ALISZA NOV

CHAPTER

Principles of Good
Soft-Tissue Technique

1.1 Importance of correct

handling of soft tissues
Fractures are nearly always
associated with some degree of softtissue injury

Surgeons can through skillful use of

instruments and retraction, avoid
further injury to these traumatized
tissues

Soft-tissue
Soft-tissue
techniques
techniques are
are not
not
described
described in
in detail
detail in
in
classic
classic textbooks
textbooks and
and
often
often senior
senior surgeons
surgeons
delegate
delegate the
the surgical
surgical
approach
approach and
and
debridement
debridement to
to junior
junior
members
members
thereby foregoing the
opportunity
to teach
good soft-tissue
handling

This
This chapter
chapter
will
will teach
teach the
the
fundamentals
fundamentals
of
of instrument
instrument
handling
handling and
and
retraction
retraction

1.2 Preparation for surgery

Skin preparation
Use of the tourniquet
Planning Incisions

Skin
Preparation

There
There are
are several
several
different
different solutions
solutions
available
available for
for effective
effective
skin
skin disinfection
disinfection
In
In general,
general, open
open wounds
wounds
should
should be
be debrided
debrided of
of
large
large foreign
foreign bodies
bodies
such
such as
as dirt,
dirt, large
large pieces
pieces
of
of gravel
gravel and
and leaves
leaves
prior
prior

Superficial abrasions with

embedded gravel, rocks or
other foreign debris require
special attention

surgical scrub with a scrub

brush of the type used to
scrub the surgeons hands

Care must be taken to ensure that no

additional damage to the soft tissue
is caused by overly aggressive,
course debridement

Use Of The Tourniquet

Tourniquets are often used in extremity surgery to reduce
bleeding and to facilitate difficult preparation
Tourniquet is not routinely required, particularly during
the debridement procedure

Planning incisions
The
The skin
skin incision
incision should
should be
be extensile,
extensile,
which
which is
is best
best done
done with
with straight
straight
incisions
incisions rather
rather than
than curved
curved ones
ones

Approaches
Approaches make
make use
use of
of Langer
Langer lines
lines
(( cleavage
cleavage lines)
lines)

What is Langer
lines ?
They are topological lines
drawn on a map of the
human body along which
the skin has the least
flexibility. They correspond
to the natural orientation of
collagen
fibers
in
the
dermis

IfIf aa surgeon
surgeon can
can
choose
choose where
where and
and in
in
which
which direction
direction to
to
place
place an
an incision,
incision, he
he or
or
she
she may
may decide
decide to
to cut
cut
in
in the
the direction
direction of
of
Langer
Langer lines
lines

Incisions
Incisions made
made parallel
parallel
to
to Langer
Langer lines
lines may
may
heal
heal better
better and
and
produce
produce less
less scarring
scarring
than
than those
those cutting
cutting
across
across

AA situation
situation which
which often
often arises
arises is
is the
the issue
issue of
of aa transverse
transverse laceration.
laceration. This
This
laceration
laceration compromises
compromises the
the skin
skin distal
distal to
to itit because
because itit disrupts
disrupts the
the
longitudinal
longitudinal blood
blood flow
flow within
within the
the fascia.
fascia.

This
This requires
requires extension
extension of
of the
the wound
wound to
to allow
allow adequate
adequate exposure
exposure for
for
inspection,
inspection, debridement
debridement and
and eventually
eventually repair
repair

Extension
Extension can
can be
be performed
performed in
in two
two ways
ways ::
Z-fashion
Z-fashion or
or T-fashion
T-fashion

1.3 Intraoperative
Principles
1.3.1 Choice of instruments
Introduction
Forceps or pick-ups
Scissors
Tissue clamps
Retractors

Introduction
Each surgeon has a
preference for
which instrument
to use in a given
situation
Instruments are an
extension of the
surgeons hands
used to manipulate
the tissues, expose
the surgical field or
reduce and fix a
fracture

Forceps or Pick-Ups
There are numerous types of forceps commonly used
in orthopaedic surgery :

