Final year‎ > ‎

14.01.10 Suturing

Mechanisms
  • Shear
    • e.g. Knife
  • Tension
    • Distributed impact over bony prominence
    • => Devitilised tissue
  • Compression
    • Hard/focused impact over bony prominence


Considerations

  • Diabetes
    • Microvascular insufficiency delays healing
  • Drugs
    • Steroids, Aspirin
    • OCP (mechanism unknown)
  • Region
    • Thick skin heals slowly


Initial exploration

  • Document well! cf Medico-legal
  • Length / Breadth
  • Depth
    • Fascia / Muscle / Bone
  • NV status
  • Tendon injury
    • Make sure you move the distal structure over the full range, to check for damage initially hidden


Xrays

  • FB
  • Bony injusry
  • Pneuomo/haemo peritoneum/thorax
  • Air track
    • Air trapped in tissue reveals depth of wound
    • => Can tell if joint cavity penetrated
  • May need to use a marker to identify site


Lignocaine

  • Use 1%
  • Max:
    • 3-4 mg/kg plain
    • 7 mg/kg with 1:100,000 adrenaline
  • i.e. Max approx. 20 ml typically
  • Infiltrate from WITHIN wound, not through skin


Closure

  • Pressure with WET gauze to control haemorrhage
  • Use antiseptics BEFORE irrigation
  • 50 ml syringe + green needle + one hand provides appropriate pressure for cleaning
  • Staples interfere with CT - e.g. Head injury
  • Don't put glue in wound - Overlay after approximation
  • Suture
    • Absorbable (vicryl) for tissue under skin
    • Non-absorbable (ethilon, prolene) for skin
  • Sizes:
    • 5, 4, 3, 2, 1, 0, 00 (2-0), 000 (3-0) .... (11-0)
    • 4-0 - 6-0 usual for skin
  • Plain forceps are ONLY for FB removal (crush tissue)
  • Scalpel to debride if necessary
  • Pretty much always simple interrupted:
    • 1 cm between sutures, 0.5 cm on face
    • 3-4 mm from wound edge
  • Can use a layer of simple interrupted in fat layer underneath to close in layers
  • Don't strangulate tissue with know - Leave room for oedema


Timing

  • Within 6-8 hrs => Primary closure
    • Or within 24 hrs on face (better blood supply, cleaner)
  • >8 hrs wait
    • Inadine dressing (povidone-iodine)
    • Prophylactic Abx
  • >4 days => Secondary closure
    • Infection would be there by this stage
    • May have to freshen edges with gauze/scalpel to encourage healing



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