Suture Techniques in Primary Care Shawn A. Sutterlin, PA-C Watauga Orthopaedics

Objectives Review wound types and classification Understand the principles of wound healing Describe the 3 types of wound closure Overview of Suture materials Wound closure techniques

Wound Classification Four Classes Clean Clean-contaminated Dirty/infected

Clean Wounds Most common is elective surgical incision Primary closure 1-5% rate of infection

Clean Contaminated Wounds contaminated by local flora despite aseptic technique Cholecystectomy, appendectomy and hysterectomy 3-11% infection rate

Contaminated Open traumatic wounds in nonsterile environment Open fractures Surgical procedures in which there is a gross deviation from sterile technique (emergent open cardiac massage) 10-17% infection rate

Dirty or Infected Gross/heavy contamination or active infection Perforated viscera, abscess and traumatic wounds >27% infection rate

Wound Healing Four Stages Hemostasis Inflammatory Proliferative Remodeling

Phase I: Hemostasis Vasoconstriction stimulated by endothelial injury Platelet aggregation Coagulation cascade is activated and fibrin clot formed Platelets release pro inflammatory mediators and PDGF in preparation for subsequent phases

Hemostasis

Phase II: Inflammatory Inflammatory mediators released Vasodilation - provides increased blood supply to injury site Increase vascular permeability - allows plasma proteins, WBCs, into injured tissue Migration of WBCs from circulation into interstitium and phagocytose debris/microbes

Inflammation

Phase III: Proliferative Angiogenesis Granulation fibroblasts deposit extracellular matrix including collagen/elastin Characteristic beefy red appearance

Phase III: Proliferative Epithelialization keratinocytes Contraction Fibroblast release of actin

Phase IV: Remodeling Collagen remodeled along tension lines Cells no longer needed are removed by apoptosis May take many months

Patient factors Age Weight Nutrition Dehydration Blood supply Immunocompromised Chronic Disease Radiation therapy

Wound Closure Primary closure Secondary closure Tertiary closure

Primary Closure Most common Preferred method when appropriate Wounds are re-approximated acutely Dermis-dermis apposition Best cosmetic outcome

Secondary Closure Known as healing by secondary intention Wound edges are left un-approximated Granulation tissue formed Migration of keratinocytes provide re- epithelialization over granulation tissue Appropriate in wounds with soft tissue loss or severe contamination not closable by primary or tertiary means

Tertiary Closure Contaminated wound is I&D’d and left open for several days Wound is then closed as in primary closure when risk of complications declines Preferred method for high energy and highly contaminated wounds

Suture Materials Traits needed by suture Tensile Strength Knot security Ease of handling Low tissue reactivity

Characteristics Size Tensile Strength Monofiliment (nylon, prolene, monocryl) Multifiliment (vicryl, ethibond, Silk) Absorbable Non Absorbable

Characteristics Dyed Undyed Sizes 11-0 to 6

Suture Sizing

Absorbable Broken down in tissues by hydrolysis, enzymes and inflammation Time to resorb varies by material and diameter includes vicryl, monocryl, PDS, gut.

Non Absorbable Not broken down by hydrolysis or inflammatory reaction Walled off in body by fibroblasts or physically removed (skin sutures) Includes nylon, prolene, stainless steel, silk, polyester (ethibond)

Suture

Size by Location

Needles Cutting - skin and other tough tissue Taper - softer tissues inside body (bowel,vessels). Dilates tissues Blunt - felt to pose less risk of needle sticks. Most useful in fascial closure.

Before Closing Hemostasis Evaluate Irrigate Debride devitalized/contaminated tissues Should it be closed primarily?

Before Closing Evaluate the wound Time of injury Size and shape of wound Soft tissue loss Gross contamination/foreign body

Before Closing Wound depth Nerve, tendon, vascular involvement Bone involvement (open Fx) Uncontrolled hemorrhage

Wound Preparation Single most important step in preventing complications Control bleeding Remove all debris and devitalized tissue Irrigate copiously with NS Do not use iodine or hydrogen peroxide in the wound

When to Consult Specialist Deep wounds to hands/feet, thorax, abdomen, or pelvis Full thickness lac to eyelids, lips or ears Lacerations which involve bone, joint, tendon, artery, muscle or nerve Markedly contaminated wounds Crush injuries Concerns about cosmesis You don’t feel comfortable

When to Not Close Active infection Erythema/induration Puncture wounds Human/animal bites Delayed onset of treatment 12 hours for body 24 hours for face

Anesthesia General/spinal Anesthesia Used for large wounds and more invasive procedures Regional Anesthesia Lidocaine/bupivicaine infiltrated near peripheral nerve to produce anesthesia distally in extremity Digital, wrist and ankle blocks most common

Anesthesia Local Anesthetic agent infused directly into the tissues being treated Most common method in outpatient setting

Lidocaine Most common 1% should be adequate for most procedures Sodium channel blocker Rapid onset Relatively short duration of action Available with epinephrine helps control bleeding prolong duration of action

Bupivicaine Longer duration of action Useful in prolonged procedures as well as post procedure pain control Also available with epinephrine

Local Anesthetics

Caution!! Do not use local anesthetic with epinephrine on structures with limited circulation ears, nose, fingers, toes, penis

Equipment

General Considerations Handle tissues as little as possible Limit the time and force used in retracting tissues Do not pinch tissues with forceps, Gently lift wound edges to place suture Irrigate frequently to minimize contaminants and maintain moist wound bed Approximate, don’t strangulate

Needle should be secured 1/2 - 2/3 down the length needle from the tip Needle Position Needle should be secured 1/2 - 2/3 down the length needle from the tip

Always cross skin at 90 degree angle

Rule of Halves Allows better approximation of tissues Avoids “dog ears”

Rule of Halves 3 1 2

The Instrument Tie How to tie a perfect square knot every time Place needle driver parallel to and directly over incision Always wrap needle end over driver toward tail When tightening each throw, move needle driver to opposite side of incision. The key is to always wrap OVER needle driver and to always alternate sides

Basic Suture Methods Simple interrupted Simple running locked running Horizontal mattress Vertical mattress Running Subcuticular Subcutaneous (buried knot)

Simple Interrupted Most common closure performed Used in superficial wounds with minimal tension. Nylon or prolene Be careful of knot security

Simple Interrupted

Simple Continuous Rapid Best in short lacerations with no tension Helps with hemostasis If one knot fails, the entire closure is compromised Contraindicated in infected tissues as infection can propagate along suture line

Locked Continuous Used in wounds closed with moderate tension Helpful in obtaining hemostasis Similar concerns with knot security and integrity of closure

Horizontal Mattress For fragile tissue Distributes tension over wider area Helps evert skin edges

Horizontal Mattress

Vertical Mattress Used for maximal edge eversion Minimizes deadspace in deeper tissues Helps minimize tension

Vertical Mattress

Running Subcuticular Provides optimum cosmetic results Not for contaminated or infected wounds

Running Subcuticular

Subcutaneous Buries the knot Useful for minimizing deadspace in deeper wounds Helps relieve tension on skin closure May be used in dermis as well

Subcutaneous

After Closure Apply antibiotic ointment Non adherant sterile dressing Splint if appropriate Tetanus Antibiotics Schedule follow up 2-3 days

Suture Removal Face: 3-5 days Scalp: 7 days Chest and extremities: 8-10 days Joints, palms, soles: 10-14 days