Lacerations

Suturing Techniques

-Simple
-Running ("baseball")
--Subcuticular running
-Half-buried mattress (corner
-Single interrupted
-Horizontal mattress technique
-Vertical mattress technique

Irrigation

-Tap water is safe to use for irrigation
-Copious irrigation w/ normal saline or tap water washes away foreign matter and dilutes the bacterial concentration to decrease post-repair infection -Warmed irrigation solution is more comfortable for the patient
-30- to 60-mL syringe with 18-ga needle cleanses at 5 to 8 lb per square inch of pressure w/o damaging tissue
- NO! Povidone-iodine solution, hydrogen peroxide, and detergents should NOT be used because their toxicity to fibro-blasts impedes healing

Immediate Eval of a Laceration

-Evaluation of wound
-Bleeding controlled using direct pressure
-Patient history including mechanism and time of injury and
-Personal health information (e.g., human immunodeficiency virus and diabetes status; tetanus immunization history; allergies to latex, local anesthesia, tape, or antibiotics).
-Careful exploration of the laceration to determine severity and whether it involves muscle, tendons, nerves, blood vessels, or bone
-Baseline neurovascular and functional status of the involved
-Lacerations that expose underlying tissue or continue bleeding should be repaired

Goals of Laceration Repair

-Achieve hemostasis
-Avoid infection
-Restore function
-Achieve optimal cosmetic results

Definitive Laceration Management

Depends on the
-time since injury
-the extent and location of the wound
-available laceration repair materials -skill of the physician

Guidelines for Seeking Surgical Consultation for Laceration Repair

-Deep wounds of the hand or foot
-Full-thickness lacerations of the eyelid, lip, or ear
-Lacerations involving nerves, arteries, bones, or joints
-Penetrating wounds of unknown depth
-Severe crush injuries
-Severely contaminated wounds requiring drainage
-Wounds leading to a strong concern about cosmetic outcome

Optimal Time Interval from Injury to Repair

Anatomic location of the wound, health of the patient, mechanism of injury, and wound contamination are factors
-Noncontaminated: up to 12 hours post-injury
-Clean, well-vascularized tissue, such as the face and scalp >12 hours
-Older lacerations can be repaired with loose, single interrupted sutures that are sufficient to close the wound
-If no wound infection develops, it may be packed for three to five days followed by delayed primary closure.
-If infection occurs, it should be allowed to heal by secondary intention

Local Anesthesia for Repair

-Lidocaine 1% max 3-5 mg/kg or with epi 7 mg/kg
-Bupivacaine 0.25% max 1-2 mg/kg or with epi 3 mg/kg
-Epinephrine to decrease wound bleeding through vasoconstriction -Avoid epi w/ anatomic areas with end arterioles, such as the digits, nose, penis, and earlobes
-25 to 30 gauge, injecting slowly
-Warming the anesthetic solution, or buffering the solution with sodium bicarbonate 8.4% (1 mL of sodium bicarbonate per 10 mL of local anesthetic)
-In persons allergic to amide forms of local anesthetics, intradermal diphenhydramine 1% (created by adding 1 mL of diphenhydramine, 50 mg per mL solution, to 4 mL of sterile saline) may be substituted
-Lidocaine/prilocaine cream (EMLA) applied to intact skin and covered with an occlusive dressing one to four hours prior to repair
-In newborns, a maximum of one hour to avoid the theoretic risk of acquired methemoglobinemia

Laceration Repair Options

-Sutures: extensive debridement or multiple-layer closure, high skin tension over joints, thick dermis such as the back
-Tissue adhesives (dermabond): low skin tension, such as on the face, shin, and dorsal hand, may be effectively repaired with tissue adhesives, especially in children
-Staples: high skin tension over joints, thick dermis such as the back
-Skin-closure tape (steri strips): low-tension areas that are well-approximated

Which Suture?

-Absorbable sutures: polyglactin 910 (Vicryl), polyglycolic acid (Dexon), and poliglecaprone 25 (Monocryl), are used to close deep, multiple-layer lacerations
-Usually absorb within four to eight weeks
-Nylon, monofilament nonabsorbable sutures (e.g., polypropylene [Prolene]) must eventually be removed
-Silk sutures are no longer used to close the skin because of their poor tensile strength and high tissue reactivity.
-Optimal cosmetic results can by using the finest suture possible
--3-0 or 4-0 suture on the trunk
--4-0 or 5-0 on the extremities & scalp
--5-0 or 6-0 on the face
Blue-colored sutures may be beneficial for scalp lacerations in appropriate populations to differentiate the suture from the hair.
-Absorbable 3-0 or 4-0 suture for mucosal lacerations (e.g., mouth, tongue, genitalia) with significant hemorrhage or depth that involve muscular layers, or that may have significant functional or cosmetic outcomes, such as a split tongue, should be repaired

