Carry out a rapid general assessment of the whole patient to make sure that their airway, breathing and circulation are satisfactory (ABC, then D and E; see Chapter 42) before focusing in on the presenting injury.

Try to find out how long ago the wound occurred and whether the object that caused it was likely to have been clean or contaminated, or even whether any noxious chemicals or electrical burn may be involved (see Chapter 45). Clean cuts that occurred recently are managed completely differently from dirty wounds or those that may already be infected.

Check distal neurovascular status. The sooner that damage to a vessel or nerve can be identified, the better the chance that a repair can be performed and the function of the limb saved.

An X-ray is useful to exclude fracture or dislocation. Two views need to be taken at right angles to each other, centred on the injured area. The entry wound can be marked with a paper clip taped to the skin. Ultrasound may be better than an X-ray for finding glass.

Wounds must not be closed if there is any chance that they might become infected. Copious volumes of saline should be used to wash the wound out – dead and contaminated tissue must be removed.

If at the end of your best efforts you cannot be sure that the wound is clean then pack it and review the situation daily until you are sure it is clean. Then, and only then, should you close it.

Good light is needed to inspect a wound properly. Local or general anaesthesia may also be needed, so wounds are best explored in an operating theatre. If the limb was in a different position when the injury occurred to its position when the examination is performed, it is easy to miss the depth of the wound. For example, it is easy to miss that the knuckle joint has been penetrated in an injury from a punch onto the teeth of an opponent. If the hand is examined with the fingers extended, the skin wound appears to be well away from the knuckle itself.

Damaged nerves, vessels, ligaments and bones should be repaired as soon as possible, but the first priority must be to remove non-viable tissue and then to ensure that there is adequate skin and soft tissue cover to ensure infection-free healing.

Prophylaxis against tetanus must be up to date or tetanus toxoid will be needed. Prophylactic antibiotics may also be given but are no substitute for proper wound cleaning.

Wounds are painful and can lead to wasting and stiffness if no effort is made to ensure that the patient builds up muscle strength and mobility as quickly as possible. This is especially important in the hand where the role of the physiotherapist is crucial.

When stitching a wound make sure the edges are everted.