Chapter 92. General Principles of Wound Management

An acute wound can be defined as an unplanned disruption in the integrity of the skin, including the epidermis and dermis. The goals of wound management are to restore tissue continuity and function, minimize infection, repair with minimal cosmetic deformity, and be able to distinguish wounds that require special care. The principles of wound management should be emphasized over the repair technique. Appropriate wound management prior to approximating the wound will allow it to heal with minimal complications. This includes wound cleansing, debridement of the wound edges, wound approximation, and prevention of secondary injury.

Phases of Wound Healing

The response of tissue to an injury is described in three phases. The first phase is coagulation and inflammation. The second phase is the proliferative phase. The final phase is the reepithelialization or remodeling phase.

Phase I consists of coagulation and inflammation. It occurs in the first 5 days. This phase is also known as the vascular phase. A fibrin clot forms a transitional matrix that allows for the migration of cells into the wound site over a period of 72 hours. Inflammatory cells (i.e., neutrophils, monocytes, and macrophages) kill microbes, prevent microbial colonization, break down soluble wound debris, and secrete cytokines. The cytokines signal synthetic cells, such as fibroblasts, to initiate phase II. Most sutured wounds develop an epithelial covering that is impermeable to water within 24 to 28 hours.

Phase II is the proliferative phase. It occurs during days 5 to 14 after the injury. Fibroblasts proliferate and synthesize a new connective tissue matrix that replaces the transitional fibrin matrix. Granulation tissue consisting of fibroblasts, immature connective tissue, epidermal cells that have migrated, and abundant capillaries forms within the wound. Fibroblasts release collagen, a protein substance that is the chief constituent of connective tissue. At 5 days, the tensile strength of the wound itself is 5% that of normal skin. Collagen formation peaks at day 7.

Phase III is known as the remodeling, reepithelialization, or maturation phase. It occurs from day 14 and lasts until there is complete healing of the wound. The new granulation tissue is being converted into a scar. The scar consists of a rich matrix with decreasing cell density, decreasing vascular density, and increasing thickness of collagen fiber bundles packed in parallel arrays.1 The wound will have 15% to 20% of its full strength at 3 weeks and 60% of its full strength at 4 months. Tensile strength continues to increase up to 1 year after wounding. The skin will eventually regain only 70% to 90% of its original tensile strength.

Factors Affecting Normal Repair

The most common causes of improper wound healing are tension on the wound edges, necrosis and/or ischemia of the tissues from local conditions (e.g., crush injuries and contusions decrease blood flow and lymphatic drainage, which alters local defense mechanisms), or shock. Hypovolemia is the major deterrent to wound healing in patients with hemorrhage and shock, hemorrhage from inadequate hemostasis, infection, or retention of foreign bodies. Systemic conditions such as malnutrition, immunosuppression, shock, diabetes secondary to microangiopathy, decreased oxygen and nutrient delivery to the wound, renal insufficiency, cytotoxic drugs, vitamin deficiency, trace metal deficiency, and collagen vascular disease can result in poor wound healing. Polymorphonuclear leukocyte function is known to be impaired from hyperglycemia, jaundice, uremia, cancer, or chronic infections.

Drugs and medications can contribute to good wound healing or affect it adversely. Malnutrition, lack of protein, and lack of vitamins (e.g., vitamins A and C) may inhibit or prolong healing. Zinc deficiency, which is reversible, may play a role in retarding the healing process.3 Anti-inflammatory drugs (e.g., colchicine, aspirin, and glucocorticoids) disrupt macrophage function, collagen synthesis, and polymorphonuclear neutrophil concentrations. Pretreatment or early introduction of glucocorticoids results in retarded wound repair by slowing cell proliferation.4

Scar Formation

Some 6 to 12 months are required to form a mature scar. This explains why scars should not be revised until 12 months have passed. A wider scar, inadequate wound closure, or a wound dehiscence may occur in areas with increased skin tension or if the wound is in an area of excessive motion (e.g., over joints). Adequate immobilization of the approximated wound (but not necessarily the entire anatomic part) is mandatory after wound closure for efficient healing and minimal scar formation. Contractures can develop when a scar crosses perpendicular to a joint crease. These patients may require physical therapy to prevent the loss of range of motion secondary to contractures.

Hypertrophic scars result from full-thickness injuries. Hypertrophic scars are characterized by a thick and raised scar that remains within the boundaries of the original injury. They must often be corrected by surgical intervention.1

Keloids are hypertrophic scars (i.e., thick and raised) that exceed the boundaries of the initial injury. They can develop from superficial injuries and appear to have a genetic basis. Surgical intervention rarely resolves keloids. They may be prevented or minimized by the local application of pressure dressings, Silastic dressings, glucocorticoids, and calcium channel blockers.1

The repair procedure may result in more scar tissue. Absorbable suture materials contribute to the formation of suture marks because of their increased reactivity, whereas nonabsorbable materials do not. Wounds that are approximated too tightly can result in tissue ischemia and more scar tissue formation.

Primary Intention

Primary intention involves surgically approximating the wound edges shortly after the time of injury. The skin's greatest strength is in the dermal layer. The best repair results when the entire depth of the dermis is accurately approximated to the entire depth of the opposite dermis. Accurate approximation of the epidermis gives a cosmetically appealing effect to the repair but does not contribute to its strength. Wound eversion and the use of buried sutures can greatly improve healing by primary intention.

Secondary Intention

Secondary intention involves allowing the wound to heal without any surgical intervention. The wound is left open and allowed to heal from the inner layer to the outer surface. It is a more complicated and prolonged healing process than primary intention. Infection, excessive trauma, tissue loss, or imprecise approximation of tissue can result due to healing by secondary intention. Wound contraction by granulation tissue containing myofibroblasts is the major influence on this type of healing. Wound contraction becomes more significant when the dermis is lost.

Concave skin wounds heal with the best results. These areas often heal better by secondary intention than by primary intention. Such concave areas include the inner ear, the nasal alar crease, the nasolabial fold, the temple, and the concave areas of the pinna. Flat surfaces can also heal well by secondary intention, although surgical intervention may be best. Some examples include the forehead, the side of the nose, and periorbital areas. Wounds on convex surfaces are not optimal for healing by secondary intention. Convex surfaces include the malar cheek, the tip of the nose, and the vermilion border of the lip.2

Tertiary Intention

Tertiary intention, or delayed primary closure, can often decrease infection rates. Wound closure by tertiary intention is accomplished 3 to 5 days following the initial injury. It is a combination of allowing the wound to heal secondarily for 3 to 5 days and then primarily closing the wound. It is the safest method of repair for wounds that are contaminated, dirty, infected, traumatic, associated with extensive tissue loss, at high risk for infection, and for wounds that are “too old” to close. The ultimate cosmetic result is the same as that of primary wound closure. This method may not be suitable for young children, having to return a second time for an uncomfortable procedure.

