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Thinking About Wound Repair & Minor Surgery - Part 1

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  • Thinking About Wound Repair & Minor Surgery - Part 1

    Thinking About Wound Repair & Minor Surgery - Part 1

    Not giving up on the lab medicine thread, far from it, but this is always an area with a lot of interest and questions, one that has generated a few e-mails in the last week or two. In fact, it is the most requested of any topic that I have taught. One could argue that there are far more important things to learn first, such as ABC’s, trauma management, disease prevention and public health - and you’d be right, too. But fortunately most people recognize that and already have some training, with plans to gain more, so that this becomes another tool in their capability kit, rather than a substitute for the basics. Don’t fall prey to “shiny steel syndrome” and persue this in preference to learning the full spectrum of medical care - basics first, always!

    Wound repair is both an art and a science, about 50/50 I think. It is not as hard as it
    sounds but not as easy as it sounds either. I know that does not make sense, this is what I mean: the mechanics of manipulating the instruments is easier than most people think, but the judgment of what to do, how to do it, when to do it, and perhaps most important what NOT to do are much more complex than most realize. It takes study, practice, and experience to develop the skills and judgment needed, particularly for the more challenging/difficult problems. Add that into the difficulties associated with operations in the remote/disaster environment and you can find yourself ass-deep in alligators before you know it. In short, don’t think that you can stick a few tools in the box and a book on the shelf and get by without prior instruction and practice. Wound repair is fun. No question. Neat tools, blood, injections - how can you not like that? But it is not easy.

    Nationally about 12% of all ER visits are due to wounds. 50% are on the face/scalp, 35%on upper extremities, 13% lower, 2% elsewhere. Interesting distribution, huh? About 13% of the wounds have significant contamination, about 5% become infected.

    When evaluating wounds there are several steps that need to be done. First, you need
    some patient and injury history. Determine the mechanism of injury, age of the wound,
    tetanus vaccination status, and any medication allergies. Then examine the injured area. Look at it’s location, contamination or foreign bodies, missing tissue, underlying structures, joint involvement, tendon/ligament involvement, motor & sensory function, circulation, and skeletal integrity. With this information you can then (and only then)decide if, when, and how to repair the injury. As you can see, this evaluation is enhanced by a good understanding of the anatomy and function of the area involved as well as the techniques of examination and assessment.

    The definitive textbook on wound repair is Wounds and Lacerations: Emergency Care and Closure by Alexander Trott. Pricy at $62.00 and WORTH EVERY PENNY. It has been reviewed elsewhere so I won’t go into details. Unless you have been trained to the level of an advanced practice medic or better you are a FOOL if you plan to repair wounds and don’t buy and learn this book cover to cover. Then find a mentor, learn first hand, and practice, practice, practice. If possible do, do, do.



  • #2
    I've had Trott's book for about 4 years now and I have to agree. It makes a great reference for a doc, and for anyone not otherwise formally trained in the fine art of suturing - trained and practiced that is - it is a definite must have.

    It has been previously reviewed here and the same review can be found here:

    When one considers what percentage of ER visits are for minor ailments the percentage of wound cases is actually quite significant.
    Given time a serious percentage of us will require wound repair at least once, some several times. A few cases will require repairs of several wounds from one accident. Remember, we aren't talking about a normally functioning health care system here. We are here to discuss measures for abnormal times and/or events.


    Got band-aids?
    Tricks and treachery are the practice of fools, that don't have brains enough to be honest. - Benjamin Franklin

    I have but one person on my ignore list. Can you guess who it is?


    • #3
      I've allways gone by the saying: Know your limitations and do not excede them. (well, not too much... if there is no alternative, stretch what you know into service) As far as suturing goes, my limitations are the dermis. What do you do if muscle or tendon is involved? That seems like an art form, reserved for someone that really knows what they are doing (at least if you want to regain function). How do you practice something like that? Oranges aren't going to cut it...

      You mention assessment. We were taught to do it, document it, and transport, but allmost nothing about what to do about it, especially in an extended care situation. (granted, some of it is obvious...) Care to key us in abit on diagnostic thought processes and resulting Tx implications?

      I know about "S" cuts arround joints and things like that, though others may not - be good to cover too.

      hmm.. other things: what size suture where? believe 5-0 is generally good for trunk and arms and 4-0 for face and hands (could be wrong, though), different types of suture, diff types of needles and needle holders, aseptic technique, irrigation, delayed closure, anesthesia (including epi and what that does) and of cource, what to do if there is vascular, ortho or neuro involvement - don't think this can be handled in the field - maybe vascular and some ortho, if you're REALLY good! Debridment and using a probe - never seen a good writeup on that. And of cource, no discussion of survival wound management would be complete without mentioning urine, dental floss and MAGGOTS!

      have at it doc!

