Treatment of Incised Wounds Involving Tendons
Journal of the American Medical Association
To the Editor:\p=m-\That the usual treatment of incised wounds involving tendons at their primary dressing is faulty is attested by the fact that a large number of fingers have to be amputated because of subsequent infection. While a large number of cases are infected from beginning, a certain percentage become infected from improper handling under unfavorable surroundings. There is abundant evidence to prove that the operating room is the place to suture tendons, and that only a limited number
... ly a limited number of cases are favorable for the immediate repair of the severed tendons. In my hospital service I have insisted that patients with these injuries be sent at once to the operating room, simply a sterile dressing being applied in the dispensary. Absolute asepsis in the handling of these clean tendon cases is the first requisite, for the delicate endothelial lining of the tendon sheaths has little or no resistance against invading organisms. If the tendon is sutured in the face of any infection, or if infection subsequently develops, there is distinctly more loss of tendon and hence greater impairment of function than in cases in which no primary repair was attempted. Although good results have been obtained in the primary suturing of tendons when done in the physician's office or the surgical dispensary, yet the fact remains that an unnecessary risk is taken, and the practice is to be condemned. Patients applying for treatment can be roughly grouped into three classes : 1. Clean cases. 2. Cases in which infection is liable to occur. Cases in which infection is already present. In all cases coming under Class 1, the physician should carefully scrub his hands and put on gloves before making any examination. The surrounding skin is painted with S per cent, tincture of iodin, the wound washed out with normal saline solution at body temperature, and a sterile dressing applied. The part is dressed on a splint and the patient taken to a hospital for the repair of the tendons. If hospital facilities are not available and the physician has to suture in his office, the same aseptic technic should be carried out as if the peritoneum was to be -opened. Cases coming under Class 2 are treated in the same manner as those in Class 1, except that no attempt at sutur¬ ing is done. Also the patient is instructed to keep the parts soaked with a mild antiseptic solution. If no infection occurs, suturing is permissible after seven days, the same rules holding good as in clean cases. If infection does occur, the wound is kept wide open and the parts soaked for fifteen minutes in every hour in a weak antiseptic solution. The various conditions arising must be cared for as they occur. These patients have their secondary operation for the repair of the tendons in about six to eight weeks after the wound has healed. For those cases in which infection is already present, the treatment will depend largely on conditions found, the prin¬ cipal point being to supply adequate drainage. Bier's hyperemia, wet dressing and rest will in the majority of cases assist in getting rid of the infection. In these cases it is well to wait about three months after the infection has subsided before doing a secondary tenorrhaphy. Clean cases referred to me at the hospital are taken at once to the operating room, the dressings removed and the hand painted (wound excepted) with 5 per cent, tincture of iodin. The wound is gently irrigated with a mild antiseptic solution for about fifteen minutes. Under nitrous oxid anes¬ thesia the tendons are sutured, fine arterial needles and 00 catgut or silk being used. To bring the torn flexor tendons into the wound, the hand is strongly flexed ; for the extensor, strongly extended. No instruments are used to grasp the tendons, and the practice of grasping the severed ends with hemostats is mentioned only to condemn it. Two or three mattress sutures and one or two interrupted ones are used on the tendons. The wound must be ab-^'utely dry before it is closed. If this is impossible, a few strands of silkworm gut are inserted to prevent blood clot. The hand is dressed on a splint ; in the case of the flexed tendons, over a rolled bandage so as to relieve tension on the tendons.