During the interim period, instruct the patient to apply wet-to-dry dressing changes twice a day. Upon the patients return, assess the wound for any signs of infection. Anesthetize and clean the wound. Scrub the wound base and edges with saline-moistened gauze and irrigate the wound to remove any dirt, debris, and granulation tissue. Suture the wound to approximate and evert the wound edges. The postprocedural wound care is the same as if the wound was closed primarily.

Wound infections occur as a result of the patient's resident flora and the environment. It is related to wound age, the amount of devitalized tissue, and the tissue concentration of pyogenic bacteria. A wound infection exists when there are bacterial densities of more than 10,000 organisms per gram of tissue.5 Bacteria slow wound healing by secreting proteases that directly injure the tissue in the wound.2 They also secrete other factors that lead to excess inflammatory cells in the wound, which also injures the tissue.2

Host History

A thorough and accurate history and physical examination are essential for optimum wound management. Documentation of the patient's age, prior tetanus immunization history, systemic illnesses, medications, allergies (such as to latex or local anesthetics), and the circumstances of the injury are essential to good wound management. These principles are emphasized because the presence of disease processes (such as diabetes mellitus, chronic malnutrition, alcoholism, hepatic or renal insufficiency, asplenism, malignancies, and extremes of age) may impair host defenses or complicate wound healing.6,7 Second, the wound itself is often less important than an associated injury to an adjacent structure or cavity. Associated injuries can easily be missed without a specific directed search for their presence.

Tetanus Prophylaxis

A thorough history must be obtained concerning the patient's tetanus immunization status. Important factors to consider in assessing the risk of developing tetanus include prior immunization history, the type of wound, the degree of wound contamination, the time from injury to treatment, and the presence of underlying medical disease.

Wounds may or may not be prone to tetanus (Table 92-1). The administration of tetanus prophylaxis is based upon the patient's immunization history and the risk of developing tetanus (Table 92-2). Current guidelines state that tetanus toxoid (Td) may be deferred in patients with “clean, minor” wounds who have completed a primary series or received a booster dose (Td 0.5 mL IM) within 10 years. Consider tetanus immune globulin (TIG 250 to 500 U IM) in addition to Td for patients at risk of developing tetanus. Elderly patients without documentation of a primary series, patients from nonindustrialized nations, and those from rural or inner-city areas may never have received tetanus immunization and should be considered for TIG.

Mechanism of Injury

Severity of injury as well as associated injuries can be anticipated by determining the precise mechanism of injury. This will often indicate additional soft tissue injury, the presence of a foreign body, or the amount of contamination present.

Soft tissue injuries are rarely surgical emergencies. The patient's general condition should be attended to, with priority given to observing the ABCs (airway, breathing, and circulation) of Emergency Medicine. The skin margins of a laceration can be tacked together with well-placed atraumatic sutures and the wound covered with a moist pressure dressing until the time is more opportune for definitive repair.

Important questions and answers that must be documented are exactly how the injury occurred, when and where the injury occurred, and what contaminants were present or involved. If the injury involves the hand, what position was the hand in at the time of the injury, what kind of work does the patient do, and which is the patient's dominant hand? Complicated wounds, such as those caused by animal or human bites, chemical exposure, or high-pressure injection may require a more extensive evaluation and consultation with the appropriate specialist.

Wounds are described and classified based upon their cause and the type of injury. Abrasions are the result of grinding or abrading forces on the skin. The epidermis and/or dermis is disrupted but not removed in its entirety. Crush injuries are due to compressive forces. The patient sustains a large amount of kinetic energy that results in microvascular disruption, edema, and devitalized tissue. Crush wounds are 100-fold more likely to become infected than lacerations because of the much lower bacterial loads required for infection.8

Lacerations are wounds that are caused by shear forces that result in a tearing of the tissue. They are subclassified as avulsion, shear, or tension lacerations. Avulsion lacerations are injuries where there is sharp trauma at an angle that removes the epidermal and possibly also the dermal layer of skin. The injury creates a skin flap. Shear lacerations are produced by a sharp force, usually perpendicular to the skin surface, that results in a tidy or clean wound. These wounds are usually caused by knives, glass, or sharp metal objects. There is little tissue damage, and this type of wound is not prone to infection. Tension or tensile lacerations are injuries with jagged or contused edges that are created by a compressive force. These wounds pose a greater risk for infection than shear lacerations.8

Punctures result in a wound that is deeper than it is wide. The skin opening is small and the depth of the wound is often unknown. Such wounds are made by discrete and thin objects, and they carry a high risk for infection. Irrigation is mandatory for puncture wounds; however, the pressure must not be so high as to drive contaminants deeper into the wound.

The wound may also be clinically classified based upon an estimate of microbial contamination and the subsequent risk of infection. Clean wounds are those that occur under aseptic technique. These are usually surgical incisions that are elective in nature and preceded by a thorough skin cleansing and decontamination process. Clean-contaminated wounds are those associated with the usual and normal flora of the region. There is no contamination from foreign bodies or pus. Contaminated wounds are those that are traumatic (e.g., lacerations, open fractures), less than 12 hours old, or associated with a break in aseptic technique. Most wounds seen in the Emergency Department are of the contaminated type. They may be associated with the introduction of “dirt” or foreign bodies into the wound. Dirty wounds are those that are heavily contaminated (e.g., soil or feces), occur through infected tissue, are over 12 hours old, are associated with retained foreign bodies, or associated with devitalized tissue.

Time of Injury

This is probably the most pertinent factor of the history. After 3 to 6 hours, the bacterial count in a wound increases dramatically. Few studies have been conducted to determine the maximal time in which lacerations can be closed without resulting in infectious complications. One study performed in an underdeveloped country indicated that wounds might be closed up to 18 hours postinjury.9 Lacerations of the face and scalp that are reasonably clean may be closed primarily up to 12 to 24 (or even 48) hours postinjury with little risk of infection because of the excellent circulation in these areas. Other lacerations may generally be closed primarily if they are less than 6 to 12 hours old provided that they are not heavily contaminated or located in high-risk areas (i.e., hand or foot). The infection rate rises rapidly after 12 hours.

A complete examination and documentation of the laceration is necessary. This includes noting the location and depth of the laceration, the presence of any gross contamination, the presence of an obvious foreign body, and any associated injuries.

Assessment of soft tissue wounds involves an examination of the surrounding tendons as well as the vascular and neurologic structures; bony injuries and foreign bodies should also be sought. Emergency Physicians must possess a working knowledge of functional anatomy, particularly of the face and distal upper extremity.

