Must be treated in time. Generally speaking, open wounds should be closed within 6-8 hours after injury, which can greatly reduce the incidence of postoperative infection.
Second, the way of first aid
1. When open hand injury occurs, it should be sent to the nearest hospital for treatment in time, and tetanus antitoxin should be injected routinely.
2. In the process of sending the patient to the hospital, if the bleeding is serious, the feasible method is to apply local pressure or use a belt or rubber band to stop the bleeding on the upper arm. However, if this method is used to stop bleeding, it is necessary to relax the belt or rubber band 10- 15 minutes every time, otherwise the whole limb will be necrotic.
3. If limb fracture is caused by injury, it is best to simply fix it before handling, and take materials nearby, such as wooden boards, iron bars or hard books and magazines, so as to avoid secondary damage to peripheral nerves, blood vessels, tendons and other soft tissues caused by the interrupted end during handling.
4. If there is a severed limb or finger, it is best to wrap the severed limb or finger in a plastic bag, keep it in a low-temperature insulated bucket and send it to the hospital with the patient. Do not freeze the stump or put it directly in ice water (pictured). Because the structure of the hand is very delicate and complicated, it is very important to accurately judge the injury after injury. In hand trauma, skin is often the first tissue involved, followed by muscles, tendons, nerves, blood vessels and bone joints.
1. Judgment of skin injury: Skin injury is very intuitive, but different types of skin injuries have different prognosis. Sharp instrument scratches on the skin are relatively easy to handle, while carding machine injuries or large-area skin peeling or defects are very difficult. Because the carding machine injury will cut the skin into strands, it is almost impossible to sew and mend it. However, it is often difficult to judge whether the exfoliated skin still has blood supply and whether necrosis will occur after replantation. Even if the skin is scratched by a sharp weapon, it should not be taken lightly. If it is scratched by a knife for cutting meat, the wound is very susceptible to infection, and it can't heal because the knife is contaminated with foreign protein such as pulp. The same situation will also happen to wounds bitten by people or animals.
2. Judgment of nerve injury: If there is sensory loss, disappearance and/or dyskinesia at the injured site, it is highly doubtful whether the nerve has been injured. At this time, it is not enough to go to a general hospital for debridement and suture. We must go to hand surgery to repair nerve damage as soon as possible in order to obtain the best possible curative effect.
3. Judgment of vascular injury: In open injury, bleeding is inevitable. However, if there is jet bleeding from the wound, it may hurt the artery. At this time, it is necessary to press in time to stop bleeding or put a tourniquet on its proximal end. Otherwise, the patient may go into shock or even be life-threatening because of excessive blood loss. In addition, if the distal end of the wound is pale and has no pulse, and the skin temperature is obviously reduced, it means that the blood supply in this part is extremely poor. If the blood vessels are not anastomosed and the blood circulation is rebuilt, the limbs cannot be preserved. At this time, the patient should be directly sent to a hospital with hand surgery for treatment, so as to avoid delaying treatment due to repeated transfer.
4. Judgment of muscle tendon injury: If one or several fingers have dyskinesia, but the feeling does not decrease, it may be caused by tendon or muscle injury. At this time, you should call a hand surgeon to repair it.
5. Judgment of bone and joint injury: If there is deformity or abnormal activity in the bone and joint, or there is obvious swelling and tenderness in the local area, it indicates the possibility of bone and joint injury. At this time, a film should be taken to clarify the severity of the injury. When clapping your hands, you should not only pay attention to the frontal and oblique films of the whole hand, but also pay attention to the frontal, lateral and oblique films of specific fingers or joints. In this way, it will not lead to missed diagnosis. Most general hospitals pay little attention to hand injuries, and often perform simple local anesthesia in emergency operating rooms. However, due to the poor analgesic effect of local anesthesia and small anesthesia range, it is not conducive to thorough debridement and comprehensive injury exploration, which is very likely to lead to incomplete debridement or missed diagnosis and treatment.
Generally speaking, brachial plexus block anesthesia is recommended for hand trauma, which can basically cover the whole upper limb and facilitate the use of inflatable tourniquet, which can not only reduce intraoperative bleeding, but also make the operation field cleaner and help improve the operation efficiency.
