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HAND, DISEASES AND DEFORMITIES [VOL. vi

Division of
nerves and

tendons

(2)—Complications
The prognosis of any injury is tremendously affected by the presence
Infection of added infection, which constitutes the most important of all the
complications. As infection, however, is by no means always post-
traumatic it will be dealt with in a separate section (see p. 182), but
here, before passing to a consideration of the purely mechanical
aspects, it is necessary to emphasize the warning there given against
attempts at immediate closure of incised and lacerated wounds. It is
true that many injuries are caused by materials which are not in them-
selves likely to carry a virulent infection; indeed in some cases the
material is sterile, e.g. hot turnings or splinters from a lathe or milling
machine. Nevertheless the wound is often contused and therefore lined
by devitalized tissues which are very prone to infection; such infection
may be derived from the patient's skin, if it is not healthy, or even
from parts as remote as the teeth or tonsils. Only in exceptional circum-
stances can it be necessary to close the wound at once. The patient's
rather natural desire to see the status quo ante restored should be
stoutly resisted.
As complications of many of these injuries there may also be division
of tendons, nerves, or vessels, and in all incised or lacerated wounds a
very careful examination must be made for possible division of tendons
and nerves, and care must be exercised not to mistake one for the other.
Inability to perform certain movements may be due either to involve-
ment of the nerve-supply to a muscle or to division of its tendon;
sometimes the injuries co-exist. Owing to the elasticity of the skin a
small superficial wound may be associated with extensive damage to
deeper structures, a circumstance which may mislead the unwary.
Treatment Divided tendons and nerves must be sutured, but not of necessity
immediately. In the presence of much damaged tissue or the probability
of infection, despite thorough cleansing of the wound, it is better to
identify the various divided structures and to prevent their retraction
by the passage of loose sutures (they may be individually coloured)
through them, the wound being then lightly packed with gauze "soaked
in flavine in watery solution 1 in 1,000. After a day or two, when it is
obvious that no gross infection is present, a secondary suture can be
undertaken. When many tendons in close proximity are divided, i.e.
at the wrist, difficulty may arise in deciding which to join to which; but
a knowledge of the anatomy of the part, combined with a test of the
distal ends by pulling upon each in turn and noting the movement
which occurs, will usually enable them to be correctly sorted out.
Haemorrhage Bleeding as a complication of injuries to the palm, may be difficult to
control. Owing to the close proximity of many important structures
under the palmar fascia, the blind application of artery forceps is not
advised; nevertheless bleeding here should be treated by local haemo-
stasis and not by ligature of the proximal vessels, i.e. the radial and
ulnar, except in the last resort. This means that, until the wound can