, 68 

Posterior tibial artery pulse 

in arterial insufficiency patients, 178 

in gunshot wound patients, 68 

in tibial and fibular fracture patients, 

207 

Povidone iodine, 146 

Prealbumin, serum levels of 



Pressure, as hemorrhage control 

technique, 24, 317 

Pressure earrings, 142–143 

Pressure garments, 141, 142, 327–328 

Pressure sores, 161–172 

causes of, 162 

debridement of, 161, 165–166, 167 

as decubitus ulcers, 161 

definition of, 161, 180 

early treatment of, 164–166 

ischial, 170–171 

local flap coverage for, 166–172 

prevention of, 163 

risk factors for, 162–163 

sacral, 168–169 

rotation flap coverage for, 117–118 

staging system for, 164, 165–168 


trochanteric, 169–170 

Prolene sutures, 4 

Protein 

dietary requirements for, 76 

dietary sources of, 75 

serum content of 

in malnutrition, 73 

as nutritional status indicator, 74 

Protein stores, inadequate, as 

contraindication to surgery, 176 

Proximal interphalangeal joints (PIP) 


osteoarthritis of, 365, 366 

Proximal phalanges, fractures of, 

296–298 

extraarticular, 296–297 

intraarticular, 298 

Pseudoaneurysm, 186, 317–318 

Pseudomonal infections, 59, 89 

Pulley system, flexor tendon 

in flexor tenosynovitis, 350–351 

in trigger finger, 355, 356, 357–358 

Pulse. See also Popliteal artery pulse; 

Posterior tibial artery pulse; Radial 

artery pulse; Ulnar artery pulse 

in arterial injuries, 62

386 Index 

Pulse (cont.) 

as blood pressure measure, 52 

in gunshot wound patients, 68–69 

Punch biopsy procedure, 227–228 

Puncture wounds. See also Bite wounds 

cleansing of, 60 

as hand infection cause, 341, 342 

as soft-tissue infection cause, 185 

Quadriplegic patients, pressure sores in, 

162, 163 

Rabies, 59–60, 268, 341 

Radial artery 

as axial flap blood supply source, 112 

injury to, 318 

palpable radial pulse associated with, 

270 

location of, 264, 265 

Radial artery pulse, 52, 264 

in injured hand, 269–270 

location of, 38 

Radial forearm flap, 134 

Radial nerve 

function testing of, 270 


Radial nerve block, 38 

Radiation therapy 


for keloid prevention, 143 

Radiography. See also X-rays 

Panorex, for mandibular fracture 

evaluation, 252 

Random flaps 

distant, 121–129 

local, 113, 114–119 

Recommended dietary allowances (RDA) 

