This slideshow features cases and photos featured in an article from the Consultant archives. Included are techniques for suturing and wound closure for the primary care clinician.
Adequate wound exploration is a critical step in laceration management. Poor or incomplete exploration increases the risk of a bad outcome. Be sure to explore the wound in a bloodless field through the full range of motion to its base. Also look for partial tendon injuries that might be missed on strength testing. Tendons run surprisingly close to the surface on the dorsum of the hand and fingers
A torn tendon (arrow) is visible in this laceration on the dorsum of the patient’s hand. Any tendon involvement requires antibiotic prophylaxis and specialty consultation and follow-up.
Some clinicians also prefer to use interrupted stitches in infection-prone wounds: if the wound becomes infected in just one area, some of the stitches can be removed while others are left.
Interrupted stitches are being used to close this hand laceration.
With running stitches, the first stitch and tie are the same as for a simple interrupted stitch. Generally, start at one edge of the wound, although you may start in the center if there is tension. With a linear wound, stretch the wound (to avoid translational errors) as you begin the first stitch (Figure 3 above.)
If there is tension on the wound, "lock" the stitch after the first throw by pulling both sides of the suture to one side. This holds the first throw tight and helps prevent a loose first knot. Cut the short end and continue suturing with the long end, making sure that the second stitch is close to the first.
When running stitches are used to close a wound—as in this laceration of the distal thumb—the suture runs perpendicular to the wound below the surface, while the visible portions of the suture are at a slight angle to the wound.
Tie the final knot using a "bite" of suture that is a loop rather than a single loose end (Figure 5). Because suturing done with running stitches relies on a single knot at each end, make sure that my knots have at least 5 throws each.
The vertical mattress stitch might be described as two stitches in one. It is useful in settings in which you do not want to place a deep stitch because of tension on a wound. A horizontal mattress stitch is basically 2 stitches side by side. However, in a regular interrupted stitch the suture material crosses above the wound, while in a horizontal mattress stitch, it does not
A horizontal mattress stitch was used to close this wound in the space between the patient’s second and third fingers. This stitch was used to minimize wound edge eversion.
Always consider your own safety and comfort when you close lacerations. Use proper lighting and positioning: elevate the bed or examination table until the wound is at about the level of your elbow. Use protective goggles when injecting anesthesia. Avoid grabbing the needle with your hand; use a needle driver and regular-tip forceps to handle the needle instead
By using a needle driver and regular-tip forceps (Figure 7 above), you can close a wound without ever having to grasp the needle with your hand.
As this thumb laceration is stitched, the needle tip is retrieved with forceps so that the needle need never be touched by the physician’s hands.
Here, the knot of the first stitch in a laceration repair is tied with an instrument tie. This is the easiest and safest way to tie a surgical knot.
Patients frequently ask whether they will have a scar. The appropriate answer is that all lacerations leave some form of scar, but that scarring can be minimized by appropriate sun protection. Initially, this may involve bandages and hats or clothing. Once the wound is healed, counsel patients to use sunscreen daily for at least 6 months and preferably up to a year.
Pregerson DB. Suturing and wound closure: how to achieve optimal healing. Consultant. 2007;47(12):1035-1046. https://www.consultant360.com/content/suturing-and-wound-closure-how-achieve-optimal-healing
Wound Closure Techniques for Primary Care