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

Best Management of Zanjeer Zani Wounds

• Multiple lacerations across the upper back
• Metal (chain) instrument - contaminated, often non-sterile, may have blade attachments
• Irregular wound edges from repeated strikes
• Variable depth - some superficial, some reaching fascia
• Delayed presentation - participants often present hours after the ritual ends
• High bacterial load from skin flora + metal contamination
• No single wound - multiple wounds at different stages simultaneously

Step 1 - Classify Each Wound Before Touching It

1. How deep is it? (Superficial skin only vs. into fascia/muscle)
2. How old is it? (Less than 8 hours = primary closure still possible if cleaned well; over 12 hours = delayed closure)
3. Are wound edges viable? (Devitalized, macerated tissue must be debrided first)
4. Any signs of infection already? (Redness, pus, warmth = no closure, treat open)

Step 2 - Wound Preparation (Most Important Step)

A. Anesthesia First

• Infiltrate each wound with lidocaine 1% without epinephrine (epinephrine is avoided on highly vascular areas under tension)
• Regional nerve blocks of the thoracic posterior rami can be considered for multiple simultaneous wounds

B. Skin Disinfection Around (Not Inside) the Wound

• Chlorhexidine applied to surrounding skin is preferred over povidone-iodine (meta-analysis of 13 RCTs, 6,997 patients: chlorhexidine gave 30% lower surgical site infection rate)
• Allow 2-3 minutes to dry for full effect
• Do not pour antiseptic directly into the wound - it damages tissue defences and impairs healing

C. Wound Irrigation - the single most important infection-prevention step

• Irrigate with normal saline or clean tap water
• Use moderate pressure (10-15 psi with a 35 mL syringe and 19-gauge needle, or splash shield)
• Very high pressure (>15 psi) is avoided - it drives bacteria deeper into tissue
• Volume: at least 100-200 mL per wound for heavily contaminated ones
• If extremely dirty: pre-irrigation with soap and water under running tap before anesthesia is acceptable when patient tolerates it

D. Sharp Debridement

• Remove all obviously devitalized tissue, clotted haematoma, and embedded debris with scissors or scalpel
• Metal fragments from chains must be actively searched for - use plain X-ray to locate radiopaque fragments, ultrasound for soft tissue foreign bodies
• Do not leave dead tissue behind - it is a culture medium for bacteria

E. Wound Exploration

• Systematically probe each wound for depth
• Check for tendon injury (ask patient to move shoulder and scapular muscles)
• Check neurovascular status distal to the injury site

Step 3 - Closure Decision by Wound Type

Superficial lacerations (skin/subcutaneous only, <8 hours old, clean after irrigation)

Deep lacerations (into fascia/muscle, or >8-12 hours old, or heavily contaminated)

• Pack the wound open with petrolatum (Vaseline) gauze between edges
• Start the patient on oral antibiotics (cephalexin 500 mg QID x 5 days)
• Return on Day 3 - re-anaesthetise, re-irrigate, then close primarily
• At delayed closure: use non-absorbable monofilament skin sutures only - no deep sutures, as deep sutures in contaminated wounds increase infection risk significantly

Infected / frankly purulent wounds

• Daily dressing changes
• Consider NPWT (wound VAC) for large open back wounds - changes every 2-3 days

Step 4 - Best Suture Choice for These Wounds

Never use braided sutures (Vicryl, silk, braided nylon) for skin closure in these wounds. The interstices of braided material harbour bacteria and dramatically increase infection risk in a dirty wound. Monofilament only for skin.

Technique for the Back

• Interrupted sutures - mandatory (not continuous) because:
  • If one suture site gets infected, you can remove that single suture and drain it without losing the entire closure
  • Back wounds are under tension with shoulder movement - interrupted handles differential tension better
  • Easier to adjust for irregular wound edges
• Vertical mattress sutures for areas under high tension (upper back near shoulder) - distributes tension, prevents inversion
• Do not use subcuticular sutures in these wounds - too risky in contaminated tissue, cannot be partially opened if infection develops

Siting Rule (from Bailey & Love)

• Needle entry distance from wound edge = depth of tissue being sutured (X)
• Spacing between sutures = 2X
• Knot: reef knot + 1 extra throw (3 total); for nylon/monofilament = 6 throws for security

Step 5 - Tetanus Prophylaxis (Mandatory)

Step 6 - Antibiotics

Step 7 - Dressings After Closure

• Closed wounds: non-adherent primary dressing (Mepore/Melolin) + secondary absorbent pad
• Open wounds (secondary intention): saline-moistened gauze or NPWT (Wound VAC) for large wounds
• Change dressings daily for open wounds
• Keep dry for 24-48 hours post-closure