for minerals, 77–78 

for protein, 76 

for vitamins, 77 

Redness, of skin 

infection-related, 89 

scar-related, 141–142 

around suture line, 95–96 

Red streaking, of skin 


lymphangitis-related, 339, 344 

Regional anesthesia, intravenous (Bier 

block), 42–43, 358, 363 

Regional block, upper-extremity axillary 

block, 43 

Rehabilitation, of traumatic amputation 

patients, 305 

Replantation, of traumatically-amputated 

parts, 304–305 

Respiratory depression, sedative 

medication-related, 42 

Rewarming, of frostbitten tissue, 203 

Rheumatoid arthritis, tenosynovitis 

associated with, 353 

Rhinoplasty, in cleft lip/palate patients, 

241 

Ringer’s lactate solution, 196 

Rings, removal from injured hands, 269 

Rotational deformity, of fingers, 266, 268, 

271, 296, 297 

Rotation flaps, 168–169 

Rule of nines, for determination of burned 

body surface area, 193–194 

Sacrum, pressure sores of, 163, 168–169 

rotation flap coverage for, 117–118 

Saline, as wound cleanser, 81 

Scalp injuries 

blood loss from, 52 

full-thickness lacerations, 155–156 

local anesthesia use in, 92 

SCALP mnemonic, for layers of the scalp, 

155–156 

Scars, 137–144 

abnormal, 138 

adhesive materials-related, 17–18 

appearance of, 137 

burn-related, 324 

clinician’s care for, 140–143 

contracture of, secondary wound 

closure-related, 86 

excessive redness of, 141–142 

facial wounds-related, 93, 145 

hypertrophic, 138, 139, 142 

maturation of, 137 

patient’s care for, 140 

secondary wound closure-related, 86, 

88, 89 

strength of, 137 

suture-related, 2, 3 

tight, secondary wound closure-related, 

86, 88, 89 

unstable, 138 

secondary wound closure-related, 86 

Scissors, suture, 5, 6 

Seawater-associated bacterial infections, 

187 

Sedation, as adjunct to local anesthesia, 42 

of burn patients, 197 

Sensory examination, of injured hand, 

270 

Sentinel lymph node biopsy, 233–234 

Sharp instruments 

disposal of, 47 

safety precautions for use of, 46, 47 

Shave excision, of skin lesions, 230–231 

Shellfish-related bacterial infections, 187 

Shock, 53

Shotgun injuries, 71 

Silicone breast implants, 245 

Silicone gel sheets, application to scars, 

140–141, 142 

Silk sutures, 4 

Silver nitrate, as burn treatment, 198 

Silver sulfadiazene, as burn treatment, 82, 

198, 199, 321 

Sinuses, frontal, fractures of, 155 

Skin 

anatomy of, 97–98 

defatting of, for skin flaps, 107–108 

in fingertip injuries, 285 

functions of, 191 

ischemia-related death of, 87 

Skin cancer, 221–234 

basal cell carcinoma, 223–224 



biopsy of, 225–231 

excisional, 226, 228–230 

incisional, 226, 227–228 

pathology report of, 231–232 

punch procedure, 227–228 

shave biopsy/excision, 226, 230–231 


melanoma 

appearance of, 222–223 


genetic factors in, 224 

physical examination of, 225 


sentinel lymph node biopsy of, 

233–234 

postexcision care for, 234 

squamous cell carcinoma, 221, 223, 224 


tongue reconstruction in, 134 

treatment of, 231–232 

unstable scar-associated, 86 

Skin creases 


wound closure over, 88, 89 

Skin edges 

excision of, in gunshot wounds, 70 

hemorrhage from, 23–24, 31 

undermining of, 27 

Skin grafts, 97–109 

for acute wounds, 65 

anatomic basis for, 97–99 

contraindications to, 99–100 

for eyelid laceration coverage, 154 

for facial wound coverage, 158 

full-thickness, 106–109 

amputated skin as, 303, 304 

defatting of, 107–108 


Index 387 

Skin grafts (cont.) 

split-thickness, 100–106 

aftercare for, 106 

for burn coverage, 199, 201 

for chronic wound coverage, 181 

for compartment syndrome-related 

wound closure, 210–211 

graft harvesting technique in, 

101–103 

for hand burn coverage, 324, 326, 327 

for melanoma excision site coverage, 

232 

for open fracture coverage, 212 

placement of, 104–105 

preparation of, 103–104 

for venous ulcer coverage, 179 

wound dressing for, 105–106 

for unstable scar coverage, 143 

Skin redness 


scar-related, 141–142 

as streaking 


lymphangitis-related, 339, 344 

around suture line, 95–96 

Skin staples, 16–17, 18 

Skull, occiput, pressure sores of, 163 

Smoking 

as impaired wound healing cause, 58, 

175, 282 

in crush injury patients, 332 

in skin graft recipients, 106, 109 

in traumatic amputation patients, 304 

Soft tissue, facial laceration-related loss of, 

158–159 

Soft-tissue coverage, of hand injuries, 271 

Soft-tissue infections, 183–189 

antibiotic therapy for, 186–188 

evaluation of patients with, 184–186 

general treatment of, 186 

incision and drainage of, 188–189 

Soft-tissue tumors, as chronic open 

wound cause, 175 

Soleus flap, 216–218 

Spinal cord injury 


as hypotension cause, 52, 53 

Splinting 

of acute suppurative flexor 

tenosynovitis, 351, 352 

of burned hands, 324, 327 


337, 362 

of crush injuries, 333 

of distal interphalangeal joint fractures, 

286 

of distal phalangeal fractures, 295

388 Index 

Splinting (cont.) 

