Wound Management

Wound Management

• October 11, 2001• Gavin Greenfield and Bob Johnston

Objectives

• Wound Healing• Wound Evaluation – History, Physical

examination• Wound Preparation• Wound Closure• Specific Wounds

– face, scalp, eyebrow, eyelid, ear, lips, intraoral, puncture, fingertip and nail, foreign bodies, bites

Wound Healing

• “the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions for the natural reparative processes of the wound to proceed”– Richard L. Lammers (Roberts and Hedges)

Skin Anatomy

• Epidermis– keratinized squamous epithelium– avascular

• Dermis– dense, fibro-elastic tissue– highly vascular– cells of dermis mainly fibroblasts responsible for

elaboration of collagen, elastin, ground substance• Subcutaneous layer (superficial fascia)

– connects dermis to underlying tissue– contains variable amounts of adipose tissue

Case 1

• 1st year medical student comes in with laceration to hand. You evaluate the wound and feel it is appropriate for primary closure. He asks you how the wound will go about healing itself? What do you tell him to appease his curious mind?

Wound Healing

• Stages– hemostasis– inflammation– epithelialization– fibroplasia– contraction– scar maturation

Wound Healing

• Inflammation– serves to remove bacteria, foreign debris, and

devitalized tissue – a biologic debridement– if this stage is prolonged (from infection,

foreign material, etc.) will get persistent inflammation and result in poor wound healing

Wound Healing

• Epithelialization– in sutured wounds, surface of wound

develops epithelial covering impermeable to water in 24-48 hours

– eschar and surface debris impair this process by inhibiting the migration of the epithelial cells

Wound Healing

• Fibroplasia– by fourth day fibroblasts begin synthesizing

collagen, initiating scar formation– characterized clinically by pebbled red tissue

in wound base

Wound Healing

• Contraction– movement of skin edges toward center of

defect, primarily in direction of underlying muscle

– everting skin edges at time of repair accounts for the subsequent wound contraction

Wound Healing

• Scar Maturation– amount of scar tissue influenced by physical

forces acting across wound – strength of wound increases rapidly from day

5-17, more slowly for additional 14 days, and further collagen remodeling / maturation for 2 years

– strength of scar tissue never quite reaches that of unwounded skin

Case 2

• Pt presents with two wounds – one is sharp, linear laceration on L hand from a clean knife. While riding her bike to hospital she falls on a pristine, flat, clean road and lands on dorsum of hand producing a jagged irregular laceration.

• Which of the two has higher chance of infection? Why?

Case 3

• Alcoholic, diabetic street person presents with laceration to R forearm. He thinks he did it about 24 hours ago but can’t remember mechanism. On examination small amount of soil type debris in wound.

• How will you manage this case?

Wound Evaluation – HistoryAmerican College of Emergency Physicians: Clinical policy for the initial approach to patients

presenting with penetrating extremity trauma. Ann Emerg Med Vol 33 No. 5 May 1999

• identify all extrinsic and intrinsic factors that jeopardize healing and promote infection– mechanism of injury– time of injury– environment in which wound occurred

• potential contaminants, foreign bodies

– species of animal if bite– pt’s medical problems / immune status

• tetanus immunization status• handedness / vocation

Wound Evaluation - History

• Risk Factors for wound infection (Singer et al. Risk

factors for infection in patients with traumatic lacerations. Academic Emergency Medicine. July 1, 2001; 8(7): 716-20)

– older age– diabetes– laceration width– presence of foreign body

Wound Evaluation – History (mechanism of injury)

• Type of force causing wound

• Acute traumatic wounds caused by one or combination of 3 forces– shear– compressive– tensile


• Shear Forces– produced by sharp objects that cut through

the skin– amount of energy required to cut skin with

sharp object is low therefore little energy directed to surrounding tissue with minimal cell damage

– results in lower risk of infection and problems with wound healing because remaining tissue is not devitalized


• Compressive and Tensile Forces– compressive forces produced when blunt object

impacts the skin at right angles (wounds tend to be stellate or complex with ragged/shredded edges)

– tensile forces produced when a blunt object impacts skin at oblique angles (wounds tend to be triangular or produce a flap)

– compared to shear forces much more energy deposited with high amounts applied to area around wound

