Basic Suturing and Wound Management
Wound considerations
Each wound that is encountered and considered for repair must be addressed independently. Factors such as location, size, mechanism of injury, time elapsed since injury, likelihood of contamination and patient dependent factors must be addressed prior to formal treatment. As well, the physician or student should consider whether or not they have the skill or experience to adequately manage a particular wound.
Wound location is important. Lacerations on the face, hands and perineum, for example, are more complicated for cosmetic structural reasons. These areas should be reserved for more experienced physicians. Lacerations of the scalp, trunk and proximal extremities tend to be less complex so more appropriate for beginners. As with all forms of medical care, it is important to be aware of one's own abilities and limitations and to request assistance, if necessary.A functional assessment of nerves, blood vessels, muscles and tendons is essential early in the evaluation of the wound. It must be done prior to injection of local anaesthesia, as this will obviously interfere with the assessment.
Knowledge of the mechanism of injury can provide valuable insight into the potential for injury to adjacent structures, the likelihood of contamination and the preferred method of repair. Deep puncture wounds can injure blood vessels and nerves, and contaminate several tissue planes. They are probably best left open after thorough cleansing, as there is a high risk of subsequent infection if sutured primarily. Conversely, a superficial laceration from clean glass may be cleaned and either sutured or taped to approximate the edges.
Lacerations resulting from significant blunt force often require debridement and revision of wound edges to optimize healing. As well, the edema and inflammatory response resulting from blunt injury can adversely affect the already tenuous blood supply to the area.
All traumatic wounds must be assumed to have some degree of contamination by virtue of the presence of dirt, microorganisms and devitalized tissue. An infected wound will not heal properly due to adverse effects on tissue regeneration.
The time elapsed from injury to repair has a direct bearing on the subsequent risk of wound infection. Any wound that has been exposed for greater than 8 hours is at significant risk for infection, regardless of the mechanism of injury.
Wounds that are more than 8 hours old and grossly contaminated wounds, such as animal bites and farming injuries, are at such high risk for subsequent infection that consideration should be given to leaving them open. Initial management should focus on thorough cleaning and close monitoring for infection. Suturing a grossly contaminated wound, which greatly increases the risk of infection, should always be balanced against the benefits of faster healing and better cosmetics.
Patient dependent factors known to negatively influence the process of wound healing include advanced age, poor nutritional status and co-existing illness such as diabetes. These factors can lead to delayed healing, dehiscence, abnormal scarring and infection and must be considered when instructing the patient regarding follow-up.