Primary surgical treatment of a wound

 - is the first surgical op­eration, provided in aseptic conditions, with anesthesia, which contains the following stages:

• Cutting of the wound.

• Revision of the wound channel.

• Removing of the margins, walls and bottom of the wound.

• Hemostasis.

• Rehabilitation of injured organs and structures.

• Applying of stitches on the wound with leaving of drainages (according to indica­tions).

Therefore thanks to primary surgical treatment of a wound accidental infected wound becomes cut and aseptic, which provides possibility of its quick heeling by primary covering.

Cutting of the wound is necessary for total under eye control revision of zone of spreading of wound channel and character of injury.

Removing of margins, walls and bottom of the wound is held for removing of ne­crotic tissues, foreign bodies and also all wound surfaces, which was infected while injured. After providing of this stage the wound becomes cut and sterile. The following manipulations should be provided only after changing of instruments and gloves.

It is usually recommended to cut the margins, walls and bottom of the wound out by one block on around 0.5-2.0 cm. Also the localization of the wound, its depth and kind of damaged tissues should also be taken into consideration. In dirty and squashed wounds, wounds of lower extremities the cutting out should be wide enough. In wounds on the face only necrotic tissues are removed and in cut wound the cutting out of the margins is not provided at all. Livable walls and bottom of the wound are prohibited to cut out if they are presented by tissues of internal organs (brain, heart, intestine etc.).

After cutting out an accurate hemostasis is provided for prophylaxis of hematome and possible infection complications.

Recovery stage (stitching of nerves, tendons, vessels, connecting of bones etc.) should be provided during the PST, if qualification of a surgeon lets to do so. If no - it is possible to provide a repeated operation with a delayed stitching of a tendon or a nerve, provide a delayed osteosynthesis. Recovery measures in the whole volume should not be provided during the PST in wartime.

Sewing of the wound is the finishing stage of PST. There are such possible variants of finishing of this operation.

1. Layer-by-layer sewing of the wound.

It is provided in small wounds with a little zone of injury (cut, stab-wounds etc.), not much dirt, if the wound is localized on the face, neck, trunk and superior extremities and if not much time passed since the moment of injuring.

2. Sewing of the wound with leaving of drainage (drainages).

It is provided in case of risk of development of infection, but if it's small or the wound is localized on a foot or shin, or zone of damage is big, or PST is provided in 6-12 hours since the moment of injury, or patient has an accompanying pathology, that is harmful for heeling process etc.

3. The wound is not sewed

If there is a high risk of infection complications:

• late PST,

• massive dirtying of the wound with soil,

• massive damaging of tissues

• accompanying illnesses (anemia, immune deficiency, diabetes mellitus), «localization on a foot or shin,

• middle age of the patient.

Gunshot wounds and also any wounds if the aid is provided in wartime should not be sewed. Sewing of the wound closely with presence of harmful factors is a totally unwarranted risk and a clear tactic mistake of a surgeon!

b) Main kinds

The earlier since the moment of injury PST of the wound is provided; the lower is the risk of infection complications.

Depending on remoteness of the wound three kinds of PST are used: early, delayed and late.

Early PST is held in a term till 24 hours since the moment of wound formation, it includes the principal stages and usually finishes by applying of primary stitches. In massive damage of subcutaneous cellular tissue, impossibility of full stopping of capil­lary bleeding drainage is left in the wound for 24-48 hours. Later the treatment is pro­vided like in clean postoperative wound.

DelayedPST'is provided from 24 till 48 hours after injuring. In these period effects of inflammation is develop, edema and exudates appear. The difference from early PST is providing of the operation on the background of injection of antibiotics and finishing of operation leaving the wound open (not sewed) with following applying of primarily delayed stitches.

Late PST is provided after 48 hours, when the inflammation is close to the maxi­mum and the development of infection process begins. Even after PST probability of suppuration stays high. In such situation it is necessary to leave the wound open (not to sew) and provide a course of antibiotic therapy. It is possible to applying early second­ary stitches on 7* -20^th day, when the wound is totally covered with granulations and obtains relative resistance to development of infection.

c) Indications

Presence of any deep accident wound during 48-72 hours from the moment of in­jury is the indication for providing of PST.