– results in devitalization of surrounding tissue with higher incidence of wound infection


• Shear vs. Compressive / Tensile Forces– Infection

• with compressive / tensile forces the critical number of bacteria needed to produce infection is much lower (~100,000 organisms per gram of tissue)

• with shear forces the number of bacteria needed to produce infection is much higher ~ 10,000,000 organisms per gram of tissue

Wound Evaluation – History (time of injury)

• “golden period” refers to time after injury that wound can be safely closed without increased risk of infection– delay in wound cleaning is most important variable– contrary to popular belief not a fixed number of hours– “there is little change in wound infection rates in most

areas of the body for up to 19 hours after a variety of traumatic injuries, and infection rates of simple wounds involving the head are essentially unaffected by the interval between injury and repair”

• Berk et al. Evaluation of the “golden period” for wound repair: 204 cases from a third world emergency department. Ann Emerg Med 17:496, 1988

Wound Evaluation – History (time of injury)

• accelerated growth phase of bacteria starts at 3 hours post wound

Timing of Closure

• primary, delayed primary, secondary– decision to close a laceration is multifactorial– base decision on wound history, physical

examination, host factors

• Revisit Case 3

Wound Evaluation – Physical Examination

• Examine for: – amount of tissue destruction– degree of contamination– damage to underlying structures

• Wounds may be classified into 6 categories– lacerations– abrasions– crush wounds– avulsion wounds– puncture wounds– combination wounds


• Lacerations– if caused by shear force little tissue damage

at wound edge and margins are sharp and wound appears “tidy”

– if caused by compressive or tensile forces, more force is required to produce the laceration and therefore more tissue trauma; often appear jagged, contused


• Abrasions– results from forces applied in opposite

directions (e.g. skin grinding against road surface)


• Crush Wounds– caused by impact of an object against tissue,

especially over a bony surface, which compresses the tissue

– at higher risk for subsequent compartment syndrome


• Avulsions– wounds in which a portion of tissue is

completely separated from its base and is either lost or left with a narrow base of attachment


• Puncture Wounds– wounds with a small opening and whose

depth cannot be visualized

• Combination Wounds


• Amount of tissue destruction / devitalized tissue


• Degree of Contamination– bacteria and foreign material– primary determinants of wound infection are

the amount of bacteria and dead tissue remaining in wound

– the presence of undetected reactive foreign bodies in sutured wounds almost guarantees infection


• Underlying Structures– nerves, vessels, tendons, bones, joints


• Wound Location– has considerable importance in the risk of

infection– high endogenous bacterial counts in hairy

scalp, forehead, axilla, groin, foreskin of penis, vagina, mouth, nails

– wounds in areas of high vascularity more easily resist infection (scalp, face)’

Delayed Primary Closure

• wound preparation (debridement, cleansing, etc.), dress with saline soaked fine mesh gauze, follow up in 72-96 hours for debridement, repeat cleansing and closure if no evidence of infection

Skin Preparation

• prevents transfer of bacteria into wound from instruments, suture needles, gloved fingers

• use whatever (no research suggest one better than another)

• important to distinguish between skin preparation and wound cleansing

Wound Cleansing (not skin preparation)

• Soaking– of little value and may actually increase

bacterial counts (Lammers, Fourre, Callaham et al. Effect of poviodine-iodine and

saline soaking on bacterial counts in acute, traumatic contaminated wounds. Ann Emerg Med 19: 709, 1990)


• Mechanical Scrubbing– gentle scrubbing may be useful in wounds

older than 3-4 hours (a glycoprotein matrix enters wound and may protect it from further attempts to lower bacterial counts with irrigation)

• Debridement of devitalized tissue paramount to reducing risk of infection

• Scalpel excision of wound margins can be used in grossly contaminated wounds


• Irrigation– Equipment?

• 35 cc syringe with 18 G needle produces about 7-8 psi– Solution?

