3- Skin and Soft Tissue Disorders

Question 1

What indicates a tetanus-prone wound?

Answer 1

> 6 hrs old

Deep (> 1cm)

Grossly contaminated

Avulsion/ puncture/ crush

Question 2

What is the most common pathogen a/w animal bites?

(oral flora of biting animal and human skin)

Answer 2

Pasteurella

Question 3

Dog bites are most common in children of what age/ where?

Answer 3

< 10 yo, head + neck

Question 4

Cat bites often result in deep wounds due to long slender teeth. Punctires below the periosteum may lead to what?

Answer 4

Osteomyelitis or septic arthritis

Question 5

What pathogens are most commonly a/w human bites? (3)

Answer 5

Eikenella Corrodens

Group A strep

Staph

Question 6

What must you check for when a pt presents with a human bite?

Answer 6

Meaure- maxillary inter-canine distance is > 2.5cm = adult bite

(child abuse)

Question 7

What is included in the mangement of bite wounds?

Answer 7

X-ray

Clean surface- povidone iodine

Clean depths- copious irrigation

Question 8

When is a surgical consult indicated for a bite wound?

Answer 8

Deep/ penetrating to bones, tendons, joints

Complex facial lacerations

Neurovascular compromise

Complex infections

Question 9

When are prophylactic abx indicated for a bite wound?

Answer 9

Deep/ require closure

IMC

Mod-severe + a/w crush injury

Venous/ lymphatic compromise

Hands, genitalis, face, close contact w/ bone/ joint

Question 10

What is the most common plantar puncture?

Answer 10

Stepping on a nail

Question 11

What imaging is indicated for a plantar puncture?

Answer 11

X-ray

Question 12

What should be done after occurence of a needle stick injury?

Answer 12

Cleanse w/ soap, water, alcohol

Determine HIV status (B + C)

Question 13

What are the indications for closure aside from decrease healing time, reduce likelihood of infection, decrease scar function, and improve cosmesis?

Answer 13

Extension into sub Q

Repair loss of structure or function

Question 14

What are the contraindications for closure of a wound?

Answer 14

Contaminated/ presence of FB

> 12 hrs old

Wounds involving: tendons, nerves, arteries

Question 15

What are complications of closure, aside from infection, scars, loss of function, and loss of cosmesis?

Answer 15

Wound dehiscence (wound reopens and has to close by secondary intention)

Tetanus

Question 16

What type of wound has involvement of GU, GI, and respiratory tracts?

Answer 16

Clean-contaminated

Question 17

What type of wound has gross spillage into the surgical wound (bile, stool)?

Answer 17

Contaminated

(typically traumatic)

Question 18

What type of wound closure is used for clean/ clean-contaminated wounds, involves closure of all layers, and results in minimal scarring?

Answer 18

Primary intention

Question 19

What type of wound closure involves closure of deep layers but allows for granulation of superficial laters, and can leave a wide scar?

Answer 19

Secondary intention

(requires frequent wound care)

Question 20

What type of wound closure involves closure of deep layers followed by closure of superficial layers 4-5 days later after infection is not a concern?

Answer 20

Delayed primary intention

Question 21

What type of sutures are absorbable?

Answer 21

Vicryl

PDS

Chromic gut

Question 22

What type of sutures are nonabsorbable?

Answer 22

Prolene

Nylon

Question 23

What type of suture method is frequently used to close skin lacerations?

Answer 23

Simple interrupted

Question 24

What type of suture method is useful for deep wounds and helps eliminate dead space?

Answer 24

Vertical mattress

Question 25

What type of suture method is useful in flaps or wounds under tension?

Answer 25

Horizontal mattress

Question 26

What type of suture method provides tighter closure if locked?

Answer 26

Continuous

Question 27

What type of suture method is often used for surgical or clean wounds and must be performed with absorbable suture?

Answer 27

Subcuticular

Question 28

What are defined as skin tension lines that indicate orientation of collagen fibers?

Answer 28

Langer's lines Lacerations @ right angles to lines tend to gape

Question 29

How long should a suture site be kept clean and dry?

Answer 29

No contact w/ water for 48 hours

Question 30

When should sutures generally be removed based on body location?

