This is a video in clinical medicine from The New England Journal of Medicine.
Lacerations are among the most common reasons for visits to Emergency departments. Although most lacerations will heal without treatment, repair of these reduces infection, scarring, and patient discomfort. Sutures, tissue adhesives and wound tapes may all be used for laceration repair. Tissue adhesives and wound are suitable for smaller lacerations that are not subject to substantial tension. This video, however, will demonstrate the use of simple, interrupted sutures.
Not all Lacerations are suitable for primary closure. Some should be allowed to heal by secondary intention -- in other words, granularization and re-epithelialization. The interval between injury and evaluation is important since delays of repair may increase the risk of infection. The location of the wound and the degree of contamination may affect the acceptable interval between injury and repair. For example, some contaminated wounds on the hands or feet may require closure within 6 hours whereas facial or scalp lacerations can often be safely repaired more than 24 hours after injury. The decision to suture a wound must be made on an individual basis. An interval between injury and repair may be shortened with impaired host defenses. Closure by secondary intention should also be considered in lacerations that are grossly contaminated and in most puncture and bite wounds to the extremities. Consultation with a specialist should be sought for involving substantial loss or destruction of tissue, complicated lacerations on the hands or face, or wounds thought to involve an underlying structure.
Many institutions stock pre-packaged laceration trays that contain most of the equipment needed. For preparation and anesthesia, you'll need a skin cleansing agent, sterile gauze, local anesthetic, a five or ten milliliter syringe, and a twenty-five to thirty gauge needle. One percent lidocaine is an appropriate anesthetic for most lacerations. The use of lidocaine with epinephrine offers advantages such as reduced incidence of bleeding, and an extended duration of action but its relatively contraindicated in areas with a single blood supply such as the penis or nose. A dilute one-in-two hundred thousand solution of epinephrine may be used to repair lacerations of the digits. Bupivacaine, which has an extended duration of action, may also be used. For wound irrigation, you'll need saline solution, a sterile bowl, and a thirty to sixty militer syringe with a splash guard. for suture placement, you'll need a needle holder, an Adson-Brown toothed foreceps, suture scissors, and appropriate suture material. For percutaneous sutures, non-absorbable nylon or polypropylene sutures should be used. Size "six oh" suture material is appropriate for facial lacerations. Whereas larger, "three oh", "four oh" or "five oh" should be used on the torso and extremities. Larger suture materials should be used in lacerations that are subject to high degrees of static or dynamic skin tension.
Wash your hands with soap and water before beginning the suture repair. Place all equipment on a bedside table that is within easy reach. Position the patient lying on a stretcher with the laceration fully exposed and well lit. Wear gloves and a face shield throughout the procedure to protect yourself from contact with bodily fluids. Apply a skin cleansing agent such as chlorhexidine or povidone-iodine in a circular fashion around the laceration. Cover a wide area so that the instruments and suture material are not contaminated during the procedure. Do not introduce antiseptic solution directly into the wound as many are toxic to the subcutaneous tissues and could interfere with wound healing. Next, anesthetize the tissues using the preferred local anesthetic and a twenty-five to thirty gauge needle. Place the needle directly into the exposed subcutaneous tissue at one end of the laceration.
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Pull back on the plunger to avoid intravascular placement of the agents, and then slowly inject anesthetic as you advance the needle.Inject the anesthetic in the plane between the dermis and the subcutaneous tissue because this location offers less resistance, and is less painful than direct dermal infiltration. Anesthetize the remainder of the laceration. Begin subsequent injections in regions that are already anesthetized. Irrigate the wound with normal saline solution. Vigorous irrigation with a 30 or 60 milliliter syringe and splash guard is required to provide adequate pressure for mechanical debridement. Irrigate the wound until it is visibly clean. The amount of irrigant required will vary depending on the laceration. At this point, switch to sterile gloves and apply a sterile fenestrated drape over the wound. Using a forceps or needle holder, carefully explore the wound, looking for foreign material and injuries to tendons, nerves, vessels, or underlying structures.
