Page 1817 - Cote clinical veterinary advisor dogs and cats 4th

910 Shearing/Degloving Wounds

○ Wound drainage (drains, or leaving a ■ Nonadherent/low-adherent dressings surface; skin grafting or skin flaps may be
portion of the wound open for drainage) with a topical antimicrobial ointment • Failure to completely heal usually necessitates
required.
VetBooks.ir ○ Repair collateral ligament damage (screws/ ○ A protective bandage is required to • Platelet-rich plasma (PRP) has been used to
• Joint injury associated with shearing wounds
or gel to create a (partially) occlusive
wound closure with a skin graft or flap.
environment
anchor + suture material/surgical steel
wire); persistent instability may warrant
closure in open wounds that have failed to
absorptive bandages initially for better
arthrodesis. maintain a topical dressing, with thicker improve the processes of second intention
○ Perform copious lavage for open joints; retention of discharge from highly exuda- close in a timely fashion.
in the absence of infection, the joint tive wounds.
capsule can be closed if sufficient tissue is ■ Typically, bandage changes are needed Possible Complications
available. daily (1-2 times) over the first week • Infection of the soft tissues, underlying bone,
• With extensive bruising and swelling, open of open wound management, then less or exposed joint
wound management should be considered frequently over the subsequent weeks • Failure to heal
until circulation improves, evidenced by as discharge decreases. • Persistent instability of a shearing wound
resolution of these two conditions. ■ Occlusive dressings are normally involving a joint
• Open wound management varies with changed according to the manufac- • Associated fracture nonunion
severity of trauma and extent of the wound. turer’s guidelines and the judgment • Formation of a fragile scar surface that is
Common options include of the clinician (usually q 3-5 days) subject to reinjury
○ Judicious surgical debridement with resec- when applied to a healthy wound bed.
tion of nonessential tissues of questionable Any protective bandage is changed Recommended Monitoring
viability accordingly. • Bandage care and periodic wound assessment
○ Especially with extremity wounds, it is ○ Large open wounds may require closure • Serial radiographs to assess bone healing as
advisable to delay debridement of skin of with skin grafts or skin flaps if wound needed
questionable viability (daily reassessment) closure by contraction/epithelization is
due to the limited availability of loose unlikely. PROGNOSIS & OUTCOME
elastic skin to facilitate wound closure. ■ Remember that edema and the elastic
○ Important tissue structures of questionable retraction of the skin exaggerate wound • Prognosis is generally good for return to
viability should be managed conservatively size, especially during the first week of function for mild to moderate shearing
until their status becomes apparent. If wound care. With resolution of swell- injuries with appropriate wound care.
necrotic, debridement is instituted. ing, the wound is often appreciably ○ Many shearing wounds heal by second
○ Wet-to-dry dressings are a form of smaller. intention.
mechanical debridement that may be used ■ In general, wounds affecting less than • Prognosis is guarded to good for extensive
in the setting of extensive contamination/ 90 degrees of the extremity’s circumfer- shearing injuries, depending on degree and
local infection. Cotton sponges are ence may heal by second intention in severity of the injury.
moistened with saline (or dilute povidone 6-8 weeks after injury. ○ Massive trauma to the extremities may
iodine or chlorhexidine [see above]) and ○ Extensive extremity trauma with severe necessitate limb amputation.
are placed onto the wound. Residual circulatory compromise and tissue necrosis ○ The need for amputation may not be
necrotic tissue adheres to the cotton fibers usually necessitates amputation. The total immediately apparent, as in cases with
along with partial retention of the exudate. cost of limb salvage (treatment without extensive loss of tissue viability over time
Stripping the partially dry dressing off the amputation) plays a role in the decision- or development of severe osteomyelitis.
wound helps remove this debris. Consider making process with many pet owners.
using for 3-4 consecutive days to achieve PEARLS & CONSIDERATIONS
mechanical debridement. Use sedation and Chronic Treatment
analgesics, including topical lidocaine, • Bandage and dressing changes Comments
as needed to reduce the pain of dressing • Progressive loss of circulation secondary to • Most cases of soft-tissue trauma that are
removal and replacement. trauma requires serial wound debridement presented to veterinarians are relatively simple
○ Negative-pressure wound therapy is that may include digit amputation. Severe to manage.
an alternative method of managing loss of blood supply over time may necessitate • Early tissue edema and the elastic retraction
problematic open wounds after surgical limb amputation. of the traumatized skin margins exaggerate
debridement and lavage to remove necrotic • Extensive skin loss, especially involving the the size of the wound.
tissue and contaminants. lower extremities, may require closure with • Initial partial wound closure, when possible,
○ Other suitable dressing and topical agents skin grafts or skin flaps. Loss of the metacarpal reduces the magnitude of the granulation bed
include or metatarsal pads may require reconstruction and helps promote faster closure by second
Hydrogel and hydrocolloid products with digital pad transplantation. intention healing.
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(topical application or as an occlusive • Osteostixis can be used to facilitate granula- • In the face of infection, open wound
dressing) tion tissue coverage over viable exposed bone management provides optimal drainage
Occlusive dressings (most effective when surfaces. This may be useful in preparing the and facilitates daily inspection of the entire
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a healthy granulation bed is forming wound for skin graft application. wound.
and infection/tissue necrosis is absent) • Arthrodesis may be necessary to correct • Combined closure techniques can be used
Absorptive dressings, including the chronic instability of the carpal and tarsal effectively together. In some cases, wounds
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alginates (to promote healing and joints involved in extensive shearing wounds. can be supported while second intention
provide a matrix to absorb exudate, • Wound contracture secondary to excessive healing progresses. If the wound does not
especially in the early days of open scarring may warrant surgical intervention close within 8 weeks, the wound likely will
wound care) (skin graft/flap application) and physical be smaller; closure may be accomplished with
A thick layer of honey (especially rehabilitation to reestablish regional range a smaller local flap or skin graft.
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manuka honey; sterile honey dressings of motion. • In general, the goal of wound care is to
are available) or sugar; these substances • Formation of a fragile scar may result promote formation of a healthy wound bed.
are antibacterial and hydrophilic in repeated injury to the thin epithelial In open wound management, the formation
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