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