Hemostasis can be achieved by direct pressure with a gauze sponge or gloved finger for simple lacerations. Suturing the wound best controls bleeding of the scalp. Extremity wounds, particularly of the wrist and hand, should have a pneumatic tourniquet applied after the extremity is elevated for 1 minute to promote venous drainage. Inflate the cuff above the patient's systolic blood pressure for 20 to 30 minutes at a time. A blood pressure cuff may be substituted if a pneumatic tourniquet is not available. For more severe bleeding, there are several commercial tourniquets available, as well as new hemostatic agents such as Quick Clot.37–39 Vascular structures (with the exception of small arterioles, small venules, and vessels within muscles) should not be clamped and may require special techniques for hemostasis.

Wounds may cross tissue planes, opening them and creating potential pockets or dead spaces. Elimination of the dead space has been advocated in the past to decrease the probability of this area becoming a nidus for infection. This once traditional practice of obliteration of dead space to avoid infection of a nonvascularized space or to prevent hematoma formation is now considered controversial. Studies in animal models have found the incidence of infected wounds to be consistently proportional to the number of suture layers.10,11 Leaving dead space open resulted in lower rates of infection than obliterating it with sutures.10,11 Studies in 1994 and 1996 concluded that buried absorbable sutures increase the infection rate and the degree of inflammation in contaminated wounds and do not significantly increase the degree of inflammation in noncontaminated wounds.12 Sutures placed in fat contribute no strength to the repair and fail to prevent hematoma formation and infection. Deep absorbable sutures may be placed to repair the periosteum, muscles, or fascia or to minimize tension on skin sutures. Use only enough subcutaneous sutures to restore anatomic and functional integrity. In most wounds, however, leaving potential space may be preferable to attempting to obliterate it.

It is important to explore the deep structures through a full range of motion in order to detect partial tendon lacerations or joint capsule disruption. Tendons can be evaluated by inspection, but individual muscles must also be tested for full range of motion and full strength.

A distal neurologic and vascular examination should be performed on extremity injuries. Capillary refill should be checked distally and take less than 2 seconds. Neurologic assessment involves checking distal muscle strength and sensation. Check two-point discrimination prior to the administration of anesthesia for hand and finger lacerations. Two-point discrimination at 5 mm on the radial and ulnar aspects of the finger pads is the most efficient method of assessing median and ulnar nerve function. Two-point discrimination should be less than 1 cm at the fingertips. A crush injury may be associated with decreased two-point discrimination and may take several months for recovery. Numbness may also be the first sign of a developing compartment syndrome. Nerve lacerations can be repaired immediately or the wound can be loosely approximated and repair of the lacerated nerve delayed.

Obvious as well as questionable fractures should receive a radiograph of the area. Bone injuries require checking the overlying skin to exclude an open fracture. An open fracture is an indication for surgical debridement and repair except in the case of a distal phalanx fracture, which can be treated with copious irrigation, oral antibiotics, and detailed discharge instructions.

Failure to identify foreign bodies in wounds may lead to complications such as an increased risk of infection, delayed wound healing, and loss of function.36 Foreign bodies and foreign matter greatly enhance the infectivity of a given bacterial inoculum.13 Retained foreign bodies are a common complication of simple wound repair. Perform a thorough inspection to attempt to diagnose the presence of a foreign body. Missed foreign bodies are the second leading cause (14%) of lawsuits brought against Emergency Physicians.14 Some foreign bodies cause an inflammatory reaction (e.g., wood, thorns, splinters, cloth, teeth, and rubber from shoes or foam insoles), while others do not (e.g., metal, glass, most plastics, and pencil graphite).

Wound exploration, irrigation, and radiography may be needed when the clinical setting suggests a possible foreign body. Spread the tissue during exploration. Do not cut tissue and risk neurovascular injury. Puncture wounds have not been proven to benefit by coring or probing to determine the depth of the wound. Imaging may be required to detect retained foreign bodies. Retained wood, thorns, and plastic are often detectable only by wound exploration and may not be visible on plain radiographs. Radiographs will identify retained metallic fragments and more than 90% of glass foreign bodies if the glass does not have a low lead content and the fragments are at least 2 mm long.15,16 Wound markers can be used during radiography. Radiographs obtained in two planes can help localize the object for recovery. Glass may penetrate at an angle and be buried deeper than it appears. The use of ultrasound is controversial because of its lack of specificity, lack of sensitivity, and operator dependency.

Foreign bodies that do not cause an inflammatory reaction are often not removed from lacerations. This is especially true if there are multiple fragments or if excessive tissue disruption will result with attempted removal. The patient should be made aware of any retained foreign bodies at the time of discharge, their benign presence, why removal was not attempted, the possibility of later infection, and the fact that they may eventually self-extrude. This must also be documented in the medical record. If the wound is in a complex area, such as the palm, it may be necessary to gain consultation for immediate or delayed removal. The wound can be approximated loosely and immobilized for comfort and to avoid further tissue disruption, antibiotics prescribed, and arrangements made for appropriate out-patient follow-up in 24 to 48 hours.

Soils have varied levels of contamination potential. Sandy soils present a low risk of wound contamination. Clay-containing soils are pyogenic because they impair host defense mechanisms and promote inflammation. Organic soils contain Clostridium tetani and a more concentrated bacterial inocula. Soil contaminants, when present, can be removed by copious irrigation. These contaminated wounds should be left open and allowed to heal by secondary or tertiary intention.

Many wounds require special consideration in deciding upon the method of closure, the type of suture to use, and the use of antibiotic prophylaxis. These include wounds contaminated by saliva, feces, vaginal secretions, soil, and organic material. Wounds in immunocompromised patients or patients taking immunosuppressive drugs may require antibiotics and longer times for the sutures to remain before removal. Hand wounds, including bite wounds, and foot wounds require special care. Wounds greater than 6 to 12 hours old, other than wounds on the face, may require delayed closure. Puncture wounds may require radiographs, incision and exploration, and antibiotic prophylaxis. Wounds accompanied by excessive tissue damage and devitalization or crush injuries are prone to infection. Wounds with retained foreign bodies may require radiographs, exploration, and removal. Major tissue defects may be closed with advanced wound closure techniques. Wounds overlying sites of active infection require antibiotics and delayed closure. These topics are covered further on in this chapter and in other chapters of this book (see Chapters 95, 96, 97, and 98 for details).

Anesthesia

Wounds must be anesthetized with either local or regional techniques prior to cleansing and repair. Local anesthesia distorts wound edges; therefore regional nerve blocks should be used where appropriate (e.g., the hand, face, ear, nasal cartilage, palm, sole). Refer to Chapters 123 through 129 for a complete discussion of local anesthetic agents, regional anesthesia, topical anesthesia, nitrous oxide anesthesia, and procedural sedation.

