Delaying Wound Closure
- Wounds at very high risk of infection should be considered for delayed primary closure:
- Wounds unable to be adequately debrided
- Contaminated, more than 8 hrs old
- Crush injury
- Puncture wounds especially with teeth on distal extremities
- Thoroughly clean, leave for 4 days and if no infection then close.
Wound Bed Preparation
Utilise the TIME principle:
- Tissue assessment and removal of non-viable tissue or replacement of deficient tissue
- Infection / Inflammation Control
- Moisture Balance
- Epithelial Advancement of wound edges promotion
- Best means of infection prevention is wound cleaning/debridement – not antibiotics
- Done post Local Anaesthetic infiltration
- For a clean wound – Chlorhexidine 1% cleansing
- For a dirty wound – needs thorough irrigation
- Use normal saline – 60ml per square cm
- Use 18 gauge cannula sheath with 20ml syringe
Equipment Needed for Wound Cleaning / Closure
- Sterile gloves
- Drapes / Sterile blue sheets (cut hold in blue pad to create an opening to perform task (blue to outside, white to inside) and create sterile barrier
- Local Anaesthetic, drawing needle (18), 25 gauge needle and 10ml syringe
- Cannula (for irrigation) 18/20 gauge with 20ml syringe
- Sterile saline
- Dressing Kit / additional gauze
- Suture kit
- Closure method
- Sutures / Steristrips & Friar’s Balsalm / Glue
- Dressing / method of fixing dressing
- Do not close a wound with a foreign body
- Most glass shows on plain Xray, not all (need ultrasound)
- Ensure all devitalised tissue is debrided – if extensive area refer to Plastics
- Viable tissue bleeds
- Use a scalpel blade
- Re-irrigate after debridement
Wound Closure General Principles
- Fix displaced tissue using appropriate methods (sutures, glue, steristrips, staples, dressings)
- Use the most appropriate method to close the wound while minimisng infection. Steristrips and glue have a smaller chance of infection compared to sutures or staples which are a foreign body.
- Secondarily, dress wound to manage exudate and minimise trauma on removal
- Consider use of tubigrip in lower limb injuries especially, to both hold dressings on, but also to provide compression.
- The best suture material is the one that minimises infection, which is a monofilament:“Novafil” = synthetic nylon non-resorbable monofilament
- “Caprosyn” = synthetic resorbable monofilament (usually more scarring with resorbable sutures)
- But difficult to tie knot – needs 4 throws
- Silk is a multifilament and brings an increased risk of infection, but is much easier to tie knot. Silk also produces more scarring
- Use 6 or 5 for face, 4 for most other areas and 3 for thicker skin or areas under more significant tension such as shin or thigh
- Aim is to evert edges
- Usually interrupted sutures OK
- Do mid point first, then bisect the remaining gaps (Minimises sutures / dog ears)
- Rough sizes: 0.5 cm apart, 0.5 cm deep and 0.5cm back from wound edge (on face: make dimensions 0.25 cm)
- Consider horizontal mattress sutures if difficult to evert edges eg dorsum of hand / elbows
- Ensure sutures are not too tight as this will cause “tram track” scarring (too tight if skin blanching)
Tying a Knot
- After running the suturing material through both edges of the wound using the desired technique (single interrupted, corner edge, horizontal mattress or vertical mattress), loop the thread around the closed forceps in a clockwise fashion twice on the first throw and the grab the opposite end of the thread with the forceps. Pull on the needle end of the thread to tighten the first throw and then rotate the ends of the thread 180 degrees about the knot to “lock” then knot into place. Note that it may not be possible to hold the ideal position with only the first pass – do not worry if this is the case as you will usually be able to hold the closure on the second pass.
- On the second, third and fourth passes (some prefer only three), alternate looping the thread counterclockwise / clockwise over the forceps prior to pulling through. Lock each knot into place and finally trim the excess suturing material, leaving approximately 1cm in place to allow easy removal.
Simple Interrupted Suturing Technique
- If possible, evert the edges of the wound and pierce each side separately.
- If the edges of the wound cannot be everted or are already approximated, then pierce one side of the wound with the needle and continue underneath the wound to the other side, allowing the needle to exit at approximately the same distance from the wound as at the first side.
