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