Lidocaine (Xylocaine) in a dose not to exceed 4.5 mg/kg is an effective and standard local anesthetic agent. Lidocaine anesthesia lasts approximately 60 to 90 minutes. If a longer period of anesthesia is required, bupivacaine may be used. It provides approximately 120 to 180 minutes of anesthesia. The addition of a 1:100,000 dilution of epinephrine to lidocaine or bupivacaine will prolong the duration of anesthesia, promote hemostasis, allow a larger dose to be used, and reduce systemic absorption of locally infiltrated local anesthetic solution. Epinephrine is a potent vasoconstrictor and should not be used near end organs such as the fingers or toes. It may decrease blood flow and induce ischemia. Epinephrine should also be avoided near the tip of the nose, the ear, and the penis.

Animal model studies have consistently shown that epinephrine increases the incidence of infection in contaminated wounds. This may be due to vasospasm-induced local ischemia. Epinephrine should not be used to enhance local anesthesia in contaminated wounds. Consider the use of regional anesthesia or procedural sedation in these patients.

The pain of local anesthetic injection can be reduced. The use of a 27 or 30 gauge needle, slower and deeper infiltration (into the dermis), warming the local anesthetic solution, and the addition of bicarbonate to lidocaine (9 mL lidocaine to 1 mL of bicarbonate) may decrease the pain of anesthetic injection.21–26 Other strategies involve anesthetizing as much tissue as possible through a single site, starting proximally on the extremity and moving distally. Infiltration of the local anesthetic solution through the wound edges is less painful than through intact skin.

Most “allergic” reactions are actually vasovagal or other adverse responses. Allergies to “caines” are attributed to what is often a vasovagal or other side effect. True allergies to local anesthetics are rare and are generally seen only with the ester class of local anesthetics. If an allergy to lidocaine (an amide class of local anesthetic) is suspected, the use of an ester class of local anesthetic is suggested. An alternative is the use of cardiac lidocaine, the prefilled syringes used in codes and cardiac arrests, which contains no preservative. It is felt that the preservative in lidocaine is responsible for the allergic effect. Another alternative is to use a 1% to 2% solution of diphenhydramine (Benadryl). This provides adequate but not ideal anesthesia. The most common complication of local anesthesia infiltration is hypotension and bradycardia as a result of a vasovagal reaction.

Topical anesthesia is an attractive alternative to injection, particularly in the management of pediatric patients with simple wounds. Lidocaine, epinephrine, and tetracaine (LET) gel or tetracaine, adrenaline, and cocaine (TAC) are two agents that can be used as effective local anesthesia.27 Both of these agents contain epinephrine and should not be used on areas involving an end artery or contaminated wounds. TAC involves expense and incorporates problems with the use and maintenance of a controlled substance. TAC also has the potential for toxicity, especially when applied to mucosal surfaces. EMLA (eutectic mixture of local anesthetics) cream, also used for local anesthesia, has been found to provide effective anesthesia for extremity lacerations. EMLA is a combination of 2.5% lidocaine and 2.5% prilocaine suspended in an oil-in-water emulsion. Studies have found that it takes longer to obtain optimal anesthesia with EMLA than with TAC.28

Skin Cleansing

Meticulous preparation of the skin surrounding the wound and the actual wound, irrigation, and wound debridement are tantamount to good wound healing. The goal is to remove bacteria, foreign matter, and tissue debris. Wounds should be adequately anesthetized prior to cleansing and/or local exploration. Adequate light, anesthesia, and equipment are a must in order to avoid inadequate debridement, a retained foreign body, or a wound hematoma that can result in a necrotizing soft tissue infection.

Disinfecting the intact skin surrounding the wound and ridding it of foreign bodies, debris, and particulate matter is the initial step in wound preparation. This technique can be accomplished by scrubbing the skin with povidone iodine, chlorhexidine, or poloxamer 188 (Shur Clens) skin-prep solutions. Do not expose the wound itself to these solutions. Povidone iodine and chlorhexidine solution are bactericidal and work as it dries. Its toxicity to wound tissue is controversial. Shur Clens has no tissue toxicity but also has no antibacterial activity. A wide area surrounding the wound should be prepped with an antimicrobial agent, preferably povidone iodine or chlorhexidine solution.

Hair Removal

Hair removal is often unnecessary prior to closing wounds, can be embarrassing for the patient after discharge from the Emergency Department, and may increase the risk of wound infection. Shaving can cause minimal soft tissue trauma and wound infections.17 Eyebrows should never be shaved, as they can grow back unpredictably or not at all. Simple scalp lacerations can be exposed by using antibiotic ointment (or lubricating gel) to move the hair away from the wound margins prior to placing sutures.

Wound Irrigation

Wound cleansing and preparation have been proven to be the foundations of proper wound management and the prevention of wound infections. Irrigation removes contaminants, reduces infection, and improves visualization. There are two concerns regarding wound irrigation: the pressure required for adequate cleansing of the wound and the means to irrigate the wound safely while protecting the healthcare worker from the threat of human immunodeficiency virus and hepatitis B (by contamination of their own skin surfaces, mucosal surfaces [eyes, nose, or mouth], or minor open skin wounds).

Irrigation pressures of 5 to 8 pounds per square inch (psi) are felt to be adequate to cleanse a wound that is not heavily contaminated. This surface pressure can be generated by the combination of a 35 mL syringe and a 19 gauge angiocatheter held 2 cm from the wound surface.18,40–42 Unfortunately, this process can be quite messy (Figure 92-1). High-pressure irrigation, which generates peak pressures of 25 to 40 psi, has been a controversial issue in the Emergency Medicine literature. The theory is that high pressures may cause tissue disruption and increase infection rates. High-pressure irrigation should be reserved for highly contaminated wounds. High-pressure irrigation may drive contaminants deeper into puncture wounds and should be avoided.

Though there are a variety of irrigation fluids, the optimal type is unknown. Normal saline is the most commonly used irrigant. The volume of irrigation fluid to be used has not been well established. The use of 100 to 300 mL has been suggested in the literature. Heavily contaminated wounds require larger amounts of irrigant. Anecdotal recommendations suggest using 50 mL/cm for clean wounds and 100 mL/cm for dirty wounds. Heavily contaminated wounds may have to be scrubbed (after adequate anesthesia) with fine-mesh gauze or a micropore sponge using a 1% solution of povidone iodine or poloxamer 188. Tap water can be used for irrigation with no increased incidence of infection, especially when a large volume of irrigant is required.43–47 Soaking of wounds is discouraged as a poor substitute for the preparation of contaminated or clean wounds. Do not soak wounds in any fluid. Soaking does not reduce bacterial contamination or decrease infection rates. It may actually increase infection rates. Do not use undiluted povidone-iodine, hydrogen peroxide, or detergents in the wound as they cause tissue toxicity.48

Numerous commercially available devices are available to irrigate a wound (Figure 92-2). The Combiport (Moog Medical Devices, Salt Lake City, UT) is a wound irrigation device that inserts directly into the port of an intravenous fluid bag (Figure 92-2A). Squeeze the bag of saline and direct the stream of fluid through the device and into the wound. Wound Wash Saline (Church & Dwight, East Princeton, NJ) is sterile normal saline within a pressurized can (Figure 92-2B). Direct the tip of the can toward the wound, press the button, and direct the saline stream into the wound. This is also available at retail stores for patients to use at home for wound care. The company offers a convenient chart that uses wound depth and base characteristics to determine how much saline to use to irrigate the wound. The can controls the pressure (6 to 13 psi), so that tissue is not devitalized during the irrigation. Unfortunately, using this method is quite messy as the saline and wound materials (e.g., tissue fluid, blood, and debris) splash all over.

