Suturing

SUTURING

Purpose A.

Functional

Close wound 2

Promote

more rapid

Prevent

infection

Preserve B.

healing

of wound

function

Cosmetic 1.

Promote

Adherence

to

wound these

healing

with

2 principles

least will

amount

dictate

of

scar

and deformity

how a wound

is

handled,

the

I'

techniques

II.

Types A.

B.

used

of

to

suture

close

the

wound

and

the

type

of

suture

material

used.

material

Absorbable

ex.--plain

and chromic

1.

Purpose--closure

of

deep

2.

Why close

deep

layers

a.

Close

deep

space--prevent

b.

Take

tension

c.

Prevent

of

cat

gut,

layers-sub

Dexon

Q,

fascia,

Vicryl and sub

cuticular

primarily?

skin

herniation

abscess

formation

sutures of

muscle

through

fascia

Non-absorable

; ,

1. Synthetice

monofilament-ex.

nylon,

,

Prolene I

2.

Braided

III.Principles A.

silk

which

Minimum

amount

1.

Do not

2.

Even

a.

minimize of

scarring

tension

strangulate, tension

place

on both

sutures

and

on skin appose

skin

skin

edges

deformity edges edges

at same distance

only

from

edge and at same depth

on

side of wound

b. B

Minimize

close

deep layers

primarily

amount of forei~n~

1. Use smallest

size

suture

body in wound , material

strong

enough to hold

wound together

2.

IV

c

Remove

0

Use

E

Dcbridement

F

Avoid

G

Modify

cleansing

sutures

least

of

of

B.

Size

C.

Shape

D.

Depth Relationship

skin

G

Need for

H

Is repair

step

of

Includes

wound

available

contused

edges--casts wound

to

nonviable

edge

a permanent enable

more

visible

precise

shadow

closure

History)

to surrounding

Underlying

material

and/or

configuration

Location

by

suture

ragged

inversion

of

as possible

inflammatory

A

Step

and debridement

as soon

Wound Assessment

E. ~

v.

Thorough

structures

structures debridement

or restructing

beyond your

approach

to

capabilities?

wound

repair

A.

Assessment

B

Anesthesia--only

C

Wound prep--by E.R. attendant---Betadine Additional wound prep.--Betadine

after

checking

neurologic

function scrub-saline-irrigati,on '

0 1.

For badly

contaminated

wounds-jet

E

Debridement

I:

Closure

G

Sub Q closure--interrupted

sutures

H

Sub cuticular--interrupted

with

I

Skin

of

Fascia

closure--size

Cleanse

K

Charting

wound

and

with

N/S with

periosteum

dependent

--non

J

and/or

irrigation

absorable surrounding

with inverted

on

Vicryl Knon or

running

location

monfilament tissue

-2

with

N/S

and dress

Vicryl

21g needle

v

A.

ocation

acerations--by

Specific Scalp

1. Shave area of scalp 2. Lidocaine

with

epinephrine

3. Repair galea-3 4. Skin--3

ot 4"0 Vicryl

or 4-0 Prolene

S. No dressing Face 1

1ayer after

6-0 Prolene

galea

is

3-5 days

closed

for

suture

removal

Eye brow

a.

Do not shave eye brow

b.

Proceed

c.

If

with

repair

layers

is

necessary,

debride

of

follicles

debridisment

parallel 2.

removal

essential

6. Close in single B

1 week suture

to

Eye

lids

a.

If

margins

b.

If

near

direction

of

lids

medial

are

as necessary

hair

both

involved--consult

epicanthus

look

for

sides

in

a line

opthalmology lacrimal

duct

injury

N

function

3. Cheek

a. b.

Be aware If

near

~~ 4

of

stensons

tragus

to

or

repair

over

parotid,

check

facial

or anesthesia

Lip If

vermillion

border

approximation

5

duct

of

is

Use

3

First

stitch

4.

Tatoo

vermillion

with

S.

Anesthesia--upper

lip

6.

Nerve

7.

Check to

8.

Skin--6-0.

Ear--6-0 a.

b.

If

closure at

Block--lower

is

crucial

to

get

exact

necessary border

methylene infra

lip

blue

orbital

Mental

through

nerve

and through

Prolene

Mucosal

surface

5-0 silk

Prolene cartiledge

involved,

ichondrium

only.

Anesthesia

for

occipital,

greater

of

if

vermillion

see if

it

border

2.

layered

involved

vagus

in

repai~ith

extensive

injuries

auricular,

canal) _'t-

Vicryle

use nerve

auricula

opposing

per-

blocks(lesser

temporal

and branch

Stint

dressing

Nec

D

Be sure

platysmus

On area

of

is

not

violated

Leg 1.

X-ray

knee,

looking

Generally

2

be sure

for

blood

a

4-0

b.

3-0 Vicryl

air

laceration

in

supply

doesn't

extend

into

joint--

"

joint.

to

skin

poor.

Leave

sutures

longer

10-14

days

Prolene

deep

Arm

E

1

Be sure

distal

2

Neu--sensory

vascular,

neurologic,

and motor

functions

and tendon of

median

ulnar

functions and

radial

are

intact

nerves

Tendons--

1=

a

Extensions

b

Superfi~ial

c

Wrist

of

finger

and deep

extensors

and

finger

flexors

flexors

Hand 1. Neurologic and tendon functions must be checked. 2. Digital nerve injuries if proximal to dip joint in adults repaired. 3

Tendons--repaired

Ii

Digital

5

Finger

nerve tip

a. Call

block

at

level

of metacarpals

if:

1.

greater

than

2.

bone is

exposed

3.

nail

4.

if

bed is in

1 cm. area

injured

doubt

toward

conservative

management

VI I :Speci_al Lacerations A.

Flaps Proximal Length

vs vs.

.

distally

3 corner

laceration

c

Circular

lacerstions--Dog

Infection A

based

width

R

VII

repair

avulsions

hand surgeon

Trend

b

immediately--Delayed

ears

Prophylaxis

'etanus 11-

can be

1.

If

never

immunized

2.

If

fully

immunized---greater

3.

If

fully

imrnunized---less

4.

If

fully

imrnunized---greater

cons ider

B.

Tet.

Tox

or

0.5

incomplete--Tet. than than

tox. 5 years

5 years than

and hyper

O.5cc Tet.

tet.

250

tox.

0

5 years tet.

hyper

and highlY

contaminated

250 U

",

Antibiotics 1.

Generally

2.

If

not

contaminated

necessary or

puncture

wound

consider

prophylaxis--cover

for

staph 3.

Bites---controversial, a. .b.

No sutures Generally

no consensus vs.

loose

suturing

antibiotics

1.

Human--staph

2.

Animal--coverage

given

/

agent for

staph

-~-

and pasteurella

U