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

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

• Hold needle with needle holder — Figure 7.28 and Figure 7.29

• 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

• 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

• 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

• Now do another knot looping the suture material once a round the forceps — Figure 7.38, Figure 7.39, Figure 7.40. If knot slipping, do third tie to make it firm

• 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

• Choice of 2 methods — 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 sutures — see Figure 7.43 – Figure 7.47
• Horizontal sutures — see Figure 7.48 – Figure 7.51

Vertical mattress

Horizontal mattress

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)

• Use absorbable material and horizontal mattress sutures to pull fascia together — Figure 7.52, Figure 7.53, Figure 7.54

For longitudinal laceration (wound along muscle)

• Use absorbable material and simple interrupted sutures — 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

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

• See examples of anchoring difficult angles — 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

• 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

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