of extensor tendon injuries, 308 

of finger injuries, 268 

of flexor tendon injuries, 307–308 

of hand injuries, 275–280 

of infected hands, 344, 345 

of mallet finger, 310–311, 312 

of metacarpal fractures, 299 

of phalangeal fractures, with rotational 

deformity, 297 

post-fasciotomy, 337 

of tibial and fibular fractures, 210 

of tight scars, 141 

of tuft fractures, 295 

Splints, Stack (volar), 310, 311 

Squamous cell carcinoma, 221, 223, 224 


re-excision of, 232 

tongue reconstruction in, 134 

Stab wounds, 58, 64, 268 

Staphylococcal infections, of the hand, 

343, 344, 349 

Staples, skin, 16–17, 18 

Sterile technique, 80–81 

Steristrips, 139 

Steroid injections 


362 

as keloid treatment, 142 

as trigger finger treatment, 357–358 

Steroids, deleterious effect on wound 

healing, 177 

Stick ties, 26, 318 

Streptococcus viridans infections, human 

bite wound-related, 343 

Stress, effect on dietary protein 

requirements, 76 

Sulfamylon, as burn treatment, 198 

Sun exposure, as skin cancer risk factor, 

222, 223, 225, 234 

Sunscreen 

application to scars, 140, 141 

use by skin cancer patients, 234 

Supraorbital nerve block, 38, 39–40, 41, 147 

Supratrochlear nerve block, 38, 40, 41, 147 

Surgical techniques, basic, 21–27 

blunt dissection, 26–27 

hemorrhage management, 23–25 

incisions, 21–23 

sharp dissection, 27 

undermining skin edges, 27 

Suture line, redness and irritation of, 

95–96 

Sutures 

absorbable versus nonabsorbable, for 

primary wound closure, 93 

buried intradermal, 11–12, 139 

Sutures (cont.) 

continuous, 9, 10, 15, 16 

vs. interrupted, for facial wounds, 

148–149 

for facial wounds, 148–149, 158 

figure-of-eight, 12–13 

mattress, 10–11, 14–16, 93 

removal of, 3, 15–16, 95, 149 

in children, 3 

from facial lacerations, 149 


for scalp lacerations, 156 

simple, 93 

size of, in primary wound closure, 93 

Suturing, 1–20 

alternatives to, 16–19 

of blood vessels, 24–26 

contraindications to, 86–87 

of extensor tendon injuries, 308 

of eyebrow lacerations, 154–155 

of eyelid lacerations, 153, 154 

of facial lacerations, 147–149 

of fingertip wounds, 285 

instruments for, 5–7 

of intraoral lacerations, 151–152 

of lip lacerations, 150, 151–152 

of nail bed tissue, 290 

needles for, 1–2, 6 

holder for, 5, 6 

needlestick injury prevention during, 47 

of nerve injuries, 314, 315–317 

for primary wound closure, 93–95 

effect on scarring, 139 

suture materials for, 3–4 

techniques of, 5–15 

suture placement, 7–13 

suture removal, 3, 15–16, 95, 149 

Swelling 


excessive, as contraindication to 

primary wound closure, 87 

facial laceration-related, 149 

hand infection-related, 342, 344 


Tamponade, cardiac, 53 

Tangential excision, of burns, 199, 

200–201, 325–326 

Tar, adherence to burn wounds, 197, 321 

Tearduct injury, 154 

Tendon injuries, 63 

crush injuries, 330 



extensor tendon injuries, 308–312 

flexor tendon injuries, 307–308 

mallet finger, 310–312

Tendon injuries (cont.) 

traumatic amputation-related, 303 

Tendons, with overlying wounds, 88 

Tenosynovitis 

flexor, 344 

acute suppurative, 347, 350–353 

rheumatoid arthritis-associated, 353 

stenosing. See Trigger finger 

Tensor fascia lata flaps, 169–170 

Tetanus, risk factors for, 58, 59 

Tetanus immunization, 59 

Thenar eminence, 257 

use as flap, 287–289 

Thenar flaps, for fingertip injuries, 

287–289 

Thenar muscles, fasciotomy of, 335 

Thermal injury, 192 

Thigh, as skin graft donor site, 100 

Thoracostomy, needle, 54–56 

Thumb. See also Interphalangeal joints (IP) 

splinting of, 278, 279 

Thumb spica splint, 278–279 

Tibia and fibula, fractures of, 205–219 

case example of, 205–206 

closed fractures, 206 

comminuted, 207 

compartment syndrome associated 

with, 207–211 

distant flap coverage for, 218 

free flap coverage for, 218 

local muscle flap coverage for, 212–218 

open (compound) fractures, 206, 210, 

211–218 

Tinel’s sign, 361 

Tingling, in the hand 

carpal tunnel syndrome-related, 361 


Tobacco use. See also Smoking 

Tongue 

as airway obstruction cause, 50 

in Pierre Robin syndrome, 243 

free flap reconstruction of, 133–134 

lacerations of, 152 

Tooth alignment, in facial fracture 

patients, 252 

Topical agents 

for burns, 198 

local anesthetic, 29–30 

Tourniquets 

use with Bier blocks, 42–43 

in carpal tunnel release, 363, 364, 365 

digital, 284, 368 

in exsanguinating hemorrhage control, 

64, 317 

in fingernail removal, 290 

in hand injuries, 267 

as ischemia cause, 267, 317 

Index 389 

Tourniquets (cont.) 