• NS or 1% poviodine-iodine solution (ie. diluted Betadine) (Dire and Walsh: A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990; 19:704-708)

– infection rate in poviodine arm was lower than saline arm but not statistically significant (4.3% vs 6.9%)

• Hydrogen peroxide kills fibroblasts and occludes microvasculature, chlorhexadine toxic to tissue defenses, detergents contained in scrub solutions cause tissue damage in wounds

– How much? (all expert opinion – no clinical trials)• minimum of 100-300 cc with continued irrigation until all visible particles

removed• 50-100 cc per cm of wound length• if irrigation alone is ineffective in removing contaminants from a wound, the

wound should be lightly scrubbed

Prophylactic Antibiotics - Topical

• Ointments– reduce formation of crust which could inhibit

epithelialization– prevent dressing from adhering to wound– routine use encourages pt inspection of

wound– one randomized, double blind clinical trial

demonstrated reduced infection rate • Dire et al. Prospective evaluation of topical antibiotics for preventing

infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med 2:4, 1995

Prophylactic Antibiotics - Systemic

• no role for routine antibiotic use for most wounds (Cumming et al. Antibiotics to prevent infection of simple wounds: A

meta-analysis of randomized studies. Am J Emerg Med 13:396, 1995)

• specific wounds: contaminated with debris, feces, saliva; punctures, bites, extensive tissue destruction, wounds in avascular areas, oral lacerations, wounds involving joint spaces, tendons, or bones; presence of impaired host defenses

Wound Closure - Sutures

• Classification: nonabsorbable vs absorbable

• Size (according to diameter): 6-0 face, 5-0,4-0 trunk and extremities, 3-0 scalp, sole of foot

Wound Closure – Sutures - Nonabsorbable

• Natural or Synthetic / Monofilament or Multifilament– natural incite tissue reactivity (therefore increase risk of infection,

synthetic less so)– monofilament have less pliability and knot security than

multifilament but multifilament increase risk of wound infection

• Natural multifilament - silk– easiest to handle but poses greatest risk of infection because of

tissue reactivity (it is both a natural suture and multifilament)

• Synthetic monofilament – nylon (Ethilon), polypropylene (Prolene), polybutester (Novafil)

• Synthetic multifilament – nylon, polyester (Mersilene)

Wound Closure – Sutures - Absorbable

• Natural (collagen) or Synthetic (polymers)• Natural – plain gut and chromic gut

– plain gut loses tensile strength the quickest (half life 5-7 days); produces marked tissue reactivity; generally used only for oral mucosal closures (because heal so quickly)

– chromic gut absorbed less rapidly than plain gut but faster than synthetics (half life 10-14 days); less tissue reactivity than plain gut because of chromic coating; useful in situations where suture removal may be difficult

Wound Closure – Sutures - Absorbable

• Synthetic Multifilament – polyglycolic acid (Dexon), polyglactin 910 (Vicryl)– most commonly used in emerg for sq layers

• Synthetic Monofilament - polyglyconate (Maxon), polydioxanone (PDS II)

• Remember – presence of any suture material in a wound increases risk of infection; subcutaneous sutures have highest risk

Wound Closure - Staples

• lower tissue reactivity than even the least reactive suture material

• get less accurate closure with higher chance of malapposition of wound edges and development of scar

• generally reserved for sites where scar is less of an issue (hairy scalp)

– Kanegaye et al. Comparison of skin stapling devices and standard sutures for pediatric scalp laceration: A randomized study of cost and time benefits. J Pediatr 130:808, 1997

Wound Closure - Tapes

• useful for flat, dry, nonmobile surfaces where wounds fit together with no tension –ie superficial, straight laceration under little tension

• more resistant to infection than sutured wounds• adherence of tapes improved with use of

benzoin to skin surface• recommend not getting wet but…• should stay in place as long as equivalent suture

and will spontaneously detach as underlying epithelium exfoliates

Wound Closure – Tissue Adhesives (2-octylcyanoacrylate)

• closes wounds by forming an adhesive layer on top of intact epithelium, which holds edges together

• cause inflammatory reaction within wounds• Useful

– edges less than 5 mm apart, clean, sharp edges, clean nonmobile areas, laceration less than 5 cm in length

• Not useful– wounds near eye, on mucous membranes or mucosal surfaces,

wet wounds or those exposed to body fluids, or in areas with dense hair, wounds under significant tension


• Literature– in selected lacerations produces cosmetic

appearance that is comparable with standard suture closure

• Singer et al. Prospective, randomized, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs. standard wound closure techniques for laceration repair. Acad Emerg Med 1998; 5:94-99

