The risks incident to this class of wounds are: (1) the extreme difficulty, especially when a dense fascia has been perforated, of rendering them aseptic, on account of the uncertainty as to their depth, and of the way in which the surface wound closes on the withdrawal of the instrument; (2) different forms of aneurysm may result from the puncture of a large vessel; (3) perforation of a joint, or of a serous cavity, such as the abdomen, thorax, or skull, materially adds to the danger.
Treatment.—The first indication is to purify the whole extent of the wound, and to remove any foreign body or blood-clot that may be in it. It is usually necessary to enlarge the wound, freely dividing injured fasciæ, paring away bruised tissues, and purifying the whole wound-surface. Any blood vessel that is punctured should be cut across and tied; and divided muscles, tendons, or nerves must be sutured. After hæmorrhage has been arrested, iodoform and bismuth paste is rubbed into the raw surface, and the wound closed. If there is any reason to doubt the asepticity of the wound, it is better treated by the open method, and a Bier's bandage should be applied.
Contused and Lacerated Wounds.—These may be considered together, as they so occur in practice. They are produced by crushing, biting, or tearing forms of violence—such as result from machinery accidents, firearms, or the bites of animals. In addition to the irregular wound of the integument, there is always more or less bruising of the parts beneath and around, and the subcutaneous lesions are much wider than appears on the surface.
Wounds of this variety usually gape considerably, especially when there is much laceration of the skin. It is not uncommon to have considerable portions of skin, muscle, or tendon completely torn away.
Hæmorrhage is seldom a prominent feature, as the crushing or tearing of the vessel wall leads to the obliteration of the lumen.
The special risks of these wounds are: (1) Sloughing of the bruised tissues, especially when attempts to sterilise the wound have not been successful. (2) Reactionary hæmorrhage after the initial shock has passed off. (3) Secondary hæmorrhage as a result of infective processes ensuing in the wound. (4) Loss of muscle or tendon, interfering with motion. (5) Cicatricial contraction. (6) Gangrene, which may follow occlusion of main vessels, or virulent infective processes. (7) It is not uncommon to have particles of carbon embedded in the tissues after lacerated wounds, leaving unsightly, pigmented scars. This is often seen in coal-miners, and in those injured by firearms, and is to be prevented by removing all gross dirt from the edges of the wound.
Treatment.—In severe wounds of this class implicating the extremities, the most important question that arises is whether or not the limb can be saved. In examining the limb, attention should first be directed to the state of the main blood vessels, in order to determine if the vascular supply of the part beyond the lesion is sufficient to maintain its vitality. Amputation is usually called for if there is complete absence of pulsation in the distal arteries and if the part beyond is cold. If at the same time important nerve-trunks are lacerated, so that the function of the limb would be seriously impaired, it is not worth running the risk of attempting to save it. If, in addition, there is extensive destruction of large muscular masses or of important tendons, or comminution of the bones, amputation is usually imperative. Stripping of large areas of skin is not in itself a reason for removing a limb, as much can be done by skin grafting, but when it is associated with other lesions it favours amputation. In considering these points, it must be borne in mind that the damage to the deeper tissues is always more extensive than appears on the surface, and that in many cases it is only possible to estimate the real extent of the injury by administering an anæsthetic and exploring the wound. In doubtful cases the possibility of rendering the parts aseptic will often decide the question for or against amputation. If thorough purification is accomplished, the success which attends conservative measures is often remarkable. It is permissible to run an amount of risk to save an upper extremity which would be unjustifiable in the case of a lower limb. The age and occupation of the patient must also be taken into account.
It having been decided to try and save the limb, the question is only settled for the moment; it may have to be reconsidered from day to day, or even from hour to hour, according to the progress of the case.
When it is decided to make the attempt to save the limb, the wound must be thoroughly purified. All bruised tissue in which gross dirt has become engrained should be cut away with knife or scissors. The raw surface is then cleansed with eusol, washed with sterilised salt solution followed by methylated spirit, and rubbed all over with “bipp” paste. If the purification is considered satisfactory the wound may be closed, otherwise it is left open, freely drained or packed with gauze, and the limb is immobilised by suitable splints.