      [This message has been edited by tangent (edited 04 December 2001).]


      • #4
        Allow me to jump in here.


        Suture selection depends on several factors: the skill of the person doing the suturing, the location of the laceration or wound being closed an d whether the sutures are being placed internally or externally. For sake of this discussion we'll stick to external sutures and non-absorbable threads.

        Silk: the old standby used for many years before the advent of synthetic replacements, and still in common though much less so that synthetics, today.

        Advantages are: easiest material to tie knots in, excellent handling characteristics, very good knot security (doesn't come untied on its own). Stores very well. 20 year old sealed packets retain a high degree of original strength if properly stored.

        Disadvantages: Highest tissue reaction potential of the various materials, increased potential for infection due to wicking properties of the thread. Tensile strength is wide-range.

        Nylon: Monofilament thread, unlike silk, which is braided. One of the first replacements for silk.

        Advantages: Tissue reaction is only mid-range, tensile strength is greater than silk. Stores well without deterioration.

        Disadvantages: High degree of memory (wants to return to original shape). Requires several throws to tie a secure knot. Knot security is half that of silk.

        Polypropylene [Prolene]: Another monofilament thread of newer design that nylon. Stores very well long term.

        Advantages: Very low tissue reactivity, highest overall tensile strength.

        Disadvantages: Very low knot security, high degree of memory.

        Dacron [Mersilene]: Another synthetic with a high favorability. Good storage potential. May be more affected by high heat storage conditions than others. Excellent replacement for silk.

        Advantages: Easy to handle with very good knotting characters. Knot security approximately equal to that of silk. Less risk of tissue inflammation than with silk.

        Disadvantages: Tissue reaction potential higher than other synthetics. Tensile strength half that of nylon.

        As far as selection of suture for size and needle:

        Needles: two types commonly found on pre-attached threads, (reverse) cutting and (round) tapered. The cutting needle is easier to work with. The reverse taper means the back (inside) edge is flattened to ensure the needle puncture wound is not inadvertently enlarged. The cutting needle is also thought to be less traumatic to the tissue as it passes through.

        Needle grades: cuticular and plastic.

        Cuticular: Less expensive but noticeably less sharp. Generally coded as either C (cuticular) or FS (for skin) on the box or packet.

        Plastic: refers to plastic surgery grade needles. Sharper, less traumatic. Coding usually starts with the letter F.


        Sutures are sized like shotguns. The higher the number the smaller the diameter of the thread. Sizes range commonly from 0 to 6-0, with negative numbers and higher numbers going up to 10 in the case of eye sutures. For our purposes 2-0 to 5-0 will fill the bill. 2-0 for very high stress areas and then it depends on activity level, precise location and whether scarring matters or not.

        For plastic surgery such as around faces 6-0 is preferred for the lesser chance of scarring. Plastic surgery technique also involves a lot of shorter close sutures as opposed to simple wound closer where scarring is not a concern per se. It is time consuming and an acquired skill.

        5-0 is the most commonly used size for most purposes. It had good tensile strength vs. diameter and does not have quite the scarring potential of larger diameters.

        4-0 is a good substitute for 5-0. It is also recommended for areas of greater stress. A large laceration on the biceps for instance when the patient regularly engages in heavy lifting, etc.

        3-0 should be considered for a knee or ankle joint. Greater tensile strength and the larger diameter make it less likely to pull through the tissue and rip out. Much more likely to leave the characteristic "railroad tracks" that mark old sutures.

        2-0 The largest practical diameter for our uses. Heavy use areas. Possibly a better choice in the absence of 3-0 than 4-0 would be. Determine on case by case basis.

        Got band-aids?
        Tricks and treachery are the practice of fools, that don't have brains enough to be honest. - Benjamin Franklin

        I have but one person on my ignore list. Can you guess who it is?


        • #5
          Ba da bump!


          Got sutures?
          Tricks and treachery are the practice of fools, that don't have brains enough to be honest. - Benjamin Franklin

          I have but one person on my ignore list. Can you guess who it is?


          • #6
            this is a very cool thread. thanks guys.

            i've been wanting to develop or at least try to define some skills in this area and have been having a tough time finding good info. most assumes a strong medical background. i'm going to check into the book .

            also, my brothers girlfriend is jsut about finished with vet school (cornell -which i understand has a pretty good reputation.) would she be a good source of info or instrutcion? are there some things i could ask her to show me that would be almost impossible to learn without being shown?



            • #7
              Don't forget "Steri-Strips" however. A lot of wounds that used to require suturing can now be closed without stitches at all. Your local pharmacist can order "Steri-Strips" for you.

              The First Rule of Emergency Medicine: never say "oops"!