Shia Zanjeer Zani - Back Muscle Injuries

What Happens Biomechanically

• Trapezius (upper and middle fibers) - the most exposed muscle, sits right under the skin across the upper back and shoulders
• Latissimus dorsi - the broad back muscle; gets hit in mid-back strikes
• Rhomboids (major and minor) - lie beneath the trapezius and can sustain deeper trauma if blades penetrate
• Erector spinae group (iliocostalis, longissimus, spinalis) - the paravertebral muscles running along the spine, at risk with central/lower strikes

• Muscle fiber tearing
• Hematoma formation within the muscle belly
• Damage to the thoracodorsal nerve (supplying latissimus dorsi) in severe lateral strikes
• Accessory nerve injury if the trapezius is deeply cut at the shoulder region

• Infraspinatus / teres minor (rotator cuff) - stressed during the deceleration phase of the swing
• Posterior deltoid - activated throughout the swing
• Serratus anterior - stabilizes the scapula under load
• Repeated high-velocity swinging can cause acute muscle strains or even partial rotator cuff tears, especially in participants who swing for extended durations

Skin and Superficial Tissue Layer

• Skin - lacerations, abrasions, contusions. Repeated strikes cause the skin to break down, leading to open wounds
• Subcutaneous fat - bruising and fat necrosis
• Superficial fascia - torn in deeper strikes

Infection Risk

• Tetanus - a key concern; chains are metal, often not sterile
• Staphylococcal and streptococcal wound infections
• Cellulitis progressing to necrotizing fasciitis in neglected cases (the deep fascia of the back can become infected, spreading along fascial planes)
• Osteomyelitis of posterior ribs or spinous processes is rare but documented in severe cases with very deep penetration

Neurological Risks

• Branches of the posterior rami of thoracic spinal nerves run through the back muscles - trauma can cause localized numbness or neuropathic pain patches across the back
• Spinal cord itself is protected by the vertebral column, so direct cord injury from surface strikes is extremely rare
• Pneumothorax - theoretically possible if a blade-equipped chain penetrates deep enough between the ribs, though this is uncommon

Specific Back Muscles - Summary Table

Medical Management

1. Wound cleaning - irrigation to remove debris, metal fragments
2. Tetanus prophylaxis - mandatory
3. Laceration closure - or delayed primary closure if contaminated
4. Antibiotics - if signs of infection (cellulitis, deep tissue involvement)
5. Imaging - ultrasound or CT if deep tissue injury, hematoma, or foreign bodies (chain fragments) are suspected
6. Physiotherapy - for muscle strain recovery, especially rotator cuff

Note on Formal Literature

Suture Thread Selection and Techniques

Part 1 - Characteristics of the Ideal Suture

• Easy to handle
• Predictable tensile strength
• Glides through tissues easily
• Secure knotting ability
• Minimal tissue reaction (non-allergenic, non-carcinogenic)
• Non-capillary (doesn't wick bacteria)
• Sterile and inexpensive

Part 2 - Five Key Properties to Understand Before Choosing

1. Physical Structure: Monofilament vs. Multifilament (Braided)

2. Strength

3. Tensile Behaviour (Memory)

4. Absorbability - the most critical selection factor

5. Biological Behaviour

Part 3 - Suture Materials: Absorbable vs Non-Absorbable

Absorbable Sutures

Non-Absorbable Sutures

Important: Silk and other biological non-absorbables fragment with time and should never be used in vascular anastomoses due to risk of late fistula formation. Polypropylene retains strength indefinitely and is preferred for vessels.

Part 4 - Suture Size (USP System)

Part 5 - The Four Core Suturing Techniques

1. Interrupted Sutures

• Distance from needle entry to wound edge = depth of tissue (X)
• Spacing between sutures = 2X
• Each suture is tied and cut independently
• Advantage: if one suture fails or gets infected, the rest hold
• Best for: skin closure, contaminated wounds, areas needing individual tension control
• In long wounds, place the central suture first, then halve each remaining gap

2. Continuous Sutures

• Requires an assistant to maintain even tension throughout
• Too little suture length = purse-stringing; too slack = poor apposition
• Secured at end with an Aberdeen knot, or by tying the free end to the last loop
• Advantage: faster, watertight/airtight seal in internal organs
• Best for: bowel anastomosis, peritoneum, fascial layers, vascular anastomosis

3. Mattress Sutures (Vertical and Horizontal)

• Vertical mattress: inverts or everts wound edges; useful for skin under tension
• Horizontal mattress: good for irregular depth wounds; distributes tension over a wider area
• Best for: areas under tension (scalp, back, joints), irregular wound edges, preventing inversion

4. Subcuticular (Intradermal) Suture

• Can be absorbable (buried knot) or non-absorbable (ends left protruding for later removal)
• No cross-hatched "train track" marks on the skin
• Best for: cosmetically important areas - face, neck, elective surgical incisions
• Requires well-aligned, tension-free wound edges

Part 6 - Practical Selection Guide by Location

Part 7 - Knot Tying Rules

• Tie firmly but do not strangulate tissue
• Keep the knot as small as possible to minimize foreign material
• Do not "saw" the thread - it cuts through tissue and weakens the material
• Lay the thread square during tying to prevent breakage
• Only grip the free end with the needle holder - gripping the thread body damages it
• Standard knot = reef knot + 1 extra throw (3 total)
• For monofilament sutures: 6 throws are required for security due to high memory and poor knot grip

Quick Decision Summary

Is the wound contaminated or infected?
  YES → Monofilament only (nylon, PDS), interrupted, leave open if severe

Does the layer need to dissolve?
  YES → Absorbable (Vicryl for most, PDS for prolonged support)
  NO  → Non-absorbable (Prolene/Nylon for skin, Prolene for vessels)

Is cosmesis important?
  YES → Fine monofilament (5-0/6-0), subcuticular technique

Is there high tension?
  YES → Larger size (0/1), mattress technique, consider deep layer first

Is it vascular?
  YES → Prolene only (retains strength indefinitely), continuous, fine (5-0+)

• Bailey and Love's Short Practice of Surgery, 28th Ed., pp. 125-129
• Pye's Surgical Handicraft, 22nd Ed., Table 18.1