Stitches, Staples, and Glue: Wound Repair in the Emergency Department
Stitches, Staples, and Glue: Wound Repair in the Emergency Department
Authors:
Tina A. Cocuzza, MD, Clinical Instructor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark.
Tiffany Murano, MD, Assistant Professor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark.
Miriam Kulkarni, MD, Assistant Professor, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark.
Peer Reviewer:
Catherine A. Marco, MD, FACEP, Professor, Department of Emergency Medicine, Emergency Medicine Residency Program Director, University of Toledo College of Medicine, OH.
Introduction
Lacerations are a common reason for patients to come to the emergency department (ED). According to the Centers for Disease Control and Prevention data from 2007, "open wounds (excluding the head)" were the primary leading diagnosis for men between the ages of 15 and 64 years.1 In the same report, lacerations were repaired in approximately 5.1 million visits to the ED (4.4% of all ED visits).1
Wound repair is a common area for litigation in emergency medicine, accounting for 5-20% of all malpractice claims and 3-11% of all monetary awards.2 Among the most common reasons for litigation are failure to diagnose foreign bodies, wound infections, undiagnosed injuries to underlying structures (such as nerves and tendons), and violation of the joint.2
This article presents an evidence-based review on the evaluation and management of lacerations in the ED.
Wound Evaluation
When evaluating a patient with a laceration, it is important that the emergency physician obtain a detailed history prior to inspection of the wound. The mechanism of injury may provide important clues to the depth of the wound, presence of debris or foreign bodies, degree of contamination, and the possibility of injury to underlying structures. The time that the injury occurred is also important, as delays in treatment may alter the manner in which wounds are repaired. The amount of blood lost prior to presentation to the ED may raise the clinician's suspicion of injury to vessels in the area. The patient's symptoms also are important to address. Severe pain to the area out of proportion to the visible injury or a foreign body sensation may be due to an underlying fracture or presence of a foreign body, respectively. Paresthesias or loss of sensation may represent nerve injury or compartment syndrome. The past medical history, such a co-morbid illnesses, and tetanus status should be assessed and documented.
During wound inspection, the clinician should look for and carefully document the presence of gross foreign bodies or debris in the wound. For wounds on the extremities, tendon and muscular function distal to the wound should be assessed. Focused sensory and motor examination of involved areas should be performed prior to administration of local anesthesia.
Wounds that overlay joints should be assessed for violation of the joint capsule. Wounds that penetrate the joint capsule may introduce bacteria, resulting in septic arthritis. Therefore, wounds that violate the joint capsule routinely undergo washout in the operating room.3 The most common site of traumatic arthrotomy is the knee.4 If there is clinical suspicion, the saline solution load test may be performed to evaluate for communication between the open wound and the joint capsule. The saline solution load test involves injecting sterile saline into the joint capsule at a site remote from the injury and then performing passive range of motion of the joint. Extravasation of fluid from the traumatic wound site confirms the diagnosis of traumatic arthrotomy. The amount of injected fluid necessary to make the diagnosis of traumatic arthrotomy of the knee has been examined in two recent studies. Although some textbooks have recommended volumes as low as 50 mL for a saline load test of the knee, these two articles found that a minimum volume of 145-194 mL is necessary for the test to achieve 95% sensitivity.3,4
Local and distal vasculature should be assessed carefully. If a wound is actively bleeding, direct digital pressure should be applied for 10-15 minutes. Most bleeding from venous sources will stop with properly applied direct pressure. If digital pressure alone does not control the bleeding, a compression dressing of gauze sponges secured with an elastic wrap can be applied. This, in combination with elevation, is an effective method of hemostasis. Absorbable hemostatic agents, such as Gelfoam® or Surgicel®, can be used to control diffuse oozing in wounds that will be left open to heal by secondary intention. If bleeding persists despite these noninvasive techniques, the bleeding vessels may need to be ligated. To ligate a vessel, first clamp the bleeding end with a hemostat under direct visualization. Once hemostasis with the clamp is achieved, pass a 5-0 or 6-0 absorbable suture around the clamp, and tie it. Once the suture is secured, the clamp can be released.5 If the vessel is too small to be ligated, low temperature (about 600-700°C) electrocautery is another option. If bleeding in an extremity is persistent or severe, a tourniquet may be applied to stop bleeding so that the injured vessel can be identified and addressed. A blood-pressure cuff placed on the extremity proximal to the wound and inflated to a pressure greater than that of the patient's systolic pressure can serve as a tourniquet. Once the source of bleeding has been identified, the vessel can be ligated to achieve hemostasis.
Tetanus Toxoid
Tetanus is a potentially fatal disease resulting in spasm and rigidity of the skeletal muscles. It is caused by the exotoxin of the bacterium Clostridium tetani. Injuries that historically have been considered at a high risk for developing a tetanus infection are wounds contaminated with feces, saliva, or soil, burns, frostbite, crush and missile injuries, puncture wounds, and avulsions. As part of ED wound care, tetanus toxoid should be administered according to the most current recommendations by the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention published in 2010 (summarized in Table 1).6 Prophylaxis with tetanus-diphtheria toxoid (Td) is not indicated for minor or clean wounds unless the patient has not received a booster within 10 years, has had fewer than three doses, or has an uncertain immunization history.6 Td should be given to all patients who have contaminated or tetanus-prone wounds (i.e., frostbite, avulsions, burns, crush injuries) and who have not received a dose within the past 5 years, who have had fewer than three total doses, or have an uncertain immunization history. In patients who are 19 to 64 years of age, it is recommended that patients without prior vaccination with Tdap (a combination of tetanus, diphtheria, and acellular pertussis) receive a one-time dose.6 Td is recommended for those who have received prior Tdap for subsequent boosters. Pregnancy is not a contraindication to receiving the tetanus toxoid (Td/Tdap) and should be given if indicated.6
Table 1: Recommended Tetanus Prophylaxis
History of Tetanus Immunization (doses) |
Clean or Minor Wounds |
All Other Wounds* |
||
* Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, or frostbite. |
||||
Td or Tdap |
TIG |
TD or Tdap |
TIG |
|
Less than 3 or uncertain |
Yes |
No |
Yes |
Yes |
Three or more |
No |
No |
No |
No |
Last dose greater than 5 years ago |
No |
No |
Yes |
No |
Last dose greater than 10 years ago |
Yes |
No |
Yes |
No |
s6
Tetanus immune globulin (TIG) should be administered to patients who have tetanus-prone wounds and have not received prior immunization or if the tetanus immunization history is uncertain. The recommended dose for patients of all ages for postexposure prophylaxis for tetanus is 250 units by intramuscular injection. If Tdap is also given, it should be administered in a different syringe and at a separate site than the TIG.6
Radiographs, Fractures, and Foreign Bodies
The presence of a fracture associated with an open wound may alter the treatment plan, depending on the location of the injury. Open fractures of long bones require surgical cleansing in the operating room, while those on the digits may be copiously irrigated in the ED and discharged home. Additionally, open fractures are at high risk for infection and should receive intravenous prophylactic antibiotics. If there is a clinical suspicion that there may be an injury to the underlying bone, a plain radiograph should be obtained.
