The major goal of wound closure is to restore the skin's integrity in order to reduce the risk of infection, scarring, and impaired function. This may be achieved by one of three methods: primary, secondary, and delayed closure. With primary closure, the wound is immediately closed by approximating its edges, with the main advantage being a reduction in healing time in comparison with other closure methods. Primary wound closure also may reduce bleeding and discomfort often associated with open wounds. Secondary wound closure, in which the wound is left open and allowed to close on its own, is particularly well suited for highly contaminated or infected wounds as well as in patients at high risk of infection. Although this method may reduce the risk of infection, it is relatively slow and uncomfortable and leaves a larger scar than primary closure. With delayed (or tertiary) closure, the wound is initially cleansed and then packed with dry sterile gauze covered by a sterile covering. The dressing is left undisturbed unless signs of infection—fever, purulent exudate, or spreading cellulitis—develop. After 4 to 5 days, the dressing is removed, and the wound edges can be closed if no infection has supervened. This approach may be useful for highly contaminated wounds and animal bites, and while commonly described and recommended, there is little evidence documenting the effectiveness for traumatic wounds seen in the ED.1
Lacerations may be closed by one of five commonly available methods or devices: sutures, staples, adhesive tapes, tissue adhesives, and hair apposition. Each method has advantages and disadvantages (Table 39-1). Choice of the wound closure method and timing should take into account both patient and wound characteristics.2 Cosmetic outcome is more closely related to practitioner technique and the patient's own healing characteristics than to any specific closure method or device. Many of the principles discussed in this chapter are based on experience and observation rather than on controlled trials.
Table 39-1 Advantages and Disadvantages of Wound Closure Techniques |Favorite Table|Download (.pdf)
Table 39-1 Advantages and Disadvantages of Wound Closure Techniques
Greatest tensile strength
Lowest dehiscence rate
Requires removal (if using nonabsorbable material)
Risk of needle stick to physician
Greatest tissue reactivity
Low tissue reactivity
Low risk of needle stick
Less meticulous closure
May interfere with some imaging techniques (CT, MRI)
Resistant to bacterial growth
No need for removal
No risk of needle stick
Lower tensile strength than 5-0 or larger sutures
Dehiscence over high-tension areas (joints)
Not useful on hands
Cannot bathe or swim (can shower)
Lowest infection rates
No risk of needle stick
Frequently fall off
Lower tensile strength than sutures or tissue ...
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