The Emergency Physician should use barrier protection to shield their face, eyes, skin, and submucosal surfaces during the irrigation process. There are several barrier devices on the market that decrease the splatter of irrigation fluid19 (Figure 92-2). Some of these devices are preattached to a wound irrigation device. Others can be attached to a wound irrigation device. The Zerowet Supershield (Zerowet Inc., Palos Verdes Peninsula, CA) is a dome-shaped device that attaches to a syringe (Figure 92-2C). The Combiguard Irrigation Splash Guard (Moog Medical Devices, Salt Lake City, UT) is similar in function to the Zerowet Splashield and has a slightly different shape. The Combiguard can attach to a syringe or the Combiport Wound Irrigation Device (Figure 92-2D). The Igloo Wound Irrigation System (Bionix Medical Technologies, Toledo, OH) is a similar device that provides a multiport shower effect to deliver the irrigation solution (Figure 92-2E). The Irrijet (Cooper Surgical, Trumbull, CT) is a spring-loaded, self-refilling system that is operated with one hand (Figure 92-2F). A Splashield or Splash Guard can be attached to the Irrijet. The Canyons Wound Irrigation System (Wolfe Tory Medical Inc., Salt Lake City, UT) is a similar device with the exception of using the built-in Zerowet Splashield (Figure 92-2G). The Squirt Wound Irrigation Kit (Merit Medical Systems Inc., South Jordan, UT) is a manually operated system that may be used alone or attached to the Splashield, Combiguard, or an angiocatheter (Figure 92-2H). The Klenzalac (Zerowet Inc., Palos Verdes Peninsula, CA) is a similar device with the exception of using the built-in Zerowet Splashield (Figure 92-2I). The Splashcap (Splash Medical Devices, Atlanta, GA) attaches to a bottle of sterile saline (Figure 92-2J). The Irrisept (Irrisept, Gainesville, FL) attaches to a proprietary bottle containing a saline and chlorhexidine mixture (Figure 92-2K).

Wound Debridement

Debridement creates straight and clean wound edges that are easier to repair by removing tissue that is devitalized, contaminated by bacteria, or contaminated by foreign matter and may impair the ability of the tissue to resist infection. Successful wound closure may require the transformation of a ragged laceration, the removal of devitalized tissue, or the removal of contaminated tissue in order to convert a traumatic wound into a surgical wound. Devitalized and necrotic tissue must be removed in order to remove a nidus for bacterial growth and wound infection.20

Close approximation of the wound requires that debridement of jagged edges not be too vigorous in order to avoid widening the scar and making it difficult to close. Wounds of the face or areas that are devoid of redundant tissue require conservative debridement. Debridement to simplify wound closure is not always the answer for a superior cosmetic result in the repair of irregular wound edges. The meticulous repair of complex wound edges can often provide a superior cosmetic result.

Debridement can be accomplished mechanically, hydrodynamically, or with a combination of both methods. Tissue must be removed mechanically with a #11 or #15 scalpel blade or a scissors (Figure 92-3). Superficial debris and contaminants can be removed with a pulsatile stream of normal saline solution during the irrigation process. Debridement must be performed using aseptic technique. Scrubbing is not a substitute for debridement of heavily contaminated tissue. Wound edges should be handled delicately or gingerly in order to avoid further soft tissue damage and devitalization of injured tissue.

Wound Excision

The entire wound may be excised in areas of excess tissue or tissue laxity if no blood vessels, nerves, tendons, or joints lie within or at the base of the wound (Figure 92-4). The excision of a wound creates smooth, clean edges that may be approximated with sutures. This is especially useful in wounds that are heavily contaminated. Most wounds are excised with an elliptical incision (Figure 92-4). Other types of wound excision are discussed in Chapters 95 and 96.

Carefully plan the excision before removing any tissue. Mark the edges of the proposed incision with a marking pen. The long axis of the ellipse should be two-and-a-half to four times as long as the greatest width of the ellipse. Removal of too much tissue will produce a large defect that may not be possible to close primarily. Remove the tissue using aseptic technique, preventing any contamination of the new wound edges.

Wound Undermining

The undermining of tissue creates a “flap” that involves the separation of the skin and superficial subcutaneous tissue from the deeper subcutaneous tissue and fascia (Figure 92-5). The process of undermining tissue minimizes skin tension, allows for eversion of the approximated skin edges, and relieves the extrinsic tension from sutures. Undermining is performed when the wound cannot be closed due to a tissue defect or if a wound is under tension. This procedure requires the Emergency Physician to be familiar with the local anatomy so that no blood vessels, nerves, or tendons are injured in the process. Do not undermine contaminated wounds. Undermining large areas can separate the skin from its underlying blood supply and result in a diminished blood flow that predisposes the area to infection and necrosis. Undermining may be useful on the forehead, scalp, arm, forearm, thigh, calf, and torso. Never undermine wounds on the palms, soles, and face.

Undermine tissue at the dermal-epidermal junction or within the subcutaneous adipose tissue. The amount of undermining necessary to close a laceration is approximately double the width of the gap of the laceration at its widest point. A 1 cm wide laceration should be undermined for 1 cm on both sides of the wound, including the ends (Figure 92-5). The use of a Mayo scissors versus a #15 scalpel blade to undermine tissue is based on physician experience and preference. A Mayo scissors is recommended as it may cause less secondary injury, especially in experienced hands.

Laceration repair may sometimes have to be performed in the operating room. Indications for operating room repair of lacerations include those associated with open fractures, major or complex wounds involving devitalized tissue, heavily contaminated wounds, wounds with associated injuries (e.g., visceral, neurovascular, fracture, and tendon), perineal wounds, large or complicated soft tissue injuries, compartment syndromes, wounds with extensive amounts of necrotic or ischemic tissue, the total local anesthetic solution required would exceed toxic tissue levels, and high-pressure injection injuries.

