Wound management is crucial to the practice of Emergency Medicine.
Emergency Physicians routinely care for wounds ranging from simple
lacerations to complex injuries in the trauma patient. Wound repair
is always secondary to the evaluation and stabilization of any life-threatening
emergencies. However, patients are often legitimately concerned
about the outcome of wounds and lacerations. There are several basic
suture principles that will help to provide optimal wound healing
and ensure a more than acceptable cosmetic result. The previous
chapter outlines the essential principles of wound closure. This
chapter describes the basic methods used to close wounds.
The choice of suture materials is important in wound closure.
Sutures are made of a wide variety of materials, both natural and
synthetic. Natural substances include gut (sheep and beef), cotton, and
silk. Natural substance sutures cause more
tissue reactions and scarring, which limits their use. Cotton
sutures are not discussed, as they are no longer used in clinical
practice. Synthetic sutures can be made of nylon, Dacron, polyglactin,
polypropylene, polyglycolic acid, and metal. Metal sutures are used
in the Operating Room and not in the Emergency Department as they
are difficult to handle and prone to breakage. Synthetic sutures
tend to have a problem with “memory.” That is,
they tend to retain the shape of their packaging. This can make
it difficult to manipulate the suture during wound closure.
Sutures are constructed as monofilaments or polyfilaments. Polyfilament
fibers consist of multiple filaments braided together to form one
suture. They are easier to handle than monofilament sutures, as
they tend to be more pliable. Polyfilament sutures have better knot
security and therefore reduce the incidence of knot slippage. However,
they can be associated with a higher incidence of infection than
monofilament sutures. They allow bacteria to migrate (or wick) between the
strands of the suture located at the skin surface and into the wound.
Select the smallest diameter suture
that can adequately hold the tissue edges together in order to reduce
tissue damage and scarring. The largest suture material available
is size #5. The suture sizes decrease to zero (#4, #3, #2, #1, #0)
and then are followed by #00 (2–0), #000
(3–0), and #0000 (4–0), in decreasing
size. The smallest suture commonly used in the Emergency Department
is 6–0 for facial lacerations, hand lacerations, as well
as lacerations in other cosmetically sensitive areas. The tensile
strength of sutures is related to their size. The tensile strength
of suture increases as the size increases. For example, 4–0
is stronger than 5–0.
The other main category of suture classification is absorbable
versus nonabsorbable. Absorbable sutures are primarily used to close
the subcutaneous layers of a wound. Nonabsorbable sutures are primarily
used for skin closure.
Absorbable Suture Materials
Absorbable sutures are degraded by the body and do not require
removal. They usually do not maintain their tensile strength for
longer than 60 days. Body ...