Large forceps such as rat-tooth

forceps are used for heavier
tissue such as muscle fascia,
bone fragments or tendon

Large forceps such as FerrisSmith forceps are used for the

heaviest tissues such as fascia
lata and tendon insertions

Small
Small forceps
forceps such
such
as
as Adson
Adson forceps
forceps
are
are used
used for
for skin
skin
and
and delicate
delicate
tissues
tissues such
such as
as
peritoneum
peritoneum or
or
perineurium
perineurium

DeBakey
DeBakey forceps
forceps
are
are typically
typically
used
used when
when
dissecting
dissecting
neurovascular
neurovascular
structures
structures

Scissors
Scissors should be selected according
to the tissue that is being separated
or divided
Sharp-pointed scissors are typically
used to divide tissue while bluntpointed scissors are more often used
to spread tissue

Small tenotomy and

Reynolds scissors should be
used exclusively to dissect
delicate structures such as
nerves or vessels, while
large Metzenbaum scissors
are appropriate for heavier
tissues such as the fascia
lata

Tissue Clamps

Similarly structured as forceps with sharp teeth (Kocher,

Mikulicz) or smooth (Pean) and come in different
dimensions

Retractors

There are many

different types of
retractors. Some
have a ratchet
device on the
handle, which
allows them to
be self retaining

Retractors are used

to provide exposure
of the target area
such as a fracture

Toothed
Toothed or
or sharp
sharp retractors
retractors such
such as
as
Kilner,
Kilner, McIndoe,
McIndoe, or
or Volkmann
Volkmann hooks
hooks
Blunt
Blunt retractors
retractors such
such as
as US-Army
US-Army

and
and retractors
retractors have
have hooks
hooks or
or sharp
sharp

or
or Faraboeuf
Faraboeuf retractors
retractors are
are

teeth,
teeth, which
which bite
bite into
into soft
soft tissue
tissue to
to

commonly
commonly used
used for
for retraction
retraction of
of
small
small to
to moderately
moderately large
large tissue
tissue
masses
masses

retract
retract skin
skin (Kilner,
(Kilner, McIndoe)
McIndoe) or
or
subcutaneous
subcutaneous and
and muscle
muscle tissues
tissues

Weitlaner retractors, distribute force across a large area

and expose more underlying tissue, whereas others such
as Gelpi retractors concentrate force in a narrow area

Lever retractors such as Hohmann, Bennett, and

double angle Schumacher retractors are designed
to be placed around bones with leverage applied to
retract tissue

1.3.2 Handling Of Instruments

Scalpel
For most orthopaedic procedures, the scalpel is held as one
would hold a pen, between the thumb and index finger

Large scalpels such as #21 are typically used for

incision of the skin, while #10 and #15 blades are
generally used for smaller incisions and dissection
in deeper planes

Skiving and undermining of the skin must be done

parsimoniously, as this compromises its vascularity and
healing capacity

Forceps or Pick-Ups
Forceps are used to lift or grasp tissue. All forceps require
some pressure between the tips in order to grasp tissue.

Toothed forceps can be used to lift tissue without pinching

it
Use small forceps for skin and subcutaneous tissue
Large forceps can be used on heavy fascia

Scissors
In some cases, scissors will be used to cut through tissue, in
others, for example in loose connective tissue, scissors may
also be used for blunt dissection

Dissection of subcutaneous tissue :

a. Correct : dissection following the line of incision
b. Incorrect : crosswise dissection within the incision

Retractors
Retractors should be placed as deeply as possible. Virtually
never should retractors be placed between the epidermal and
dermal layers of the skin

1.3.3 Achieving Hemostasis

Hemostasis is an important part of surgery

May be achieved by the use of direct or
indirect compression
(electrocautery or vascular occlusion)

1.3.4 Removal of blood from the operative field

Blood may be
removed from
the operative
field either by
absorptive
sponge or by
suction

Sponges can
be used to
apply direct
pressure to
small bleeding
vessels long
enough to stop
bleeding

Knowing yourself is the beginni

of all wisdom

- Aristo