Wound evaluation and tx Flashcards
4 important categories of wound evaluation
▪ Bone
– Has it gone deep enough to expose underlying bone?
– Is there potential damage to the bone?
– Is there a potential fracture to the bone?
– Has the periosteum been damaged?
– Potential complications with sequestrum formation?
▪Soft tissue
▪ Synovial
– Are synovial structures involved?
– Potential infection to any of the synovial structures?
– These need to be managed differently in the immediate assessment and most often are referred for further evaluation and lavage
▪Others (foreign body)
First 3 stages of wound evaluation
- Sterile prep /really good cleaning
- Digital palpation
– what can we feel under the skin edges?
– where do the skin edges extend to? what direction?
— can you feel tendons/ligaments underneath?
– can you stick your finger into the joint underneath? - Probe wound digitally or by (sterile) probe
– Sterile radiodense (metal) probes or sterile swabs can be used
- useful to extend all around the border of the wound
Remember that the position of the limb at the time of injury may mean that deeper pathology is not at the site of skin penetration
– e.g. if the knees (carpus) is bent during injury it’s likely the injury site is a lot more proximal
Clinical Examination: Palpation
▪Weight bearing & non weight bearing
▪Range of motion?
▪Pain on flexion?
Site / Extent / Severity
▪ Heat
▪ Pain
▪ Swelling
▪ Crepitus
▪ Effusion
Factors to consider for limb wound evaluation
▪ Location
▪Size
▪ Depth
▪ Direction
▪Degree of contamination
▪Damage to regional blood/ nerve supply
First opinion diagnostic modalities
- radiography
- US
Radiography
- can radiograph with probes in situ
– can see exactly where it goes, how close to joints etc - look for evidence of bony trauma
- marker on lateral aspect
- do complete series of radiographs
Ultrasound
- soft tissue focus
- quite sensitive to picking up bony fragment (artefact underneath as can’t travel through bone
- can be used to aid removal of foreign material
– minimises trauma when removing
Synovial sepsis/contamination exclusion
Pressure test
▪Sterile prep of the joint
▪Insert needle in joint
▪Try and aspirate fluid for macroscopic analysis
▪Inject sterile saline in the joint until it’s fully distended
▪You need to distend the balloon fully to see a leak
- Trying to distend the synovial structure and build up a degree of pressure
- if you can the synovial structure is intact, therefore not communicating with the wound
– go from the other side of the wound to prevent accidental contamination
Factors to consider for decision making
▪Financial constraints
▪ Insured?
▪Horse’s purpose
▪Horse’s age
What is the best decision if synovial contamination is identified?
- referral
Steps for wound tx
- Desensitisation
- Debridement
- Wound repair
Desensitisation
- LA
Debridement goal
- Remove devitalised tissues, foreign material and bacteria
Debridement - options
- Sharp dissection
- Osmotic dressings
- Lavage
Sharp dissection for debridement
- most commonly used
- sharp scalpel blade and forceps
