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Suture Techniques

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

Objectives
Review wound types and classification
Understand the principles of wound
healing

Describe the 3 types of wound closure


Overview of Suture materials
Wound closure techniques

Wound
Classification
Four Classes
Clean
Clean-contaminated
Contaminated
Dirty/infected

Clean Wounds
Most common is elective surgical
incision

Primary closure
1-5% rate of infection

Clean
Contaminated
Wounds contaminated by local

flora despite aseptic technique

Cholecystectomy, appendectomy
and hysterectomy

3-11% infection rate

Contaminated
Open traumatic wounds in nonsterile
environment

Open fractures
Surgical procedures in which there is
a gross deviation from sterile
technique (emergent open cardiac
massage)

10-17% infection rate

Dirty or Infected
Gross/heavy contamination or
active infection

Perforated viscera, abscess and


traumatic wounds

>27% infection rate

Wound Healing
Four Stages
Hemostasis
Inflammatory
Proliferative
Remodeling

Phase I:
Hemostasis

Vasoconstriction stimulated by
endothelial injury

Platelet aggregation
Coagulation cascade is activated
and fibrin clot formed

Platelets release pro inflammatory

mediators and PDGF in preparation


for subsequent phases

Hemostasis

Phase II:
Inflammatory

Inflammatory mediators released


Vasodilation - provides increased
blood supply to injury site

Increase vascular permeability -

allows plasma proteins, WBCs, into


injured tissue

Migration of WBCs from circulation


into interstitium and phagocytose
debris/microbes

Inflammation

Phase III:
Proliferative
Angiogenesis
Granulation
fibroblasts deposit extracellular

matrix including collagen/elastin

Characteristic beefy red


appearance

Phase III:
Proliferative
Epithelialization
keratinocytes
Contraction
Fibroblast release of actin

Phase IV:
Remodeling
Collagen remodeled along tension
lines

Cells no longer needed are


removed by apoptosis

May take many months

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

Wound Closure
Primary closure
Secondary closure
Tertiary closure

Primary Closure
Most common
Preferred method when appropriate
Wounds are re-approximated
acutely

Dermis-dermis apposition
Best cosmetic outcome

Secondary Closure
Known as healing by secondary intention
Wound edges are left un-approximated
Granulation tissue formed
Migration of keratinocytes provide re-

epithelialization over granulation tissue

Appropriate in wounds with soft tissue

loss or severe contamination not closable


by primary or tertiary means

Tertiary Closure
Contaminated wound is I&Dd and
left open for several days

Wound is then closed as in primary


closure when risk of complications
declines

Preferred method for high energy


and highly contaminated wounds

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

Characteristics
Size
Tensile Strength
Monofiliment (nylon, prolene,
monocryl)

Multifiliment (vicryl, ethibond, Silk)


Absorbable
Non Absorbable

Characteristics
Dyed
Undyed
Sizes 11-0 to 6

Suture Sizing

Absorbable
Broken down in tissues by
hydrolysis, enzymes and
inflammation

Time to resorb varies by material


and diameter

includes vicryl, monocryl, PDS, gut.

Non Absorbable
Not broken down by hydrolysis or
inflammatory reaction

Walled off in body by fibroblasts or


physically removed (skin sutures)

Includes nylon, prolene, stainless


steel, silk, polyester (ethibond)

Suture

Size by Location

Needles
Cutting - skin and other tough
tissue

Taper - softer tissues inside body


(bowel,vessels). Dilates tissues

Blunt - felt to pose less risk of


needle sticks. Most useful in
fascial closure.

Before Closing
Hemostasis
Evaluate
Irrigate
Debride devitalized/contaminated
tissues

Should it be closed primarily?

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

Before Closing
Wound depth
Nerve, tendon, vascular
involvement

Bone involvement (open Fx)


Uncontrolled hemorrhage

Wound Preparation
Single most important step in preventing
complications

Control bleeding
Remove all debris and devitalized tissue
Irrigate copiously with NS
Do not use iodine or hydrogen peroxide in
the wound

When to Consult
Specialist

Deep wounds to hands/feet, thorax, abdomen, or pelvis


Full thickness lac to eyelids, lips or ears
Lacerations which involve bone, joint, tendon, artery,
muscle or nerve

Markedly contaminated wounds


Crush injuries
Concerns about cosmesis
You dont feel comfortable

When to Not Close


Active infection
Erythema/induration
Puncture wounds
Human/animal bites
Delayed onset of treatment
12 hours for body
24 hours for face

Anesthesia
General/spinal Anesthesia
Used for large wounds and more
invasive procedures

Regional Anesthesia
Lidocaine/bupivicaine infiltrated

near peripheral nerve to produce


anesthesia distally in extremity

Digital, wrist and ankle blocks most


common

Anesthesia
Local
Anesthetic agent infused directly
into the tissues being treated

Most common method in


outpatient setting

Lidocaine
Most common
1% should be adequate for most procedures
Sodium channel blocker
Rapid onset
Relatively short duration of action
Available with epinephrine
helps control bleeding
prolong duration of action

Bupivicaine
Longer duration of action
Useful in prolonged procedures as

well as post procedure pain control

Also available with epinephrine

Local Anesthetics

Caution!!
Do not use local anesthetic with
epinephrine on structures with
limited circulation

ears, nose, fingers, toes, penis

Equipment

General
Considerations

Handle tissues as little as possible


Limit the time and force used in retracting
tissues

Do not pinch tissues with forceps, Gently lift


wound edges to place suture

Irrigate frequently to minimize contaminants


and maintain moist wound bed

Approximate, dont strangulate

Needle
Position
Needle should be secured
1/2 - 2/3 down the length
needle from the tip

Always cross skin at 90


degree angle

Rule of Halves
Allows better approximation of
tissues

Avoids dog ears

Rule of Halves

The Instrument Tie


How to tie a perfect square knot every time
Place needle driver parallel to and directly
over incision

Always wrap needle end over driver toward


tail

When tightening each throw, move needle


driver to opposite side of incision.

The key is to always wrap OVER needle


driver and to always alternate sides

Basic Suture
Methods

Simple interrupted
Simple running
locked running
Horizontal mattress
Vertical mattress
Running Subcuticular
Subcutaneous (buried knot)

Simple Interrupted
Most common closure performed
Used in superficial wounds with
minimal tension.

Nylon or prolene
Be careful of knot security

Simple Interrupted

Simple Continuous
Rapid
Best in short lacerations with no tension
Helps with hemostasis
If one knot fails, the entire closure is
compromised

Contraindicated in infected tissues as

infection can propagate along suture line

Locked Continuous
Used in wounds closed with
moderate tension

Helpful in obtaining hemostasis


Similar concerns with knot security
and integrity of closure

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

Horizontal
Mattress

Vertical Mattress
Used for maximal edge eversion
Minimizes deadspace in deeper
tissues

Helps minimize tension

Vertical Mattress

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

Running
Subcuticular

Subcutaneous
Buries the knot
Useful for minimizing deadspace in
deeper wounds

Helps relieve tension on skin


closure

May be used in dermis as well

Subcutaneous

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

Suture Removal
Face: 3-5 days
Scalp: 7 days
Chest and extremities: 8-10 days
Joints, palms, soles: 10-14 days