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Hold the needle holder in the palm of your dominant hand, with your index finger extended. This position allows for maximum control and proper angle of entry. Hold the forceps in your non dominant hand, the way you would hold a pencil. Load the needle at the very tip of the holder at a ninety degree angle. Grasp the needle at the junction of the proximal and middle third of the needle. Keep in mind the following principles during laceration repair: You should insert insert the needle into the skin at a ninety degree angle and take a curvilinear path through the dermis and subcutaneous tissues. You should make sure that the bite width and bite depth are the same on each side of the laceration. Ideally the bite depth should be greater than the bite width. By following these principles, you will create sutures that follow a curvilinear path through the tissues and result in eversion of the wound edges. Eversion is necessary for proper healing and results in the best possible cosmetic result. Position yourself so that the laceration is parallel to the frontal plane of your body. Place the first stitch in the center of the wound so that it bisects the laceration. Use the forceps to gently evert the wound edge opposite you. Do not pinch the tissues between the tips of the forceps, because this may injure the tissues. Enter the skin at a 90 degree angle and then supinate your wrist to drive the needle through the tissues. Use the forceps and then the needle holder to grasp the needle near its tip, being careful not to crush the actual needle tip before supinating your wrist again to complete the first half of the stitch. Repeat the process on the opposite side of the laceration, first everting the wound edge with the forceps, and then driving the needle through the tissues by supinating your wrist. Pull the suture material through the wound, so that a three centimeter tail remains on the entry side. To begin the first knot, place the needle holder parallel over the wound, hold the needle end of the suture with your non dominant hand, allowing the needle to rest on the sterile drape. Next, wrap the suture over the needle holder twice. This forms the surgeon’s knot, which prevents the first throw from loosening. Rotate the needle holder ninety degrees, grasp the free end of the suture, and use your hand to pull each end in opposite directions, across the laceration, tightening the knot only enough to approximate the wound edges. Begin the second throw by again placing the needle holder parallel over the laceration. On this, and all subsequent throws, wrap the suture end over the needle holder only once. Grasp the free end with the needle holder and use your hands to pull each end in opposite directions across the wound. Place two more throws in the same fashion. To ensure that all knots you tie are square knots, remember to position the needle driver parallel over the wound, draw the sutures over the needle driver, and move your hands back and forth across the laceration without crossing each other. After securing the final throw, offset the knot form the center of the wound. Finally, cut the suture ends with the scissors, leaving tails of approximately one centimeter. Continue the repair by placing additional sutures, each time bisecting segments along the laceration. This approach facilitates proper alignment of the wound edges. As the edges become approximated, you may place sutures in a single pass without having to come up through the center of the wound. No steadfast rules exist regarding the number of sutures required for a given length of laceration. Enough sutures should be placed so that all gaps in the wound edges are eliminated. Generally, the space between sutures is approximately equal to the bite width. Once finished, remove the drape, and wipe off the antiseptic solution. Activate safety devices such as the safety caps, and dispose of all the instruments and needles in appropriate biohazard containers.
Cover repaired lacerations, except those on the face and scalp, with a sterile, nonadherent dressing. The use of topical antibiotics and creams is of limited benefit and is not mandatory, however, they should be used on uncovered wounds in order to maintain a moist environment. Administer tetanus prophylaxis if the patient’s immunization is not current. Prophylactic antibiotics are not needed for simple, clean lacerations, however, they may be considered in patients with grossly contaminated wounds, crush injuries, or impaired host offenses. Instruct the patient to keep the wound dry for 12 to 24 hours. Subsequently, the patient should be encouraged to wash the wound gently with soap and water, but prolonged immersion should be minimized. Provide the patient with written wound care instructions, including ways to spot signs of infection. Facial sutures should be removed within five days to prevent scarring. Sutures placed in the scalp, torso, or extremities, should be removed within seven to ten days. Sutures subject to a substantial degree of tension, such as those overlying joints, benefit from being left for a longer interval and should be removed in ten to fourteen days.
Early complications of laceration repair include infection and wound dehiscence. Early follow-up with a wound check in twenty-four to forty-eight hours should be arranged if these issues are a concern at the time of primary repair. Additional complications include a retained foreign body, unrecognized deep-structure injury, and scar formation.
