Laceration repair: Difference between revisions
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[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Procedures]]
[[Category:Procedures]]
==Chart==
{{Suture chart}}
==Types==
{| class="wikitable sortable"
|+ Absorbable Sutures
|-
! scope="col" | '''Suture Type'''
! scope="col" | '''Days of Tensile Strength'''
! scope="col" | '''Complete Absorption'''
! scope="col" | '''Descriptions'''
|-
| Chromic Gut||7-21 days||90 days||Chromium treated to decrease tissue reactivity
|-
| PDS (Polydioxone)||14 days||180-240 days||Monofilament synthetic absorbable suture
|-
| Vicryl (Polyglactin)||21 days||90 days||Synthetic
|-
| Vicryl Rapid||10 days||42 days||Synthetic with radiation treatment for increased absorption
|}
{| class="wikitable sortable"
|+ Non Absorbable Sutures
|-
! scope="col"|'''Suture Type'''
! scope="col"|'''Tensile Strength'''
! scope="col"|'''Body Reactivity'''
! scope="col"|'''Filament'''
|-
| Nylon||High||Low||Monofilament
|-
| Silk||Low||High||Multifilament
|-
| Prolene (Polypropylene)||Moderate||Low||Monofilament stiff
|}
==Technique==
[[File:Simple_Interrupted_Suture.png|thumb|Simple Interrupted]]
[[File:Horizontal mattress suture.svg|thumb|Horizontal mattress]]
[[File:Vertical mattress suture.svg|thumb|Vertical mattress]]
[[File:Suture, before and after, RMO.jpg|thumb|Wound before and after suture closure. The closure incorporates five simple interrupted sutures and one vertical mattress suture (center) at the apex of the wound.]]
*Simple Interrupted
**Less potential for causing wound edema or impaired circulation
**Allows for alignment adjustments
*Simple Running
**Useful for long, linear wounds
**Risk of dehiscence if suture ruptures
*Horizontal Mattress
**Spreads tension over wound
**Useful for high tension wounds
*Vertical Mattress
**Great for wound eversion, closure of both superior and deep layers
**Useful when there is a contraindication to deep sutures
==See Also==
*[[Laceration Repair]]
==External Links==
*[https://www.msdmanuals.com/professional/injuries-poisoning/how-to-care-for-wounds-and-lacerations/how-to-repair-a-laceration-with-simple-interrupted-sutures?query=how%20to%20repair%20a%20laceration Merck Manual - How To Repair a Laceration With Simple Interrupted Sutures]
*[https://www.msdmanuals.com/professional/injuries-poisoning/how-to-care-for-wounds-and-lacerations/how-to-repair-a-laceration-with-horizontal-mattress-sutures?query=how%20to%20repair%20a%20laceration Merck Manual - How To Repair a Laceration With Horizontal Mattress Sutures]
*[https://www.msdmanuals.com/professional/injuries-poisoning/how-to-care-for-wounds-and-lacerations/how-to-repair-a-laceration-with-vertical-mattress-sutures?query=how%20to%20repair%20a%20laceration Merck Manual - How To Repair a Laceration With Vertical Mattress Sutures]
===Videos===
{{#widget:YouTube|id=TFwFMav_cpE}}
==References==
*Tajirian Ani et al. ''A review of sutures and other skin closure materials''. Journal of Cosmetic and Laser Therapy. 2010 Dec;12(6):296-302.
[[Category:Trauma]]

Revision as of 18:00, 1 March 2023

Indications

Contraindications

  • Body laceration >12 hours old
  • Face/scalp wounds >24 hours old

Management

Wound Preparation

  • Debridement is most important step in reducing infection/ promoting healing
  • Avoid betadine/chlorhexadine in wound
  • Not necessary to remove hair as this can increase chances of infection (if do, avoid using razor)
    • Can use antibiotic ointment to help keep hair out of the way

Irrigation

  • High pressure irrigation is best (can be achieved with 18 gauge syringe)
  • Tap water is as effective as sterile water/ normal saline[1][2][3]
    • Pressure from tap is ~45 psi, higher than syringe[4]
  • Irrigation optional for face/scalp wound as long as:
    • Not a bite wound
    • Not a contaminated wound
    • Not older than 6 hours
      • Often best to avoid irrigation of face and opt for cleaning with gauze to help prevent tissue distortion