Wounds potentially may contain occult foreign bodies of various compositions, such as metal, plastic, gravel, glass, and wood. Detection and removal of this debris is important as it may delay wound healing, serve as a nidus for local inflammation and potential infection, and may result in subsequent loss of function. In the 1990s, undetected foreign bodies were a significant cause of litigation in the ED, accounting for 14% of all lawsuits and 5% of settlements.7
There are several radiologic modalities that can be used to detect foreign bodies in a traumatic wound. In the ED, plain radiographs, computed tomography (CT) scans, and ultrasound imaging are the most commonly available techniques. The sensitivity of each modality varies and is dependent on the composition of the foreign body.
Figure 1: Radiograph of Patient Stabbed in the Head
These are A-P and lateral plain radiographs of the skull of a patient who was stabbed in the head with a knife. The arrows point to a metal foreign body that happened to be the tip of the knife that broke off and was retained in the wound.
Figure 2: CT of Patient with Multiple Facial Lacerations
This is a CT scan of the head of a patient who had multiple facial lacerations from a motor vehicle accident. The arrow points to retained glass in one of the wounds.
Plain radiographs are the standard screening method used by emergency physicians to look for foreign bodies in wounds. Although useful for detecting radiopaque objects such as metal and glass, its sensitivity for detection of radiolucent objects, such as plastic and wood, is low. (See Figure 1.) In a retrospective study of the clinical characteristics and management of wound foreign bodies in the ED, Levine et al. found that the sensitivity of plain films for detecting foreign bodies was 98.6% for metal, 75.5% for glass foreign bodies, and 7.4% for wood foreign bodies.8 While computed tomography scanning is 100 times more sensitive in differentiating foreign bodies than plain radiographs,2 the degree of radiation exposure and cost of the examination limit the use of CT scanning for the sole purpose of detecting foreign bodies. For the last few years, ultrasound has been increasingly used for detecting foreign bodies in the ED. (See Figures 3 and 4.) The accuracy of ultrasound to detect foreign bodies is dependent on the equipment specifications, skill of the operator, and size of the foreign body. Several studies comparing foreign bodies of various compositions suggest that ultrasound is a better study to detect foreign bodies such as wood and gravel when compared to plain films.9,10 While MRI is highly accurate for detecting foreign bodies, its use for this purpose is impractical and should be reserved for cases in which there is suspected vegetative matter that is unseen on other imaging modalities.11
Figure 3: Ultrasound Showing Wooden Foreign Body12
The echogenic focus and prominent acoustic shadow are signs of foreign body.
Reprinted with permission from Hill R, Conron R, Greissinger P, et al. Ultrasound for the detection of foreign bodies in human tissue. Ann Emerg Med 1997;29:353-356.
Figure 4: Ultrasound Showing a 2 cm Foreign Body in Longitudinal Section12
Reprinted with permission from Hill R, Conron R, Greissinger P, et al. Ultrasound for the detection of foreign bodies in human tissue. Ann Emerg Med 1997;29:353-356.
Foreign bodies that are visualized on physical examination should be removed prior to primary closure of the wound. The presence of one foreign body should heighten the clinician's suspicion for additional foreign bodies. If a foreign body is radiographically detected but is not visible in the wound upon inspection, the physician needs to weigh the risk of destroying adjacent tissues in its retrieval against leaving it in the wound. If the foreign body can be located without causing extensive trauma to surrounding tissues, an attempt should be made to locate and remove the object. If there are any small foreign bodies that were detected by radiography but that are not visible on physical exam, the wound should be copiously irrigated. The emergency physician should inform the patient of these findings and that, despite a good faith effort to remove these objects, remnants still may be left in the wound. These facts should be carefully documented in the patient's medical record.
Anesthesia
Adequate anesthesia of the wound is necessary to perform thorough wound exploration, cleansing, and debridement, as well as optimal closure. Local anesthesia may be injected into the intradermal tissues, around regional sensory nerves, or applied topically to the surrounding skin.
Anesthetics are classified into two groups: amides (examples: lidocaine and bupivacaine) and esters (examples: procaine, tetracaine). Since there is little cross-reactivity between the two groups, if there is a reported prior allergic reaction to agents in one class, it is generally safe to use an agent in a different class.