• Quinn et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of laceration. JAMA 1997;277:1527-1530

• Quinn et al. Tissue adhesive versus suture wound repair at 1 year: Randomized clinical trial correlating early, 3 month, and 1 year cosmetic outcome. Ann Emerg Med 1998;32:645-649

• Maw et al. A prospective comparison of octylcyanoacrylate tissue adhesive and suture for the closure of head and neck incisions. J Otolaryngol 1997;26:26-30

– may be useful for wounds under higher skin tension• Saxena Octylcyanoacrylate tissue adhesive in the repair of pediatric extremity

lacerations. Am Surg 1999 May;65(5):470-2• in above study they looked at 32 children with high skin tension lacerations (hand, feet,

over joints). Following closure splints were applied to restrict movement


• Application– hold wound edges together with tissue

forceps (???), lightly wipe applicator tip over area starting at least 5 mm from edge of wound in direction of long axis of wound (some authors support perpendicular application), 3-4 thin layers, hold wound edges together for 60 s post application

– avoid ointments and dressings


• Tips– avoid latex gloves – use vinyl gloves– avoid plastic instruments (ie. tissue forceps)– if enters wound needs to be wet sponged

immediately– use antibiotic ointment for removal of

hardened Dermabond in wound

Specific Wounds – Face

• high vascularity therefore low incidence of infection

• debride minimally to preserve normal facial contours

• be more aggressive with layered closure

Specific Wounds - Forehead

• unrepaired muscle layers more likely to produce scars

• be liberal with deeper sutures in wounds under tension

• reapproximate skin tension lines and hairline precisely

Case 7

• 8 month old boy presents with 2 days progressive lethargy with weakness L side of body. 1 month ago was bitten on scalp by dog. What has happened and how?

Specific Wounds - Scalp

• 5 layers• can bleed +++• shaving increases risk of infection; clip hair or

use ointment to mat it down• check for disruption of galea and repair if

present (either single or layered closure)• subaponeurotic (subgaleal) loose connective

tissue contains emissary veins that communicate with intra-cranial venous sinuses– subgaleal hematomas can become infected and

infection can be transmitted intra-cranially via emissary veins

Specific Wounds - Eyebrow

• minimal if any debridement; if needed angle scalpel parallel to direction of hair shafts to minimize damage to hair follicles and resulting alopecia

• never shave eyebrows

• use edges to serve as landmarks for reapproximation

Specific Wounds - Eyelids

• Layers (out to in): skin, subcutaneous tissue, muscle (orbicularis oculi and levator palpebrae in upper eyelid), supporting tissue (forward continuation of sub-galeal aponeurotic layer of scalp), tarsal plate (dense fibroelastic plate), conjunctiva

• with any eyelid laceration ensure no penetrating globe injury

Specific Wounds - Eyelids

• When to repair– superficial; use 6-0 or 7-0 nonabsorbable synthetic,

small bites

• When to refer– lacerations involving inner surface of lid– lacerations involving lid margins (imperfect closure

results in ectropion or entropion)– lacerations involving lacrimal duct (clue is laceration

of lower lid medial to punctum)– lacerations associated with ptosis (levator injury)– lacerations extending into tarsal plate

Specific Wounds - Ears

• Anatomy– auricle (pinna) – modified horn shaped structure

composed of elastic cartilage covered by skin – converges onto the external auditory meatus (canal)

– earlobe

• with blunt forces ensure no ruptured TM• examine closely for subchondral hematoma

– absolutely have to avoid persistent hematoma– need perfect hemostasis to prevent formation of

hematoma– if present consider plastics or ENT referral

Specific Wounds - Ears

• gaping through and through lacerations require 3 layer closure– 1st – one or two sutures will approximate

cartilage edges, include anterior and posterior perichondrium in suture

– 2nd – approximate posterior skin– 3rd – anterior surface of ear using landmarks

joined point to point

• all repaired ears should be enclosed with compression dressing

Specific Wounds - Nose

• Anatomy– separated into two halves by the septum (cartilaginous structure)– tip formed by two C-shaped alar cartilages covered directly by

skin

• Exposed cartilage increases risk of infection and therefore needs to be covered

