Closing a wound

  • Consider best way to close wound
    • Sutures, staples, skin adhesive, adhesive strips, daily dressings to allow ‘healing by second intention’, delayed primary closure
    • Combination of methods (eg sutures and adhesive strips) especially on ragged wounds or thin skin
    • Tying clumps of child's hair together to close head wound. If hair too fine — spray with plastic skin to thicken
    • Give local anaesthetic if needed
  • Immunisation status — tetanus
  • Consider pain relief to take home — see Pain management
  • Antibiotics — see Injuries — soft tissue, Bites — animal or human, Injuries — spear and knife (stab) wounds

Do not

  • Do not close bite wounds

Surgical consultations

  • Plastic surgeon or other surgical specialist consult for
    • Large wounds — best closed in theatre, or needing grafting
    • Severely contaminated wounds
    • Tendon, nerve, vessel damage
    • Open fractures, amputations, joint penetrations. Laceration over site of fracture — treat as open/compound fracture even if exposure of bone unlikely
    • Compression injuries — can cause extensive soft tissue and muscle damage that may not be obvious straight away
    • Puncture or high-pressure injection wounds (eg paint or grease gun) — can later develop widespread tissue injury
    • Concern about cosmetic outcome by patient or family
    • Beware of wounds to chest or abdomen — may involve organs underneath

Suturing

Suture materials

  • Use smallest material possible, but strong enough to hold skin/tissue in place and close wound
  • Choice depends on depth and location of wound, age and occupation of person, conditions that may delay healing

Table 7.2  Suture material sizes and removal times  

Table 7.3 Suture material by wound type  

Putting in sutures

Attention

The bigger the area of skin/tissue being pulled together and the more strain on suture, the bigger the suture will need to be. Compromise is needed

  • Do not shave eyebrows — may not grow back
  • Make sure sutures are not too tight, too loose, too close together. Skin should not be puckered, buckled, gaping
    • Edges of wound should be slightly raised and pressing together (kissing), so healthy tissue meets healthy tissue
  • Count how many sutures you put in, record in file notes
  • Make sure person knows when sutures need to come out
  • If wound in prominent place (eg face) — consider sending for specialist cosmetic consult
  • Use of subcutaneous suture will take tension from skin sutures, minimise risk of wound breakdown and allow skin sutures to be removed earlier

Do not suture

  • Dirty or infected wounds
  • If there could be a fracture underneath
  • Wounds more than 8 hours old
  • Fingers — risk of damage with swelling. A couple of loose sutures are ok, close with adhesive strips if needed
  • Deep wounds (especially in hands or feet) until you are sure there is no damage to tendons, nerves, deep muscle
  • Coral cuts
  • Stab wound (eg spear, knife)
  • Gunshot wounds
  • Anything you are not confident with, especially on face

What you need

  • Sterile dressing pack
    • Extra sterile gauze
  • Sterile gloves
  • Sterile suture set — scissors, toothed forceps, needle holders
  • Suture material needed
  • Lidocaine (lignocaine) 1%
  • Syringe and needles
  • Wound dressing and tape

What you do

For all sutures

  • Clean wound
  • Give local anaesthetic
  • Lay out dressing pack and equipment
  • Wash hands, put on sterile gloves
  • Check local anaesthetic working
  • Suture using appropriate technique — see below
  • Record number of sutures in file notes
  • Dress wound
  • Tell person
    • To keep wound dry for 48 hours — after this can shower and pat dry
    • Do not submerge in water
    • When to come back to have sutures removed — Table 7.2

Simple interrupted sutures

Figure 7.28  

Figure 7.29  

Figure 7.30  
  • Start by putting first suture in middle of wound
  • Put needle in at 90° (right angle) far enough from edge for skin not to tear, push down through skin
  • Take big enough ‘bite’ to get under skin layers but not into deep fat or muscle — Figure 7.30
  • Gently lift the skin on one side of the wound with the forceps and push needle through to the middle of the wound — Figure 7.31
  • Pull suture material through leaving a 2–3cm strand on the entry side
  • Re-grasp the needle and push it through the skin on the other side of the wound until it curves up and out, still at 90° (right angle) and same distance from wound edge as other side — Figure 7.32
  • Pull the suture through — Figure 7.33

Figure 7.31  

Figure 7.32  

Figure 7.33  
  • Loop the suture material around the forceps 3 times — Figure 7.34 then grasp and pull the loose end of the suture through to make a knot — Figure 7.35