Despite the best wound care and management, the rate of infection has been determined to be approximately 1% to 12%. Not all wounds result in infection. Most uncomplicated wounds heal without the need for antibiotics. Wounds associated with an increased risk for infection are those of the extremities (especially the lower), complex wounds, or wounds over 3 to 5 cm in length. The use of antibiotics for traumatic wounds is controversial. Prophylactic antibiotics are not indicated for uncomplicated minor wounds with a low chance of becoming infected. It has not been proven that oral antibiotic administration following injury actually reduces the probability of infection. However, the use of topical antibiotics can decrease the rate of wound infection.34 Useful preparations include bacitracin, triple antibiotic ointment, or silver sulfadiazine.

It is necessary to identify those patients who may benefit from early antibiotics. Antibiotic therapy should be considered in the following situations: where wounds are heavily contaminated or associated with major soft tissue injury; open fractures, intraoral lacerations, wounds associated with active infection; when there is a delay in care that results in a prolonged time from debridement or treatment (>3 hours); when the patient is immunocompromised or has cardiac valvular disease; when there are bites to the hand or face, deep puncture wounds, or lacerations to lymphedematous tissue; or when the patient has prosthetic joints (Table 92-3).

Suture Types

Proper size suture material can be summarized as the smallest suture needed to approximate the edges of a wound. This will reduce tissue damage caused by the suture, and the resulting scar will be minimized. The tensile strength of the suture should never exceed the tensile strength of the tissue, or it can pull through and damage the tissue. The sutures should be at least as strong as the normal tissue through which they are being placed.

The size of the suture material is related to the diameter of the suture. As the number of 0s in the suture size increases, the diameter of the strand decreases. For example, size 5-0, or 00000, is smaller in diameter than size 4-0, or 0000. The smaller the size, the less tensile strength the suture will have.

Suture description entails numerous characteristics. Sutures can be classified into two major groups based upon the number of strands of which they are composed. Monofilament sutures are made of a single strand of material. They encounter less resistance passing through tissue and resist harboring organisms that may cause suture-line infections. Multifilament sutures consist of several filaments, or strands, that are twisted or braided together. This affords greater tensile strength, pliability, and flexibility. Unfortunately, bacteria can migrate between the filaments and into the wound.

Another classification is based on the ability of the body to break down and absorb the suture material. Absorbable sutures are digested by body enzymes or hydrolyzed in body tissue. Nonabsorbable sutures are not digested by body enzymes or hydrolyzed.

Absorbable suture can be made of natural or synthetic material. Natural absorbable suture is classified as surgical gut (plain or chromic). Plain surgical gut is composed of collagen from bovine or sheep intestine. It is rapidly absorbed, maintaining its tensile strength for only 7 to 10 days, and is completely absorbed within 70 days. Chromic gut is treated with a chromium salt solution to resist body enzymes. It retains its tensile strength for 10 to 14 days and is absorbed over 90 days.

Synthetic absorbable sutures include polyglactin 910 (Vicryl, Ethicon) and polyglycolic acid (Dexon). They were developed because of the tissue reaction, suture antigenicity, and unpredictable rates of absorption of natural absorbable sutures. These sutures are braided synthetic materials that retain 50% of their initial strength at 4 weeks. The synthetic absorbable sutures retain their tensile strength long enough to ensure the security of the subcutaneous layers after the removal of percutaneous sutures.

Nonabsorbable sutures are made of silk, nylon, polypropylene, cotton, linen, or metal. They can be monofilament or multifilament in construction. Nylon is the most commonly used suture in the Emergency Department. It is used to approximate lacerations at the skin surface. Silk may occasionally be used in the mouth. It causes significant tissue reactions that result in inflammation and granuloma formation as the body “fights off” this natural fiber. The other types of nonabsorbable sutures are generally not utilized in the Emergency Department.

Several factors must be considered in choosing suture material. Choose sutures that match the healing properties of the tissues. Approximate slow-healing tissues (e.g., fascia and tendons) with nonabsorbable sutures or a long-lasting absorbable suture. Foreign bodies in potentially contaminated tissues may result in an infection. Multifilament sutures can act as a foreign body and may convert a contaminated wound into an infected one. Multifilament sutures should generally be avoided. Use monofilament sutures or absorbable sutures that resist harboring infection. Use the smallest inert monofilament suture materials (such as nylon or polypropylene), avoid using skin sutures alone (use subcuticular closure whenever possible), and use sterile skin closure strips for apposition when possible. Use the smallest possible size of the chosen suture type that is capable of closing the wound to help minimize scarring.

Needles

Needles are generally of two types, tapered and cutting (Figure 92-6). Cutting needles have sharp ends and sharp edges that act as a cutting instrument (Figure 92-6A). The cutting needle is commonly used for tougher tissues such as subcutaneous, intradermal, and cutaneous (skin) closure. In addition to the two cutting edges, conventional cutting needles have a third cutting edge on the inside concave curvature of the needle. This needle type may be prone to “cutout” of tissue because the inside cutting edge cuts toward the edges of the incision or wound.

Reverse cutting needles are as sharp as the conventional cutting needle except that the third cutting edge is located on the outer convex curvature of the needle (Figure 92-6B). Reverse cutting needles have more strength than similar-sized conventional cutting needles. The danger of tissue “cutout” is greatly reduced. The hole left by the needle leaves a wide wall of tissue against which the suture is to be tied.

Taper point needles have a pointed end (Figure 92-6C). The rest of the needle is a smooth, rounded tube with no cutting edges. This type of needle is commonly used in surgery to close tissues with minimal trauma. It is used for all tissues except skin.

Two other types of needles are often available but not used in the Emergency Department. The blunt point needle has a smooth tip and tapered body (Figure 92-6D). It is used for suturing friable tissue and blunt dissection. The taper cut needle has a cutting tip and a tapered body (Figure 92-6E). It is a combination of the tapered point and cutting needle. It is used to place sutures through tough tissues. Numerous other needles are available, as are modifications of the five basic needle types. These needles are used by Surgeons for specialized tissues.

Always keep some general principles in mind when suturing. Needles should be pulled through tissue using a needle driver and never a hemostat. A hemostat or other clamp can damage the needle. Avoid injury to yourself and others. Keep all open needles in a place so that they will not injure you or your assistant. Account for and discard all suture needles in a “sharps” container. Following these two steps will dramatically decrease the chance for a needle-stick injury.

Needle Drivers and Handling Sutures

Always use a needle driver when suturing. The use of a hemostat or other type of “clamp” can damage the needle and cause it to bend or break in the tissue. Needle drivers are generally made of steel with a jaw designed to hold the needle securely without damaging it. They come in numerous sizes and shapes. Choose a needle driver that is an appropriate size for the needle that is to be grasped. A 4.5 to 6 in. long needle driver is appropriate for Emergency Department use. Grasp and remove a clean needle from its package with your hands, forceps, or a needle driver. Securely grasp the proximal one-third to one-half of the needle with the needle driver (Figure 92-7A). Do not grasp the distal one-third of the needle. This can damage its cutting surfaces. Always use the tips of the needle driver to grasp the needle (Figure 92-7B). Grasping a needle with the base of the jaws may damage the needle.

