TABLE 353 Physical Examination

Wound characteristics are important to note. Large wounds, both in length and width (gaping), are at increased risk of infection. Likewise, wounds with flaps, stellate shape, complex arrangement, avulsed tissue, jagged edges, or deep penetration are at increased risk of infection.

The skin has static and dynamic forces that normally create tension within the tissue and vary depending on anatomic site. Lacerations heal with the best results when the long axis of a laceration is in the direction of the maximal skin tension. When static skin tension is perpendicular to the wound edges, tissue retracts and the wound edges gap. Although Langer more than a century ago published his text on the orientation of these forces on the human body, it is now realized that the majority of his findings were incorrect and have almost no application in the care of acute traumatic wounds. The degree of skin tension depends more on the length and configuration of the wound: there is less tension on a jagged wound compared with a straight wound because of the increased length of the laceration in a jagged wound. Therefore, the meticulous repair of a jagged wound, rather than converting it into a straight wound, results in a more cosmetically satisfactory outcome.

Neurologic function should be assessed by evaluating distal sensory and motor function. Absent distal pulses and capillary refill indicate a vascular injury, but their presence does not exclude one. Tendon function should be performed for each one in isolation, where possible. The underlying and adjacent structures should be carefully inspected. The wound should be inspected to its full extent and depth for visible contamination and foreign bodies.

Although most traumatic wounds can be treated by an emergency physician, a prudent physician knows when to call for a consultant (Iab!e35-4).

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