Suturing and splintingSuturing and splinting

Presented by

Dr. Osama Kentab, M.D, FAAP, FACEP

Assistant Professor Pediatrics and Emergency Medicine

King Saud bin Abdulaziz University for Health silences

October 2014

ObjectivesObjectives Describe the principles of wound healing Identify the various types and sizes of suture material. Choose the proper instruments for suturing. Identify the different injectable anesthetic agents and correct dosages. Demonstrate various biopsy methods: punch, excision, shave. Demonstrate different types of closure techniques: simple interrupted,

continuous, subcuticular, vertical and horizontal mattress, dermal Demonstrate two-handed, one-handed, instrument ties Recommend appropriate wound care and follow-up.

Critical Wound Healing PeriodCritical Wound Healing Period

Tissue

Skin

Mucosa

Subcutaneous

Peritoneum

Fascia

5-7 days

5-7 days

7-14 days

7-14 days

14-28 days

0 5 7 14 21 28

Tissue Healing Time/Days

Model of Wound HealingModel of Wound Healing (1) Hemostasis: within minutes post-injury, platelets aggregate at the

injury site to form a fibrin clot. (2) Inflammatory: bacteria and debris are phagocytosed and removed,

and factors are released that cause the migration and division of cells involved in the proliferative phase.

(3) Proliferative: angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction

(4) Remodeling: collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis.

Wound Healing ConceptsWound Healing Concepts

Patient factorsWound classificationMechanism of injuryTetanus/antibiotics/local anestheticsSurgical principles and wound prepSuture/needle/stitch choiceManagement/care/follow-up

Common Patient FactorsCommon Patient Factors

Age Blood supply to the

area Nutritional status Tissue quality Revision/infection Compliance

Weight Dehydration Chronic disease Immune response Radiation therapy

CDC Surgical Wound ClassificationCDC Surgical Wound Classification

Clean: (1-5% risk of infection) uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.

Clean-contaminated: (3-11% risk) operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.

CDC Surgical Wound ClassificationCDC Surgical Wound Classification

Contaminated: (10-17% risk) open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered.

Dirty or infected: (>27% risk) old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

Surgical PrinciplesSurgical Principles

Incision Dissection Tissue handling Hemostasis Moisture/site Remove infected,

foreign, dead areas Length of time open

Choice of closure material/mechanism

Primary or secondary Cellular responses Eliminate dead space Closing tension Distraction forces and

immobilization/care

Suture MaterialsSuture Materials

Criteria – Tensile strength– Good knot security– Workability in handling– Low tissue reactivity– Ability to resist bacterial infection

Types of SuturesTypes of Sutures Absorbable or non-absorbable (natural or synthetic) Monofilament or multifilament (braided) Dyed or undyed Sizes 3 to 12-0 (numbers alone indicate progressively

larger sutures, whereas numbers followed by 0 indicate progressively smaller)

New antibacterial sutures

Non-absorbableNon-absorbable Not biodegradable

and permanent– Nylon (Ethilon)– Prolene– Stainless steel– Silk (natural, can

break down over years)

Degraded via inflammatory response– Vicryl– Monocryl– PDS– Chromic– Cat gut (natural)

AbsorbableAbsorbable

Natural SutureNatural Suture

Biological Cause inflammatory

reaction– Catgut (connective

from cow or sheep)– Silk (from silkworm

fibers)– Chromic catgut

SyntheticSynthetic

Synthetic polymers Do not cause

inflammatory response– Nylon– Vicryl– Monocryl– PDS– Prolene

MonofilamentMonofilament Single strand of suture

material Minimal tissue trauma Smooth tying but more

knots needed Harder to handle due to

memory Examples: nylon, monocryl,

prolene, PDS

Multifilament (braided)Multifilament (braided) Fibers are braided or twisted

together More tissue resistance Easier to handle Fewer knots needed Examples: vicryl, silk,

chromic

Suture MaterialsSuture Materials

Suture SelectionSuture Selection

Do not use dyed sutures on the skin Use monofilament on the skin as multifilament

harbor BACTERIA Non-absorbable cause less scarring but must be

removed Plus sutures (staph, monocryl for E. coli,

Klebsiella) Location and layer, patient factors, strength,

healing, site and availability

Suture SelectionSuture Selection

Absorbable for GI, urinary or biliaryNon-absorbable or extended for up to 6 mos

for skin, tendons, fasciaCosmetics = monofilament or subcuticularLigatures usually absorbable