Use the needle driver when pushing the needle through the tissue to place a suture (Figure 92-7C). Apply the force in a direction following the curve of the needle. Do not twist or force the needle to push the point through the tissue and out the other side. Use a larger needle if the first one is too short or too small. Do not use a needle that has become dull and difficult to pass through the tissue. Obtain a new needle and continue the procedure. Grasp the distal tip of the needle with a needle driver when it emerges from the tissues (Figure 92-7D). Always grasp the needle proximal to its distal third to prevent damage to the cutting edges.

Always use caution when handing a needle driver armed with a needle to another person. Grasp the needle driver between the thumb, index, and middle fingers (Figure 92-7E). Hand the base of the needle driver to another person. Do not blindly pass the needle driver. Do not pass the needle driver over a third party without their knowledge of the transfer. Never grasp the distal end of an armed needle driver.

Typical needle drivers contained within most disposable, commercially available laceration repair trays are not ideal. The suture often snags on the jaws or hinge when performing an instrument tie. Some needle drivers are designed to be snag-free (Figure 92-8). Two of these, the Centurion SnagFree (Centurion Healthcare Products, Howell, MI) and the SutureCut (SutureCut LLC, Lexington, KY) needle drivers, are available both as individual disposable instruments and in disposable laceration repair trays.

Suturing lacerations can take a significant amount of time. Much of this time is spent tying knots or switching between instruments (i.e., the needle driver and scissors). Two needle drivers are designed to also cut suture. This decreases the total time required to repair a laceration as well as avoiding the constant switching between instruments. The SutureCut (SutureCut LLC, Lexington, KY) and the Olsen-Hagar (Henry Schein Inc., Port Washington, NY) needle drivers cut the suture in their specially designed joint located at the base of the jaws.

We are all not fortunate to have suture-cutting needle drivers in our laceration repair trays. A needle driver and scissors can be simultaneously held in the same hand to improve efficiency (Figure 92-9). While awkward at first, this technique is easy to learn. Grasp a scissors with the tip pointing ulnarly (Figure 92-9A). Insert your middle finger through the adjacent ring on the handle. Grasp a needle driver in the same hand with the tip pointing radially (Figure 92-9A). Insert your thumb and ring finger through the rings on the handle of the needle driver. Grasp a suture needle with the needle driver. Place a stitch and tie it. Remove your thumb from the ring of the needle driver and place it in the open ring of the scissors. Use the thumb to open and close the scissors. Cut off the excess suture (Figure 92-9B). Place your thumb back into the ring of the needle driver and place the next stitch. Repeat this process until the laceration is closed.

The goal of wound closure is approximation of the skin under minimal tension while achieving eversion of the wound edges (Chapter 93). Wound eversion slightly raises the wound edges to keep the epidermal cells from migrating into the dermal layers, therefore leaving a flat scar (Figure 92-10). Sutures should be placed closely enough to approximate wound edges, but not so tight as to cause tissue necrosis. The time from the injury to the presentation and the mechanism of injury will indicate whether the laceration mandates delayed closure instead of primary closure and whether tetanus prophylaxis is required. With the exception of patients who are immunocompromised or taking immunosuppressive therapy, those with high-risk wounds should be considered for delayed closure.

Single-Layer versus Multilayer Closure

The greatest strength of the skin (and of the wound) is contained within the dermis. The better the coaptation of the dermal edges, the narrower the scar will be. The best results occur when the entire depth of the dermis is accurately approximated to the entire depth of the opposite dermis. Dermal closure is best performed with synthetic monofilament absorbable suture that requires enzymatic degradation (e.g., Vicryl). Chromic or plain catgut suture dissolves much more rapidly by means of hydrolysis.

Close the wound in multiple layers if the goal is cosmesis. Close the wound with a minimal number of sutures in a single layer if the goal is a functional result. Do not suture through fat and muscle. Fat has no tensile strength. Sutures placed tightly in fat can cause ischemia and necrosis in the wound and increase the risk of a wound infection. Muscle fibers do not support sutures. Muscle is best treated by repair of the overlying fascia and immobilization to prevent motion and to allow coaptation of the muscle fibers.

Sterile Gloves

It is a common practice to wear sterile gloves when repairing a laceration. The advantages of sterile gloves include a better fit, improved tactile sensitivity, and improved dexterity. The use of sterile gloves for laceration repair costs significantly more than using nonsterile, clean gloves from a box. Clean, nonsterile, powder-free, boxed examination gloves can be used for uncomplicated wound repair in the Emergency Department. No clinically important differences in infection rates has been found when comparing sterile gloves to clean gloves.49,50

The use of clean gloves from a box is not always ideal. Clean gloves come in a limited number of sizes (i.e., extra small, small, medium, large, and extra large). The fit and feel of clean gloves may not be as comfortable for the Emergency Physician. Clean gloves may have more manufacturing defects when compared to sterile gloves.51 These defects can result in the loss of personnel protection and the potential to contaminate the wound. Others have shown clean gloves to have comparable quality to sterile gloves.52–54 A box of clean gloves that has become wet can harbor mold.55 While the use of clean gloves in uncomplicated wound repair is acceptable, the decision is physician dependent.

Wound Closure Procedure

Clean any dirt and debris from the skin. Scrub the skin surrounding the wound with an antiseptic skin cleanser (e.g., povidone iodine or chlorhexidine). Anesthetize the wound with a 27 to 30 gauge hypodermic needle and local anesthetic solution. Irrigate the wound with normal saline. Use a mask with a face shield to prevent exposure to the patient's blood and tissue fluid. Debride and undermine the wound as necessary. Irrigate the wound again to remove exposed debris and devitalized tissue. Repair the wound with sutures or pack it with saline-soaked fine-mesh gauze for delayed closure. Clean the repaired wound with normal saline and apply a dressing for comfort and protection. Consider the application of a splint for wounds across joints or muscle lacerations.

Write a procedure note describing the sterile preparation of the wound, the type and volume of anesthesia administered, the type of suture(s) used in the repair, the layers repaired, the type of repair (interrupted vs. continuous), and how the procedure was tolerated by the patient. Any complications should also be noted.

Wound care has become a specialty involving sophisticated research in many areas, including dressings and the environment in which wounds heal best. Clean the area surrounding the repaired wound with normal saline to remove any antimicrobial agents and blood. It has been demonstrated that optimal growth of fibroblasts in tissue culture occurs at low partial pressures of oxygen (5 to 10 mmHg). Epidermal cell growth is inhibited at oxygen levels higher than that in surrounding air. It has been shown clinically that hydrocolloid dressings are capable of maintaining low oxygen tension independent of the underlying disease process.29 The application of an occlusive dressing has been shown to increase the rate of wound healing by approximately 40%, as well as preventing environmental trauma and keeping bacteria out of the wound.