Anesthesia

  • Can be topical or injected.
  • Topical
    • LET for open wound, EMLA for intact skin
      • EMLA needs to be left on 1-2 hours [5]
      • LET onset is 20-30 minutes[5], area will appear pale
  • Evaluate motor/sensation before giving local anesthesia
  • To decrease pain of injection:
    • Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine)
    • Inject slowly
  • Consider nerve blocks to avoid tissue distortion for cosmetic areas such as vermillion border
    • Also helpful for extremities, sole of foot
    • Digital block for finger lacerations

Maximum Doses of Anesthetic Agents

Agent Without Epinephrine With Epinephrine Duration Notes
Lidocaine 5 mg/kg (max 300mg) 7 mg/kg (max 500mg) 30-90 min
  • 1% soln contains 10 mg/ml
  • 2% soln contains 20 mg/ml
Mepivicaine 7 mg/kg 8 mg/kg
Bupivicaine 2.5 mg/kg (max 175mg) 3 mg/kg (max 225mg) 6-8 hr
  • 0.5% soln contains 5 mg/ml
  • May cause cardiac arrest if injected intravascularly
  • Do not buffer with bicarbonate
Ropivacaine 3 mg/kg
Prilocaine 6 mg/kg
Tetracaine 1 mg/kg 1.5 mg/kg 3hrs (10hrs with epi)
Procaine 7 mg/kg 10 mg/kg 30min (90min with epi)

Exploration

  • See Soft tissue foreign body
  • Explore to base of wound
  • Ideally done in bloodless field
  • Look for foreign bodies, tendon injury, or fracture
  • Possible glass or metal in wound = get XR or US to evaluate

Suturing

  • If laceration not closed immediately secondary to age of wound:
    • Irrigate and explore wound, then pack with non-adherent or vaseline gauze
    • Re-check in 3 days - may suture at that point if wound appears clean.

Steri-Strips

  • Just as good a suturing according to this [6] and other articles. Picture on how to do it property from the same article [6] which is under CC BY-NC-SA 4.0 license:
Steri-Strips

Skin Glue

  • Useful for areas of low tension and well approximated wounds
  • Apply 3 layers allowing 30 seconds for first layer to dry
  • Avoid in bite wounds, contaminated wounds, puncture wounds, mucosal surfaces, areas of high moisture (groin, axilla)
  • Avoid antibiotic ointments which can prematurely dissolve glue
  • If you accidentally glue the eyes shut use dexamethasone, neomycin, polymyxin B eyedrops (brand name Maxitrol in the U.S.) on the glue then gentle rubbing after 45 or 90 seconds [7]

Scalp Laceration

  • Scalp laceration can be done with staples or if the patient has enough hair with Hair Apposition Technique by twisting hair together and using dermabond.
  • Can bleed a lot, consider figure of 8 stitch to help with hemostasis
  • Often accompanied by hematomas which may require evacuation for proper skin alignment

Aftercare

  • Consider antibiotics for
    • Wounds contaminated by debris or feces
    • Caused by punctures or bites
    • Tissue destruction or in avascular areas
    • Neglected wounds
    • Underlying systemic immunodeficiency (diabetes, HIV, chronic steroid use, etc)
    • Impaired local defenses, such as peripheral arterial disease or lymphedema
    • Retained foreign body

Wounds contaminated by fresh water and plantar puncture wounds through athletic shoes should include Pseudomonas coverage

  • Splinting
    • Wounds over flexor surfaces or tension
  • Tetanus prophylaxis
    • Tdap 0.5cc IM to patients >7y with no booster within 5 yr
    • Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given
      • Require follow up Tdap at 1mo & 1 yr; age>60 = high risk of poor immunization
  • Dressing
    • Keep moist, not wet
      • Bandaid, xeroform, or ointment
  • Wound check
    • 48-72 hrs ONLY if high risk wound
      • No point in checking before 48hr (takes this long for infection to occur)

Scar Minimization

  • Preventing infection
    • Keep wound clean and covered
    • Apply antibiotic ointment twice daily
  • Once healed, encourage daily sunscreen use and Vitamin E creams

When to Call a Consultant

  • Signs of neurovascular or tendon injury
  • Facial wounds that cross cosmetic boundaries
  • Tissue loss

