Wound management for healthcare providers

Below are videos describing some alternative wound closure techniques.

Not all wounds need sutures. In fact, there are many great reasons to avoid suturing when feasible. Sutures are a foreign body in a wound, which causes tissue inflammation and in some cases can lead to infection.  Sutures left for too long in the epidermal later can cause punctate “train tracking” marks on certain skin tones that are unsightly.  Sutures are inconvenient and most need to be removed, which means an additional visit for the patient.

Hair apposition technique

Scalp lacerations over hair-bearing areas have traditionally been closed with staples. An alternative technique is the Hair Apposition Technique, also known as the HAT trick. This technique provides a more cost-effective, faster, and less painful approach to scalp laceration repair. This is not a new thing.  It’s been discussed in the literature since 2002, but it astounds me how many experienced practitioners have not adopted this simple and time-saving technique.'

(Laceration Repair, 2014)

Short hair apposition

It’s also important to recognize that hair apposition is not just for the rapunzels out there with long, glorious flowing locks. It works great in short haired people too. The only real modification you have to make is to get a pair of kelly clamps, lock up the hair on both ends, twist, and glue.

(Laceration Repair, 2014)

Staples

Staples are a tried and true method of quickly and efficiently closing lacerations.

(Laceration Repair, 2014)

Tissue adhesive glue

Tissue adhesive glue has been a revolutionary step in the management of lacerations. Tissue glue is indicated for low tension wounds, or occasionally higher tension wounds that have been properly undermined and layered. Its advantages include speed of application for the clinician, painless application for the patient, and decreased tissue inflammatory response compared with sutures.  Also, there is typically no need for a follow up visit unless complications with the wound occur. Here’s a video reviewing the proper application of tissue glue demonstrated on a pig foot model.

(Laceration Repair, 2014)

Tissue adhesive tape

Surgical tape for closure of traumatic wounds is an old technique that we often neglect to consider in the ER.  Tapes are most useful for superficial lacerations under little tension – but don’t forget about undermining and placement of deep dermal sutures to minimize tension, which can allow tape closure for the superficial layer. The video below demonstrates proper application of tissue adhesive tapes, and some of the important principles to keep in mind in their application. Disclaimer: they don’t stick as well to a slimy pig’s foot as compared with properly prepared human skin!

(Laceration Repair, 2014

Field block of the ear

The ear is a sensitive area.  You’ll want to anesthetize it well before any painful procedure. This includes laceration repair, incision and drainage, or treatment of auricular haematoma.

Direct local injection of a laceration on the ear itself can distend margins near the cartilage, making approximation all the more difficult. Alternatively, one might consider a nerve block. This works well for various regions of the face, such as the infraorbital nerve block for lacerations below the eye.  However, the ear is innervated by multiple cranial nerve branches and cervical nerve roots. Thus, trying to block all of them is an exercise in futility. Rather, field block–eg local anesthetic surrounding the ear to catch all of the small branches of the nerve supply–is the way to go. I recommend the following technique shown in the two minute video below.

(Laceration Repair, 2014)

Mental nerve block

The mental nerve block is an excellent means of anesthetizing the lower lip & the lower face. It is relatively simple to learn and safe in that few vital structures pass nearby the area. It is not effective for lacerations that cross the angle of the mandible, so be weary of its use for chin lacerations that sit right at the cusp. It also doesn’t provide anesthesia to the underlying teeth, as would a block of its parent, the inferior alveolar nerve.

(Laceration Repair, 2014)

The ring block: the “can’t fail” method

Though the anatomy of the digit remains unchanged after millennia, it seems there are at least half a dozen descriptions of “correct” ways to accomplish digital block anesthesia. After ten years of performing digital blocks, I’ve come to the conclusion that the less precise you attempt to be, and the more anesthetic you are willing to instill, the more likely your block will work. Hence, the “can’t fail” method, as shown in the video below.

(Laceration Repair, 2014)

Infraorbital nerve block

Infraorbital nerve block is an elegant technique for achieving anesthesia of the mid face region for laceration repair. The infraorbital nerve is a branch of the maxillary nerve (Trigeminal V2) which enters the face through the infraorbital canal. This point of exit is the target for an effective block. I especially like this one for repair of upper lip lacerations, as seen in the video below.

(Laceration Repair, 2014)

Simple interrupted suturing

Simple interrupted suturing is the most basic and most important of the suturing techniques. Here is a short demo video, meant for the beginning/infrequent practitioner to review prior to suturing a laceration.

(Laceration Repair, 2014)

Simple interrupted errors

A demonstration of three of the most common errors I see students and residents make as they learn to master this technique.

(Laceration Repair, 2014)

Vertical mattress sutures

An excellent and underutilized technique is the placement of vertical mattress sutures in traumatic wounds, which combines the advantages of the deep dermal (removing tension from the skin surface) and the epidermal simple interrupted suture (wound edge approximation & eversion).

This is an especially useful technique for areas where skin is lax or thin and tends not to hold tension well, such as the shins.  Another time to consider these sutures is when you are trying to close with simple interrupted sutures and find the wound edges naturally trying to invert on closure.

(Laceration Repair, 2014)

Deep dermal sutures

Simple interrupted dermal sutures (more commonly referred to as deep dermal sutures) are sutures placed within the dermal layer to reduce the static tension on a gaping wound with poor edge apposition. In contrast to the epidermal layer, where you will most often be using non-absorbable suture material like nylon or silk, the dermal layer should be closed with absorbable sutures since you won’t be able to remove them later.  Ideally, a suture material with minimal tissue reactivity but a longer period of effective wound support is best. I typically use vicryl sutures for this purpose, size 3-0 or 4-0 depending on how much tensile strength I anticipate will be needed.