Suture SizesSuture Sizes

Surgical NeedlesSurgical Needles

Wide variety with different company’s naming systems

2 basic configurations for curved needles

– Cutting: cutting edge can cut through tough tissue, such as skin

– Tapered: no cutting edge. For softer tissue inside the body

Surgical NeedlesSurgical Needles

Surgical InstrumentsSurgical Instruments

Scalpel BladesScalpel Blades

Anesthetic SolutionsAnesthetic Solutions Lidocaine (Xylocaine®)

– Most commonly used– Rapid onset – Strength: 0.5%, 1.0%, &

2.0% – Maximum dose:

5 mg / kg, or 300 mg

– 1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc

– 300 mg = 0.03 liter = 30 ml

Lidocaine (Xylocaine®) with epinephrine– Vasoconstriction– Decreased bleeding– Prolongs duration – Strength: 0.5% & 1.0%– Maximum individual

dose: 7mg/kg, or 500mg

Anesthetic SolutionsAnesthetic Solutions

CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: – Eyes, Ears, Nose – Fingers, Toes– Penis, Scrotum

Anesthetic SolutionsAnesthetic Solutions

BUPIVACAINE (MARCAINE):– Slow onset– Long duration– Strength: 0.25%– DOSE: maximum individual dose 3mg/kg

Local AnestheticsLocal Anesthetics

Injection TechniquesInjection Techniques

25, 27, or 30-gauge needle

6 or 10 cc syringe Check for allergies Insert the needle at the

inner wound edge

Aspirate Inject agent into tissue

SLOWLY  Wait… After anesthesia has

taken effect, suturing may begin

Wound EvaluationWound Evaluation

Time of incidentSize of woundDepth of woundTendon / nerve involvementBleeding at site

When to ReferWhen to Refer

Deep wounds of hands or feet, or unknown depth of penetration

Full thickness lacerations of eyelids, lips or ears Injuries involving nerves, larger arteries, bones,

joints or tendons Crush injuries Markedly contaminated wounds requiring

drainage Concern about cosmesis

Contraindications to SuturingContraindications to Suturing

Redness Edema of the wound margins Infection Fever Puncture wounds Animal bites Tendon, nerve, or vessel involvement Wound more than 12 hours old (body) and 24 hrs

(face)

Closure TypesClosure Types Primary closure (primary intention)

– Wound edges are brought together so that they are adjacent to each other (re-approximated)

– Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery

Secondary closure (secondary intention)– Wound is left open and closes naturally (granulation)– Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly

reduced fractures

Tertiary closure (delayed primary closure)– Wound is left open for a number of days and then closed if it is found to be

clean– Examples: healing of wounds by use of tissue grafts.

Wound PreparationWound Preparation

Most important step for reducing the risk of wound infection.

Remove all contaminants and devitalized tissue before wound closure.– IRRIGATE w/ NS or TAP WATER (AVOID H2O2,

POVIDONE-IODINE)– CUT OUT DEAD, FRAGMENTED TISSUE

If not, the risk of infection and of a cosmetically poor scar are greatly increased

Personal Precautions

Basic Laceration RepairBasic Laceration Repair

Principles And Techniques

Langer’s Lines

Principles And TechniquesPrinciples And Techniques Minimize trauma in skin

handling Gentle apposition with slight

eversion of wound edges– Visualize an Erlenmeyer

flask Make yourself comfortable

– Adjust the chair and the light

Change the laceration – Debride crushed tissue

Types of ClosuresTypes of Closures● Simple interrupted closure – most commonly used, good for shallow

wounds without edge tension● Continuous closure (running sutures) – good for hemostasis (scalp

wounds) and long wounds with minimal tension● Locking continuous - useful in wounds under moderate tension or in those

requiring additional hemostasis because of oozing from the skin edges● Subcuticular – good for cosmetic results● Vertical mattress – useful in maximizing wound eversion, reducing dead

space, and minimizing tension across the wound● Horizontal mattress – good for fragile skin and high tension wounds● Percutaneous (deep) closure – good to close dead space and decrease

wound tension

Simple Interrupted SuturingSimple Interrupted Suturing

Apply the needle to the needle driver– Clasp needle 1/2 to 2/3 back from tip

Rule of halves:– Matches wound edges better; avoids dog ears– Vary from rule when too much tension across

wound

Simple Interrupted SuturingSimple Interrupted Suturing

Rule of halves

Simple Interrupted SuturingSimple Interrupted Suturing

Rule of halves

SuturingSuturing The needle enters the

skin with a 1/4-inch bite from the wound edge at 90 degrees– Visualize Erlenmeyer

flask– Evert wound edges

Because scars contract over time

SuturingSuturing Release the needle from the needle driver, reach into the wound and

grasp the needle with the needle driver. Pull it free to give enough suture material to enter the opposite side of the wound.

Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites.

Rotate your wrist to follow the arc of the needle.

Principle: minimize trauma to the skin, and don’t bend the needle. Follow the path of least resistance.

SuturingSuturing

Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2-inch suture strand protruding form the bites site.

Release the needle from the needle driver and wrap the suture around the needle driver two times.

Simple Interrupted SuturingSimple Interrupted Suturing Grasp the end of the suture material with the needle driver and

pull the two lines across the wound site in opposite direction (this is one throw).

Do not position the knot directly over the wound edge.

Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap.

Cut the ends of the suture 1/4-inch from the knot.

The remaining sutures are inserted in the same manner

Simple, InterruptedSimple, Interrupted

http://www.youtube.com/watch?v=PFQ5-tquFqY

The trick to an instrument tieThe trick to an instrument tie

Always place the suture holder parallel to the wound’s direction.

Hold the longer side of the suture (with the needle) and wrap OVER the suture holder.

With each tie, move your suture-holding hand to the OTHER side.

By always wrapping OVER and moving the hand to the OTHER side = square knots!!

Continuous Locking and Nonlocking SuturesContinuous Locking and Nonlocking Sutures

http://www.youtube.com/watch?v=xY4cAqk30K4

http://cal.vet.upenn.edu/projects/surgery/5000.htm

http://www.youtube.com/watch?v=sgOaBojcX-chttps://www.youtube.com/watch?v=hIqTDvofekM

Vertical MattressVertical Mattress

Good for everting wound edges (neck, forehead creases, concave surfaces)

http://www.youtube.com/watch?v=824FhFUJ6wc

Horizontal MattressHorizontal Mattress

Good for closing wound edges under high tension,and for hemostasis.

Horizontal MattressHorizontal Mattress

http://www.youtube.com/watch?v=9DdaooEXshk

http://www.youtube.com/watch?v=I7C7nsl5Tuk

Suturing - finishingSuturing - finishing

After sutures placed, clean the site with normal saline.

Apply a small amount of Bacitracin or white petroleum and cover with a sterile non-adherent compression dressing (Tefla).

Suturing - before you go…Suturing - before you go… Need for tetanus globulin and/or vaccine?

– Dirty (playground nail) vs clean (kitchen knife)– Immunization history (>10 yrs need booster or >5 yrs if

contaminated)

Tell pt to return in one day for recheck, for signs of infection (redness, heat, pain, puss, etc), inadequate analgesia, or suture complications (suture strangulation or knot failure with possible wound dehiscence)

It should be emphasized to patients that they return at the appropriate time for suture removal or complications may arise leading to further scarring or subsequent surgical removal of buried sutures.

Patient instructions and follow up carePatient instructions and follow up care

Wound care – After the first 24-48 hours, patients should gently wash

the wound with soap and water, dry it carefully, apply topical antibiotic ointment, and replace the dressing/bandages.

– Facial wounds generally only need topical antibiotic ointment without bandaging.

– Eschar or scab formation should be avoided. – Sunscreen spf 30 should be applied to the wound to

prevent subsequent hyperpigmentation.

Suture RemovalSuture Removal

Average time frame is 7 – 10 days– FACE: 3 – 5 d– NECK: 5 – 7 d– SCALP: 7 – 12 days– UPPER EXTREMITY, TRUNK: 10 – 14 days– LOWER EXTREMITY: 14 – 28 days– SOLES, PALMS, BACK OR OVER JOINTS: 10 days

Any suture with pus or signs of infections should be removed immediately.

Suture RemovalSuture Removal

Clean with hydrogen peroxide to remove any crusting or dried blood

Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin

Pull the suture line through the tissue- in the direction that keeps the wound closed - and place on a 4x4. Count them.

Most wounds have < 15% of final wound strength after 2 wks, so steri-strips should be applied afterwards.

