Case Presentations

Case 1: Complicated Wrist Injury

History:  This patient was in a car accident several days before we saw him.  He was initially treated in a rural clinic, where his open wounds were washed and loosely sutured closed.  He was then referred to our hospital for further treatment.

Pertinent physical exam:  On exam, the suture lines are clean, and the area shows no signs of infection.  He was unable to flex any of his fingers or thumb, and the palmar surface of his hand from thumb to ring finger was numb. 

Treatment options/What was done:  These findings indicate an injury of the median nerve and laceration to most of the tendons to his hand- this requires operative intervention to prevent lifelong disability from this now almost totally useless hand.  A hand surgeon operated on this patient.  The median nerve was repaired and the profundus tendons to all fingers and thumb were repaired.  This photo shows the more natural resting posture of his hand postoperatively (note that in the original photo the fingers and thumb are all extended, and in this postoperative photo, the fingers and thumb are flexed).  His hand was kept splinted for six weeks and then therapy was started to improve hand function.

Corresponding chapters for further information.  6,26,27,32,33

Case 2: Complicated Lip Laceration

History: This patient came into the ER with this terrible looking lip laceration.

Before addressing the injury first, be sure there are no other more life threatening injuries.  Ask the patient about what caused the injury to get an idea if you need to be concerned about something more serious.  For example, if this injury was due to a road traffic injury and the patient has neck pain or lost consciousness at the time of injury- be sure to rule out any head or neck injuries. 

Next, check the patient’s tetanus toxoid status- and if needed, give the tetanus toxoid immunization.

Physical exam: At first inspection, it looks as if there has been loss of lip tissue- but you can’t be sure until you thoroughly clean the wound and then reexamine it.  Inject local anesthesia, for example 1% lidocaine (lignocaine) with epinephrine into the tissues around the wound and then cleanse the wound with lots of saline.  Finally, wipe the wound with betadine (providine iodine or other cleansing solution). There was actually no tissue loss, just a large blood clot present at the lip surface which was removed with the cleansing.  The wound is gaping because the lip muscle has contracted and this makes the wound look larger and wider than it really is.

Treatment options/What was done: This is a full thickness lip laceration which means that the lip skin, muscle, and mucosa have all been cut.  Each layer must be repaired separately. 

In addition, the lip has important landmarks that must be lined up as well as possible, to get the best result.  The lip landmarks of importance are:

1. the vermilion border:  where the red part of the lip meets the skin.  It’s important to line this up as best as possible or there is a noticeable ‘notch’.
2. wet-dry mucosal surface:  look at your own lip.  You will notice that there is an area were the shiny mucosal surface (the “wet” mucosa) changes to a “dry” surface.  This area needs to be lined up or again, there is a noticeable irregularity to the lip.

Suturing:  start by sewing the muscle back together to close the gap in the wound.  Use a long lasting absorbable suture (for example, vicryl, polydioxanone, or polyglycolic acid) and place 2-3 sutures or 1-2 figure-of-eight sutures.  Leave one of the suture tails long, so an assistant can pull on this suture (gently) to retract the lip to make repair of the undersurface easier.

Next, repair the mucosa surface, starting with inner “wet” surface.  Use an absorbable, relatively short-lasting suture (for example, chromic catgut).  Place a few simple interrupted sutures.
Gradually work your way to the outer surface of the lip- being sure to line up the previously noted borders. 

When you get to the vermilion border and come to the lip skin, change to a small nonabsorbable suture material such as nylon or prolene.  Nonabsorbable sutures are preferable for this area as they leave a less noticeable scar, but if the patient can not return for suture removal (in ~5 days), continue using the shorter lasting absorbable material.

Apply topical antibiotic ointment to the area.  Cleanse daily with gentle soap and water.  The patient should also rinse his mouth with salt water after meals to keep the area clean.  In addition, the patient should not open his mouth widely for a few weeks to keep tension off of the repair.

Corresponding chapters for further information. 3, 5, 6, 16