Tissue Adhesives

2-octylcyanoacrylate (Dermabond)
-Slough off spontaneously within five to 10 days
-Form a protective barrier to promote wound healing
-Can have antimicrobial effects
-Inappropriate for high-tension areas, such as over joints, unless the area is immobilized
-Contraindicated in patients at higher risk of poor healing (e.g., those who are immunosuppressed or have diabetes)
-Not be used for contaminated, complex, or jagged lacerations
-Should also be avoided on mucosal surfaces and areas that maintain moisture, such as the groin or axillae

Application of Tissue Adhesives

-After irrigation, the wound should be dried with sterile gauze and placed in a horizontal position
-Wound edges approximated
-Adhesive is applied in a thin layer over the wound with a 5-mm overlap on each side
-Three to four layers are applied with 30 seconds between applications
-Full tensile strength is achieved after 2.5 minutes.
-Antibiotic and white petrolatum ointments can remove tissue adhesive; therefore, patients must be instructed to avoid using them on the repaired wound
-Hair apposition technique is best for non-actively bleeding wounds that are less than 10 cm long when scalp hair is longer than 3 cm

Follow-up on Laceration Repair

Prevent infection and promote healing, an Ax or white petrolatum ointment can be applied daily to wounds not repaired with tissue adhesives. (Ax and white petrolatum ointments are equally effective)

Timing of Suture Removal in Days

Face - 3-4
Neck - 5
Scalp - 6-7
Arms and back of hands - 7
Trunk (chest and abdomen) - 7-10
Legs and top of feet - 10
Back - 10-12
Palms or soles - 14

TDAP

Give: unknown status, < 3 doses, >10 years for clean minor wound, >5 years for unclean major wound

Do not give if: > 3 doses and <10 years and clean wound, or < 5 years unclean major wound

TIG = tetanus immune globulin

Only give if < 3 doses or unknown and major unclean wound

When NOT to suture

-Grossly contaminated wounds
-Bites
-Gunshot wounds
-Fragmentation wounds
-Wounds > 12 hours old
Delayed closure should be completed 5 days after jury or debridement
-allows for the wound to pass the period of greatest risk of infection and heal equally fast as normal primary closure

Usual Secondary Infections for Lacerations

Gram +
-Staphylococcus aureus
-Streptococci
Gram -
-Proteus
-Klebsiella
-Pseudomonas

How to minimize scarring

-Maintain uniform tensile strength
-Make precise approximation of skin edges
-Close all dead space in wound
-Avoid excessive suturing

Indications for Ax with Lacerations

-The risk for infection is > than the side affects
-Wounds > 6 hours old
-Crushing wounds with compromised tissue
-Contaminated wounds that required extensive irrigation and/or debridement
-Extensive lacs to hands
-Immunocompromised or DM patients

Rationale for Suturing Lacerations

-Avoid infection and promote healing
-Minimize scarring
-Repair the loss of tissue integrity

When to Consult on Lacerations

-Complex lacerations
-Involvement of artery, bone, ligament, nerve, or tendon
- More than 6 hours old

When to use Lidocaine w/ Epi

Wounds that have considerable amount of bleeding characteristics
-scalp
-eyebrowns
AVOID!! digits and appendages d/t vasoconstriction

Suture Procedure

-Position patient
-Apply betadine at the beginning edges and expanding out in a circular pattern
-Gloves
-Inflitrate with 1% Lido (25-27ga)
-Inspect for foreign bodies or structures
-Irrigate as needed with sterile NS
-Trim ragged edges with iris scissors (undermine some to give good approximation
-Load needle driver
-Use forceps to evert edges
-Insert needle approx 0.5cm (<1cm) from edge
-Suture as desired
-Cleanse with sterile NS
-Pat dry and apply drsg

Documentation of Suture Procedure

-Anesthetic used
-Cleansing preparation
-Irrigation and amount
-Type of suture material
-Number of sutures
-Outcome
-How procedure was tolerated

Patient Education for Suturing

-Keep wound clean and dry
-Do not wash x24 hours
-May be OTA after 24 hours (covering will > risk of infection)
-Bathing after 48 hours
-If crust/ scab develops:
--Cleanse with H2O2 and cotton
--Gently
--Rinse with warm water
--Blot dry with clean cotton
-Acet. #3 q4-6h prn x 24 hrs, then acet, ibup, or napoxen q4H prn
-Watch for S/S of infection (pain after 24hrs, > temp, redness, swelling, yellow or green drainage, or foul odor)
-Apply Ax oint to lessen scab development
-Return to office in 48 hours for wound check

