Advanced Derm Procedures (Kief) - SRS

Question 1

What structures should a wound be evaluated for prior to treating a wound?

Answer 1

• Nerves
• tendons
• vessels
• joints
• bones
• foreign bodies
• body cavity penetration

Question 2

See sensory abnormality distal to wound = ?

Answer 2

High suspisioun of laceration near course of major nerve

Question 3

How should you examine for nervous abnormalitis related to wounds?

Answer 3

Light touch

Motor function

2 point discrimination

(compare bilaterally)

Question 4

A complete tendon laceration causes what kind of deformity?

Answer 4

Resting deformity - eg achilles tendon laceration = foot drop

d/t unopposed muscle groups

Question 5

How should tendon injuries be evaluated?

Answer 5

through the full range of motion - tendon may have retracted and not be visible when in resting position.

Question 6

Vasular injury is suggested by „signs of ischemia, such as pallor, decreased pulses, or perhaps delayed capillary refill distal to the laceration (all compared with the uninjured side). Or when a laceration traverses the territory of a major artery and is deep or complex or results from penetrating trauma.

What are some other signs of vascular injury?

Answer 6

a rapidly expanding or pulsatile mass or a bruit

Question 7

When should a bone injury be suspected?

How would you rule out?

Answer 7

• based on nature of MOI„
• Should be suspected particularly after penetrating trauma or when injury occurs over a bony prominence
• plain x-rays are taken to rule out fracture.

Question 8

Foreign bodies are „Sometimes present in wounds, depending on the mechanism. Wounds involving glass are likely to have foreign bodies, lacerations from sharp metal rarely do. What suggests a foreing body might be present?

What is critical in evaluating this?

Answer 8

„Localized pain or tenderness in a high-risk wound also is suggestive, particularly if pain worsens with active or passive motion.

Also, if patient thinks something is in there.

Important to retract the wound a visualize full depth

Question 9

„Wound examination and exploration are not sensitive for small foreign bodies unless the wound is superficial and its full depth is visible. What should be done for inorganic and organic foreign bodies?

Answer 9

Imaging studies,

„If glass or inorganic material (eg, stones, metal fragments) is involved, plain x-rays are taken; glass bits as small as 1 mm are usually visible.

„Organic materials (eg, wood splinters, plastic) are rarely detected with plain x-rays (although the outline of larger objects may be visible because of their displacement of normal tissue); various other modalities have been used, including xerography, ultrasonography, CT, and MRI.

Question 10

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. What are 5 circumstances are associated with an unacceptably high risk of infection? (contraindications to primary wound closure)

Answer 10

1. „An acute wound > 6 hours old (with the exception of facial wounds)
2. „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
3. „Active oozing of blood
4. „Dead space under the skin closure
5. „Too much tension on the wound

Question 11

„Delayed primary closure is a compromise between primary repair and allowing an acute wound to heal secondarily. It may be considered for a wound over 6 hours old even though primary closure is preferable such as a large wound or a wound near a skin crease

In delayed primary closure, what is the approach to this?

Answer 11

„you initially treat the wound with wet-to-dry dressing changes for a few (2–3) days with the hope of being able to suture the wound closed within 3–4 days.

Question 12

„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.

When can you make the call to close the wound?

Answer 12

If the wound shows no signs of infection and can be closed without tension,

Question 13

Under what circumstances should you seek surgical consult for laceration repair? 7

Answer 13

1. „Deep wounds of the hand or foot
2. „Full-thickness lacerations of the eyelid, lip, or ear
3. „Lacerations involving nerves, arteries, bones, or joints
4. „Penetrating wounds of unknown depth
5. „Severe crush injuries
6. „Severely contaminated wounds requiring placement of a drain
7. „Wounds leading to a strong concern about cosmetic outcome

Question 14

What should be used to irrigate a wound?

What should specifically not be used?

What should you not forget to do?

Answer 14

USE

• saline
• tap water

Do not use

• providone/iodine
• detergents
• hydrogen peroxide

Do not forget

• To anesthatize the wound

Question 15

Generally what agents are good for anethetizing wounds?

Answer 15

Injectable lidocaine or bupivacane

Question 16

For wounds of the face or scalp, the addition of what decreases bleeding by suture placement?

Answer 16

Epinephrine

Question 17

How long does the effect of lidoicaine last?

Bupivacaine?

Answer 17

Lidocaine - 1 hr

bupivavaine - 2-4 hours

Question 18

In what situations is epinephrine CI?

Answer 18

digits

nose

penis

earlobes

Children: use with caution

Question 19

„Inject the anesthetic with as small a needle as possible.

„A 25 gauge needle is acceptable, but use the smallest needle that you have.

„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.

„Inject enough anesthetic to make the tissues swell just a little.

What is better than loval anesthetic?

Answer 19

NErve block is better if possible.

Question 20

What should you try to adhere to when closing, or excising stuff?

Answer 20

Wounds location in relation to Langer’s lines.

Question 21

What is silk suture material used for?

Answer 21

Larger surgical wounds

Question 22

Nylon (Dermalon, Ethilon) – Nylon was the first synthetic suture introduced; it is popular due to its high tensile strength, excellent elastic properties, minimal tissue reactivity, and low cost. Its main disadvantage is?

Answer 22

prominent memory that requires an increased number of knot throws (3 to 4) to hold a suture in place

Question 23

Polypropylene (Surgilene, Prolene) – Polypropylene is a plastic, synthetic suture that has low tissue reactivity and high tensile strength similar to nylon. It is slippery and requires extra throws to secure the knot (4 to 5). What is a rather unique characteristic of this material?

