Resident Manual of Trauma to the Face, Head and Neck

VII. Special Circumstances A. Abrasions y y Ensure that wounds are thoroughly cleansed and debrided. y y Remove foreign material, especially dark particulate matter, while wounds are open if possible, as it will lead to dermal tattooing. y y Keep wounds moist with antibiotic ointments, and later petroleum jelly, to promote epithelial migration and healing. B. Avulsion Injuries Avulsion injuries typically involve soft tissue appendages that are focally anchored to the craniofacial skeleton. Tissue viability must be assessed based on the mechanism of injury (i.e., blunt versus shearing or laceration), ischemic time since injury, and method of preservation and transport of the tissue. See the auricle discussion under section V.C, above. C. Facial Nerve Injuries y y Physical examination must assess facial nerve status at the time of presentation. y y For blunt injuries that present with facial nerve paresis or paralysis, see Chapter 6 for management of temporal bone trauma. y y For penetrating soft tissue injuries with nerve paresis, close observa- tion and the use of diagnostic testing, such as nerve excitability and conduction tests, are warranted. y y For penetrating injuries with facial nerve paralysis in the distribution of the soft tissue trauma, nerve exploration is required. y y Within 72 hours of injury, a nerve stimulator may assist in identifica- tion of the distal segment prior to Wallerian degeneration. y y Anastomosis of the proximal and distal segments is performed with tension-free, epineurial repair using microscopic assistance. y y If the segments are identified, but intervening tissue is lost, an interposition nerve graft will be needed. Great auricular and sural nerves are the donors of choice. D. Bite Injuries All bites should be considered contaminated wounds. Teeth from the animal or human attacker are always a potential foreign body in any bite wound. Bite injuries typically only involve soft tissue. However, the force imparted in the bite may lead to bony trauma as well. For small punctate penetrating wounds, it is preferable to excise the puncture tract with a 2-, 3-, or 4-mm dermatologic punch, thereby removing damaged and contaminated tissue. This clean, cylindrical

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