Wound closure March 2018 | by EMauthor Types of wound closure •Primary closure, this is suitable for most wounds where the wound is closed at the time of the assessment by whatever method •Delayed primary closure, the wound is left open for 3-5 days after which it is closed •Secondary closure, were the wound is left to heal by granulation and usually results in a significant scarring, this method needs a senior decision, many such wounds may need plastic surgery referral, seek consultant opinion Wounds not suitable for primary closure •Infected wounds •Delayed wounds, more than 12 hours, seek senior advice •Grossly contaminated wound/devitalised wounds where there is doubt about adequate debridement •Human and animal bites, except facial wounds, seek consultant's advice •Severe crush wounds These wounds should be debrided and cleaned, dressing applied (non-adherent like jelonet with betadine added) and patient started on oral antibiotics, the patient is reviewed after 3 days Methods of closure •Steri-strips oThey cause less scarring as there is much less tension on skin edges oThey are less secure than other methods so they are not suitable for moving parts and over joints oThey are ideal for pre-tibial lacerations and flapped lacerations were viability of wound edges is in doubt oThey should be left in place for same time period as conventional suture •Tissue glue (Histoacryl) oThis is a very effective way of wound closure and gives excellent cosmetic results if applied properly oIt is suitable principally for superficial wounds in children and for scalp and facial lacerations oThe wound should be clean and dry oIt is not suitable for deep wounds, contaminated wounds or wounds over joints oThe gluing is best achieved if two persons do the procedure, one to hold the wound edges well opposed and the other to spot weld the wound. The glue should not be applied inside the wound oKeep the edges opposed for about 50 seconds and then test the integrity of wound closure oAdvise the patient to keep the wound dry for 5 days and not to pick on the glue, advise the patient to return to the department if the wound dehisces •Sutures oThis the conventional way of wound closures oUse strong monofilament non-absorbable sutures for skin closure with size appropriate to the site of wound oUse interrupted sutures; sub-cuticular sutures may give better cosmetic results but are more suitable for elective surgery rather than ED setting where the potential of infection is higher oFor deeper structures (deep fascia and subcutaneous tissues) use fine monofilament sutures (such as 4/0 or 5/0 vicryl) •For skin closure, a guide for appropriate suture size is oFace; 5/0 or 6/0 oMost other sites; 4/0 oOver major joints; 3/0 Removal of sutures should be done by the GP’s practice nurse unless there is a specific problem associated with the wound. The approximate time for removal of sutures is as follows; •Face and neck 5 days •Hand 7 days •Arm 8-10 days •Trunk / leg 10-14 days |
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