Core Skills:
- Suture
selection
- Needle
selection
- Laceration
repair
- Skin
Biopsy- punch, shave, excision
Online
Reference: Pfennigers
Procedures in Primary Care (MD Consult) (Graphics
below are from this reference.)
Review
Article on Laceration
Management
Best Online Sites:
http://www.bumc.bu.edu/Departments/PageMain.asp?Page=5914&DepartmentID=69
http://www.bumc.bu.edu/Departments/PageMain.asp?Page=6067&DepartmentID=69
http://www.practicalplasticsurgery.org/techique-bk.html
Also useful, and specific
information regarding plastic repair and perineal repair:
http://www.emedicine.com/derm/topic828.htm
http://www.plasticsurgery.org/medical_professionals/publications/Everyday-Wounds-Ch09-Suturing-Principles.cfm
http://www.moondragon.org/obgyn/procedures/suturing2.html
Suture Selection
See
Table for types of suture, components and average duration of tensile strength.
| Absorbable |
| Gut |
Plain |
Mammalian
collagen |
7
to 10 days |
|
| Gut |
Chromic |
Mammalian
collagen |
21
to 28 days |
|
| Polyglycolic
acid (Dexon *
) |
Mono |
Synthetic
polymer |
20%
in 15 days 5% in 28days |
|
| Polydioxanone
(PDS) |
Mono |
Polyester
polymer |
70%
in 14 days 50% in 28 days |
|
| Polyglactic
acid (Vicryl) |
Braided |
Coated
polymer |
60%
in 14 days 30% in 21 days |
|
| Polyglyconate
(Maxon) |
Mono |
PoIyester |
81%
in 14 days 59% In 28 days |
|
| Nonabsorbable |
| Cotton |
Twisted
fibers |
Cotton
fiber |
50%
in 6 months 30% in 2 years |
|
| Silk |
Braided |
Silkworm
spun fiber |
Gone
in one year |
|
| Steel |
Mono |
Alloy
Fe-Ni-Cr |
Indefinite |
|
| Nylon
(Ethilon, Dermalon) |
Mono |
Synthetic
polymer |
Loses
20% a year |
|
| Polyester
(Mersilene) |
Braided |
Polyester |
Indefinite |
|
| Polypropylene
(Prolene
) |
Mono |
Synthetic
polymer |
|
|
Needle Selection
Types:
1.
Cutting - for dermal, subcuticular or full skin thickness penetration
2.
Tapered
- for subcutaneous or organ wall closures
Suture Selection
External
Nylon
(3-0 to 4-0) - non-absorbable
Subcuticular
Vicryl or Dexon (2-0 to 4-0) - absorbable
Facial
or scalp gut or fine nylon (5-0 to 6-0) - Gut - absorbable, Nylon -
non-absorbable
Suture Size
Selection
Undermining
Separate
layer below dermis from adipose layer
Reduces
wound tension
Interrupted Sutures
Commonly
used for laceration repair
Deep
stitches needed for dead space closure. Invert
if possible.
Interrupted Technique
Enter/exit
skin at perpendicular angle to encourage eversion of the skin layer.
Mattress Stitch
Ideal
for high tension wounds
Holds
deep layer as well as superficial
Everts
skin layer
Instrument Tie
Initiate
with a Surgeons knot to hold in place
4
ties for most suture
Inverted Suturing
Enter
deep into tissue with needle initially
Allows
knot to be buried deep.
Subcuticular Stitches
Running
stitch through sub-Q layer.
Anchor
on at least one end, usually both ends.
Inverted
stitches to bury anchoring knots.
Punch Biopsy
Circular
punch after local anesthesia
Specimen
should contain full dermal thickness.
Shave Biopsy
Excisional biopsy
3-4
to 1 ratio length to width for excisional biopsy
Triangular Laceration
3
point suture to bring wound edges together
Spares
vascular supply to tip of skin wedge
Resolving Dog Ears
Lift
and fold over, then excise the
excess tissue.
Removal of Sutures
(Adults)
Face
and head 5-7 days
Trunk
7 days
Arms
8 days
Hands
8-10 days
Legs
9 days
Feet
10 days
Children
about 1 day less at each site
What not to close
Grossly
contaminated wounds (sticks, dirt)
Bites
Gunshot
or fragmentation wounds
Wounds
> 12 hours old.
Managing
Contaminated Wounds
-
Initially
clean and debride
-
Pack wound
with gauze
-
Leave packing
in place for 3-5 days. Check wound daily.
-
Day 5 -
consider delayed primary closure
Delayed Primary Closure
Wound
closure done at day 5 post injury
Will
heal equally fast as normal primary closure
Allows
for wound to pass period of greatest risk of infection
Debride
dead tissue from wound before closing.
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