Allergies to lidocaine are rare.13,14 Reactions are generally attributed to the preservative methylparaben, which is contained in the multiple-dose vials. To complicate matters, methylparaben is molecularly similar to one of the degradation products of the anesthetics in the ester class, and, therefore, use of esters in these patients may also be problematic. In this case, lidocaine from a single-dose source that does not contain a preservative (such as the lidocaine used to treat cardiac arrhythmias) may be used. If a patient reports prior allergic reactions to medications in both the amide and ester groups, local infiltration with diphenhydramine or benzyl alcohol may be used as an alternative. Studies have shown that when infiltrated locally, diphenhy-dramine and benzyl alcohol provide anesthesia that is comparable to that of 1% lidocaine.15,16 While local infiltration of benzyl alcohol has been shown to be significantly less painful than diphenhydramine, its duration of anesthesia is shorter when compared to lidocaine but is comparable to diphenhydramine.15
Table 2: Properties of Common Anesthetics Used for Local Infiltration20-22
|
Anesthetic Agent |
Range of Concentration (%) |
Maximal Dose |
(mg/kg) |
Duration of Action (hours)* |
|
* Duration of action is dependent on concentration, location of infiltration, and combined use with a vasoconstrictive agent. |
||||
|
(-) epi |
(+) epi |
|||
|
Amides |
||||
|
Lidocaine (Xylocaine) |
0.5-2 |
4.5 |
7 |
0.5-2 |
|
Bupivacaine (Marcaine) |
0.125-0.5 |
2 |
3 |
1.5-8 |
|
Mepivacaine |
0.5-1 |
4.5 |
7 |
0.25-2 |
|
Esters |
||||
|
Procaine (Novocaine) |
0.5-1 |
7 |
9 |
0.25-1 |
Although the onset of action of each agent generally ranges between 2 to 5 minutes, the duration of action and maximum doses vary. (See Table 2.) An anesthetic combined with a vasoconstrictive agent, such as epinephrine (5 µg/mL of a 1:200,000 solution), has several advantages. Anesthetic solutions that contain epinephrine may be helpful in achieving hemostasis, as the vasoconstrictive effects reduce local blood flow. It also reduces the rate of vascular absorption, allowing more anesthetic molecules to reach nerve membranes, resulting in greater depth and duration of anesthetic effects.17
It has been taught for many years that anesthetics containing epinephrine should not be administered to the tip of the nose, digits, ears, or the penis, as it may theoretically cause irreversible vasoconstriction of the end-arterioles, leading to necrosis. However, this tenet has been refuted by recent studies of digit and hand surgery using epinephrine-containing anesthetics and critical reviews of the literature. Lalonde et al. prospectively studied the use of anesthetic agents containing low-dose epinephrine (≤ 1:100,000) in elective finger and hand surgeries and found no digital infarction in any of the 3110 enrolled patients (1340 of the cases involved injections into the fingers).18 The authors do warn that since the contraindications for epinephrine use are not well established, caution should be taken in patients with pre-existing vascular insufficiency.18,19 The authors also comment that injection of epinephrine-containing anesthetics into digits should be used by those physicians who are well educated in the use of phentolamine for reversal in the event of ischemia.18,19
Topical anesthetics have been employed for years in the pediatric population and are an excellent alternative for patients who have aversions to needles. Topical agents contain combinations of various anesthetic and vasoconstrictive substances and are applied directly to the wound or designated area. The ideal location for topical anesthetic use is one that is highly vascular, allowing for maximal and expeditious absorption. TAC (tetracaine, adrenaline, and cocaine) was once a popular agent, but its use has fallen out of favor after it was found to be associated with seizures, cardiac arrest, and death.23-25 Subsequent combinations with a higher safety profile, such as LET (lidocaine, epinephrine, and tetracaine) and EMLA (eutectic mixture of local anesthesia, which contains 2.5% lidocaine and 2.5% prilocaine), have been developed. Studies comparing EMLA to TAC have found that more wounds initially treated with TAC required subsequent local wound infiltration (55% of TAC-treated wounds vs. 15% of EMLA-treated wounds).26 However, the onset of anesthesia was faster with TAC (29 minutes) as compared to EMLA (55 minutes).26 The long onset of action and depth of absorption, which may require additional local infiltration for wounds requiring multiple layer closure, are the main disadvantages to topical anesthetic use for wound closure in the ED.
Pain will be associated with the local injection of the anesthetic agent. The emergency physician may use methods to reduce the discomfort associated with infiltration. Studies have shown that buffering the local anesthetic with 8.4% sodium bicarbonate solution used in a 1:10 bicarbonate:anesthetic ratio results in less pain during injection and faster onset of anesthetic effect without adversely affecting the wound infection rate.27,28 The use of smaller-gauge needles (27 to 30 gauge) will reduce the amount of pain at the site of injection.22,29 In addition, there are data that show that patients experience less pain with infiltration of local anesthesia when the needle was placed through the wound edges rather than through the surrounding intact skin.30
Regional anesthesia, or nerve blocks, involves anesthetizing a specific peripheral nerve remote from the site of injury. Advantages of regional anesthesia over local infiltration include less pain with administration, lower amounts of agent required for desired anesthetic effect, and less tissue distortion, allowing for improved cosmesis. The main disadvantages are that it requires a cooperative patient to achieve infiltration at appropriate landmarks and it carries a risk of inadvertent intravascular injection.
Wound Preparation and Cleansing
Although studies have found no significant difference in infection rates in wounds repaired with the physician wearing non-sterile gloves, implementation of a sterile technique is still recommended for all wound closure in the ED.22,31 The emergency physician should use clean or sterile powder-free surgical gloves. Cleansing of the surrounding skin with an antiseptic agent should be performed prior to local wound infiltration with anesthetics. The most common antiseptic agents contain either iodophor or chlorhexidine. Caution should be taken to avoid application or inadvertent spillage of these solutions directly into the wounds, as they have been shown to have deleterious effects on wound healing.29
When performed properly, wounds that are irrigated prior to primary closure result in improved wound healing and a lower rate of infection. Sterile normal saline is a common solution for wound irrigation; however, the use of tap water for irrigation is acceptable, as some studies have found that tap water irrigation is effective without an increase in wound infection.32,33 Irrigation with tap water allows for large volumes to be delivered into the wound, but its use may be limited by the low irrigation pressure from the faucet and the fact that wounds in certain locations may make their positioning over a sink difficult. Agents such as povidone iodine, hydrogen peroxide, or other detergents should not be used to irrigate wounds, as they have toxic effects on tissues, can impair wound healing, and do not alter wound infection rates.34
The amount of irrigation fluid used will depend on the size of the wound and the degree of contamination. The efficacy of irrigation to reduce bacterial colonization of a contaminated wound is directly proportional to the pressure applied to the wound surface.29 Low-pressure irrigation, defined as 0.5 pounds per square inch (psi), is used for relatively clean wounds and may be achieved using a bulb syringe. High-pressure irrigation, defined as 7 psi, is used for wounds that are highly contaminated.29 High-pressure irrigation may be achieved by using a 19-gauge needle or catheter attached to a 30 to 60 mL syringe.22,29 Although it significantly reduces the incidence of infection in contaminated wounds, high-pressure irrigation may cause significant tissue damage and theoretically may increase the risk of infection due to dissemination of bacteria.
