Skin and soft tissue injuries of the human body

Surgical topic of soft tissue injuries with in depth discussion

1. SKIN AND SOFT TISSUE INJURIES

2. ANATOMY OF THE SKIN The skin can be divided into 2 layers; the outer epidermis and inner dermis. EPIDERMIS Outer most layer and constitute 5% of the skin and is composed of 5 layers of keratinised,stratified squamous epithelium - the strata: basalis (deep), spinosum, granulosum, lucidum and corneum (superficial). Most epidermal cells are keratinocytes arranged in layers.

3. DERMIS: Dermis comprises 95% of skin It consists of sweat glands,sebaceous glands,hair follicles,blood vessels and nerve endings. The skin also contains specialised cells such as Langer-han's cells, whose role is to engulf antigens and present them to T cells.

4. SKIN ADNEXA Adnexal structures such as hair follicles, sebaceous and sweat glands span both the epidermal and dermal layers and contain some keratinocytes in their ducts.

5. FUNCTION OF THE SKIN Human skin and subcutaneous tissue have several important functions: • Barrier to the environment enveloping the body and protecting against trauma, radiation and pathogens. . Regulates temperature and water homeostasis,Organ of excretion of of urea,sodium chloride, potassium and water, as well as sulphur-containing metabolites from drugs (e.g. dimethyl sulphoxide) or food (garlic, cumin).

6. The skin has significant endocrine and metabolic functions and interactions. Skin cells contain receptors for and respond to: peptides, steroid sex hormones, thyroid hormones and neurotransmitters and they both produce (cholecalciferol) and metabolise (androgens) hormones and precursors to activate, potentiate and inactivate their functions. Sensory organ with multiple receptors for pain, pressure and movement.

7. SOFT TISSUE INJURY Soft tissues are a variety of tissues that support, connect, or surround other structures in the human body, and that are not rigid like bone A soft tissue injury is the damage that can occur at a localized area of soft tissue as the result of some sort of physical trauma or repetitive abuse

8. CLOSED SOFT TISSUE INJURY The soft tissue is damaged but the skin is not broken. It can be contusion Hematoma Crush injury If small blood vessels are damages ecchymosis will cover the area. If large blood vessels are torn, hematoma will appear

9. OPEN WOUNDS It is characterised by disruption in the skin. It is potentially more serious than closed wounds. Vulnerable to infections. Greater potential for serious blood loss.

10. CRUSH INJURY An injury to the underlying soft tissue and bones. Caused by a body part being crushed between 2 solid object. It can cause internal organ rupture.

11. CONTUSION : It is commonly described as bruise. Capillaries beneath skin ruptured by a blunt blow. Injuries to the cells and blood vessels in the dermis. Localised pain and swelling at the site. Blood accumulation in the surrounding tissue causes discolouration.

12. HEMATOMA : Force impact on arteries and veins on closed skin. It involves damage to larger blood vessels. Larger amount of tissue damage. Shock can result due to blood loss.

13. Classification - soft tissue injury GUSTILO classification : Gustilo and Anderson developed their classification on the basis of a retrospective and prospective analysis of 1,025 open fractures. They initially described three types.

14. Type I Fractures with a clean wound of less than 1 cm in size Little or no contamination Wound results from an inside-out perforation The fracture pattern is simple Type II Skin laceration is longer than 1 cm The surrounding tissues have minor or no signs of contusion No dead muscle present The fracture instability is moderate to severe.

15. Type III Extensive soft-tissue damage Frequently with compromised vascularity with or without severe wound contamination The fracture pattern is complex with marked fracture instability. Type IIIA High-energy trauma Adequate soft-tissue coverage of the fractured bone, despite extensive soft-tissue laceration or flaps

16. Туре ІІIB Extensive soft-tissue loss with periosteal stripping and bone exposure Usually associated with massive contamination Type IIIC Any open fracture associated with arterial injury requiring repair Independent of the fracture type

17. TSCHERNE Classification : Open fracture grade I The skin is lacerated by a bone fragment from the inside There is no or minimal contusion of the skin Simple fracture Result of indirect trauma Open fracture grade II Skin laceration with a circumferential skin or soft-tissue contusion and moderate contamination All open fractures resulting from direct trauma.

18. Open fracture grade III Extensive soft tissue damage Often with an additional major vessel and/ or nerve injury Every open fracture that is accompanied by ischemia and severe bone comminution belongs in this group. Open fracture grade IV These are subtotal and total amputations. Subtotal amputation Separation of all important anatomical structures, especially the major vessels, with total ischemia.

19. Management Aim of management: To reduce local tissue temperature To reduce pain To limit and reduce inflammatory exudate To reduce metabolic demands of the tissues To protect the damaged tissue from further injury To protect the newly formed fibrin bonds from disruption To promote collagen fibre growth and realignment To maintain general level of cardio-respiratory and musculoskeletal activity

20. Principles of management: Initial Management RICE Protocol Rest- Rest your injury for the first 2 To 3 days. The casualty must decease immediately from further activity until the severity of the injury can be safely assessed. Ice- ice should be applied to the injury and surrounding tissues for 10-20 minutes every 2-3 hours for upto 72 hours after injury. This will help decrease swelling, pain, bleeding and potential chronic pain in future. Compression- compression helps mobilize the joint and reduce swelling dramatically through the reduced space for the swelling to increase and spread. An elastic wrap and bandage can be used to apply firm and even pressure on the injured area. Elevation- keep the injured area elevated. This help prevent blood loss from pooling in the injured area which can result in additional swelling.

21. Pain management Medication- Analgesics Nsaids (Non steroidal anti inflammatory drugs) Eg. – Ibuprofen, Paracetamol Note- Avoid overuse as it can be detrimental to recovery and healing process

22. Using slings and splints Goals of splinting- Reduction of inflammation from trauma Control of pain External support Substitute for weak or imbalance muscle

23. Exercise Evidence supports for the use of exercise therapy in the treatment of ankle sprains and it reduces the risk of a recurring injury- Benefits of exercise Restores mobility Restores strength and proprioception Use pain as a guide to progress exercises gradually to increased levels of difficulty

24. Surgical intervention Indications for surgery Stage 3 and 4 injuries required surgical intervention to obtain wound closure. Necrosis of wound Osteomyelitis Wound causing systemic infection Persistent Non healing wound Severe tears and serious functional deficit in patients in age group of 20 to 30 years Patients in age group of 30 to 50 yrs who have acute tendon tear secondary due to a particular event. Competitive athletes may require orthopaedic surgery such as repairing the tendons or ligaments and to restore the normal strength needed. Patients with major tendon defects should receive surgical treatment and the area with defect should be rebuild surgically using grafts.

25. Types of surgical procedure Tendon repair surgery Surgical Wound closure Femoral resection DisarticulationSummary

26. Investigations

27. X-ray MRI USG

28. X-RAY TO RULE OUT FRACTURE An X-ray won't show subtle bone injuries, soft tissue injuries or inflammation. However, even if your doctor suspects a soft tissue injury like a tendon tear, an X-ray might be ordered to rule out a fracture

29. MRI It includes assessment of tendons, ligaments, muscles etc. It will help in finding the LOCATION & EXTEND of Injury In cases of hemorrhage, MRI helps to find the AGE OF HEMORRHAGE.