Answer 30

Face, ear = shortest (~4-5 days) Scalp, trunk, extremities (~7-14) Hand, foot, fingertips = longest (~8-14)

Question 31

When are antibiotics indicated for wound repair? (aside from bites, crush wounds, contaminated wounds, IMC)

Answer 31

\> 12 hrs old (esp on hands) Avascular areas (ex. ear) Joint spaces, tendon, bone Hx of valvular heart disease

Question 32

Does hair need to be shaved off prior to suturing?

Answer 32

No (can increase risk of infection and leave particles in wound)

Question 33

What is the most important means to decrease infection risk?

Answer 33

Irrigation

Question 34

When are suture wounds re-checked?

Answer 34

24-48 hrs + additional re-check in 48-72 hrs if highly contaminated

Question 35

Pt presents with localized pain, swlling, tenderness, erythema and warmth but absence of abscess, purulent drainage or ulceration. You suspect an acute infection that does not involve fascia or muscles. What is this called?

Answer 35

**Cellulitis** - nonnecrotizing inflammation of skin + subq tissues

Question 36

What is the most common etiology of cellulitis for immunocompetent vs IMC pts?

Answer 36

Immunocompetent- A strep, S. aureus IMC- Pseudomonas

Question 37

What signs/ sxs of cellulitis indicate deep soft-tissue infection and therefore require emergent sugical eval? (6)

Answer 37

Violaceous bullae Cutaneous hemorrhage Skin sloughing Skin anesthesia Rapid progression Gas in tissue

Question 38

Outpt care of cellulitis is indicated for mild, local sxs w/o evidence of systemic disease. What is included in care? (strep most likely pathogen)

Answer 38

Limb elevation, empiric abx x 5 days F/u 48-72 hrs

Question 39

When is inpatient management for cellulitis considered (aside from IMC and comorbidities)?

Answer 39

Facial cellulitis of odontogenic origin Orbital cellulitis Cellulitis affecting \> 1/4 of extremity

Question 40

What is 1st line abx treatment for cellulitis?

Answer 40

Beta-lactams x 10-14 days (Amoxicillin, amoxicillin- clavulante)

Question 41

How is recurrent cellulitis defined and what is the tx?

Answer 41

3-4 episodes/ yr (usually due to venous/ lymphatic obstruction) Penicillin/ Erythromycin BID x 4-52 weeks

Question 42

Hx of MRSA, break in skin, and IMC puts pts at increased risk for what?

Answer 42

Abscess

Question 43

When do abscesses require surgical referral for drainage? (5) (body locations)

Answer 43

Perirectal Neck Hand Breast (near aeola/ nipple) Adjacent to vital nerves/ blood vessels (facial nerve, carotid/ femoral artery)

Question 44

What is included in the home care for abscesses and when should the pt f/u?

Answer 44

Change packing q 24 hrs If recurrent infections- bathe w/ chlorhexidine daily F/u 24-48 hrs

Question 45

Cellulitis with abscess or recurrent abscesses may indicate a MRSA infection. What is included as part of the 5 day decolonization regimen?

Answer 45

BID nasal mupirocin Daily chlorhexidine washes Daily decontamination of personal items (towels, sheets)

Question 46

If pt with a burn wound infection develops cellulitis, what drugs should prescribed for tx?

Answer 46

IV Cefazolin/ Clindamycin/ Vancomycin

Question 47

What is defined as an infection of the deep soft tissues, and results in progressive destruction of muscle fascia/ overlying sub-q fat?

Answer 47

Necrotizing fasciitis

Question 48

What is spared in necrotizing fasciitis and what is the likely pathogen?

Answer 48

Spares muscle GAS or beta-hemolytic strep

Question 49

Pt presents with severe pain starting in the anterior abd wall and migrates to gluteal muscles, scrotum and penis. You note tense edema outside the involved skin, blisters/ bullae, crepitus, and sub-q gas. Systemic sxs include fever, tachycardia, and hypotension. What are you concerned for and what is the tx?

Answer 49

Fournier's Gangrene Aggressive surgical debridement + broad spectrum abx