Surgical consultation should be obtained for highly contaminated wounds requiring extensive wound debridement and/or extensive cleaning.
When irrigating wounds, the emergency physician should use a protective eye shield and a commercial device that reduces the amount of splatter, if available.35
When managing wounds that are in areas that contain hair, it is sometimes helpful to remove the surrounding hair to facilitate wound closure. Some literature has shown that use of razors for hair removal releases the normal bacteria flora that resides in the follicles and, thus, results in a higher rate of wound infection.36 Thus, it is recommended that hair be removed by using scissors to trim the surrounding hair. Eyebrows should never be shaved, as they serve as important cosmetic landmarks for wound approximation and the degree of hair re-growth is unpredictable.
Wound Debridement
Devitalized or heavily contaminated tissue does not promote wound healing, as it acts as a medium for promoting bacterial growth and inhibiting phagocytosis.29 Debridement is a process by which these tissues are removed from the wound. Although devitalized fat, muscle, and skin are equally capable of promoting bacterial growth, identification of the precise limits of these tissues presents a challenge.29 The emergency physician should obtain a surgical consultation if there are any questions of tissue viability, if the wounds are heavily contaminated, or if there is involvement of specialized tissues such as tendons or nerves. These wounds frequently require surgical cleansing, exploration, and debridement in the operating room. In general, as little tissue as possible should be removed. Wounds that require extensive debridement or are heavily contaminated are frequently best treated by delayed primary closure, as they are at high risk for infection. In this manner, the risk of infection can be reduced, and the wound and tissue viability may be reassessed.
Time of Closure
When to close a traumatic wound is an important decision and is based on the amount of time between the onset of injury and presentation to the ED, the location of the wound, the degree of contamination, and risk of wound infection.
Primary Closure. Primary closure is when a wound is repaired upon initial presentation within hours of the injury. This method has multiple advantages over other closures because it provides the best functional and cosmetic outcomes, reduces patient discomfort, and speeds wound healing.
The majority of lacerations are repaired using primary closure, which results in more rapid healing and less patient discomfort when compared to secondary closure.22 The wound-infection rate is relatively low for lacerations primarily repaired in the ED, occurring less than 5% of the time. While most studies of laceration management focus on infection rates as the primary endpoint,16 investigators have recently found that patients are more concerned with the cosmetic appearance of healed lacerations,22,37 and research has shifted toward measuring wound cosmesis as the primary outcome.
The main disadvantage of primary closure is the increased risk of infection in contaminated wounds.38 With contaminated wounds, the emergency physician should strongly consider opting for treatment with delayed primary closure or secondary closure.
Delayed Primary Closure. Delayed primary closure is when a wound is sutured closed 3-5 days after the time of injury. The underlying principle behind delayed primary closure is that bacterial colonization levels decrease over time in wounds that are left open, reaching their lowest point 96 hours after the wound occurs.38 At this point, there is less of a risk of infection, and closure of the wound is permissible. The wound should be irrigated, debrided, and dressed at the time of presentation. The wound can be irrigated again and closed with sutures in 4 days.29 Delayed primary closure has a lower risk of infection than primary closure and a better cosmetic outcome than allowing the wound to heal by secondary closure.
Delayed closure is the method of choice for wounds that are clearly contaminated or at high risk for infection.38 Other wounds that may be candidates for delayed closure are wounds that present after a delay. There is controversy surrounding the "golden hour" for wound repair. While some studies have found an increased infection rate in wounds closed more than 4 hours after injury, others have found no difference in wounds closed up to 19 hours post injury.22,39 Wounds on the scalp and face are less likely to become infected than wounds on the trunk and extremities.22 Delayed closure may be the option of choice for late-presenting wounds in immunocompromised patients, such as diabetics.22
Secondary Closure. Secondary closure (or secondary intention) is when the wound is not repaired but is allowed to heal by the formation of granulation tissue. The disadvantage of secondary closure is that it produces more scarring than primary closure, producing a poorer functional and cosmetic outcome. Secondary closure is the method of choice for infected wounds and contaminated small wounds such as puncture wounds.38 Superficial eyelid lacerations that comprise less than 25% of the lid also heal well by secondary intention.40
Methods of Closure
Deep Sutures. Deep sutures are those that are placed in tissues below the epidermal layer. Placing deep, dermal sutures helps relieve skin tension and decreases dead space and hematoma formation.41 There have been animal studies showing that dermal sutures increase the infection rate in highly contaminated wounds.42 However, other studies have found no effect on infection rate in clean, noncontaminated wounds.43 Sutures placed through adipose tissue do not hold tension and have been shown to increase infection rates, especially in contaminated wounds and, thus, should be avoided.22,44,45
Some studies have found that the placement of deep sutures improves cosmetic outcomes.45 However, a large retrospective analysis found that the placement of deep sutures had no effect on three-month cosmetic outcome, and wounds with poor cosmetic outcomes tended to be wider than those with optimal cosmesis.46
Singer et al. performed a randomized, controlled trial that compared single-layer and double-layer closure of small (less than 3 cm) and non-gaping (less than 10 mm wide) facial lacerations. The study found that while the closures performed with deep sutures took longer to perform, there was no difference in cosmetic outcome between single-layer and double-layer closure.47
Wound Repair Technique
Simple Interrupted and Running Sutures. Simple interrupted sutures consist of a single loop through the skin and subcutaneous tissues that is secured at the skin. Multiple simple interrupted sutures are usually required along the length of a wound. Simple interrupted sutures have several advantages they are easily mastered, and they can be adjusted to maintain wound eversion.48,49 Wound eversion is important to the final appearance of the healed scar. Wounds that are not everted can become inverted or indented as the wound heals, producing a cosmetically unsatisfactory scar.49
One major disadvantage of simple interrupted sutures is the tendency to produce cross-hatch scarring along the edges of the wound, especially in wounds under high tension. This can be avoided by placing deep or buried sutures in gaping or high-tension wounds.48
A variation on the simple interrupted suture is the running suture, in which the stitch is extended beyond one throw to produce a line of interconnected loops that close the entire defect in one stitch. The advantages of the running suture are that it can be performed rapidly, and tension is evenly distributed across the wound. There are several disadvantages to the running suture. Like the simple interrupted stitch, it can produce cross-hatch scarring. It can also produce puckering of the wound if the skin is too loose or too tight. Unlike interrupted sutures, final adjustments cannot be made without removing the entire suture from the skin. The resulting approximation of the edges may be less accurate than that achieved with interrupted sutures.48 Running sutures are best used in wounds under low tension and in areas where suture placement is not critical for the ultimate cosmetic result.48
Mattress Sutures. Vertical mattress sutures are often used to close wounds under high tension, since they are able to produce eversion of the wound edges while reducing wound tension and eliminating dead space.48,50 Because the external segments of the vertical mattress stitch compress the skin adjacent to the wound, vertical mattress sutures can produce scarring, especially in tissues that are extremely edematous. (See Figure 5.)48 Despite these concerns, one small study that compared the cosmetic results of surgical incisions closed with vertical mattress stitches to those closed with running stitches found that the vertical mattress stitch produced a better cosmetic outcome at six weeks and one year.50
Figure 5: Classic Vertical Mattress Suture48
Reprinted with permission from Adams B, Anwar J, Wrone D, et al. Techniques for cutaneous sutured closures: Variants and indications. Semin Cutan Med Surg 2003;33:306-316.
