Goals are to optimize wound strength, reduce inflammation, avoid infection, and minimize scar formation
Time to wound cleaning is the most important factor
To preserve viable tissue and restore continuity and function of tissue
CONTRAINDICATIONS
Heavily contaminated wounds
Presentation time for primary closure is after 12 hours for standard lacerations
Presentation time for primary closure is after 24 hours for lacerations of the face, scalp, or other highly vascular areas
Wounds under high tension should not be closed by skin adhesives alone
Animal or human bite and most puncture wounds should not be closed on initial presentation
RISK/CONSENT ISSUES
Cleaning and repair of wounds cause pain
Local anesthetics are indicated for all wound repairs in conscious, alert patients
Infection is always a risk in wound repair
Wound repair always results in some scarring and can affect cosmetic appearance permanently
Tendon, nerve, and vascular injuries can occur at time of initial injury or at time of repair
Risk of retained foreign body exists despite best methods of foreign body identification and removal, such as local exploration, radiographs, ultrasonography, and irrigation
Thorough exploration for foreign bodies must be performed and documented
General Basic Steps
Anesthetize wound
Clean wound
Explore wound
Consider radiography
Repair wound
TECHNIQUE
Patient and Wound Preparation
Position the patient to prevent falling or fainting during wound repair
Practice universal precautions
Prepare the surrounding skin with povidone–iodine solution and cover with sterile drapes before manipulation of any kind
Local Anesthesia: Lidocaine (1% or 2%) with or without epinephrine
Epinephrine is contraindicated in areas of high risk for ischemia, such as fingers, ears, nose, toes, and penis
Use small-gauge needle (25 or 27 gauge) to directly inject into subcutaneous (SQ) tissue within the laceration
To decrease pain, inject through the wound and not through the skin
Use adequate amount for anesthesia but avoid high volumes that will lead to significant tissue distortion, possible cosmetic embarrassment, or systemic toxicity
Maximum dose: 3 to 5 mg/kg 1% lidocaine, 7 mg/kg 1% lidocaine with epinephrine.
Consider regional blocks for repairs in cosmetically important areas (face, hands, etc.) to avoid distortion of tissue
Wound Cleansing
Copious amounts of sterile water or sterile saline via high-power irrigation with a large syringe and splatter shield or an 18-gauge catheter. Tap water equally effective.
Wound Exploration
After cleansing, the true depth of the wound is appreciated
Look for deeper tissue involvement and explore the wound
If tendon or vascular structures are visualized, inspect through full range of motion, test for state of function, and document findings
Radiography and/or Sonography
If the possibility of underlying fracture and/or foreign body exists, image the affected area and document
Select Method of Repair
2-Octyl cyanoacrylate
Staples
Sutures
DERMABOND (LIQUID ADHESIVE)
Indicated for simple wounds under low tension
Advantages
Ease of use, speed, and safety
No return visit necessary (sloughs off in 5 to 10 days and serves as own dressing)
Much less painful
Disadvantages
Moderate closure strength—cannot be used on joints or areas with high tension
Cannot be used in areas with excessive hair
Caution when using around eyes to prevent accidental runoff into eyes
Equivalent tensile strength at 7 days when compared to sutures
Procedure
Clean the wound
Approximate wound edges with forceps or fingers
Apply three to four layers along the wound length or perpendicularly to it (as strips)
Maintain manual support for 60 seconds
STAPLES
Indicated for superficial scalp lacerations, linear lacerations on extremities, trunk, and wounds under low tension
Advantages
Ease of use, speed, and safety
Easily removed and excellent tensile strength
Disadvantages
Less refined closure
Possible greater scarring
Uncomfortable removal (TABLE 69.1)
No significant differences found with infection, healing, or patient acceptance when compared to suturing
Size | Superficial (nonabsorbable) | Deep (absorbable) |
2-0 | Suture chest tube |
|
3-0 | Foot | Chest, abdomen, back |
4-0 | Scalp, chest, abdomen, foot, extremity | Scalp, extremity, foot |
5-0 | Scalp, brow, mouth, chest, abdomen, hand | Brow, nose, lip, face, hand |
6-0 | Ear, lid, brow, face, mouth, nose |
|
Procedure
Anesthetize, clean, and debride wound as necessary
If necessary, close deep fascia with absorbable sutures with a buried knot
Evert wound edges before placing staple, if possible utilizing the services of an assistant with forceps. Do not press too hard.
Allow the staple crossbar to sit 1 to 2 mm above wound edge
Place enough staples to adequately appose tissue edges
SUTURES
General Rules
Deep stitches require 3-0 or 4-0 absorbable sutures
Skin closure requires 4-0 or 5-0 nonabsorbable sutures
Face, lips, and eyelid wounds: Consider 6-0 sutures
High skin tension areas: Consider 3-0 or 4-0 sutures
Always select the smallest size that will hold the skin edges together
Nonabsorbable Sutures
Silk: Has the best knot security, the best tie ability, the least tensile strength, and causes significant tissue reactivity. Used in intraoral mucosa.
Ethilon: Has good knot security, good tensile strength, minimal tissue reactivity, and good tie ability. Best suited suture material for typical wound closure.
Prolene: Poorest knot security, best tensile strength, least tissue reactivity, and fair tie ability
Absorbable Sutures
Vicryl: Good knot security, good tensile strength, minimal tissue reactivity, best tie ability, and 30-day suture duration. Used for deep repair to reduce wound tension.
Surgical and chromic gut: Fair knot security, fair tensile strength, greatest tissue reactivity, poor tie ability, and 5- to 7-day suture duration. Used for intraoral wounds.
Procedure
Anesthetize, clean, and debride wound as necessary
Prepare the skin with povidone–iodine or chlorhexidine solution
Minimize trauma by handling skin with toothed forceps and by using small sutures
Relieve tension by undermining with a scissor and by using layered sutures (FIGURE 69.1)
Subcutaneous Layer Closure
Reapproximate fascia as needed
Close the SQ layer in sections, starting in the middle and then bisecting adjacent sections until adequate tension has been relieved from the skin edges
Insert the suture at the bottom of the layer and draw it through to just beneath the dermis on the same side of the wound
Reenter beneath the dermis on the adjacent side and draw through to the bottom of the SQ layer
Tie the knot such that it remains at the bottom of the wound, thereby preventing a palpable knot near the skin surface
Interrupted Stitch
Most commonly used stitch. If one fails, the rest will maintain closure.
Insert the needle at 90 degrees to the skin surface and include sufficient SQ tissue in the bite and carry the suture through to the opposite side