Quiz 3 - Wound Closure

Indications for secondary closure

-Deep stab or puncture wounds that cannot be adequately irrigated -Contaminated wounds -Abscess cavities -Presentation after a significant delay (eg, >24 hours) -Noncosmetic animal bites

Contraindications and relative contraindications for wound closure

-Grossly contaminated wound -Cause of wound is due to puncture -Cause of wound is due to human and animal bite -Delayed in seeking tx: up to 24 hrs face and scalp, <6hrs for hands and feet -Superficial wounds that would be expected to heal w/o significant scarring, such as lacerations or abrasions that only involve the epidermis.

What are the indications for abx prophylaxis for wound closure?

-Wound older than 8 hrs or grossly contaminated, unless the wound is on face or if edges will be excised before closure -Pt with DM, immunosupression or on steroids.

List the points regarding wound care follow-up

-Wound re-evaluation is rec in 48 hours -F/u with a specialist is needed for any wounds with tendon, nerve or deep-structure involvement

Contraindications for primary wound closure

-lacerations for which suturing will significantly increase the risk of wound infection -superficial wounds that would be expected to heal without significant scarring (wound involving epidermis) -dog, cat, and human bites are relative CI

What size sutures are appropriate for the face?

5-0 to 6-0

________ _________ do not possess the synovial membrane and can be either repaired or closed over after debridement and copious irrigation and referred for follow-up with a hand specialists.

Extensor tendons

________ _________ lacerations usually involve the synovial membrane and should always be handled by a hand specialist immediately. Repair of the tendon should not be attempted due to risk of _____________. Debridement with copious irrigation should be performed.

Flexor tendon, tenosynovitis

Example simple interrupted sutures

Grab needle at 1/3 junction Push needle through skin and then through the other side of the wound adjacent to the first insertion Loop the needle end of the material 2 times and then grasp the tail with the needle holder and pull across keeping the twist flat Then loop 1 time in the opposite direction keeping twist flat Cut material 1 cm above the knot and repeat for more sutures!

The advantage of this technique is speed compared to a simple suture. The disadvantage is that it doesn't evert as effectively as a vertical mattress suture. The first throw is made like a simple interrupted suture, but a second throw is made about 1 cm down the wound edge on the same side, entering perpendicular to the wound and exiting on the side where you began. The suture is then tied using either an instrument tie or surgical tying method.

Horizontal mattress suture

Indication for delayed primary closure (or tertiary wound closure)

Should be considered for uncomplicated wounds that present after the safe period for primary closure.

The benefit of this wound closure technique is that it is easy to use, painless and cost-effective. However, this is not the first choice for pts in an area with a lot of water exposure or water activities and they should not get wet.

Skin adhesive

This method of wound closure is ideal for superficial wounds as a re-enforcement of suture, staples and glue closure. It tends to fall off prematurely and causes the highest rate of wound dehiscence compared to other methods when used alone.

Skin tape

How long can skin adhesive take to work?

Some can take up to 24 hours to gain full maximum strength and last 5-7 days before strength decreases

The benefit of this wound closure includes minimal time required for procedure, decrease tissue reactivity and decreased cost.

Staple

________ is a great method of would closure that offers, precision-wound edge approximation, and tensile strength.

Suture

What is the significance of the vermilion border in wound closure

Unlike facial skin, the vermilion border is made of stratified squamous epithelium wo keratin and fewer melanocytes making underlying blood vessels more apparent. Improper closure can lead to disfigurement.

Describe the vertical mattress suture technique

Utilizes a "far-far-near-near" order of bites. The "far-far" loop enters and exits the skin surface at a 90 degree angle, 4 mm-8 mm from the wound edge. The "near-near" loop enters and exits the skin surface 1 mm to 2 mm from the wound margin. The suture is then tied using either an instrument tie or surgical tying method.

This method of suturing has 2 components. The first is used for wound tension and is deep into the dermis, and the second component is superficial and everts the wound edges. These components allow for meticulous wound-edge approximation.

Vertical mattress suture

What is the best method for everting wound edges for healing and best used in areas where inversion easily occurs, such as the palmer surface of hand?

Vertical mattress suture

When should plastic surgery repair be considered for lip laceration?

Wounds extensively involving large pieces of vermilion border and/or where the commissure is missing

The decision of whether to perform primary closure, allow a wound to heal by secondary intention, or perform a tertiary (ie, delayed primary) closure is dependent upon the _____ of the injury as well as the mechanism and degree of ________________. The presence of a cellulitis or abscess (ie, redness, warmth, swelling, and pain with or without pus drainage) is an __________ contraindication to wound closure. In the absence of these findings, the decision to close a wound must be made based upon clinical judgment.

age, contamination, absolute

For sutures, you hold the needle driver with your ___________ hand with the thumb in one hole and the ______ finger in the other. Use your index finger to support the needle holder, allow you to open the locking mechanism. After you have properly loaded the needle with the needle driver, remover fingers from the holes and hold the needle driver in the palm of your hand.

dominant, ring

Skin adhesive should not get wet, be placed over _____ or mobile areas, or be placed on wounds with high tension or skin-edge distance that have a greater chance of dehiscence than suture or staple closures. They are ideal for ________ and ______ lacerations

joints, superficial, small

The type of closure for a wound will depend on the type of wound, __________, time since injury, contamination and depth

location

For sutures, the forceps will be held with your ___________ hand, between the thumb and index fingers (hold like you would a pen)

nondominant

Sutures are appropriate to use for _____________ closure of skin lacerations when the wound extends through the dermis and is likely to cause excess scarring if the wound edges are not properly opposed.

primary

The disadvantage of staples is that the provider does not have the same control with this method of closure and the staples interfere with some ___________ studies. Also, they cannot be used on the ______

radiological (CT scan/MRI), face

The disadvantage of sutures are the need for injectable anesthetic, removal of sutures, tissue reactivity (esp. with absorbable sutures), increased cost and increased time for procedure. There is also pt expectation for a perfect closure and no _____ formation

scar

The below are examples of which type of wound (primary, secondary or tertiary): Animal and human bites, which likely harbor high bacterial loads coupled with complex injuries to the soft tissue (ie, crushing, avulsions, and multiple perforations) Wounds older than 24 hours that were insufficiently cleansed, debrided, or decontaminated Wounds older than 24 hours that present in the setting of advanced age, diabetes mellitus, renal impairment, impaired nutrition, smoking, obesity, and chronic steroid use

tertiary