16.1 Traumatic Wounds: Lacerations, Bites, Degloving & Open Fractures
Key Takeaways
- Tetanus prophylaxis depends on the wound and vaccine history: clean minor wounds need a tetanus toxoid booster only if the patient has fewer than 3 doses, an unknown history, or 10 or more years since the last dose; other wounds need a booster at 5 or more years, and tetanus immune globulin is added when the primary series is incomplete or unknown.
- High-risk bites (cat bites, hand bites, deep punctures, crush injuries, immunocompromised or asplenic patients) warrant prophylactic amoxicillin-clavulanate; typical organisms include Pasteurella in cat and dog bites, Eikenella in human bites, and Capnocytophaga in dog bites of asplenic patients.
- Gustilo-Anderson open fracture types: I (wound under 1 cm, clean), II (1 to 10 cm, moderate soft tissue injury), IIIA (adequate soft tissue coverage despite extensive injury), IIIB (periosteal stripping needing flap coverage), and IIIC (arterial injury needing repair).
- Open fractures need antibiotics as soon as possible (within about 1 hour), tetanus prophylaxis, prompt surgical debridement, stabilization, and early soft tissue coverage; the WOLLF trial found no difference in disability or deep infection between NPWT and standard dressings after debridement of severe open leg fractures.
- A puncture wound through a sneaker sole that becomes infected days to weeks later suggests Pseudomonas aeruginosa osteomyelitis or osteochondritis, which needs surgical debridement and antipseudomonal antibiotics.
16.1 Traumatic Wounds: Lacerations, Bites, Degloving & Open Fractures
Core Clinical Principle: Traumatic wounds are contaminated from the start and often involve crushed or devitalized tissue. Good outcomes depend on early cleansing and debridement, correct tetanus and antibiotic decisions, recognizing hidden injury to deeper structures, and choosing the right time and method of closure.
The CWSP outline lists trauma under Etiological Considerations. Burns and frostbite have their own section, and skin tears are also covered with dermatologic conditions; this section addresses mechanical trauma.
Initial Assessment
- Mechanism and time: Sharp versus blunt or crush, bite, high-pressure injection, gunshot, and hours since injury.
- Contamination: Soil, farm, or water exposure; foreign bodies such as glass, gravel, or wood.
- Deep structures: Test tendon, nerve, and vascular function distal to the wound before anesthesia. Obtain radiographs for suspected fractures, foreign bodies, or glass; wood may need ultrasound.
- Host factors: Diabetes, immunosuppression, asplenia, peripheral artery disease, and anticoagulants.
- Tetanus status and allergies.
Cleansing and Closure
- Irrigation: Use large volumes of potable water or saline. In the FLOW trial of open fractures, soap solution led to more reoperations than saline, and irrigation pressure (very low, low, or high) made little difference, so saline at low pressure is reasonable.
- Debridement: Remove foreign material and devitalized tissue. Abrasions ("road rash") should be scrubbed free of embedded grit early to prevent permanent traumatic tattooing.
- Primary closure: Most clean lacerations can be closed within about 12 to 24 hours of injury, and facial wounds with good blood supply often later.
- Delayed primary closure or secondary intention: For heavily contaminated wounds, many bites, crush injuries, and wounds presenting late.
- Elderly pretibial lacerations and flap wounds: Avoid tight sutures in thin skin; reposition the flap, support it with adhesive strips placed loosely or silicone dressings, and consider compression and elevation for hematoma prevention.
Tetanus Prophylaxis (ACIP)
| Vaccination History | Clean, Minor Wound | All Other Wounds (dirty, puncture, avulsion, crush, burn, frostbite) |
|---|---|---|
| Fewer than 3 doses or unknown | Tdap or Td; no tetanus immune globulin (TIG) | Tdap or Td plus TIG |
| 3 or more doses | Tdap or Td only if 10 or more years since last dose | Tdap or Td only if 5 or more years since last dose; no TIG |
People with HIV infection or severe immunodeficiency who have contaminated wounds should also receive TIG regardless of vaccination history.
