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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.1–6 Wound repair is always secondary to the evaluation and stabilization of any life-threatening and limb-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 management. This chapter describes the basic methods used to close wounds.
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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, polyethylene (Dacron), polyglactin (Vicryl), polypropylene (Surgilene, Prolene), polyglycolic acid (Dexon), poliglecaprone (Monocryl), polydiaxanone (PDS), polyglyconate (Maxon), and metal.6 Metal sutures are used in the Operating Room and not in the Emergency Department as they are difficult to handle, prone to breakage, and indicated in only a few situations. 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.
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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.
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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, nail bed lacerations, as well as lacerations in 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.
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The other main category of suture classification is absorbable versus nonabsorbable. In the past, absorbable sutures were primarily used to close the subcutaneous layers of a wound. More recently, absorbable sutures have also been used for skin closure. Nonabsorbable sutures are primarily used for skin ...