Management of soft tissue injury

The fate of a surgical wound is held in a delicate balance between the host's resistance to infection and the causal factors of infection. Considerable insight into this relationship between the host and pathogen can be gained from the results of quantitative bacteriologic measurements. Newer rapid slide techniques have been developed which provide the surgeon with this information within 20 minutes. In most soft tissue injuries, the wound bacterial count gives an accurate prediction of subsequent infection. Wounds combining greater than 10(5) bacteria per gram of tissue are destined to develop infection. When the bacterial count is below that level, the wounds will usually heal per primam without infection. This large number of bacteria required to elicit infection reflects the remarkable ability of soft tissues to resist infection. This state of high resistance to infection can be reduced by several factors which include circulatory embarrassment, tissue injury, dead space, and the presence of foreign bodies (dirt, sutures, drains, etc.). When treating soft tissue injuries, the surgeon must employ specific therapeutic modalities that allow the wound to heal per primam without infection. On the basis of experimental studies supported by clinical experience, the following treatment protocol for soft tissue injuries is recommended. Using strict aseptic technique, the wound must be first anesthetized with 1 per cent Xylocaine to permit painless sound cleansing. All wounds should be subjected to high pressure syringe irrigation to remove bacteria, foreign bodies, and blood clots. When necessary, debridement of all devitalized tissue should be performed with a stainless steel scalpel. Many wounds caused by sharp wounding agents contain no foreign bodies and few bacteria and exhibit considerable resistance to infection. In these wounds, primary closure can be initiated after irrigation without the development of infection. Wounds resulting from impact forces have a diminished resistance to infection and are susceptible to infection by low level of bacterial contamination. Immediate antibiotic treatment of patients with impact injuries subjected to meticulous debridement and cleansing will permit a safe primary closure. In wounds contacted by pus or feces, open wound management followed by delayed primary closure is usually indicated. Antimicrobial prophylaxis is also recommended for patients with such wounds. Ideal postoperative care of all traumatic wounds includes a surgical dressing and immobilization and elevation of the site of injury.