Figure 7.34  

Figure 7.35  
  • Don’t pull wound edges together too tightly, just enough so edges are slightly raised when they meet (kissing) — Figure 7.36
  • Pull knot over to one side — Figure 7.37. Use same side for every knot

Figure 7.36  

Figure 7.37  

Figure 7.38  

Figure 7.39  

Figure 7.40  
  • Cut both ends, leaving about 1.5cm
  • Keep dividing wound in half with sutures until edges are together along whole length
  • As the wound starts coming together you should be able to make a suture by pushing the needle through both sides of the wound in one movement — instead of piercing each side separately (as shown in Figure 7.31 and Figure 7.32)

Figure of 8 sutures

Attention

  • For artery that won’t stop bleeding
  • Good for scalp and head wounds
  • Use size 2.0 suture material

What you do

Figure 7.41  

Figure 7.42  

Figure of 8 sutures, method 1

  • Put in needle and direct diagonally down to opposite side of wound
  • Exit wound and take suture material horizontally to original side of wound external to skin
  • Put in needle and direct diagonally up to opposite side of wound
  • Exit point will be horizontally across from first insertion point
  • Tie off suture at original insertion point
  • Example of continuous suture pattern — enter upper right, exit lower left, enter lower right, exit upper left
  • Creates a cross within the tissue and 2 parallel lines on skin surface

Figure of 8 sutures, method 2

  • Put in needle and direct horizontally to opposite side of wound
  • Exit wound and take suture material diagonally down to original side of wound external to skin
  • Put in needle and direct horizontally to opposite side of wound
  • Exit point will be diagonally opposite first insertion point
  • Tie off suture at original insertion point
  • Example of continuous suture pattern — enter upper right, exit upper left, enter lower right, exit lower left
  • Creates 2 parallel stitches within the tissue and a cross on skin surface

Mattress sutures — horizontal and vertical

Attention

  • Vertical — good for anchoring ragged edges that tend to invert  (fall into wound)
  • Horizontal — good for wounds under tension

What you do

Vertical mattress

Figure 7.43  

Figure 7.44  

Figure 7.45  

Figure 7.46  

Figure 7.47  

Horizontal mattress

Figure 7.48  

Figure 7.49  

Figure 7.50  

Figure 7.51  

Suturing muscle

Attention

  • Suture small tears in fascia (muscle sheath) or muscle may bulge (hernia)
  • Do not use simple sutures on wounds across muscle. Will pull through muscle fibres

What you do

For traverse laceration (wound across muscle)

Figure 7.52  

Figure 7.53  

Figure 7.54  
For longitudinal laceration (wound along muscle)

Figure 7.55  

Figure 7.56  

Suturing the scalp

Attention

  • Always explore wounds carefully to check for fractures underneath
  • Staples ideal for closing scalp wounds

What you do

  • Use interrupted sutures. Large needle, size 3.0 strong material for tough scalp skin
  • If bleeding is a problem — try closing wound quickly using large figure of 8 sutures, then apply pressure
  • Yellow suture material (eg Radene) easier to see

Suturing an eyebrow

Attention

Do not shave off eyebrows. Regrowth unpredictable

  • Make sure eyebrow lines up properly

What you do

  • Close small wounds with simple sutures, size 5.0 non-absorbable material

Suturing a lip

Attention

  • vermilion border (where skin and lip join) usually needs sutures
  • Mucosal surface may not need suturing if good blood supply and edges are joining well — but skin surface should be closed
  • Inside of mouth only needs suturing if large, loose flaps of skin
  • Use as few sutures as possible, lips can swell a lot

What you do

  • If wound crosses edge of lip — first suture should be put through both edges of divided vermilion border — Figure 7.57

Figure 7.57  

Suturing an ear

Attention

  • Do not suture through cartilage — it will tear, high risk of infection
  • Do not leave open with cartilage showing through skin edges — will not heal
  • Make sure edges of ear line up exactly 

What you do

For wounds with little or no cartilage damage

  • If missing cartilage is less than 0.5cm — close skin with simple interrupted sutures
  • Line up edges carefully

For wounds with cartilage damage

  • Trim as little cartilage as possible. If needed, trim up to 5mm so skin edges can be brought together without too much stretching
  • Suture skin together to cover cartilage and bring edges of cartilage together
  • Perichondrium (fibrous outer cover of cartilage) needs to be included in suture so stitch will hold. Do not include cartilage