Horizontal mattress sutures minimize wound tension and are often suggested as methods of closure for gaping wounds and flap wounds under high tension.48 Like the vertical mattress stitch, the external segments of the horizontal mattress stitch can compress the surrounding skin and produce scarring.48
Figure 6: The Corner Stitch48
Reprinted with permission from Adams B, Anwar J, Wrone D, et al. Techniques for cutaneous sutured closures: Variants and indications. Semin Cutan Med Surg 2003;33:306-316.
The corner stitch is a useful variation on the horizontal mattress stitch in which the suture enters through the skin on one side of the flap, is passed through the dermal tissues, and exits through the skin on the opposite side of the flap. (See Figure 6.)48 This avoids penetrating the epidermis of the flap with a loop that could cause strangulation. One study demonstrated improved blood flow (measured by laser Doppler) in the tips of flaps that were closed with a corner stitch as opposed to flaps closed with vertical loop stitches.51
Material
The ideal wound-closure device would allow for meticulous wound closure, be rapid and easy to use, painless, result in excellent cosmesis with a low infection rate, be of low risk to the health care provider, and be cost-effective.22,52 None of the currently available wound closure devices meet all these criteria, and there are advantages and disadvantages to all of the available choices.52 Currently, sutures are the most common material used for wound closure, with tissue adhesives, staples, and surgical tapes being other options.22,52
Adhesive Tapes. A noninvasive choice for wound closure is adhesive tapes. These tapes are not often used for primary wound closure in the ED, mainly due to high rates of wound dehiscence.41,45 Adhesive tapes alone cannot maintain wound integrity, especially in areas subject to tension.22,53 However, they are sometimes used after suture removal to decrease tension on the healing wound and can be used to close linear wounds that are under minimal tension.41,45
Another disadvantage associated with the use of adhesive tapes is that they require the use of adjuncts, such as tincture of benzoin. These adjuncts have been shown to increase induration and wound infection despite the fact that the tapes themselves are less reactive than other methods of closure.22,54,55 These adjuncts are also toxic to wounds and must not enter the wound.22
Sutures. Sutures offer the greatest tensile strength and lowest risk of wound dehiscence. Sutures can be described based on the following characteristics: composition, handling characteristics, absorption, tissue reactivity, size, and retention of tensile strength.5 Desirable handling characteristics in a suture include smooth passage through tissues, ease in knot tying, and stability of the knot once tied. Smooth sutures pull through tissues easily, but knots slip more readily.5 Options for sutures can be described as natural vs. synthetic, monofilament vs. polyfilament, and further classified as absorbable vs. nonabsorbable. (See Table 3.)
Table 3: Classification of Sutures
|
Absorbable |
Suture Type |
Nonabsorbable |
Suture Type |
|
Plain catgut |
Natural monofilament |
Nylon |
Synthetic monofilament |
|
Chromic catgut |
Natural monofilament |
Polypropylene |
Synthetic monofilament |
|
Polyglactin (Vicryl) |
Synthetic polyfilament |
Silk |
Natural polyfilament |
|
Polyglycolic acid |
Synthetic polyfilament |
Linen |
Natural polyfilament |
|
Polydioxanone (PDS) |
Synthetic polyfilament |
||
Nonabsorbable sutures retain most of their tensile strength for more than 60 days, are relatively nonreactive, and are appropriate for closure of the outermost layer of the laceration.22,41 Nonabsorbable sutures are made from natural fibers, such as silk, and have more tissue reactivity than synthetic fibers. Consequently, natural-fiber sutures increase the risk of infection and should be avoided in wounds with bacterial contamination.41,45 Removal of nonabsorbable sutures is required.
