Wound Closure and Suture Techniques

imagesGoals are to optimize wound strength, reduce inflammation, avoid infection, and minimize scar formation

   imagesTime to wound cleaning is the most important factor

   imagesTo preserve viable tissue and restore continuity and function of tissue


imagesHeavily contaminated wounds

imagesPresentation time for primary closure is after 12 hours for standard lacerations

imagesPresentation time for primary closure is after 24 hours for lacerations of the face, scalp, or other highly vascular areas

imagesWounds under high tension should not be closed by skin adhesives alone

imagesAnimal or human bite and most puncture wounds should not be closed on initial presentation


imagesCleaning and repair of wounds cause pain

   imagesLocal anesthetics are indicated for all wound repairs in conscious, alert patients

imagesInfection is always a risk in wound repair

imagesWound repair always results in some scarring and can affect cosmetic appearance permanently

imagesTendon, nerve, and vascular injuries can occur at time of initial injury or at time of repair

imagesRisk of retained foreign body exists despite best methods of foreign body identification and removal, such as local exploration, radiographs, ultrasonography, and irrigation

   imagesThorough exploration for foreign bodies must be performed and documented

imagesGeneral Basic Steps

   imagesAnesthetize wound

   imagesClean wound

   imagesExplore wound

   imagesConsider radiography

   imagesRepair wound


imagesPatient and Wound Preparation

   imagesPosition the patient to prevent falling or fainting during wound repair

   imagesPractice universal precautions

   imagesPrepare the surrounding skin with povidone–iodine solution and cover with sterile drapes before manipulation of any kind

imagesLocal Anesthesia: Lidocaine (1% or 2%) with or without epinephrine

   imagesEpinephrine is contraindicated in areas of high risk for ischemia, such as fingers, ears, nose, toes, and penis

   imagesUse small-gauge needle (25 or 27 gauge) to directly inject into subcutaneous (SQ) tissue within the laceration

   imagesTo decrease pain, inject through the wound and not through the skin

   imagesUse adequate amount for anesthesia but avoid high volumes that will lead to significant tissue distortion, possible cosmetic embarrassment, or systemic toxicity

      imagesMaximum dose: 3 to 5 mg/kg 1% lidocaine, 7 mg/kg 1% lidocaine with epinephrine.

   imagesConsider regional blocks for repairs in cosmetically important areas (face, hands, etc.) to avoid distortion of tissue

imagesWound Cleansing

   imagesCopious 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.

imagesWound Exploration

   imagesAfter cleansing, the true depth of the wound is appreciated

   imagesLook for deeper tissue involvement and explore the wound

   imagesIf tendon or vascular structures are visualized, inspect through full range of motion, test for state of function, and document findings

imagesRadiography and/or Sonography

   imagesIf the possibility of underlying fracture and/or foreign body exists, image the affected area and document

imagesSelect Method of Repair

   images2-Octyl cyanoacrylate




imagesIndicated for simple wounds under low tension


   imagesEase of use, speed, and safety

   imagesNo return visit necessary (sloughs off in 5 to 10 days and serves as own dressing)

   imagesMuch less painful


   imagesModerate closure strength—cannot be used on joints or areas with high tension

   imagesCannot be used in areas with excessive hair

imagesCaution when using around eyes to prevent accidental runoff into eyes

imagesEquivalent tensile strength at 7 days when compared to sutures


   imagesClean the wound

   imagesApproximate wound edges with forceps or fingers

   imagesApply three to four layers along the wound length or perpendicularly to it (as strips)

   imagesMaintain manual support for 60 seconds


imagesIndicated for superficial scalp lacerations, linear lacerations on extremities, trunk, and wounds under low tension


   imagesEase of use, speed, and safety

   imagesEasily removed and excellent tensile strength


   imagesLess refined closure

   imagesPossible greater scarring

   imagesUncomfortable removal (TABLE 69.1)

imagesNo significant differences found with infection, healing, or patient acceptance when compared to suturing

TABLE 69.1.



Superficial (nonabsorbable)

Deep (absorbable)


Suture chest tube




Chest, abdomen, back


Scalp, chest, abdomen, foot, extremity

Scalp, extremity, foot


Scalp, brow, mouth, chest, abdomen, hand

Brow, nose, lip, face, hand


Ear, lid, brow, face, mouth, nose



   imagesAnesthetize, clean, and debride wound as necessary

   imagesIf necessary, close deep fascia with absorbable sutures with a buried knot

   imagesEvert wound edges before placing staple, if possible utilizing the services of an assistant with forceps. Do not press too hard.

   imagesAllow the staple crossbar to sit 1 to 2 mm above wound edge

   imagesPlace enough staples to adequately appose tissue edges


imagesGeneral Rules

   imagesDeep stitches require 3-0 or 4-0 absorbable sutures

   imagesSkin closure requires 4-0 or 5-0 nonabsorbable sutures

   imagesFace, lips, and eyelid wounds: Consider 6-0 sutures

   imagesHigh skin tension areas: Consider 3-0 or 4-0 sutures

   imagesAlways select the smallest size that will hold the skin edges together

imagesNonabsorbable Sutures

   imagesSilk: Has the best knot security, the best tie ability, the least tensile strength, and causes significant tissue reactivity. Used in intraoral mucosa.

   imagesEthilon: Has good knot security, good tensile strength, minimal tissue reactivity, and good tie ability. Best suited suture material for typical wound closure.

   imagesProlene: Poorest knot security, best tensile strength, least tissue reactivity, and fair tie ability

imagesAbsorbable Sutures

   imagesVicryl: 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.

   imagesSurgical 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.


   imagesAnesthetize, clean, and debride wound as necessary

   imagesPrepare the skin with povidone–iodine or chlorhexidine solution

   imagesMinimize trauma by handling skin with toothed forceps and by using small sutures

   imagesRelieve tension by undermining with a scissor and by using layered sutures (FIGURE 69.1)

   imagesSubcutaneous Layer Closure

      imagesReapproximate fascia as needed

      imagesClose the SQ layer in sections, starting in the middle and then bisecting adjacent sections until adequate tension has been relieved from the skin edges

      imagesInsert the suture at the bottom of the layer and draw it through to just beneath the dermis on the same side of the wound

      imagesReenter beneath the dermis on the adjacent side and draw through to the bottom of the SQ layer

      imagesTie the knot such that it remains at the bottom of the wound, thereby preventing a palpable knot near the skin surface

   imagesInterrupted Stitch

      imagesMost commonly used stitch. If one fails, the rest will maintain closure.

      imagesInsert 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


FIGURE 69.1 Undermining a wound reduces the degree of tension present after the repair. (From McNamara R, Loiselle J. Laceration repair. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:1152, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Wound Closure and Suture Techniques
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