Which Suture for Extremities

-External: 4-0 or 5-0 polypropylene (Prolene) nonabsorbable
-Buried: 3-0 or 4-0 mild chromic gut (Vicyrl)

General Recommendations for Suture Selection

-Larger number the smaller the filament thickness
-Absorbable sutures >inflammation rxns than nonabsorbable
-Monofilaments require more knots
-Braided handle and knot easily but harbor bacteria
-Fascia heals slowly: use bigger, stronger sutures
-Mucosa heals faster: use small sutures

Which Suture for Trunk

-External: 4-0 or 5-0 polypropylene (Prolene) nonabsorbable
-Buried: 3-0 or 4-0 mild chromic gut (Vicyrl)

Which Suture for Face

-External: 5-0 or 6-0 nylon (Ethilon) nonabsorbable
-Buried: 4-0 or 5-0 absorbable

Why Do You Remove Sutures?

- > inflammation
- > scarring

Standard Suture Removal Technique

-Position patient
-Determine suture technique that was used on insertion
-Locate the end tie knot
-If crust is present, wipe away with cotton ball soaked H2O2, rinse with sterile H2O and dry
-Use forceps to grasp tip of suture, slide scissors under and cut
-Repeat until all sutures are removed
-Blot with 4x4 prn
-If suture line appears unstable, use steri strips or butterfly band-aid

Running Suture Line Removal Technique

-Position patient
-Determine suture technique that was used on insertion
-Locate the end tie knot
-If crust is present, wipe away with cotton ball soaked H2O2, rinse with sterile H2O and dry
-Cut the knot at the distal end of the suture line
-Grasp the opposite end know with forceps
-Gently pull with continuous steady motion
-Blot with 4x4 prn
-If suture line appears unstable, use steri strips or butterfly band-aid

Small Loop, Closed, and Difficult Suture Removal Technique

-Position patient
-Determine suture technique that was used on insertion
-Locate the end tie knot
-If crust is present, wipe away with cotton ball soaked H2O2, rinse with sterile H2O and dry
-Use #11 scalpel and place flat on skin
-Slide scalpel under suture and cut
-Grasp suture with forceps and remove
-Blot with 4x4 prn
-If suture line appears unstable, use steri strips or butterfly band-aid

Running ("baseball")

Use for long, low-tension wounds with properly placed deep sutures
-Used to secure a split- or full-thickness skin graft. T
-Theoretically, less scarring occurs because fewer knots are made
-Advantages: quicker placement, and rapid reapproximation of edges -Disadvantages: crosshatching, dehiscence, difficulty making fine adjustments along the suture line, and puckering of the suture line

Subcuticular Running Suture Technique

Used for closing small lacerations in low skin-tension areas where cosmetics is important, such as on the face
-the ends of this suture do not need to be tied, but they may be secured with slip knots or tape

Half-buried Mattress (corner) Suture Technique

Used for closure of a triangular edge b/c it does not compromise blood supply
-theoretically < tip necrosis
-used in cosmetically important areas such as the face.

Single Interrupted Suture Technique

Used for deep, multiple-layer wounds
-Easy to place
-Greater tensile strength
-Less potential for causing wound edema and impaired cutaneous circulation
-Allows adjustments prn to properly align wound edges as the wound is sutured
-Disadvantages: length of time required for placement and greater risk of crosshatched marks

Horizontal Mattress Suture Technique

-Used for gaping wounds
-High-tension wounds
-Wounds on fragile skin because it spreads the tension along the wound edge
-May also be used for temporary approximation of wound edges, allowing placement of simple interrupted or subcuticular stitches
-High risk of producing suture marks if left in place > than 7 days.
-May be placed prior to excision as a skin expansion technique to reduce tension
-High risk of tissue strangulation and wound edge necrosis if tied too tightly

Vertical Mattress Suture Technique

Use for everting wound edges in areas that tend to invert, such as the posterior neck or concave skin surfaces
-Maximizes eversion, reducing dead space, and minimizing tension across the wound.
-Disadvantages: crosshatching
-Removal is 5-7 days to < scarring
-Bolsters may be placed between the suture and the skin to minimize contact -Placing each stitch precisely and taking symmetric bites is especially important with this suture.