Absorbable sutures are used for closure of structures deeper than the epidermis. Use of absorbable sutures is generally reserved for deep dermal closure; however, some studies suggest their use for skin closure in children to avoid the discomfort of suture removal is appropriate.45,56 Synthetic absorbable sutures have less reactivity and greater tensile strength than natural absorbable sutures, such as catgut. The synthetic absorbable sutures increase the time the wound retains 50% of its tensile strength from 1 week to 1-2 months.42,45 These synthetic absorbable sutures are particularly useful for closures under a lot of tension or for dynamic areas.41
A monofilament suture is made of a single strand. This structure is relatively more resistant to harboring microorganisms, thus having lower infection rates compared to polyfilaments. The major disadvantage of monofilaments is premature suture failure due to weakening of the sutures by crushing or crimping the suture during placement.57
Polyfilament sutures are composed of several filaments twisted or braided together. These sutures offer greater tensile strength and better pliability and flexibility than monofilament sutures. Because polyfilament materials have increased capillarity, the increased absorption of fluid may act as a tract for the introduction of pathogens.57
In general, monofilament sutures decrease tissue reactivity and infection rates as compared to polyfilament sutures, while polyfilament sutures offer better workability and tensile strength. Synthetic and monofilament sutures have decreased infection rates compared to natural and polyfilament or braided sutures and are generally preferred for this reason.45,58
Size of suture material (thread diameter) is related to the tensile strength of the suture threads. In other words, threads of greater diameter are stronger. Choosing the correct suture size to use depends on the tensile strength of that tissue.5,59,60 The tensile strength of the suture material should be only slightly greater than that of the tissue, because local tissue damage is proportional to the amount of suture material placed in the wound.5,59,60
The numbers that classify the suture are inversely related to its size. Thus, 0-0 suture material is larger in diameter than 7-0 suture material. In general, deep structures, such as fascia, can be closed with 3-0 or 4-0 sutures, subcutaneous tissue can be closed with 4-0 or 5-0 absorbable sutures, and skin closure can be performed with 4-0 or 5-0 nonabsorbable material.5 Exceptions to this are facial wounds, including lips and eyelids, and wounds under high tension, such as wounds over joints. Facial wounds should be repaired with 6-0 or smaller nonabsorbable sutures, while high-tension wounds should be repaired with 3-0 or 4-0 non-absorbable materials. (See Table 4.)5
Table 4: Suture Choices for Wound Closure5
|
Location |
Suture Size |
Type of Suture |
|
Subcutaneous tissue |
4-0 or 5-0 |
Absorbable |
|
Trunk/extremities |
4-0 or 5-0 |
Nonabsorbable |
|
Face |
6-0 |
Nonabsorbable |
|
Joints |
3-0 or 4-0 |
Nonabsorbable |
Staples. There are advantages and disadvantages to using staples for wound closure. The major advantages are that they can be applied more quickly than sutures and have been shown to have less tissue reactivity and a lower infection rate than sutures.5,62-64 It should be noted, however, that the lower rates of bacterial growth and infections with the use of staples as compared to sutures has been shown only in animal models.63 Other studies have shown that there is limited clinical significance to the differences in bacterial growth and infection rate.65 The use of staples is also advantageous when saving time is important, such as in mass-casualty incidents or patients with multiple wounds.46
The major disadvantage is that staples do not allow for as meticulous a closure as sutures and they cause more discomfort during removal.45,62 Staple removal also requires a staple-removal device, which may or may not be available at primary care offices.41 Overall, staples are considered useful for scalp, trunk, and extremity wounds.61,65
Table 5: Antibiotic Prophylaxis Is Recommended for the Following High-risk Traumatic Wounds
- Open fractures (wounds with underlying fractures)
- Wounds violating joint capsules
- Grossly contaminated (presence of soil, debris)
- Retained foreign body
- Wounds involving tendons or cartilage
- Animal, marine, or human bites
- Delayed presentation prior to closure (> 18 hours)
- Puncture wounds or crush injuries
Tissue Adhesives. Tissue adhesives have been used outside the United States for many years. They were approved for use in the United States in August 1998 and have rapidly gained popularity.22 This is likely because there have been studies showing superior speed of application, patient preference, and similar short- and long-term cosmesis compared to other standard methods of closure.66
The tissue adhesives, as a class, contain cyanoacrylates, which are formed by the condensation of cyanoacetate and formaldehyde.67 When this molecule comes in contact with anionic substances, such as blood, the cyanoacrylate molecules come together into long chains, forming a solid film that holds the wound edges together.68 This adhesive film sloughs off in 5-10 days as the outer layer of skin regenerates and the wound heals; thus, there is no need to remove the adhesive.68
One initial concern with the tissue adhesives was the histotoxicity associated with the formaldehyde that is part of the cyanoacrylate molecule. However, no significant degradation occurs until the tissue adhesives have sloughed off and, as long as these tissue adhesives are used topically, the formaldehyde does not cause any toxicity.
There have been many studies that have examined infection rates and cosmetic outcome in wounds repaired with cyanoacrylates compared to standard suturing methods. One study showed equivalent rates of wound infection, dehiscence, and cosmesis when comparing wounds closed with tissue adhesives vs. sutures.68 A randomized, controlled trial comparing 900 lacerations and surgical incisions at 10 clinical sites found wound closure to be faster when using cyanoacrylates, but outcomes of wound infection, dehiscence, and cosmesis were comparable.69 These findings have been replicated in many studies and in a wide range of specialties.67 A recent meta-analysis concluded that rates of wound infection and cosmetic outcomes were similar after repair of surgical incisions with either sutures or tissue adhesives.70
Some studies have shown less comparable results when adhesives were used for traumatic lacerations. A systematic review of eight randomized, controlled trials comparing cyanoacrylates to suturing for traumatic lacerations (including low- and high-tension wounds) and surgical incisions showed a statistically significant increase in the rate of wound dehiscence when cyanoacrylates were used for traumatic lacerations. They concluded that topical skin adhesives should only be used for low-tension lacerations and surgical incisions.67,71 Another option is to use deep dermal sutures in combination with tissue adhesives and immobilization for higher-tension wounds.67,72
The major advantages of the tissue adhesives is that they can be applied rapidly, do not require local anesthesia, and do not need to be removed.72 One quoted disadvantage is the cost of the tissue adhesives. However, when you include the cost of suture kits, suture removal kits, and dressings required for standard suturing, tissue adhesives may actually be less costly.76
Tissue adhesives should not be used alone for high-tension traumatic lacerations or wounds over major joints.67 They also should not be used on mucous membranes, hair-bearing areas, or areas exposed to frequent moisture or friction to avoid early sloughing and wound dehiscence.67
If the tissue adhesive results in suboptimal wound closure or requires removal for improper placement of the adhesive, applying antibiotic ointment or petroleum jelly may facilitate removal. If rapid removal of the adhesive is required, acetone can also be used.
Antibiotic Prophylaxis
Although it varies from study to study, the incidence of traumatic wound infections ranges between 4.5-6.3%.39 Whether this rate can be reduced with post-injury prophylactic antibiotics is controversial due to lack of good supportive data, however this practice remains the standard of care in many situations.
