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

2. 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

3. Wound Classification Four Classes Clean Clean-contaminated
Dirty/infected

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

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

6. 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

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

8. Wound Healing Four Stages Hemostasis Inflammatory Proliferative
Remodeling

9. 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

10. Hemostasis

11. 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

12. Inflammation

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

14. Phase III: Proliferative
Epithelialization
keratinocytes
Contraction
Fibroblast release of actin

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

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

17. Wound Closure
Primary closure
Secondary closure
Tertiary closure

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

19. 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

20. 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

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

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

23. Characteristics
Dyed
Undyed
Sizes 11-0 to 6

24. Suture Sizing

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

26. 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)

27. Suture

28. Size by Location

29. 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.

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

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

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

33. 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

34. 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

35. 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

36. 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

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

38. 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

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

40. Local Anesthetics

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

42. Equipment

43. 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

44. 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

45. Always cross skin at 90 degree angle

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

47. Rule of Halves 3 1 2

48. 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

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

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

52. Simple Interrupted

53. 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

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

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

58. Horizontal Mattress

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

60. Vertical Mattress

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

62. Running Subcuticular

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

64. Subcutaneous

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

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