Suture Removal Timeline for Back Wounds

Summary - Quick Decision Card for Zanjeer Zani

Every wound → irrigate first, debride devitalized tissue, search for metal fragments

< 8 hours old + clean after irrigation?
  → Primary closure: interrupted monofilament nylon 3-0, no braided sutures

> 8-12 hours old OR heavily contaminated?
  → Pack open, antibiotics, delayed primary closure Day 3

Infected / purulent?
  → Leave open, secondary intention, daily dressings

ALWAYS: Tetanus prophylaxis, assess vaccination status
ALWAYS: X-ray to exclude retained metal fragments

Suturing and Dressing Precautions in Hot Summer Weather

Why Hot Weather Makes Wounds Worse - The 5 Mechanisms

1. Sweating = Moisture = Bacterial Growth

2. Maceration

3. Excess Wound Exudate

4. Desiccation at the Wound Surface

5. Dressing Adhesive Failure

Precautions During the Suturing Procedure Itself

Keep the Wound and Operative Field Cool and Dry

• Work in an air-conditioned or shaded, cool environment if possible
• Patient should be lying prone (for back wounds) and comfortable - excessive sweating during the procedure itself contaminates the field
• Fan or cool cloth on non-operative areas reduces sweating during procedure

Do Not Rush Wound Preparation

Suture Selection Adjustments for Hot Weather

Do Not Use Subcuticular/Intradermal Sutures in Summer Back Wounds

Dressing Selection in Hot Weather

Dressing Types and Their Summer Suitability

Best Choice for Back Wounds in Summer (Zanjeer Zani context):

1. Primary layer: Petroleum gauze (Jelonet) or non-adherent silicone layer (Mepitel) - atraumatic, won't stick to wound surface
2. Secondary layer: Foam dressing (Mepilex/Allevyn) - absorbs sweat + exudate, breathable, stays in place better than plain gauze
3. For high infection risk: Add silver alginate layer against the wound bed before foam

Dressing Change Frequency in Summer

1. Gentle cleansing with normal saline (not povidone-iodine directly into wound)
2. Visual inspection for early infection signs (see below)
3. Fresh dressing applied to dry skin

Warning Signs to Actively Teach the Patient (Especially in Summer)

• Redness spreading beyond the wound edges (cellulitis)
• Increasing warmth and throbbing pain after the first 24 hours (pain should be decreasing, not increasing)
• Pus or cloudy discharge from the wound
• Fever >38°C
• Red lines tracking up from the wound (lymphangitis - this is a medical emergency)
• Foul odour from the wound or dressing
• Sutures cutting into swollen, tight skin
• Dressing coming off and wound being exposed to dirt/sweat for hours

Patient Instructions Specific to Summer

Keep the Wound Area Cool and Dry

• Stay in shade or air-conditioned areas as much as possible
• Do not leave the wound exposed to direct sunlight - UV and heat both impair healing and increase inflammation
• Avoid activities causing heavy sweating for at least the first 48-72 hours

Clothing

• Wear loose, breathable cotton over back wounds - not tight synthetic fabric that traps heat and sweat against the wound
• No polyester, no tight elastic waistbands near wounds

Hydration - Critical and Often Overlooked

• Hot weather dehydration reduces blood volume directly
• Less blood flow to the wound = less oxygen + fewer immune cells delivered = slower healing + higher infection risk
• Minimum 2.5-3 litres of water per day in summer for wound patients

Bathing

• Safe to gently wet the wound 24 hours after repair
• After bathing: pat dry immediately, do not rub; re-apply dressing
• No swimming or immersion in water (pools, rivers) until fully healed - these carry high bacterial load + prolonged moisture exposure

Nutrition

• Protein (chicken, fish, lentils), Vitamin C (citrus), and Zinc (nuts, seeds) all directly support wound healing
• These requirements are elevated in summer when the body is under thermal stress

Suture Removal - Adjust for Summer

• Wound edges are fully approximated and sealed
• No signs of infection
• Skin around sutures is not macerated or breaking down

Quick Summer Wound Checklist

AT SUTURING:
 ✓ Cool environment, chlorhexidine skin prep, allow to dry 2-3 min
 ✓ Monofilament sutures only (nylon/Prolene) for skin
 ✓ Slightly looser ties - allow for swelling
 ✓ Minimum sutures needed - avoid unnecessary deep sutures
 ✓ Tetanus prophylaxis (especially for metal wounds)

DRESSING:
 ✓ Non-adherent primary layer (Jelonet or Mepitel)
 ✓ Absorptive foam secondary layer - NOT plain dry gauze alone
 ✓ Silver-containing layer if contaminated/high risk
 ✓ Change every 24h minimum; twice daily in heavy sweating

PATIENT INSTRUCTIONS:
 ✓ Stay cool, loose cotton clothing
 ✓ Hydrate 2.5-3L/day
 ✓ No swimming, no direct sun on wound
 ✓ Return immediately for: spreading redness, fever, pus, red lines, foul smell
 ✓ Suture removal at 12-14 days (back wounds)

Can a Mask Protect the Face During Zanjeer Zani?