Contraindications for Tissue Adhesives

-Lacs that require larger than 5-0 suture
-Adhesive sensitivity
-Jagged or irregular lacs
-Mucosa or moist surface
-Contaminated wounds
-Bites or punctures
-Highly movable sites that can't be splinted (hands, feet)
-Crush wounds
-Axillae or perineum
-Potential for purulent exudate
- > 5cm big

Procedure for Using Tissue Adhesives

-Assess wound and irrigate prn
-Apply betadine at the beginning edges and expanding out in a circular pattern, then remove with Etoh pad and allow to dry
-Gloves
-Apply topic anesthetic prn
-Oppose wound edges with good approximation
-Crush Dermabound vial and invert (do not use excessive pressure)
-Apply to approximated wound edges when gtt is at applicators tip, use gentle brushing motion to edge
-Hold edges for 30 seconds (only 10 seconds to make corrections)
-If wound not appropriately approximated then wipe as much off as possible and apply liberally petroleum jelly for 30 minutes
-Apply x3 layers (layer must be dry before adding another) (do not blow or fan as this does not < drying time)
-Use the addition of Steri strips in high-tension areas

Patient Education for Tissue Adhesives

-No bandage required for adults, children may use to prevent picking
-Shower x6 hours later (short showers, dry off)
-No topical Ax (weakens glue)
-Will peel in 5-10 days
-Watch for S/S of infection
-Watch for S/S of infection (pain after 24hrs, > temp, redness, swelling, yellow or green drainage, or foul odor) return to office if +
-Return to office in 48 hours for wound check

Indications for Staple Insertion

-Rapid closure
- < skin allergies
-Prevent unsightly wound healing
-Promote accelerated wound healing
-Long linear lacs
-Scalp wounds
-Wounds of < cosmetic importance

Contraindications for Staple Use

-Crush wounds
-Ischemic wounds
-Highly contaminated wounds

Procedure for Staple Use

-Position patient
-Irrigate prn
-Cleanse 3-inch diameter
-Gloves
-Infiltrate with anesthetic (1% or 2%) may need epi
-Approximate skin edges
-Start at the center and work outward to prevent puckering
-Staple device perpendicular to skin and depress handle
-1/4 inch intervals
-Apply topical Ax oint
-Apply nonstick drsg
-Cover with 4x4
-Secure with tape

Patient Education for Staple Use

-Remove drsg after 48 hours
-Keep clean and dry
-Watch for S/S of infection (pain after 24hrs, > temp, redness, swelling, yellow or green drainage, or foul odor) return to office if +

Removal of Facial Staples

3-5 days
(also neck)

Removal of Ear Staples

5-7 days
(also ear)

Removal of Extremity Staples

7-10 days (or more)
Arms
Legs
Hands
Feet

Removal of Torso Staples

7-10 days (or more)
Chest
Back
Abdomen

Complete Removal of Staples

For small, well approximated, non-oozing wounds
-Position patient
-Gloves
-Insert bottom prongs of staple remover under staple and depress top handle (edges of staple will rise)
-Rock staple from side to side to remove from edges of skin
-Repeat til all staples are removed
-Cleanse with Etoh pads

Partial Removal of Staples

For large, healing poorly wounds with possibility of evisceration
-Position patient
-Gloves
-Insert bottom prongs of staple remover under staple and depress top handle (edges of staple will rise)
-Rock staple from side to side to remove from edges of skin
-Repeat with every other staple
-Apply benzoin in spaces where staples were removed (spread away from wound 1 1/2 inches)
-Apply Steri strips between remaining staples
-Cleanse with Etoh pads

Patient Education for Removal of Staples

-Watch for S/S of infection (pain after 24hrs, > temp, redness, swelling, yellow or green drainage, or foul odor) return to office if +

Indications for Steri-strip Application

- More resistance to infection
-Small and superficial wounds
-Little tension on wounds
-Extra support for sutured or stapled wounds

Procedure for Steri-strip Application

-Position patient
-Cleanse 3 inches in diameter
-Apply benzoin or other skin adhesive
-Start next to edge and extend outward 1 1/2 inch
-Allow skin adhesive to become tacky
-Apply strip pulling one skin edge to the other
-Apply enough strips to ensure closure
-Apply nonocclusive drsg (4x4) to keep C/D/I for the first 24 hours

Patient Education for Steri-strip Application

-Remove nonocclusive drsg x24hrs and keep OTA
-Keep clean and dry
-Return if wound separates when strip falls off
-Small amount of redness is normal
-Watch for S/S of infection (pain after 24hrs, > temp, redness, swelling, yellow or green drainage, or foul odor) return to office if +
-Return in 1 week for recheck and possible removal

Essentials of Skin Laceration Repair

-Administering anesthetic slowly, and warming or buffering the solution
-Tap water is safe to use for irrigation
-White petrolatum oint. is as effective as Ax ointment in postprocedure care
-Wetting the wound as early as 12 hours does not > risk of infection
-Patient education and appropriate procedural coding are important