(Laceration Repair, 2014)

Horizontal mattress sutures

Horizontal mattress suturing is a fairly useful back-pocket trick to have in your repair arsenal. I don’t personally use these sutures often for primary repair, as they don’t create as meticulous of a wound edge apposition as simple interrupted sutures or vertical mattress sutures.

I find these sutures most useful for temporary placement amidst a difficult repair with high tension.  Sometimes, it can be difficult to bring those wound edges together to facilitate simple interrupted suturing.  The placement of a horizontal mattress suture can overcome this barrier, as shown in this video.

(Laceration Repair, 2014)

Corner stitch

More formally known as the half-buried horizontal mattress suture, the corner stitch is an invaluable technique for closure of stellate lacerations.  It is most suitable for “Y” shaped lacerations with a flap edge, but variations can also be employed for “V” and “X” shaped lacerations.  When employed, the corner stitch should be placed first in order to preserve landmarks for the rest of the repair.

(Laceration Repair, 2014)

The Surgeon’s knot

The Surgeon’s knot, aka the “two-handed tie,” is a useful tool to master.  In situations where you are tying under tension or where better control of the suture is required (compared with the instrument tie method), understanding how to make a surgeon’s knot can be invaluable.

The video above uses slow motion, multiple angles, and voiceover to help break down the knot tying process.  Many thanks to Dr. Morgan Gilani, the medical resident whose hands are featured in this video.

(Laceration Repair, 2014)

Suture removal

Many patients who have sutures placed for the first time wonder, “is it going to hurt to get these taken out?” In fact, I’ve found some patients really agonize over the anticipation of suture removal, especially in the pediatric population.

Hopefully the 2 minute video below (demonstrating simple interrupted suture removal) answers these questions for you.

(Laceration Repair, 2014)

Undermining

'Undermining is one of the most underutilized, but superbly useful techniques in high tension laceration repair. Undermining refers to the technique of using sterile scissors to bluntly dissect the dermal layer away from the underlying connective tissue. Through the use of this technique, you can take away some of the connective tissue adhesions which anchor the skin in place and remove static tension on the wound.'

(Laceration Repair, 2014)

Running percutaneous sutures

'The running percutaneous suturing technique is a nice technique to help you speed up lengthy wound closures. Simple interrupted suturing is still a preferred technique when you want the most meticulous repair, but when dealing with less cosmetic areas, I like this technique as it is involves less knot tying and gets the job done a lot faster without sacrificing much in terms of wound appearance.

Advantages of the running percutaneous suturing technique include more equal distribution of tension across the entire wound, allowing for tissue expansion due to edema and great tissue eversion.'

(Laceration Repair, 2014)

Running percutaneous locked sutures

'A variation of the running percutaneous suturing technique involves “locking” each loop of suture as you go.  This is accomplished by passing the needle through the loop of sutures. This added step will allow each loop of suture to act more independently in holding tension (almost like, but not quite as good as, a simple interrupted suture).  This is most useful for a long laceration that is mostly linear but may have a little curve to it.  Be advised, with locking the equal tension distribution which was an advantage of the basic running technique is lost, so you have a higher risk of tissue strangulation.'

(Laceration Repair, 2014)

Running subcuticular sutures

'Running subcuticular sutures are considered to be the “holy grail” of suturing techniques by many.  That is to say, when done correctly, they give the best cosmetic outcome. Hand in hand with that, they are certainly the most technically challenging and time consuming of suturing techniques.  While they are common practice in the OR and second nature for surgeons, it is all but an abandoned technique for emergency practitioners.'

(Laceration Repair, 2014)

“Dog ear” correction

'When the lengths of two opposite sides of a wound are uneven, simple closure can distort the adjacent skin, resulting in formation of a “dog ear.”  Typically, this can be avoided by placing the suture in the midpoint of each side of the wound and bisecting the wound sequentially.  However, the dog ear can be an unavoidable consequence if there is gross disparity of wound edge lengths, especially with use of techniques like the “V-to-Y” conversion.

Several techniques are described for correcting a dog ear.  If the cause is simply a failure to place sutures equally on each wound edge, I would recommend removing the sutures and starting again. On the other hand, if the dog ear is unavoidable, as in cases where the edges of the wound are of different lengths, here is a simple technique to fix it.'

(Laceration Repair, 2014)

Layered closure

'“Layered” repair typically refers to the use of absorbable sutures to bring together the dermis and underlying subcutaneous tissue, which both closes dead space (where otherwise infection/abscess may accumulate) and relieves tension on the epidermis. After this, surface closure of the epidermis is performed with less tension, and thus better cosmesis.'

(Laceration Repair, 2014)

V-to-Y conversion flaps

'Occasionally we run into lacerations in the ED involving a large tissue flap avulsion. These are usually the injuries that catch the eyes of nurses and staff, if for nothing else but for the gore factor. The large, V-shaped rent through the forearm of this patient was pretty interesting to treat…but not for the guts/gore factor–rather, I was interested in figuring out how to achieve a tension-free closure that would allow this self-employed carpenter to get back to work as soon as safely possible. I saw this as an opportunity to get creative for the good of the patient. The video below outlines the problem and the solution.'

(Laceration Repair, 2014)

This online course covers the basics of managing wounds in a range of settings and severity. 

Video: Part I: Assessment, anesthesia, and preparation

(Laceration Repair, 2014)

Video: Part II: Basic suturing

(Laceration Repair, 2014)

Video: Part III: Alternative wound closure techniques

(Laceration Repair, 2014)

Video: Part IV:  Advanced suturing techniques

(Laceration Repair, 2014)

Video: Part V: Aftercare, follow up, and summary

(Laceration Repair, 2014)