1. Wound Closure Workshop
Stanford University
Division of Emergency Medicine

2. Overview Good Wound Care Practices Wound Closure Techniques
- Basic suturing techniques
Tissue adhesive application
Staple placement
Adhesive Tapes

3. Good Wound Care Practices History
Mechanism - foreign body? - crush mechanism? - degree of contamination? - site and timing of the injury?

4. History Patient Factors
factors predisposing to poor wound healing; immunosuppression, diabetes, collagen disorders
tetanus status
allergies; antibiotics, anesthetics, latex

5. CDC Tetanus Guidelines

6. Good Wound Care Practices Physical Exam
Before anesthesia a detailed neurovascular and functional exam - may reveal a significant injury needing consultation and/or operative repair before exploration.
After anesthesia a repeat functional exam with exploration for foreign bodies and partial injuries.

7. Local Anesthetics

8. Local Anesthetics
True Allergic reactions to amides impossible (usually due to preservative)
Buffering, warming and slow injection decreases pain
Topical agents can provide adequate anesthesia in certain areas and can decrease the pain of infiltration
Theoretically they are histotoxic, but clinically this is not significant

9. Wound Preparation
Disinfecting solutions are bactericidal and cytotoxic and in general should not be used directly in wounds.
Best way to decrease infection is by pressure irrigation which will lower colonization.
no benefit to expensive antibiotic irrigants, saline and tap water are just as effective.

10. Selection of Wound Closure Devices

11. Suturing Techniques Simple Suture Dermal or Deep Suture
Mattress Sutures
Suture techniques for flaps

12. Simple Percutaneous Suture
Time honored
Can be used to close any wound with excellent cosmesis
Divide the wound in halves to avoid dog ears

13. Simple Suture Placement
The needle enters at 900 and is rolled in an arc resulting in
equidistant entry and exit points. Taking more depth than
width gives desired edge eversion.

14. The Use of Dermal or Deep Sutures
Advantages - remove tension off the wound to prevent scar widening over time - close potential dead space
Disadvantages - foreign bodies which potentiate infection

15. When Should Dermal Sutures Be Used?
Site
Age of Laceration
Degree of Contamination
Wound Tension: Dynamic vs. Static

16. Dynamic Wound Tension > 5 mm dermal sutures < 5 mm recommended
not required

17. Placement of Dermal Sutures
Note that the knot is buried in the depth of the wound
and the suture is in the dermis not fat

18. Vertical Mattress Sutures
Useful to take tension of wound edges without using dermal sutures
Everts wound edges Use in combination with simple sutures Remove on time to avoid track marks

19. Suturing Flaps
Traumatizing tips and flaps can cause vascular compromise
Flaps with less than 1/3 of the pedicle remaining should be removed and attached as a skin graft
Avoid
Proper Technique

21. Timing For Suture Removal
*Secure wounds with adhesive tapes or tissue adhesive after removal

22. Wound Aftercare for Sutures
Keep clean and dry
Ointments for hours only
Wounds prone to surface contamination for hours
Avoid sun exposure

23. Tensile Strength of a Wound Over Time

24. Pearls for Adjunctive Closures Staples
With the stapler centered over the wound, press it gently but firmly against the wound and depressed the trigger
This is a common mistake. People often apply no pressure and end up with partially applied “floating staples”.
Properly applied staples naturally evert the wound edges.

25. Pearls for Adjunctive Closures Tapes and Steri strips
Hemostatsis is necessary
Benzoin can improve adherence but must be kept out of the wound
Apply the tapes individually
apply securely on one side
then pulling the tape across, everting the edges

26. Pearls for Adjunctive Closures: Tissue Adhesives
Use proper good wound care practices
Achieve hemostasis - Topical anesthetics with epinephrine (LET, TAC etc.) are helpful and allow for proper wound cleansing
Appose wound edges tightly
DO NOT GET ADHESIVE IN THE WOUND!!!

27. Pearls for Adjunctive Closures: Tissue Adhesives
Wound approximation is key to optimal use
Steri strips can be used to achieve wound approximation
Cut them short and narrow
Leave in place to further re-enforce the wound

28. Well apposed wound edges with proper topical application
Laceration at
3 months

29. Wound Aftercare For Tissue Adhesives
Keep Dry
Do Not Use Ointments
Avoid Trauma
Sloughs on own