What is skin injury?
Skin injuries are very common especially in the hand as it is so exposed and so widely used in day to day activities. Skin injuries may be simple puncture wounds such as from a needle or in the garden, they may be small or large cuts, grazes and worst of all crush injuries where a large area of skin may even die exposing the tissues below. Fortunately the hand heals very well so most skin injuries do not cause problems.
What do they look like?
Injuries are usually obvious as there is pain and bleeding. With crush injuries there may be little or no bleeding but usually a lot of local swelling and often colour changes (discolouration) in the skin.
What treatment is needed?
Most skin injuries are treated by the patient or their family at home with cleaning and a simple dressing. Generally that is all that is needed. In the Hand even cuts of 2cm (nearly an inch) heal as well if left open or sewn up so most small cuts do not need to be seen by a doctor.
For larger cuts, dirty wounds or where there has been some loss of skin such as a large graze the wound should e assessed by a nurse or doctor. The most important treatment is cleaning which is best performed with the area numbed. That is usually easily achieved in the wrist or hand in an adult. Children especially < 12yo usually need a general anaesthetic for anything but the simplest of cleaning. Very contaminated wounds and complex injuries with other deeper injuries such as to bones or other soft tissues like ligaments or nerves usually need to be explored and cleaned in the surgical operating theatres. Some deep injuries can be repaired under local anaesthetic particularly in the fingers but many patients will need a general anaesthetic.
If the wound is reasonably small and is clean or can be well cleaned then it will usually be sewn up. Mostly this is with non-absorbable stitches (sutures) which need to be removed after about 10 – 14 days, but we are starting to use absorbable (dissolving) stitches more often so they do not need to be removed.
If there has been a large area of skin loss this needs to be replaced to seal in the deep tissues. If left the area of skin loss may heal but very slowly and with a lot of scarring causing stiffness. The skin loss is often replaced with skin grafts i.e. skin moved from elsewhere on the body (usually the same arm) and stitched in to cover the area of skin loss. The new skin heals from the local blood supply. For certain specific areas in the hand, skin and some deeper tissues may be moved from the neighbouring areas such as the next finger or from somewhere on the same finger. These are called flaps typically of skin and sometimes other tissues.
What happens in the next few weeks?
The care of the hand in the post-injury/post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation.
Comfort and elevation: These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine) if the hand/wrist/elbow has been operated upon. The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.
Dressings: The bandage can be removed after 2-7 days as directed by the treating team. The patient or GP practice nurse can do this. If well healed at that stage then the wound can be left open (exposed). If in doubt it can be covered with a light dressing for a few more days. The patient may be reviewed in clinic between 2-4 weeks following the injury if there are concerns about wound healing.
Movement: Most of the movement gained following surgery occurs in the first 6 weeks and this time must be used productively to ensure a good result. The key is regular long gentle stretches both into straightening and into bending. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people manage to stretch 5-6 times a day. Elevation and icing the elbow also help reduce swelling and thus pain and improve movement.
Wound massage: The wound(s) should be massaged by the patient 5-6 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces the scar sensitivity which can be a nuisance. If this is marked hand therapy may be organised to help reduce the scar tenderness but this is rarely required. Patients should avoid pressing heavily on the scar for 3 months following the operation as this will be quite painful. Examples of activities to avoid are using the palm to grip/twist a heavy or tight object or use the palm to help get out of a chair.
Return to daily activities: The hand can be used for normal activity after the first few days. Most patients can drive after a days. Most patients return to work immediately or in days in but this varies with occupation; return heavy manual work may take up to 2-4 weeks. It is rather variable depending upon the wound and treatment. The treating team should advise about this.
What are the results of treatment?
Most patients heal without problems although cuts on the ends of the fingers/thumb can be quite sensitive and tender. This can usually be resolved with desensitisation exercises (wound massages – see above). This needs to be started as soon as possible after wound healing as the more established it becomes the longer it takes and the more difficult it is to resolve.
The scar usually improves for a good 2 years from injury and most scars in the hand are of only mild cosmetic concern.
Are there any risks from surgery?
All interventions in medicine have risks. In general the larger the operation the greater the risks. With injuries the outcome is mainly due to the severity of the initial injury. For skin grafting or flaps the risks include:
· The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
· Aching at the site may last for several months
· Grip strength can also take some months to return to normal.
· Stiffness may occur in particular in the fingers.
· Numbness can occur around the scar but this rarely causes any functional problems.
· Wound infections occur in about 1-5% of cases. These usually quickly resolve with antibiotics.
· Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which improve very slowly.
· Any operation can have unforeseen consequences and leave a patient worse than before surgery.