Dressings, regardless of the type used, should produce a moist but not macerated wound that is free of infection, toxic chemicals, and foreign material while maintaining an optimum temperature and pH. Layered dressings of nonadherent gauze, such as Xeroform, covered with dry gauze can be used for large sutured lacerations and abrasions. This dressing draws exudate into a layer that can be replaced without disturbing the underlying wound. Shear wounds or hematomas may require gauze that is fluffed and formed into a pressure dressing. Dressings of antibiotic ointment with a standard adhesive bandage (e.g., Band-Aid) provide adequate healing and protection for smaller repaired lacerations. The topical application of topical antibiotics to the suture line after wound closure may help to protect against exogenous bacterial contamination. No studies have shown that topical antibiotic ointments have an effect on the final outcome of a wound. Despite this, their use is still recommended because they keep the wound surface moist and their use has not been shown to have any negative effects. The use of paper gauze and Telfa pads is not advisable.

High-risk wounds such as animal and/or human bites, hand wounds, heavily contaminated wounds, and wounds that require prophylactic antibiotic coverage should be reevaluated within 24 hours.

Patients should be made aware, orally and in writing, that up to one in 10 persons develops a wound infection that can be treated with an oral antibiotic. Puncture wounds are considered high-risk injuries that can result in bone infections. Patients should immediately return to the Emergency Department or their primary physician if a wound becomes red or has a discharge, if redness or red streaks are emanating from the wound, or if they develop a fever.

Explain briefly the progression of healing. The new scar's appearance is usually worst at 3 to 5 weeks. Most scars remodel within 6 to 12 months. Any revision of the wound should be postponed for at least 6 to 12 months from the time of injury.

The length of time that the sutures remain in place depends upon the location of the wound, the amount of tension on the wound, and the healing time of the involved tissue. Some general guidelines are listed in Table 92-4. Appropriate and timely removal of sutures minimizes scarring. Full-thickness sutures can be left in place for 2 or more weeks without risk of suture-track formation in areas where sebaceous glands and other adnexal structures are not present, such as the plantar and palmar surfaces. Leaving sutures in place too long results in epithelialization of the suture tracts, larger scars, and possibly infections. Suture removal kits are commercially available. They typically contain a metal or plastic forceps, a scissors, and a few gauze squares. These kits are inexpensive, disposable, and intended for single-patient use.

Sutures should be removed using aseptic and sterile techniques. Clean the wound with saline. Apply hydrogen peroxide to remove any dried blood and serum encrusted around the sutures. Grasp the suture at the knot with forceps (Figure 92-11). Lift the knot off the skin. Cut the suture as close to the skin as possible with a scissors and where the suture enters the skin (Figure 92-11). This will avoid drawing contaminated suture through the depth of the wound. Sutures that are close together, small, or tight may require a #11 scalpel blade to cut them rather than a scissors. Gently pull the suture strand out of the tissue with the forceps and across the wound. Pulling a suture out away from the wound may result in the wound edges opening (dehiscing). Remove one to three sutures and ensure that the wound edges do not dehisce. Remove the remaining sutures. Apply skin adhesive strips (e.g., Steri-strips) across the wound to provide support.

Puncture wounds are considered to be at higher risk for infection than simple lacerations. They should be allowed to heal by delayed intention, particularly if they penetrate into the subcutaneous tissues. Local cleansing is the initial step in management. High-pressure irrigation, coring, and probing are generally not recommended.

Infection is most frequently due to Staphylococcus aureus, Staphylococcus epidermidis, or streptococcal species. Treatment should be reserved for compromised hosts, dirty wounds, or actual infected wounds.30 Puncture wounds of the foot are of special concern due to the risk of Pseudomonas aeruginosa infection, particularly with wounds through athletic shoes. A tender wound that is not infected usually indicates that there may be a retained foreign body. Persistent infection from a plantar wound suggests an underlying osteomyelitis that requires radiographs and treatment with a fluoroquinolone.31

Pediatric patients less than 15 years of age experience infection rates of less than 1% for clean surgical wounds.7 This is less than that seen in adults. Young children, despite the ultimate in the way of gentle reassurance, will sometimes require sedation in order to make painful or difficult procedures possible. Safe and effective procedural sedation for patient comfort or cooperation to facilitate or expedite medical care is described in Chapter 129. Undermining is not useful in most pediatric wounds as they do not usually require advancement of skin over a significant tissue defect. Scalp lacerations account for 30% of pediatric lacerations. Scalp lacerations are well suited for single-layer repair with staples. Cosmetic results are comparable with those of sutured repairs, with no differences in complication and infection rates. Staples are six times faster, less expensive in cost of supplies and physician time than standard sutures, and can be implanted rapidly and accurately, even in a moving child.

Alternative methods of wound closure include skin closure tapes, tissue adhesives, and staples. These are mentioned briefly below. A more complete discussion can be found in Chapters 93 and 94.

Skin Closure Tapes

Skin closure tapes are adhesive strips that are used when skin tension and wound contamination are not concerning factors. Adhesive-backed long and narrow strips are used for approximating the edges of lacerations (with or without staples or sutures) and for closing the skin following many operative procedures. The most common type is the Steri-strip. Skin closure tapes are felt to develop and increase wound tensile strength faster than sutured wounds because uniformly orienting collagen fibers apply equal stress across the wound. Skin closure tapes are porous, which allows for good air inflow and the escape of water vapor from the wound during the healing process. Strips are placed perpendicular to the wound in conjunction with an adhesive such as tincture of benzoin, taking care not to get benzoin in the wound.

Tissue Adhesives

Tissue adhesives such as the older and weaker butyl cyanoacrylates focused on small linear lacerations. Newer and stronger medical-grade octyl cyanoacrylate formulations have been approved by the US Food and Drug Administration. It has been clinically proven that there is no difference 1 year after treatment in the cosmetic outcome of wounds repaired with suture versus those closed with octyl cyanoacrylate tissue adhesive.32

Staples

Staple closure is time-efficient compared to the suture repair of lacerations.33 It is primarily used for large wounds that are not on the face, neck, hands, or feet. Stapling is especially useful for closure of incisions in hair-bearing skin (i.e., scalp) areas as well as the trunk and extremities. The wound edges require manual eversion with forceps prior to placing the staples.

Expert wound management consists of attention to the details surrounding the wound, gleaning important information concerning the host's history, as well as meticulous wound preparation. Aggressive attention to the presence of foreign bodies, underlying injury to anatomic structures of significance, and the possibility of subsequent wound infection should be kept in mind at all times. An effort should be made to educate the patient about the possible outcomes of wounds and lacerations and to encourage expedited follow-up.