For patients who have compromised immune systems (such as those patients who are taking chemotherapeutic or immunosuppressive agents, or have diabetes or HIV), the use of prophylactic antibiotics is less controversial and is recommended.39 The use of prophylactic antibiotics for traumatic wounds in patients with intact immune systems is not so straightforward, and there are limited data to support this practice. In fact, there are no current data to support the routine use of antibiotic prophylaxis for simple wounds in immunocompetent patients.39
Traumatic head and neck wounds have been shown to have lower rates of infection, presumably due to the highly vascular nature of these areas.22,39,77 Antibiotic prophylaxis is still recommended for oral wounds because of the increased levels of the endogenous flora (>106 bacteria per gram of tissue), in spite of the paucity of supportive data.29 Similarly, antibiotic prophylaxis is advised for hand wounds and wounds involving tendon injuries, although there are no compelling data to support this recommendation.39
When compared to shearing injuries, crush or compression injuries are generally considered wounds that are at an increased risk for infection due to the larger amount of energy exerted on the involved tissues resulting in reduction of blood flow to the wound edges.29
There are certain high-risk wounds that require antibiotic prophylaxis regardless of the location of the wound and the immunocompetency of the patient. Animal and human bites, wounds that contain debris or soil, or those that have underlying fractures require antibiotics due to the increased risk of infection.
The choice of antibiotics for prophylaxis should be similar to that for established infections and should cover the routine skin flora in addition to any site- and source-specific flora. Although administration of a parenteral dose prior to discharge will expedite adequate tissue concentrations, this practice has been shown to have no advantage over the oral route.78 The course of prophylactic treatment should be between 3 and 5 days.39 Recent literature has shown community-acquired methicillin-resistant Staphylococcus aureus (MRSA) to be the most common source of skin infections; however, since the overall carriage rates for MRSA among the general population are low, the routine use of antibiotic prophylaxis to specifically cover this organism has not been recommended.79,80
Current recommendations for prophylactic antibiotic use for open fractures are dependent on the classification of the fracture. Patients with Type I (fracture with an open wound that is clean and less than 1 cm) and Type II (fractures with an open wound that is greater than 1 cm in length and without extensive soft-tissue damage) injuries should receive a first- or second-generation cephalosporin to cover gram-positive organisms. A fluoroquinolone may be given as an alternative to the cephalosporin. Antibiotics should be initiated as soon as possible following the injury and continued for no longer than 24 hours after wound closure.73,74 Type III injuries have extensive soft-tissue damage and require broader coverage to include gram-negative organisms; therefore, a cephalosporin plus an aminoglycoside (i.e., gentamicin) is recommended.73-75 Because of a high failure rate when used alone in Type III fractures, fluoroquinolones should be given in combination with a cephalosporin. Patients with Type III open fractures should receive antibiotics for 72 hours following the injury or no longer than 24 hours after soft-tissue coverage has been achieved.73 For injuries that are contaminated with feces or are at high risk for infection with Clostridium species, such as farming accidents, high-dose penicillin should be added to the regimen.73,75
Although many emergency physicians use topical antibiotics, such as neomycin and bacitracin, there are no definitive studies that show its use to be efficacious in preventing wound infections.39
Animal and Human Bites
Animal Bites. The majority of bites are from dogs and comprise 85-90% of all bite wounds seen in the ED. Other causes include bite wounds from cats (5-10%), rodents, and humans (2-3%).81 According to the CDC data from 2007, dog bites accounted for approximately 365,000 visits to the ED nationwide.1
Dog bites often produce lacerations, puncture wounds, and superficial abrasions.81 Cultures of infected dog bites grow multiple organisms; however, Pasteurella multocida is the most commonly isolated organism. Other commonly found species include alpha-hemolytic streptococci, Staphylococcus aureus, and anerobes.82
Cat bites are likely to be puncture wounds rather than abrasions or lacerations due to the long, sharp nature of cat teeth.81 The puncture nature of these wounds, coupled with the higher incidence of Pasteurella multocida, makes cat bites more prone to infection than dog-bite wounds.81
In patients presenting with a dog or cat bite, the need for rabies prophylaxis should be addressed. The rabies virus is transmitted through the saliva and brain or nervous system tissue of infected animals. Any mammal may contract the rabies virus, but the most common wild reservoirs are skunks, bats, foxes, and raccoons. In the United States, the most commonly reported domestic animals infected with rabies are cats, cattle, and dogs.
Very small rodents, such as rats, mice, squirrels, and gerbils, tend not to survive infection with the disease and, thus, do not serve as reservoirs. Likewise, rabbits and other lagomorphs are not thought to be reservoirs for the disease. Prophylaxis is not recommended after bites from these animals. Very large rodents, such as beavers and woodchucks, can carry rabies.83
In the United States and other developed countries, bites from domestic animals account for fewer than 10% of all reported cases of rabies. The vast majority of cases are caused by exposure to wild animals, such as raccoons, skunks, foxes, coyotes, and, especially, bats. It should be noted that even casual contact with bats can result in infection with the disease.83
Rabies prophylaxis is unnecessary in bites from healthy dogs and cats, and from animals that can be observed for 10 to 14 days.81 A reduced, 4-dose vaccine schedule for postexposure prophylaxis is recommended by the Advisory Committee on Immunization Practices. It has been found that four rabies vaccine doses in combination with rabies immunoglobulin elicited adequate immune response; the fifth dose previously recommended did not contribute to more favorable outcomes.84 The first dose of the rabies vaccine should be administered as soon as possible after the exposure in combination with the rabies immunoglobulin, and additional doses of the vaccine are to be given at days 3, 7, and 14.84 For immunocompromised patients, the 5-dose postexposure prophylaxis schedule with vaccinations on days 0, 3, 7, 14, and 28 is still recommended. As part of the postexposure prophylaxis, it is also recommended that rabies immune globulin (20 mg/kg) be administered by injecting half of the dose via intramuscular route and the remaining half infiltrated into and around the wound.84
Human Bites. Human bites occur by two mechanisms: occlusion, which occurs by the actual biting of a body part, and clenched-fist injury, which occurs when the fist of the patient contacts the teeth of an adversary at the metacarpal-phalangeal joint (MCP).85 These bites produce crushing or tearing injuries.