What Are You Protecting Against?

1. Accidental chain swing - the chain overshoots and strikes the face (most common injury mechanism)
2. Blade-tipped chains - lacerations to cheek, nose, periorbital area
3. Blunt impact - from chain links hitting the nose, cheekbones, or orbit
4. Eye injury - the orbit is the most dangerous - even a single chain link at velocity can rupture the globe

Types of Face Protection - What Works and What Doesn't

1. Cloth / Surgical Masks

• Designed only for respiratory protection (dust, droplets)
• Offer zero resistance to chain impact or lacerations
• Actually dangerous if used with a false sense of security
• Do NOT use as trauma protection

2. Hard Polycarbonate Face Shield (Full-Face or Half-Face)

• The gold standard for high-impact facial protection
• Polycarbonate is shatter-resistant, lightweight, and can absorb and disperse kinetic energy
• Used in combat sports, industrial work, and by surgeons repairing facial fractures to prevent re-injury
• Covers: forehead, nose, cheeks, chin
• Custom-made versions (moulded over a cast of the face) offer the best fit and energy dissipation
• Off-the-shelf versions (e.g., anti-riot shields, sports face guards) offer good protection at lower cost
• Evidence: helmets and face guards reduce facial injury risk by 28-69% in high-impact sports (American Association of Oral and Maxillofacial Surgeons data)

3. Wire Cage / Metal Face Guard (like a fencing mask or hockey cage)

• The cage structure deflects chain links effectively
• Used in ice hockey, lacrosse, cricket wicket-keepers
• Gaps between wire = risk of thin blade-tipped chain link passing through at high velocity
• Better than nothing; ideal if polycarbonate is unavailable
• Must fit tightly - a loose cage can be pushed into the face on impact

4. Sports Face Guard (Attached to Helmet)

• Football/rugby/cricket helmet + face guard combination
• Helmet protects the skull and temporal region; face guard deflects chain from face
• NOCSAE-standard face guards (US standard) are tested for significant impact
• Bulky but provides the most comprehensive craniofacial protection
• Ideal for those wishing to participate while minimising all risk

5. Eye Protection (Goggles / Wraparound Glasses)

• Orbital blowout fractures and globe rupture are the most devastating injuries from chain strikes
• A chain link hitting the orbit at speed can cause permanent vision loss
• Use polycarbonate wraparound goggles (not regular glasses - glass lenses shatter and worsen injury)
• These should be worn even under a full face shield as a secondary layer
• Industrial safety goggles rated for ballistic/impact (ANSI Z87.1 standard) are appropriate

6. Nose Guard (Nasal Splint/Shield)

• Thermoplastic or polycarbonate nasal guards protect the nasal bones from fracture
• Used by athletes after nasal fracture repair to prevent re-injury
• Covers only the nose - does not protect the rest of the face
• Useful as additional coverage if a full face mask is not worn

The Most Important Vulnerable Areas on the Face

What to Actually Recommend

Minimum Protection

• Polycarbonate wraparound safety goggles (impact-rated) - mandatory for eye protection
• A wire cage face guard or half-face polycarbonate shield covering nose and cheeks

Best Protection

• Full-face polycarbonate shield (like a motorcycle visor or industrial face shield)
• Polycarbonate goggles underneath for secondary eye protection
• Mouthguard (boil-and-bite or custom) to protect teeth and absorb jaw impact

For Bystanders / Medical Personnel

• Surgical/N95 mask + eye protection - adequate for bloodborne exposure protection (splatter from open wounds)
• This is actually important: open back wounds in multiple participants = hepatitis B/C and HIV transmission risk from chain sharing and blood splatter

Why the Face is So High-Risk - Anatomically

1. Rich blood supply - facial lacerations bleed heavily even when small; chain cuts to the face bleed dramatically
2. Thin bone - the nasal bones, orbital walls (as thin as paper in places), and the zygomatic arch fracture relatively easily
3. Vital structures close to surface - the globe, facial nerve branches, parotid duct, lacrimal system are all superficial
4. Cosmetic consequences - facial scars are permanent and visible; sutures on the face must be fine (5-0 / 6-0) and meticulous
5. Airway proximity - severe mid-face trauma can compromise the nasal airway

If a Face Injury Occurs Despite Protection

Bottom Line