Topical AdhesivesTopical Adhesives

Indications: selection of approximated, superficial, clean wounds especially face, torso, limbs. May be used in conjunction with deep sutures

Benefits: Cosmetic, seals out bacteria, apply in 3 min, holds 7 days (5-10 to slough), seal moisture, faster, clear, convenient, less supplies, no removal, less expensive

Contraindicated with infection, gangrene, mucosal, damp or hairy areas, allergy to formaldehyde or cryanoacrylate, or high tension areas

DermabondDermabond®®

A sterile, liquid topical skin adhesive

Reacts with moisture on skin surface to form a strong, flexible bond

Only for easily approximated skin edges of wounds– punctures from minimally

invasive surgery– simple, thoroughly cleansed,

lacerations

DermabondDermabond®®

Standard surgical wound prep and dry Crack ampule or applicator tip up; invert Hold skin edges approximated horizontally Gently and evenly apply at least two thin layers on

the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky

Apply dressing

http://www.youtube.com/watch?v=oa13wriWTus&feature=related

http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1

Follow Up Care with AdhesivesFollow Up Care with Adhesives No ointments or medications on dressing May shower but no swimming or scrubbing Sloughs naturally in 5-10 days, but if need to remove use

acetone or petroleum jelly to peel but not pull apart skin edges

Pt education and documentation

EBM Take Home PointsEBM Take Home Points

Suturing is preferred technique for skin laceration repair LOE SORT C

Saline or tap water should be used for wound irrigation LOE SORT B

Use of white petrolatum to promote wound healing is as effective as antibiotic ointment LOE SORT B

Tissue adhesives show comparable results with regards to cosmetic, infection or dehisence rates LOE SORT A

ReferencesReferences

http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct.

355: 17. Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988. www.uptodateonline.com; 2009, topic lacerations, etc. http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf http://www.mnpa.us/handouts/Session%2005%20%20-%20%20Basic%20Suturing

%20%202010%20MNPA.pdf http://www.practicalplasticsurgery.org/docs/Practical_01.pdf http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE8-

7EB5D06CE8DF/0/wound_healing_manual.pdf Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family

Physicians. AAFP Scientific Assembly. 2010. http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/assembly/2010handouts/071.Par.0001.File.tmp/071-072.pdf

Splinting and Casting

Immediate Treatment of Orthopedic Injury

• One primary goal– Reduction of swelling

• PRICE– Protection– Rest– Ice– Compression– Elevation

Cold Application

• Decreases pain

• Produces vasoconstriction

• Controls hemorrhage and edema

• Decreases local cell metabolism– Decreases tissues’ need for oxygen– Reduces hypoxia

• Sensations- Cold, burning, aching, numb

Emergency Splinting

• Two vital principles– Splint from one joint above the fracture to

one joint below the fracture– Splint the injury in the position it is found

Indications for Splinting

• Fractures• Sprains• Joint infections• Tenosynovitis• Acute arthritis / gout• Lacerations over joints• Puncture wounds and animal

bites of the hands or feet

Splinting Equipment• Plaster of Paris

– Made from gypsum - calcium sulfate dihydrate– Exothermic reaction when wet - recrystallizes (can

burn patient)– Warm water - faster set, but increases risk of burns– Fast drying - 5 - 8 minutes to set– Extra fast-drying - 2 - 4 minutes to set - less time to

mold– Can take up to 1 day to cure (reach maximum

strength)– Upper extremities - use 8-10 layers– Lower extremities - 12-15 layers, up to 20 if big

person (increased risk of burn!)

Splinting Equipment• Ready Made Splinting Material

– Plaster (OCL)• 10 -20 sheets of plaster with padding and cloth

cover

– Fiberglass (Orthoglass)• Cure rapidly (20 minutes)• Less messy• Stronger, lighter, wicks moisture better• Less moldable

Splinting Equipment• Stockinette

• protects skin, looks nifty (often not necessary)• cut longer than splint• 2,3,4,8,10,12-in. widths

• Padding - Webril• 2-3 layers, more if anticipate lots of swelling• Extra over elbows, heels• Be generous over bony prominences• Always pad between digits when splinting hands/feet or when

buddy taping• Avoid wrinkles• Do not tighten - ischemia!• Avoid circumfrential use

• Ace wraps

Specific Splints and OrthosesUpper Extremity• Elbow/Forearm

– Long Arm Posterior– Double Sugar - Tong

• Forearm/Wrist– Volar Forearm / Cockup– Sugar - Tong

• Hand/Fingers– Ulnar Gutter– Radial Gutter– Thumb Spica– Finger Splints

Lower Extremity• Knee

– Knee Immobilizer / Bledsoe– Bulky Jones– Posterior Knee Splint

• Ankle– Posterior Ankle– Stirrup

• Foot – Hard Shoe

Long Arm Posterior Splint

• Indications– Elbow and forearm injuries:– Distal humerus fx– Both-bone forearm fx– Unstable proximal radius or

ulna fx (sugar-tong better)• Doesn’t completely eliminate

supination / pronation -either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx.