pain associated with use of, 317 

in suppurative flexor tenosynovitis 

drainage, 351 

in tangential excision of burns, 327 

in trigger finger release, 358 

TRAM (transverse rectus abdominis 

muscle) flap, 246–248 

Transferrin, serum levels of 



Transverse rectus abdominis muscle 

(TRAM) flap, 246–248 

Trauma patients 


ABCs of, 49–53 

case study of, 54 

needle thoracostomy in, 54–56 

neurologic examination in, 53–54 

Trigeminal nerve branches, anatomy of, 

38, 39, 40, 41 

Trigger finger, 355–360 

Triple antibiotic ointment, 82 

Trochanter, pressure sores of, 163, 169–170 

Tuft fractures, 294–295 

Tying off, of blood vessels, 24–25 

Ulcers 

decubitus, 161 

of the leg, 177–180 

Ulnar artery 

injury to, 318–319 

ulnar nerve injury associated with, 

260 

location of, 264, 265 

Ulnar artery pulse, 264 

Ulnar gutter splint, 279–280 

Ulnar nerve 

function testing of, 263, 270 



Ulnar nerve block, 37 

Unconscious patients, hand injury 

evaluation in, 271–273 

Undermining, of skin edges, 27 

Valium. See Diazepam 

Varicose veins, 178 

Vascular examination, of injured hand, 

269–270 

Vascular injuries, hand, 317–319 


Vasoconstriction 

epinephrine-related, 31, 32, 151, 152, 

153 

nicotine-related, 175 

Vegetables, as protein source, 75

390 Index 

Venous insufficiency 

capillary refill in, 265–266 

as leg ulcer cause, 177, 178, 179, 180 

Vermilion border, in lip lacerations, 149, 

150, 151 

Vesicles, herpetic infection-associated, 

350 

Vibrio infections, 187, 343 

Visiting surgeon programs, 241–242 

Vitamin A, 76–77 

Vitamin A supplementation, for wound 

healing, 176, 177 

Vitamin C, 77 

Vitamin C supplementation 

for pressure sore prevention, 164 

for wound healing, 176 

Vitamin E, 77 

Vitamin E supplementation, for wound 

healing, 176, 177 

V-Y advancement flaps, 114, 118–119, 

170–171 

Water, sterile, as wound cleanser, 81 

Watson knife. See Knife, skin-graft 

(Humby) 

Wound care, 79–84 

dressing techniques for, 82–84 

inadequate, as chronic wound cause, 

173 

supplies for, 80–82 

Wound closure 

guidelines for, 88–89 

primary, 91–96 

aftercare in, 95 

anesthetization for, 92 

contraindications to, 91 

delayed, 96 

of facial wounds, 145 

scarring associated with, 139 

of skin lesion biopsy sites, 228, 

229–230, 232 

suturing procedure in, 93–95 

“reconstructive ladder” of, 64–65, 85 

secondary, 85–89 

contraindications to, 88 

indications for, 86–87 

scarring associated with, 139 

of skin lesion biopsy sites, 228–229, 

230, 232 

skin edge undermining in, 27, 115–116 

of traumatic amputations, 304 

Wound healing 

impairment of 

malnutrition-related, 58, 73 

medical illness-related, 58 

Wound healing (cont.) 

impairment of (cont.) 

smoking-related, 58, 106, 109, 175, 

282, 304, 332 

nutritional requirements during, 76–78, 

176, 180 

after primary would closure, 91 

after secondary wound closure, 85 

effect of suture techniques on, 4 

Wounds 

acute, 57–65 

closure of, 58, 64–65 

contaminated, 58, 59, 64 

events surrounding, 58–60 

examination of, 60–62 

formal (surgical) exploration of, 58, 

62, 63, 64 

hemorrhage control in, 57, 58, 63–64 

injury to underlying structures in, 

62–63 

patient history in, 57–58 

chronic, 173–181 

causes and treatment of, 173–177, 180 

infected, 80 

problematic wounds, 177–180 

squamous cell carcinoma 

development in, 224 

clean, definition of, 79 

dirty/contaminated 


of the hand, 268 

secondary closure of, 87 

wet-to-dry dressings for, 82–83 

infected 

after primary closure, 95–96 


wet-to-dry dressings for, 82–83 

large, split-thickness skin grafts for, 

100–106 

Wrist nerve blocks 

of median nerve, 35–37 

of radial nerve, 38 

of ulnar nerve, 37 

X-rays 

of facial fractures, 253 

of foreign bodies, 61, 64 

of gunshot wounds, 68 

of hand infections, 342 

of soft-tissue infections, 185, 186 

of traumatic amputations, 305 

Zinc, dietary intake of, 77 

Zinc supplementation 

for wound healing, 176

Practical Plastic Surgery for Nonsurgeons

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