• Nasal trauma can result in septal hematoma– can lead to permanent thickening of the septum with subsequent

airway obstruction– pressure from a septal hematoma may cause necrosis and

subsequent erosion / rupture of septum– aspirate with 18G needle or horizontal incision at base; nasal

packing following drainage will prevent reaccumulation

Specific Wounds - Lips

• Anatomy– skin, vermilion border, vermilion, oral mucosa– obicularis oris

• Always inspect intraoral and mucosal lip wounds for foreign bodies – esp. teeth and teeth fragments

• Lacerations through vermilion border– use traction to the lips place first stitch at vermilion

border – need perfect alignment– then repair obicularis oris– then repair skin and remainder of lip

Specific Wounds - Lips

• Through and through lacerations– 3 layer closure – 1st – mucosal layer with

rapidly absorbable suture – 2nd – orbicularis oris – 3rd – skin

Specific Wounds – IntraoralArmstrong. Lacerations of the Mouth. Emergency Medicine Clinics of North America Vol

18, No 3 August 2000

• Irrigation as per normal• lacerations of buccal mucosa and gingiva heal

without repair of wound edges not widely separated

• Small (<2cm) intraoral lacerations need not be repaired

• Close bigger lacerations and lacerations with flaps that fall between chewing surfaces with absorbable sutures (plain gut, chromic gut or synthetic absorbables)

Specific Wounds – Finger tip and nail injuries

• Anatomy– eponychium, lunula, nail root, nail,

hyponychium, germinal matrix, nail bed (matrix)

– finger tip injuries are defined as occurring distal to the insertion of the flexor and extensor tendons at the level of the lunula

– classified as Zone I, II, III


• Tip injuries with skin and pulp tissue loss only (no exposed bone)– if less than 1 square cm can treat conservatively with

serial dressing changes alone (wound heals by secondary intention)

– if severed skin tip available can use as full thickness graft; amputated tissue is debrided, de-fatted, then sutured in place

– if greater than 1 square cm can consider using split or full thickness graft from distant site vs conservative management


• Tip injuries with exposed bone– if bony protuberance < 0.5 cm and soft tissue defect

less than 1 square cm trim back bone with rongeuer and consider leaving wound open to heal by secondary intention with serial dressing changes

– if wound dorsal obliquely angulated can treat with bone shortening followed by primary closure of wound using adjacent volar tissue

– amputations in a transverse or volar obliquely angulated often require referral for sophisticated flaps


• Nail Growth– germinal matrix produces bulk of nail plate– sterile matrix produces a layer of cells that is

added to the under surface of the growing nail– if nail bed injury results in scarring of sterile

matrix will get a poorly adherent nail with ridging – cosmetically not appealing

– takes 4 months for a new nail to reach hyponychium


• Injuries to nail and surrounding structures– nail bed injured when force directed to dorsum of nail crushing

nail bed against underlying tuft of distal phalanx

• Subungual hematoma– tradition deems that if occupies more than 50% of nail bed area,

remove nail and repair associated nail bed laceration– Two prospective studies found simple trephination produced

good results (Seaberg et al. Treatment of subungual hematomas with nail trephination: A prospective study: Am J Emerg Med 9:209, 1991. Meek et al. Subungual hematomas: is simple trephining enough? J Accid Emerg Med 15:269, 1998)

– Roberts and Hedges suggest that if nail adherent do not routinely remove nail to search for bed laceration

– remove nail and fix bed lacerations if nail partly avulsed or loose, or if there are deep lacerations that involve the nailbed

– replace avulsed nail after bed repair and suture in place

Case 4

• 16 year old healthy male playing tennis steps on a nail that punctures bottom of shoe and punctures sole of foot.

• How will you approach and manage this pt?

Specific Wounds – Puncture Wounds

Reference: Up To Date 2000

• usually due to nails• deeper the penetration, higher the

incidence of infection• wounds in area of MTP joints penetrate

deeper because this is weight bearing area

• increased risk of infection with wounds to forefoot or shoe wearing at time of puncture


• Microbiology– partly dependent on environmental location– Staph aureus, beta-hemolytic streptococci

(GAS), gram negatives– pseudomonas common with wounds through

shoes


• Evaluation– routine wound evaluation as previously

discussed– have low threshold for x-rays, especially re

presence of foreign body


• Initial Management– no prospective trials in literature– Tetanus– foreign body removal– surface scrubbing– questionable role for irrigation– probably no role for coring, probing– rest, foot elevation


• Antibiotics– no prospective, randomized trials– consider wound and host factors

Case 5

• Pt working in lumbar yard and walks by piece of wound – catches leg on it and ends up puncturing lower leg with piece of wood. He feels “something is in there”.

