Author
Mark P. Brady, PA-C
Chief Physician Assistant
Department of Emergency Medicine
Cambridge Hospital
Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Richard S. Krause, MD
Senior Faculty
Department of Emergency Medicine
State University of New York at Buffalo School of Medicine
Buffalo, New York
Disclosure: Richard S. Krause, MD, has disclosed no relevant financial relationships.
Skin lacerations are common injuries seen in the emergency department, with over 11 million wounds treated each year in the United States. Most lacerations can be repaired with primary wound closure. There are various options for repair of lacerations including traditional suture materials and techniques, staples, adhesive strips, and tissue adhesives. Clinicians should be familiar with wound management including the various closure materials and techniques. These include simple interrupted (shown), mattress, running, and subcuticular sutures. Image courtesy of Wikimedia Commons.
The goals of primary wound closure are to stop bleeding, prevent infection, preserve function, and restore cosmetic appearance. Lacerations of the lip should begin with placement of the first suture through the vermilion border (shown). This technique helps avoid a cosmetically undesirable irregular contour to the healed wound. If the laceration is deep and underlying tissue or muscle is also lacerated, subcutaneous sutures may be required to approximate muscle, tendon, or deep tissue layers.
There is no specific time limit for primary closure of lacerations. Anatomic location of the wound, mechanism of injury, wound contamination, and health of the patient (including immunodeficiency, diabetes, and tetanus immunization status) factor into the decision about the suitability of primary closure. The majority of clean wounds can be successfully repaired up to 12 hours after the injury. Some wounds older than 12 hours in healthy patients can reasonably be closed, usually with loose interrupted sutures (arrow). Image courtesy of Wikimedia Commons.
Simple interrupted sutures are easy to place and have excellent tensile strength. They allow for easy alignment of wound edges during suturing. Simple interrupted sutures may require more time for placement than other techniques and may have a greater risk for crosshatched marks (ie, train tracks) across the suture line. The risk for crosshatching can be minimized by removing sutures early and avoiding excessive tension during suture placement. Image courtesy of Wikimedia Commons.
When placing a simple interrupted suture, the point of the needle initially pierces the skin at a perpendicular angle (1) and is advanced until it emerges, and then pulled through (2). The trailing thread is then tied (3). Sutures should approximate the wound edges but should not be so tight as to cause blanching, which implies decreased blood supply and may impede healing, worsen scar formation, and increase the risk for infection. The sutured skin margins should slightly evert (red arrows), and the depth and width of the sutured tissue should be roughly equal (4).
The vertical mattress suture (shown) is the preferred technique for many wounds due to its ability to simultaneously achieve deep and superficial wound closure, eversion of wound edges, and precise vertical alignment of the wound margins. Placing each suture precisely and taking symmetrical bites is crucial with this suture. The vertical mattress suture does have a greater tendency to create crosshatched marks on the skin, limiting its use in cosmetically sensitive areas, such as the face. Image courtesy of Wikimedia Commons.
The vertical mattress suture is placed in a "far-far-near-near” sequence (shown). The "far-far" loop enters and exits the skin surface at a 90-degree angle, 4-8 mm from the wound margin, and passes deep into the dermis. The "near-near" loop enters and exits the skin surface 1-2 mm from the wound margin. Bites must be symmetrical or the wound will invariably misalign. The knot is tightened only enough to achieve approximation and eversion of wound edges.
Subcuticular running sutures (shown) are ideal for low-tension, cosmetically important wounds. The ends of this suture do not have to be tied and may be secured with slip knots or tape. The running suture technique is faster but risks failing if the suture is cut in just one place. The running subcuticular suture is valuable in areas in which the tension is minimal, the dead space has been eliminated, and the best possible cosmetic result is desired. Because the epidermis is punctured only at the beginning and end of the suture line, the subcuticular suture practically eliminates the risk for crosshatching. Image courtesy of Wikimedia Commons.
A horizontal mattress suture (shown) is excellent for high-tension wounds due to its strength and ability to provide wound eversion. This suture is best for closure of gaping or high-tension wounds or wounds on fragile skin because of its ability to spread the tension along the wound edge. This suture can also be used as a temporary suture to temporarily approximate wound edges, allowing placement of simple interrupted or subcuticular stitches. In areas of extremely high tension at risk for dehiscence, horizontal mattress sutures may be left in place even after removal of the superficial skin sutures. Image courtesy of Wikimedia Commons.
When placing a horizontal mattress suture, enter the skin 5 mm to 1 cm from the wound edge. Pass the needle and suture deep into the dermis to the opposite side of the suture line and exit the skin equidistant from the wound edge (in effect, a deep simple interrupted stitch). The needle reenters the skin on the same side of the suture line 5 mm to 1 cm lateral of the exit point. The suture is passed deep to the opposite side of the wound where it exits the skin and the knot is tied.
A variation of the horizontal mattress suture known as the half-buried mattress, or "tip suture" (shown), is ideal to close a triangular edge as it does not compromise the blood supply and may therefore reduce necrosis of the tip. The half-buried horizontal suture is used primarily to position the corners and tips of flaps and is used in cosmetically important areas such as the face. However, in larger flaps with greater tension, this suture may position the flap tip deeper than the surrounding tissue, often resulting in a depressed scar.