Of course, if only the fingertip is injured, finger root anesthesia can also be combined with finger root tourniquet, regardless of other flap transposition operations. At present, the most popular finger root anesthesia is intrathecal injection anesthesia of flexor tendon. The advantage of this kind of anesthesia is that it only needs one injection to achieve the anesthetic effect, and the patient's pain is small and the anesthetic effect is certain.
If you have multiple limb injuries, or plan to perform flap or tissue flap transposition surgery in other parts, or if the patient is a child and cannot cooperate with anesthesia, you can consider general anesthesia. Emergency debridement of open wounds is very important, and the quality of debridement directly determines whether the wounds can heal in the first stage and whether infection will occur after operation. During debridement, necrotic, inactivated and seriously polluted tissues should be thoroughly cleaned as far as possible, and then the wound surface should be washed repeatedly with normal saline, hydrogen peroxide and iodophor. After irrigation, secondary debridement is necessary until the wound is clean and fresh.
Previous teaching materials of hand surgery emphasized thorough debridement, that is, all contaminated tissues were removed, and some important tissues were reconstructed after thorough debridement. However, for many important tissues (such as nerves, main arteries, etc. ), once removed, the reconstruction effect may not be ideal. In addition, with the development of modern antibiotic technology, doctors can carry out limited debridement in some cases, keep some lightly polluted important tissues, or only peel off their polluted adventitia tissues, and try to preserve the function of the affected limb through pathogen culture and drug sensitivity test of locally polluted tissues, supplemented by local or systemic use of antibiotics.
The possibility of Clostridium perfringens infection should be considered for cases with serious pollution and long-term open wounds. Therefore, smear examination of wound exudate should be carried out before operation to check whether there is gram-positive crude bacteria or capsule. If Clostridium perfringens infection is suspected, the operation should be performed in a separate operating room, and the surgical wound should not be sutured in the first stage (or the wound can be sutured only after repeated smearing after debridement to confirm that there are no coarse bacilli or spores). If conditions permit, after the operation. If the wound is not particularly polluted, hand trauma advocates primary tissue repair and reconstruction. If there are defects in skin, tendons, bones and nerves, tissue transplantation should be carried out except in some special cases, because if the tissue is barely closed, it is likely to cause contracture or shortening of the tissue, which will seriously affect its function and appearance.
Of course, in the case of serious wound pollution, the first stage of tissue repair is risky. This situation can also be temporarily debrided, and tissue repair and reconstruction can be carried out in the second phase. Generally, the drainage strip is pulled out every 2 days after hand injury. If the wound is drained by intubation, the extubation time depends on the drainage volume. Generally, when the drainage volume is less than 15ml, the drainage volume can be removed within 24 hours. If the hand wound is not infected, it is not necessary to change the dressing frequently, but only once every 5-7 days. If the wound oozes a lot, you can change the dressing every 1-2 days. If the patient's blood sugar is normal and the wound is not infected, the stitches can be removed 12- 14 days after operation. For diabetic patients, the removal of stitches can be delayed.
After replantation of severed fingers (limbs), patients with vascular injury or free tissue transplantation, various factors inducing vascular contraction after operation should be reduced as much as possible to avoid surgical failure due to postoperative vascular crisis. First of all, we should try to reduce the stimulation of pain, and we can use painkillers and analgesic pumps. Secondly, we should try to avoid the stimulation of colds and cigarettes. Of course, it would be better to use appropriate antispasmodic and vasodilator drugs if possible, and you can also use baking lamps to irradiate the affected limbs.
For patients with vascular, tendon and nerve injuries, plaster fixation is usually assisted after operation. This plaster usually needs to be fixed for 3-4 weeks. When the plaster is fixed, do not remove the plaster without authorization, otherwise the sutured blood vessels, tendons or nerves will easily break again. After gypsum removal, functional exercise should be carried out under the guidance of a doctor. For patients with special requirements or patients who are allergic to gypsum, various braces can also be used for fixation.
For patients who still have certain dysfunction after functional exercise, the second operation can be considered 4-6 months after the first operation for tissue release, repair or functional reconstruction.