• Manage

Soft Tissue Foreign Bodies

• foreign bodies promote infection, prolong inflammatory phase of healing and result in poor wound healing

• infections resulting from foreign bodies are typically resistant to antibiotics

• every wound has a potential foreign body• listen to pt’s if they think “something in there”• all wounds require deliberate and careful

exploration


• Radio-opaque– metal, aluminum, bone, teeth, glass, certain plastics,

gravel, sand– obtain x-rays with underpenetrated “soft-tissue

technique”

• Radio-lucent– organic material like wood, thorns, cactus spines,

some fish bones, most plastics– sometimes indirect evidence of presence (radiolucent

filling defect when object is less dense than surrounding tissue)


• if wound caused by radio-opaque material and no foreign body found on exploration or plain films – end search; otherwise:

• CT

• Ultrasound

• MRI


• Not all need to be removed

• Indications for foreign body removal– Potential for inflammation or infection– Toxicity– Functional and cosmetic problems– Potential for later injury

Case 6

• 25 year old female piano player presents with 8 cm curvilinear laceration to dorsum of dominant hand from a dog bite.

Specific Wounds - Bites

• Epidemiology– 60-90% dog bites, cats 1-15%, rodents 1-7%,

other species less than 2%

• Dog Bites– jaws can exert +++force but teeth not sharp– results in relatively superficial crush injuries– face and scalp most common site in children– incidence of infection 5-10%– infection rate on face 1-5%


• Cat Bites– typical bite is a puncture wound– possess long, slender, pointed teeth– overall infection rate about 14% (80%

according to 2001 Sanford Guide); 28-80% in NEJM article


• Microbiology of dog and cat bites (Talan et al. Bacteriologic

Analysis of Infected Dog and Cat Bites. NEJM January 14, 1999)

– almost always polymicrobial– aerobes, anaerobes– Pasteurella canis most common isolate in dog bites– Pasteurella multocida most common isolate in cat

bites– authors suggest that if antibiotics prescribed a beta

lactam antibiotic combined with a beta lactamase inhibitor would be appropriate choice for prophylaxis


• Dog Bite Management (Cummings. Antibiotics to prevent

infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med 1994;23)

– face, scalp, trunk – solid support for primary closure

– ?distal extremities – look at wound and patient factors; can probably primarily suture all dog bite wounds

– prophylactic antibiotics only in high risk wounds (hands, wound / patient factors)

Specific Wounds – Bites

• Cat Bite Management– puncture wounds should be left open– primary closure on face and scalp only– consider delayed primary closure in other

locations– consider prophylactic antibiotics in all cases

Specific Wounds – Human Bites

• Epidemiology– 60-75% hands and upper extremities

• Microbiology– polymicrobial– mixed gram positive, gram negative, aerobic,

anaerobic– eikenella corrodens– Hepatitis B

• Complications of human bites most commonly occur in hand wounds

Specific Wounds – Human Bites

• Management– routine wound evaluation and care– non-hand wounds can be closed primarily– hand wounds need to be left open to heal by

secondary intention or delayed primary closure

– routine prophylactic antibiotics in hand wounds only

Objectives

• Wound Healing• Wound Evaluation – History, Physical

examination• Wound Preparation• Wound Closure• Specific Wounds

– face, scalp, eyebrow, eyelid, ear, lips, intraoral, puncture, fingertip and nail, foreign bodies, bites

Take Home Points

• Evaluate wound and patient factors when determining closure, risk of infection, antibiotics, etc.; infection is enemy

• Lacerations caused by compressive/tensile forces result in more complications than lacerations caused by knife cut (shear forces)

• “golden period” is not fixed and dependent on many variables

• V-Y plasty for fingertip amputations• re bites: routine antibiotics for all cat bites and

dog and human bites to hand

Wound Management

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