Simple running sutures are useful for long wounds in which wound tension has been minimized with properly placed deep sutures and in which the wound edges are well approximated. Advantages of the simple running suture include quicker placement and more rapid reapproximation of wound edges, compared with simple interrupted sutures. Disadvantages include possible crosshatching, the risk of dehiscence if the suture material ruptures, and difficulty in making fine adjustments along the suture line.
The running locked suture (shown) is similar to the running suture. However, this suture passes through the preceding loop before reentering the skin. Running locked sutures have increased tensile strength and are useful in wounds under moderate tension or in wounds requiring additional hemostasis. Because the sutures are locked into preceding loops, the sutures are more secure. Running sutures take more time, and tissue can be strangled if the sutures are placed too tightly. Therefore, this type of suture should be used only in areas with good vascularization such as the scalp.
The pulley suture (shown) facilitates greater stretching of the wound edges and is used when additional wound closure strength is required. The pulley suture is a modified vertical mattress suture. When using a pulley suture, a vertical mattress suture is placed initially. The knot is left untied, the suture is looped through the external loop on the far side of the incision and pulled across, and then the knot is tied. This new loop functions as a pulley, directing tension away from the other strands.
Another suture that has a similar function as the pulley suture is the "far-near-near-far" modification of the vertical mattress suture (shown). This suture is useful when tissue expansion is desired, and it can be used intraoperatively for this purpose. This suture is also useful when beginning the closure of a wound that is under significant tension.
The extensor tendons of the hand are relatively superficial and are highly susceptible to injury from lacerations. They are also occasionally injured in blunt trauma. The dorsum of the hand, wrist, and forearm are divided into 8 anatomic zones (shown) to facilitate classification and treatment of extensor tendon injuries. Extensor tendon injuries are frequently diagnosed in the emergency department. When evaluating a wound for possible tendon injury, it is crucial that the wound be examined through full flexion and extension of the digit. Some extensor tendon injuries can be repaired in the emergency department, while others (and essentially all significant flexor tendon injuries) need repair in the operating room. The goal of repair is to restore tendon continuity and function. This photo (arrow) shows a Zone 5 extensor tendon repair.
Indications for extensor tendon repair include tendon laceration greater than 50% of the width of the tendon; tendon lacerations less than 50% with significantly decreased strength or "triggering"; and tendon laceration associated with significant superficial tissue loss, joint space involvement, or fracture. Longitudinal lacerations of the extensor tendons are not usually sutured. Tendon injuries can be repaired immediately or within 7-10 days. If repair is delayed, the wound should be irrigated copiously, the overlying skin closed loosely with interrupted sutures, and the limb splinted. Antibiotics are also routinely given prophylactically. The modified Kessler stitch and the modified Bunnell stitch (shown) are 2 common suture techniques used in primary tendon repair.
Dermatotenodesis is a technique used for repair of the distal extensor tendon. It is performed by placing a single suture into the lateral distal end of the cut skin and including a bite from the proximal skin wound. The suture is anchored with a knot, leaving enough material to complete the stitch. Enter the skin medial to the knot and pull the suture through 1 mm from the knot. Place a stitch through the distal skin so that the needle passes through the dorsal side of the tendon. Bring the needle through to exit the dorsal side of the proximal tendon, incorporating the dorsal skin. Repeat the same stitch so that the needle exits the proximal half. Place a single suture into the medial distal end of the cut skin, and include a bite from the proximal skin wound. Pull the suture to approximate skin edges. Place the last suture to anchor to the knot.
Stapling is appropriate for wounds on the scalp, trunk, or extremities. Staples are usually removed in approximately 10 days. The staple is inserted into the skin using a surgical staple gun (red arrow) in the shape of an upside-down "U," which elevates, everts, and approximates the skin edges (blue arrow.) Staples have the advantage of being quicker, more economical, and causing fewer infections than sutures. Disadvantages of staples are permanent scars if used inappropriately and imperfect aligning of the wound edges, which can lead to improper healing. Image courtesy of Wikimedia Commons.
Compared with sutures, tissue adhesives like DERMABOND® (Ethicon, Inc., Somerville, New Jersey) (shown) are cost effective and offer similar patient satisfaction, infection rates, and risk for scarring in certain low skin-tension areas. They are not used for lips, lacerations that are over joints, deep lacerations, or most hand and foot lacerations. Adhesive strips such as Steri-Strip™ elastic skin closures (3M™, St. Paul, Minnesota) (blue arrow) are adhesive strips used for minor lacerations that are clean and have relatively straight edges that align well and approximate easily. Images courtesy of Mark P. Brady, PA-C.
There are certain lacerations that should be managed in the operating room. These include wounds with excessive depth or length, potentially requiring toxic doses of local anesthesia to obtain adequate analgesia; severe contamination requiring extensive debridement; open fractures; injury to tendons, nerves, or major blood vessels; and injury to other complex structures requiring meticulous repair such as the eyelid (arrow). Referral decisions should be based on the clinician's level of expertise, experience, and familiarity with managing lacerations.
Author
Mark P. Brady, PA-C
Chief Physician Assistant
Department of Emergency Medicine
Cambridge Hospital
Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Richard S. Krause, MD
Senior Faculty
Department of Emergency Medicine
State University of New York at Buffalo School of Medicine
Buffalo, New York
Disclosure: Richard S. Krause, MD, has disclosed no relevant financial relationships.
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