Bites
| Bite | Main Risks | Key Organisms | Management Points |
|---|---|---|---|
| Dog | Crush and tearing; lower infection rate than cat bites | Pasteurella, streptococci, staphylococci, anaerobes, Capnocytophaga canimorsus (severe sepsis in asplenic or alcohol-using patients) | Irrigate and debride; many non-hand wounds can be closed; rabies assessment |
| Cat | Deep punctures that seed tendons and joints; infection in a large share of wounds | Pasteurella multocida (rapid onset within 24 hours) | Leave punctures open; prophylactic antibiotics |
| Human (including "fight bite" over the knuckles) | Joint and tendon sheath infection | Eikenella corrodens, streptococci, staphylococci, anaerobes | Surgical exploration of knuckle wounds; do not close; antibiotics |
Prophylactic antibiotics (usually amoxicillin-clavulanate for 3 to 5 days) are recommended for cat bites, hand and face bites, deep punctures, crush injuries, wounds near joints or bones, and immunocompromised or asplenic patients. Consider rabies post-exposure prophylaxis for bites from bats, raccoons, skunks, foxes, and unobserved or unvaccinated animals.
Degloving and Crush Injuries
- Open degloving: Skin and subcutaneous tissue are torn from the underlying fascia, often by rollers or wheels. The flap looks intact but may be dead because its perforating vessels are torn; debride nonviable skin and consider using it as a skin graft source. Indocyanine green angiography can help judge viability.
- Closed degloving (Morel-Lavallée lesion): A shearing injury, classically over the greater trochanter or thigh, creates a fluid-filled space between fat and fascia. It presents as a soft, fluctuant swelling that may reaccumulate; MRI or ultrasound confirms it, and treatment ranges from compression and aspiration to drainage, sclerodesis, or open debridement.
- Crush injury: Watch for compartment syndrome and rhabdomyolysis (dark urine, very high creatine kinase, hyperkalemia, acute kidney injury); provide aggressive fluids and early fasciotomy when indicated.
- High-pressure injection injuries (paint, grease): Small entry wounds hide extensive deep damage; they are surgical emergencies.
Plantar Puncture Wounds
Stepping on a nail is common. Early infections are usually staphylococcal or streptococcal, but a puncture through a rubber-soled sneaker that becomes painful and swollen days to weeks later suggests Pseudomonas aeruginosa osteomyelitis or osteochondritis of the metatarsals or calcaneus. Evaluate with imaging (MRI) and treat with surgical debridement and antipseudomonal antibiotics. Patients with diabetes and neuropathy may not notice the injury at all.
Open Fractures
| Gustilo-Anderson Type | Description |
|---|---|
| I | Wound under 1 cm, clean, minimal soft tissue injury |
| II | Wound 1 to 10 cm, moderate soft tissue injury |
| IIIA | Extensive soft tissue injury or high-energy mechanism, but bone can still be covered by local soft tissue |
| IIIB | Extensive soft tissue loss with periosteal stripping and exposed bone, needing flap coverage |
| IIIC | Any open fracture with an arterial injury that needs repair |
Management priorities:
- Antibiotics as soon as possible (ideally within 1 hour): cefazolin for types I and II, with added gram-negative coverage for type III; add anaerobic coverage for farm or heavily soiled wounds.
- Tetanus prophylaxis.
- Early surgical debridement and irrigation, with repeat debridement as needed.
- Stabilization with external or internal fixation.
- Early definitive soft tissue coverage, ideally within about 72 hours and generally within 7 days ("fix and flap"), because delays raise infection and nonunion rates.
NPWT is widely used as a temporary dressing between debridement and coverage, but the WOLLF randomized trial (2018) found no difference in disability at 12 months or in deep surgical site infection compared with standard dressings after debridement of severe open fractures of the lower limb.
Clinical Traps
Trap 1: Closing a Cat Bite Puncture
Closing a deep puncture traps Pasteurella and can lead to abscess, tenosynovitis, or septic arthritis. Irrigate, leave it open, and give prophylactic antibiotics.
Trap 2: Trusting a "Viable-Looking" Degloved Flap
A pink degloved flap can die over 48 hours because its perforators are torn. Reassess early and debride nonviable tissue.
A 45-year-old gardener has a deep, soil-contaminated puncture wound of the hand from a rusty pitchfork. He completed the primary tetanus vaccine series in childhood and received his last booster 7 years ago. Which tetanus prophylaxis is appropriate?
A 28-year-old motorcyclist has an open tibial shaft fracture with a 14-cm wound, extensive muscle damage, and periosteal stripping that leaves bone exposed after debridement. Distal pulses and Doppler signals are normal. How is this injury classified, and what does the classification imply?
A 16-year-old stepped on a nail that went through his athletic shoe 10 days ago. The initial puncture seemed to heal, but he now has worsening pain, swelling, and drainage at the plantar forefoot, and MRI shows marrow edema in the third metatarsal head. Which organism is most likely, and what treatment is needed?