For wounds on front and back of ear (eg bite)

  • Put first stitch on outer edge of ear, leaving a long thread
  • Suture wound on front of ear
  • Hold long thread on edge of ear with artery clip, pull ear forward so back of ear can be easily seen and reached
  • Suture wound on back of ear

Suturing skin flaps, torn skin with ragged edges

Attention

  • Skin flaps tend to have thin skin edges, take care not to tear with needle
  • Adhesive strips (eg Steristrips) may be better

What you do

Figure 7.58  

Figure 7.59  

Figure 7.60  

Figure 7.61  

Staples

Quick and easy. Wounds need straight, sharp edges. Ideal for scalp wounds.

Attention

  • Do not use for face or neck wounds, wounds with jagged edges, over creases or joints, hands or feet due to discomfort
  • Do not use for people who may need CT or magnetic resonance imaging. Cause scan artifacts, may be removed by powerful magnetic field
  • Same principles apply as for suturing wound
  • In large full thickness wounds, underlying tissue will need to be sutured with dissolving sutures before stapling 

What you need

  • Sterile dressing pack
  • Sterile skin forceps
  • Stapling device, staples, staple remover
  • Lidocaine (lignocaine) 1%
  • Sterile gloves
  • Dressing for wound

What you do

  • Give local anaesthetic
  • Lay out dressing pack and equipment
  • Wash hands, put on gloves
  • Check anaesthetic working
  • Staple either from left side of wound or from the middle
  • Bring wound edges together with forceps — Figure 7.62
  • Edges of wound should be slightly raised and pressing together (kissing), so healthy tissue meets healthy tissue
  • Hold stapling device at 40–65° — Figure 7.63

Figure 7.62  

Figure 7.63  
  • Line up opening of wound with centre of marker on the stapler head — Figure 7.64
  • Using gentle pressure, slowly squeeze trigger of stapling device to insert staple into skin
  • Properly placed staple will sit slightly above skin — Figure 7.65

Figure 7.64  

Figure 7.65  
  • Put staples 0.5–1cm apart until the wound is closed — Figure 7.66

Figure 7.66  
  • Put on antibiotic ointment if ordered and waterproof dressing
  • Tell person
    • Come back next day for wound review, in 7–10 days for removal of staples
    • They can shower with stapled scalp wounds within a few hours

Skin adhesive

  • Use on clean wounds with edges that meet easily, don't need deep sutures
  • Best for small wounds, facial lacerations
  • Anaesthetic not usually needed, good for children

Attention

  • Do not use on moist skin (eg inside mouth)
  • Do not get in wound. Uncomfortable, prevents healing
  • Use as little as possible. Too much weakens it, uncomfortably hot when setting
  • If using near eyes — protect eyes with pads

What you need

  • Skin adhesive (eg Histoacryl, Dermabond, Epiglue)
  • Dressing pack
  • Normal saline
  • Dry dressing
  • Sterile gloves

What you do

  • Lay out dressing pack and equipment
  • Check manufacturer's instructions for how to apply — each is different
  • Wash hands, put on sterile gloves
  • Make sure wound is clean and dry
  • Hold edges of wound together, apply very small amount of glue across join. Keep edges together for 30 seconds
  • Put on simple dry dressing, check after 24 hours
  • Tell person to come back to clinic if wound breaks open or gets infected
  • Skin glue doesn't need to be removed, comes off by itself in 1–2 weeks

Adhesive strips

Attention

  • Use only for clean superficial wounds
  • Use care when applying to old or fragile skin — apply without tension at least 1cm apart to allow fluid to drain into dressing
  • Do not use on moist wounds, hairy or sweaty areas

What you need

  • Skin adhesive strips 
  • Wound closure tape
  • Dressing pack
  • Normal saline
  • Dry dressing (eg island dressing film or cloth, adhesive foam dressing or fragile skin silicone foam dressing)

What you do

  • Lay out dressing pack and wash hands
  • Make sure wound is clean and dry
  • Hold edges of wound together, without tension, edges 'kissing' 
  • Apply tape without stretching across middle of wound, then apply strips on either side usually 3mm apart
  • Put on simple dry dressing, check after 24 hours
  • Tell person to come back to clinic if wound breaks open or gets infected
  • Keep clean and dry for 3–5 days — leave to come off by themselves