Billing

  • Anatomical location of wound
  • Size of wound
    • Length (cm) <2.5, 2.6-5.0, 5.1-7.5, 7.6-12.5, 12.5-20.0, 20.1-30.0, >30.0
  • Complexity
    • Simple, intermediate, or complex (depends on debridement, layers, complex stitch, drain, etc.)
  • Type and number of sutures

See Also

Special Lacerations by Body Part

References

  1. ↑ Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007 May;14(5):404-9
  2. ↑ Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013 Jan 16;3(1).
  3. ↑ Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD003861.
  4. ↑ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998 Nov;5(11):1076-80.
  5. ↑ 5.0 5.1 KUNDU S, et. al. Principles of Office Anesthesia: Part II. Topical Anesthesia Am Fam Physician. 2002 Jul 1;66(1):99-102.
  6. ↑ 6.0 6.1 Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds' Scar. Adv Biomed Res. 2018;7:49. Published 2018 Mar 27. doi:10.4103/abr.abr_148_16
  7. ↑ Liu et al. Inadvertent tissue adhesive tarsorrhaphy of the eyelid: a review and exploratory trial of removal methods of Histoacryl. Emerg Med J. 2020 Apr;37(4):212-216. doi: 10.1136/emermed-2019-209177. Epub 2020 Jan 9. https://www.ncbi.nlm.nih.gov/pubmed/31919233?dopt=AbstractPlus

Chart

Laceration Areas and Their Common Suture Type and Duration

Suture Usage
Area Size Type Days to Removal
Scalp Staples or 4-0 or 5-0 non absorbable 7
Ear 6-0 non absorbable (absorbable for cartilage repair) 5-7
Eyelid 6-0 or 7-0 absorbable or nonabsorbable 5-7
Eyebrow 5-0 or 6-0 absorbable or nonabsorbable 5-7
Nose 6-0 absorbable or nonabsorbable 5-7
Lip 6-0 absorbable NA
Oral mucosa 5-0 absorbable NA
Other face / forehead 6-0 absorbable or nonabsorbable 5
Chest/abdomen 4-0 or 5-0 non absorbable 12-14
Back 4-0 or 5-0 non absorbable 7-10
Extremities 4-0 or 5-0 non absobrable 7-10
Hand 5-0 non absorbable 7-10
Foot / Sole 4-0 non absorable 12-14
Joint (Extensor) 4-0 non absorable 10-14
Joint (Flexor) 4-0 non absorbable 7-10
Vagina 4-0 absorbable NA
Penis 5-0 non absorbable 7-10
Scrotum 5-0 non absorbable 7-10

Note: consider use of Fast Absorbing Gut (5-0/6-0) on Ear, Eyelid, Eyebrow, Nose, Lip and Face if anticipated difficulty with suture removal

Note: Favor absorbable sutures for facial repair especially in children

Types

Absorbable Sutures
Suture Type Days of Tensile Strength Complete Absorption Descriptions
Chromic Gut 7-21 days 90 days Chromium treated to decrease tissue reactivity
PDS (Polydioxone) 14 days 180-240 days Monofilament synthetic absorbable suture
Vicryl (Polyglactin) 21 days 90 days Synthetic
Vicryl Rapid 10 days 42 days Synthetic with radiation treatment for increased absorption
Non Absorbable Sutures
Suture Type Tensile Strength Body Reactivity Filament
Nylon High Low Monofilament
Silk Low High Multifilament
Prolene (Polypropylene) Moderate Low Monofilament stiff

Technique

Simple Interrupted
Horizontal mattress
Vertical mattress
Wound before and after suture closure. The closure incorporates five simple interrupted sutures and one vertical mattress suture (center) at the apex of the wound.
  • Simple Interrupted
    • Less potential for causing wound edema or impaired circulation
    • Allows for alignment adjustments
  • Simple Running
    • Useful for long, linear wounds
    • Risk of dehiscence if suture ruptures
  • Horizontal Mattress
    • Spreads tension over wound
    • Useful for high tension wounds
  • Vertical Mattress
    • Great for wound eversion, closure of both superior and deep layers
    • Useful when there is a contraindication to deep sutures

See Also

External Links

Videos

{{#widget:YouTube|id=TFwFMav_cpE}}

References

  • Tajirian Ani et al. A review of sutures and other skin closure materials. Journal of Cosmetic and Laser Therapy. 2010 Dec;12(6):296-302.
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