The following kinds of wounds are not objects of PST:

- superficial wounds, scratches, abrasions,

- little wounds with divergence of margins less than on 1 cm,

- multiple little wounds without damaging of deep tissues (like small shot injury),

- stab wounds without damaging of internal organs, vessels and nerves,

- in some cases through gunshot injuries of soft tissues.

d) Contraindications

There are only two contraindications fro providing of PST of the wound:

1. Signs of development of purulent process.

2. Critical conditions of the patient (terminal condition, shock of the III stage). (2) Kinds of stitches

Prolonged existing of the wound does not promote faster functionally advantageous heeling. It is especially observed in massive injuries, when significant loss of fluid, proteins, and electrolytes takes part and there is a big risk of suppuration. Besides this filling of the wound with granulations and closing with epithelium go very slowly. That's why it's impor­tant to put the margins together as soon as possible using different kinds of stitches.

Advantages of applying of stitches:

• acceleration of heeling,

• decrease of losses through the wound surface,

• decrease of probability of repeated suppuration of the wound,

• increasing of functional and cosmetic effects,

• facilitation of treatment of the wound.

There are primary and secondary stitches, a) Primary stitches

Primary stitches are applied on the wound before the beginning of development of granulations, the wound heels by primary cover.

Usually primary stitches are applied right after finishing of the operation or PST of the wound in absence of high risk of development of purulent complications. Primary stitches should not be used in late PST, PST in wartime and PST of gunshot wound.

Removing of the stitches is provided after development of rough connective tissue commisura and epithelization in certain terms.

Primarily delayed stitches are also applied on the wound before development of granulation tissue (wound heels like primary covered). They are used in case of risk of development of infection.

Technique: the wound should not be sewed after operation (PST), inflammatory process is under control and when it goes down primarily delayed stitches are applied on l^st-5^thday.

A variety of primarily-delayed stitches are tension stitches: after the end of opera­tion stitches are applied but threads are not knotted, in such way margins of the wound are not close. Threads are knotted on l^st-5* day when the inflammation process calms down. These stitches neither differ from the usual ones in a neither way that there is nor need to do repeated anesthesia and sewing of the margins of the wound.

b) Secondary stitches

Secondary stitches are applied on granulative wounds, that heel by secondary cover. The sense of using of secondary stitches is to decrease or to remove a wound cavity. Decrease of volume of wound defect leads to decreasing of quantity of granulations, necessary for its feeling. As a result terms of heeling decrease, and content of connec­tive tissue in heeled wound is much smaller, comparatively to wounds that heeled in an opened way. It is advantaging for appearance and functional peculiarities of a scar, its size, firmness and elasticity. Putting closer the margins of the wound diminishes poten­tial entering gates for infection.

Indication for applying of secondary stitches is a granulative wound after elimina­tion of inflammatory process, without purulent leaking and purulent content, without areas of necrotic tissues. For sureness of clamed down inflammation inoculation of the wound content can be used - if there is no growth, secondary stitches can be applied.

There are early secondary stitches (they are applied on 6^ш-21^st day) and late sec­ondary stitches (plying is provided after 21^st day). The principal difference between them is in that till 3 weeks after operation in margins of the wound scar tissue is devel­oped, that prevents both from touching of the margins and process of their joining. That's why while applying early secondary stitches (before scarring) it's enough simply to sew the margins of the wound and put them together knotting the needles. While applying late secondary stitches it is necessary to cut out scarred margins of the wound in aseptic conditions ("freshen up the margins"), and after that to apply stitches and tie the needles.

For accelerating of heeling of granulative tissue besides applying of stitches, join­ing of the margins by stripes of plaster also can be used. This method doesn't as fully liquidate a wound cavity, but it can be used before absolute calming down of an inflam­mation. Joining of the margins of the wound by plaster is widely used for acceleration of heeling of purulent wounds.

Classification

Fractures of the facial skeleton are broadly clas­sified according to the most commonly observed pattern of injury. Mandibular fractures bear more resemblance to a long bone with the added complexity of carrying teeth in most instances. The mid-facial skeleton on the other hand is a complex of bones and fractures have been classified in a much more artificial fashion.

Le Fort classification

Following experimental trauma to the cadaver head and removal of the soft tissues, Le Fort dis­covered that the complex fracture patterns pro­duced in this way could be broadly subdivided into three groups (1a,b).