Answer 23

Prolene is especially noted for its plasticity, allowing the suture to stretch to accommodate wound swelling. When wound swelling recedes, the suture will remain loose

Question 24

Catgut — Catgut is a natural product derived from sheep or cattle intima. Plain catgut retains significant tensile strength for only five to seven days. Chromic gut is treated with chromium salts to resist body enzymes, thus delaying absorption time. How long does it retain tensile strength?

Answer 24

10 to 14 days

Question 25

What is the main use of chromic gut?

Answer 25

to close lacerations in the oral mucosa. Chromic gut is more rapidly absorbed in the oral cavity than most synthetic sutures, making it ideal for this environment.

Question 26

When is chromic gut less useful?

Answer 26

„less optimal for use in dermal (subcutaneous) and muscle layer closures because of increased tissue reactivity.

Question 27

What absorbable material is useful for epidermal suturing?

Answer 27

Fast-absorbing gut

Question 28

What type of suture is described here?

„ Introduced in 1974, is a lubricated, braided synthetic material with excellent handling and smooth tie-down properties. It retains significant tensile strength for three to four weeks. Complete absorption occurs in 60 to 90 days. It has decreased tissue reactivity compared with catgut as well as improved tensile strength and knot strength. is an ideal choice for subcutaneous sutures.

Answer 28

Polyglactin 910 (Vicryl)

Question 29

What type of suture material is described here?

is a monofilament suture that has superior pliability for easier handling and tying of knots. Its monofilament quality gives it a theoretical advantage over braided sutures for contaminated wounds requiring deep sutures. This suture is often used by plastic surgeons at our institution for facial lacerations closed with subcuticular running sutures. All of its tensile strength is lost by 21 days postimplantation

Answer 29

Poliglecaprone 25 (Monocryl)

Question 30

Type of suture material described here?

It is a braided polymer, is less reactive than gut sutures, and has excellent knot security. It maintains at least 50 percent of its tensile strength for 25 days [13]. The main drawback is a high friction coefficient causing “binding and snagging” when wet. Newer forms of this suture have been developed, Dexon Plus and Dexon II, which have an added synthetic coating to improve handling properties while maintaining knot security

Answer 30

Polglycolic acid (Dexon)

Question 31

The interrupted technique is easy to learn and do and allows for removal of only some of the sutures in cases of infection.

What is this best for?

What is another benefit of this?

Answer 31

Wounds that are jagged or irregular.

•If a suture breaks, the remaining sutures remain in place.

Question 32

The Continuous Technique, also called a baseball stitch closes the wound quickly.

What are some benefits of this?

What is a down side?

Answer 32

• Generally gives a better cosmetic result since tension is spread uniformly along the wound edges
• If the suture breaks the entire wound opens

Question 33

What suture technique is good for low-tension, cosmetically important wounds

Answer 33

Subcuticular running suture

Question 34

What can be done to make the continuous technique work better?

Answer 34

Have an assistant to perform the following technique to maintain tension

Question 35

What suture technique should be used for everting the wound edges in anatomic locations which tend to invert?

Answer 35

Vertical mattress suture

Question 36

What is a good suture material to use for subcuticular running sutures?

Answer 36

Vicryl

Question 37

What suture type is best for high tension wounds or wounds in fragile skin?

Answer 37

Horizontal mattress technique

Question 38

What size needle should be used for a vertical mattress suture?

Answer 38

A big, curved one.

Question 39

„Although most wounds require only skin closure, sometimes it is necessary to close the wound in layers.

„The layers may involve?

Answer 39

Muscle

Fascia

Dermis

Question 40

If the wound is widely separated or the closure will be under some tension, what should be used here?

Answer 40

A few buried dermal sutures are useful - placed just below epidermis and made of absorbable material.

Question 41

Suturing is the preferred technique for skin laceration repair however an alternative exists, what is it?

Answer 41

tissue adhesives such as 2-octylcyanoacrylate (Dermabond), are comparable with sutures in cosmetic results, dehiscence rates, and infection risk

Question 42

What type of wounds are adhesives not good for?

Answer 42

„Tissue adhesives’ low tensile strength makes them inappropriate for high-tension areas, such as over joints, unless the area is immobilized.

Question 43

In what patients are tissue adhesives CI?

Answer 43

„Immunosuppressed patients

„Diabetics

Question 44

What wounds should not get tissue adhesive treatment?

Answer 44

„Contaminated

„Complex

„Jagged

„They should also be avoided on mucosal surfaces and areas that maintain moisture, such as the groin or axillae.

Question 45

What are the two incisional biopsies?

Answer 45

„Shave biopsy—The superficial portion of the suspect area is removed.

„Punch biopsy—A small cylinder of tissue is removed using a punch tool.

Question 46

What happens in an excisional biopsy?

Answer 46

The entire area of abnormal tissue is removed.

Question 47

What are the three phases of wound repair after acute injury?

Answer 47

Inflammation

Proliferation

MAturation

Question 48

„Wound location Timing of removal (days)

Face

Scalp

Arms

Trunk

Legs

Hands or feet

Palms or soles

Answer 48

„Wound location Timing of removal (days)

Face Three to five

Scalp Seven to 10

Arms Seven to 10

Trunk 10 to 14

Legs 10 to 14

Hands or feet 10 to 14

Palms or soles 14 to 21

Question 49

„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). What should be done to help maintain the wound closure?

Answer 49

„Steri Strips (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.