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Primary Surgery Vol.2 – Trauma |  |
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Primary Surgery Vol.2 – Trauma | |
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Immediate primary suture is usually advised for joint wounds, but in knee wounds in particular, it can be disastrous. Although it is unwise to leave a joint widely open, it is equally unwise to close it tightly. An effective compromise is to do a thorough wound toilet, as for any other wound, and to close it immediately, leaving a corner of the joint open to improve drainage and the chance of healing. Some joints will be destroyed and need an arthrodesis, but this will happen anyway. Don’t let the presence of an opening into a joint influence your decision as to whether to close the rest of a wound immediately, or by delayed primary suture.
Antibiotics have the same rather uncertain role that they do in other contaminated wounds (54.1).
Excise the edges of all layers of the patient’s wound, remove dirt and wash out the joint cavity forcibly with saline from a syringe. If necessary, open his wound wider by the standard incision for the joint (7.17), and feel around inside it. You may feel a piece of the patient’s trousers inside his knee! Even if his injury is a recent one, don’t sew up the joint capsule completely. Instead, leave the joint and the wound at least partly open, so that pus can discharge. Don’t insert a rubber drain. If the bones in a joint wound are dislocated and the wound is open, reduce it urgently. Every hour’s delay makes the loss of the joint more certain. Leave the skin wound partly open and pack it with gauze. If a patient’s wound is already badly infected, it maybe helpful to leave a plastic tube with side holes cut in it to irrigate it. Don’t try to immobilize a wounded joint, or it may never move again. Instead, encourage early gentle movements. Make these more and more vigorous as the joint heals. Close the wound as soon as the danger of infection has passed usually after about 3 days. The superficial tissues may need a skin graft. If the knee is involved, apply skin or skeletal traction (78.4) to take tension away from it. CAUTION! Don’t forget tetanus toxoid.
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Primary Surgery Vol.2 – Trauma | |
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