- Complete by tying a knot
Horizontal Mattress Suturing Technique
- The horizontal mattress suture everts the skin well and spreads tension along the wound edge. This makes it ideal for holding together fragile skin as well as skin under high tension such as the distant edges of a large laceration or as the initial holding suture in complicated repair.
- The knot is adjacent to the wound edge and should not be completed too tightly as this will compromise blood supply.
- Begin on one side of the wound (A1), then run underneath the wound to exit on the opposite side (B1). Staying on the opposite site and on the external surface, run the needle to a place approximately 5mm horizontally and penetrate the skin (B2). From this position, continue deep to the wound and exit on the original side, 5mm horizontally to the initial thread entry point (A2).
Vertical Mattress Suturing Technique
- The vertical mattress suture is most commonly used in anatomic locations which tend to invert, such as the posterior aspect of the neck, the palm of the hand, and sites of greater skin laxity such as closure of lax skin after removing a dermoid cyst.
- It useful for deep lacerations, where it can replace two layers of deep and superficial sutures.
- It can help bring the deep layers together alone, allowing several simple interrupted or running stitches to close the remaining superficial skin.
- The technique used is a “far-far-near-near” order of bites. The “far-far” loop enters and exits the skin surface at a 90 degree angle, 5mm from the wound margin. It passes relatively deeply into the dermis. The “near-near” loop enters and exits the skin surface 2mm from the wound margin, traversing the wound at 1mm depth.
- Because of the precise degree of control that the vertical mattress stitch provides, bites must be symmetrical. The knot is tightened only until sufficient opposition and eversion is achieved.
Wound Flap Suturing
- Flaps that point proximally are at high risk of dying because of impaired blood supply.
- Small distal pointing flaps can be sutured in ED:
- An initial suture at the apex is required, from distal skin through subcutaneous tissue of the point of the flap back to the distal skin (aka “corner suture” as pictured) – alternatively use a horizontal mattress suture.
- Complete with simple / horizontal sutures to sides
Removal of Sutures
- The longer sutures are left in place, the greater the scarring and potential for irritation and infection, but also the stronger the scar. As a general rule of thumb, sutures should be removed in the following timeframe:
- Face – 5 days
- Scalp, limb, chin, chest, abdo – 7 days
- Foot, back, shins, over joints – 10 to 14 days
- To remove the sutures, place the “stitch cutter” flat against the skin and underneath the knot. Simply turn the stitch cutter 90 degrees to break the thread and remove the suture material with forceps.
Steristrips / Tissue Glue
- No needles, good for kids
- Quick, easy
- On correctly chosen wounds, resu lt is as good as sutures
- Minimises infection
- Use on wounds that edges oppose well
- Do not use on wounds under tension or over joints
- Cleanse then dry the wound
- Evert edges with hands or forceps
- Consider applying benzoin / friar’s balsalm to wound edges to allow better adherence of of steristrip (do not get in wound)
- Explain care – do not get wet, both glue and steristrips will fall off by themselves
- Dry dressing over wound
- Return if wound opens
- Run along everted edges, or row of drops, hold for 30 secs.
- Can sting
- Do not allow into wound (acts as foreign body)
- Keep dry until falls off at about 10 days
- Stapling is an alternative method of closure which is often used where there is a long wound which would require extensive suturing.
- Simply oppose the wound and centre the stapler over the wound
- As with suturing, keep the staples approximately 0.5cm apart
Removal of Staples
- The longer the staples are left in place, the greater the scarring and potential for irritation and infection, but also the stronger the scar. As staples are generally left over longer wounds where cosmesis is less important, staples should be removed in 10-14 days
- To remove the staples, place the lower “hook” of the staple remover under the staple and then close the staple remover handles which draws the staple up and out. Pull gently up and remove.
- Aim to keep skin edges dry, dressing should absorb any fluid/ooze eg melolin
- Consider vaseline gauze on abrasions/wounds that might adhere to dressing
- Ideally keep dressing on until ROS
- Change if filled with moisture
- If cannot dress eg scalp, can get minimally wet after 48 hours – dab dry, do not soak