Soft tissue trauma ranges from insignificant minor contusions and small superficial clean abrasions to massive, complex, very contaminated lacerations and avulsions, surrounded by extensive abrasion and dirt tattoo. Minor contusions are much more prevalent, or at least apparent, these days because of the large number of people on NSAID’s or other blood thinners. Hematomas are seen more frequently for the same reason. Contaminated abrasions occur routinely about the margins of dirty wounds resulting from blunt trauma.

Wounds come in a variety of shapes, depths and orientations and, as noted above, tissue may be missing. There may be fracturing of the fat and muscle and skeletalization of the neurovascular bundles. Underlying non-displaced or displaced fractures may be present, particularly about the face.

Lacerations are often described as far as configuration is concerned as being linear, curvilinear, flap-like or stellate. When an avulsion is part of the problem, the amount of tissue missing usually appears larger than actual because of tissue tension. If the wound margins are mirror images of each other after tension forces have been corrected, it is probable that no tissue is missing. If the margins are not mirror images, it is likely that an avulsion has occurred. Often the inexperienced will diagnose an avulsion when the spreading of the wound margins is purely secondary to normal tissue elasticity. Spreading of the margins of lip lacerations is a prime example, as are wounds of the extremities in children when the wounds are not oriented parallel to the natural lines of tension.

Wounds over bony prominences resulting from blunt trauma almost always extend to the bone. The dermis is the strongest layer between epithelium and bone in most areas and if the dermis is ruptured so usually is the underlying fat and muscle such defects are seen frequently about the forehead and upper face and chin, especially in children. Occasionally the underlying bone will be fractured but the fragments rarely are significantly displaced. One thing to keep in mind regarding scalp wounds is that if the wound is actually pulsating the defect goes completely through the calvarium to the dura and the pulsation is secondary to that transmitted from the brain.

It is important to realize that open fractures of the facial bones do not have the same implication as far as prompt coverage as in other areas, such as the extremities. This is because of the rich blood supply of the head and neck.

The tissue paper thin skin flaps seen in the elderly and in patients on steroids often are full thickness in nature, usually are intact, in the sense that no significant amount of tissue is missing, but may be fragmented and quite irregular in outline. If the flaps are full thickness, they should be sutured back into place. Almost always such repairs are possible using the proper technique - see the chapter on Special Situations.