Infections from human bite wounds are polymicrobial, with Streptococci and Staphylococcus aureus as the most common species, followed by Eikenella and anaerobes.82,84
Particular attention should be given to clenched-fist injuries, which can be deceptively serious.87 When the patient's fist strikes the other person's teeth, the teeth can penetrate through the skin all the way to the head of the metacarpal bone. When the patient extends his MCP joints after the injury, the inoculated tissue is retracted proximally. It is important to examine the wound throughout the full range of motion to look for injuries to the underlying bones, tendons, and joints.81,87 Radiographs should be obtained in these patients to exclude foreign bodies (such as tooth fragments) and fractures. Fractures in these patients are open and should be treated with debridement in the operating room.87
Patients with clenched-fist injuries who present early without evidence of joint involvement and without fracture can be managed with extensive irrigation in the ED. The wound is then left open, splinted, and allowed to heal by secondary intention. Patients who present after 24 hours, who have fractures or joint involvement, or who present with signs of infection should be managed operatively.87
Management of Bite Wounds. There is some controversy about whether primary repair of bite wounds is safe. It was standard practice to allow bite wounds to heal by primary delayed closure or secondary closure since they are considered contaminated wounds. An exception to this principle would be if optimal cosmetic outcome is a concern, such as with a facial wound. Whether primary closure would be a reasonable approach was partially answered from a retrospective review performed on 122 patients with dog and human bite wounds that found an infection rate of 7% after primary repair.88 Thus, depending on the severity, bite wounds may be repaired with primary closure with close outpatient follow-up. Another option would be to use delayed primary closure or secondary closure with scar revision at a later time.
While antibiotics are commonly administered to patients after bite wounds, there is little clinical trial evidence to support this practice in general.89 A recent systematic review concluded that antibiotic administration was associated with a statistically significant reduction in the rate of wound infections in patients with human bites and with bites on the hand, but not in patients with cat and dog bites in other locations.89
Amoxicillin-clavulanic acid is a frequently chosen antibiotic for dog, cat, and human bites. Amoxicillin-clavulanic acid has been shown to be effective in treating both infected human and dog bites.82 Patients who are allergic to penicillin can be treated with a fluoroquinolone with enhanced aerobic activity, such as moxifloxicin.86 In patients who present with infected wounds, wound cultures can be obtained and used to guide antibiotic choice.
Wound Care and Suture Removal
Patients who are discharged from the ED should receive detailed instructions on wound care. Since the epithelialization phase of wound healing occurs within the first 48 hours, wounds should be kept clean.29 For wounds that undergo primary closure in the ED, patients can be instructed to use a nonadherent, semi-occlusive, and semi-absorbable dressing. There are no data that demonstrate the benefit of one type of dressing over another. Although a national survey of emergency physicians from the early 1990s revealed that emergency physicians most commonly use simple dry gauze with a topical antibiotic ointment, there is no consensus among emergency physicians about a superior dressing for simple wounds.90,91 Surgical tape and tissue adhesives do not require dressings.
Wounds closed with skin adhesives should be kept clean and dry to prevent premature sloughing of the adhesive. Patients should avoid picking, scrubbing, or soaking the wound and they should be cautioned that swimming and heavy perspiration may also cause premature sloughing. Dry dressings are acceptable; however, no liquids or ointments, including topical antibiotics, should be applied over wounds closed with tissue adhesives, as this may cause the adhesive film to loosen.
It is permissible for wounds to be cleansed gently after 24 hours, but patients should be instructed to abstain from swimming or submerging the wound for prolonged periods of time.
Patients should be instructed on what medications to take for management of their pain. Patients should also be instructed, in layman's terms, to seek medical attention if the wound appears erythematous, inflamed, has purulent drainage, or if there is an associated fever. Bite wounds should be closely followed, and patients should return within 48 hours for a wound check.
Surgical tapes and skin adhesives do not require the patient to return for removal; however, if sutures or staples are placed, the patient should be instructed when to return for removal. While removal of sutures and staples after 7 days is sufficient for most areas of the body, there are a few exceptions.45 To help prevent poor cosmetic outcome from formation of sinus tracts, facial sutures should be removed within 3 to 5 days.41,45 In contrast, sutures placed in areas of high tension, such as over joints, should be kept in longer, for 10-14 days, before removal. (See Table 6.)41,45
Table 6: Optimal Time for Suture Removal
|
Location |
Number of Days |
|
Source: Modified from Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am 2003;21:205-231. |
|
|
Face |
3-5 |
|
Scalp |
7 |
|
Trunk |
7-10 |
|
Upper extremity |
7-10 |
|
Hand |
10 |
|
Elbow |
10-14 |
|
Lower extremity |
7-10 |
|
Knee |
10-14 |
|
Foot |
7-10 |
Summary
Wound repair is a common procedure performed in EDs throughout the country and is a common area of litigation for emergency physicians. The ultimate goal for wound repair is to evaluate and treat in a timely manner, minimize patient discomfort and the risk of wound infection, and optimize cosmetic outcome. Careful evaluation of each wound is necessary to identify potential foreign bodies and concomitant injuries to underlying structures such as tendons, nerves, and bones. Aside from diagnosing fractures, plain films are useful for the identification of retained objects made of metal and certain types of glass; however, ultrasound has an advantage over plain radiographs for the detection of foreign bodies made of plastic or wood. The type of anesthetic agent and method of its infiltration is dependent upon the size and location of the wound, patient compliance, and physician preference. When performing anesthesia for wound repair, the emergency physician should use techniques to keep the patient's pain at a minimum.
Most wounds are closed at the time of injury, but delayed closure or healing by secondary intention are more appropriate options for wounds that are highly contaminated or at risk for infection. Appropriate wound cleansing and debridement is essential for promotion of wound healing and decreasing the risk for infection. All wounds should be repaired using sterile technique. The choice of suture material is dependent on physician preference and location of the wound. Deep sutures are used for wounds that involve multiple layers and allow for better wound approximation and relieve surface tension.
Wounds that are at an increased risk for infection are those contaminated with feces, saliva, or soil, crush injuries, and bites by humans and animals. Tetanus prophylaxis with Td or Tdap and TIG should be given to those patients with highly contaminated wounds who are in need of a booster, or who have incomplete immunization or unknown immunization history. Although there is a paucity of supportive data for its routine use, antibiotic prophylaxis is recommended for patients who are immune incompetent and/or have wounds that are contaminated with feces, saliva, or soil, crush injuries, those with underlying fractures, tendon or cartilage injury, or those with delayed presentation to closure.
Patients discharged from the ED should receive detailed instructions on wound care, follow-up, and pain management.
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Lacerations are a common reason for patients to come to the emergency department (ED). According to the Centers for Disease Control and Prevention data from 2007, "open wounds (excluding the head)" were the primary leading diagnosis for men between the ages of 15 and 64 years.Subscribe Now for Access
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