Double Sugar Tong

• Indications– Elbow and forearm fx -

prox/mid/distal radius and ulnar fx.

– Better for most distal forearm and elbow fx because limits flex/extension and pronation / supination.

10

90

Forearm Volar Splint aka ‘Cockup’ Splint

• Indications– Soft tissue hand / wrist

injuries - sprain, carpal tunnel night splints, etc

– Most wrist fx, 2nd -5th metacarpal fx.

– Most add a dorsal splint for increased stability - ‘sandwich splint’ (B).

– Not used for distal radius or ulnar fx - can still supinate and pronate.

Forearm Sugar Tong

• Indications– Distal radius and

ulnar fx.

• Prevents pronation / supination and immobilizes elbow.

Hand Splinting

• The correct position for most hand splints is the position of function, a.k.a. the neutral position.

• This is with the the hand in the “beer can” position (which may have contributed to the injury in the first place) : wrist slightly extended (10-25°) with fingers flexed as shown.

• When immobilizing metacarpal neck fractures, the MCP joint should be flexed to 90°.

• Have the patient hold an ace wrap (or a beer can if available) until the splint hardens.

• For thumb fx, immobilize the thumb as if holding a wine glass.

Radial and Ulnar Gutter

•Indications•Fractures, phalangeal and metacarpal, and soft tissue injuries of the little and ring fingers.

•Indications•Fractures, phalangeal and metacarpal, and soft tissue injuries of index and long fingers.

Thumb Spica• Indications

– Scaphoid fx - seen or suspected (check snuffbox tenderness)

– De Quervain tenosynovitis. • Notching the plaster (shown)

prevents buckling when wrapping around thumb.

• Wine glass position.

Finger Splints

• Sprains - dynamic splinting (buddy taping).

• Dorsal/Volar finger splints - phalangeal fx, though gutter splints probably better for proximal fxs.

Jones Compression Dressing - aka Bulky Jones

• Indications– Short term immobilization

of soft tissue and ligamentous injuries to the knee or calf.

• Allows slight flexion and extension - may add posterior knee splint to further immobilize the knee.

• Procedure– Stockinette and

Webril.– 1-2 layers of thick

cotton padding.– 6 inch ace wrap.

Posterior Ankle Splint

• Indications– Distal tibia/fibula fx.– Reduced dislocations– Severe sprains– Tarsal / metatarsal fx

• Use at least 12-15 layers of plaster.

• Adding a coaptation splint (stirrup) to the posterior splint eliminates inversion / eversion - especially useful for unstable fx and sprains.

Stirrup Splint

• Indications– Similiar to posterior splint.– Less inversion /eversion

and actually less plantar flexion compared to posterior splint.

– Great for ankle sprains.– 12-15 layers of 4-6 inch

plaster.

Other Orthoses• Knee Immobilizer

– Semirigid brace, many models– Fastens with Velcro– Worn over clothing

• Bledsoe Brace– Articulated knee brace– Amount of allowed flexion and extension can be adjusted– Used for ligamentous knee injuries and post-op

• AirCast/ Airsplint– Resembles a stirrup splint with air bladders– Worn inside shoe

• Hard Shoe– Used for foot fractures or soft tissue injuries

Complications• Burns

– Thermal injury as plaster dries– Hot water, Increased number of

layers, extra fast-drying, poor padding - all increase risk

– If significant pain - remove splint to cool

• Ischemia– Reduced risk compared to

casting but still a possibility– Do not apply Webril and ace

wraps tightly– Instruct to ice and elevate

extremity– Close follow up if high risk for

swelling, ischemia.– When in doubt, cut it off and look– Remember - pulses lost late.

• Pressure sores– Smooth Webril and plaster well

• Infection– Clean, debride and dress all

wounds before splint application

– Recheck if significant wound or increasing pain

Any complaints of worsening pain - Take the splint off and look!