Methods For Wound Closure

Julia Martin Rob Herfel

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The ideal wound closure is one that will repair tissue, recover function, reduce the risk of infection, and restore appearance. In order to obtain a cosmetic closure, it is important to understand the principles of wound healing, have a knowledge of the different techniques, and practice these approaches to become efficient. This chapter addresses the general concepts of closure techniques useful in the emergency department (ED).

After wound preparation, the physical integrity and function of the injured tissue must be restored. Most wounds seen in the ED require some form of closure, and the method chosen depends on the type of wound. There are three categories of wound closure: primary, delayed primary, and secondary.

Primary wound closure is the closing of the wound near the time of injury. Primary closure without tissue loss is almost always possible with clean wounds seen within 4 h after injury. The incidence of bacterial contamination and the risk of infection increase with injuries more than 4 h old. However, with clean wounds in highly vascular areas (scalp, face, and neck), the incidence of infection is so low that primary closure may be possible even up to 24 h after injury. 1 Primary closure of wounds in areas with poor blood supply (e.g., distal extremities) and cxontamination (e.g., debris) can generally be attempted if they are seen within 4 to 8 h and should be avoided if they present after 12 h from the time of the injury. Wounds with associated tissue loss usually require grafts or flaps to close the defect; these procedures are usually performed by specialists, often in the operating room.

Delayed primary closure is the approach of cleaning the wound, leaving the wound open under a moist dressing for approximately 4 to 5 days, and then suturing the wound if there is no evidence of infection. Heavily contaminated wounds, wounds resulting from high-energy missile injuries, or large wounds due to animal bites are ideal for delayed primary closure. Wounds contaminated by pus, vaginal discharge, feces, or saliva as well as those where treatment is delayed longer than 12 h should also be considered for open wound management. The first step in delayed primary closure is through cleaning and removal of debris and devitalized tissue. Prophylactic antibiotics should be started in the ED. The wound is packed open with moist, sterile, fine-meshed gauze and then covered by a dry sterile dressing. The wound should not be disturbed for the first 4 to 5 days after injury unless the patient develops an unexplained fever; unnecessary inspection during this period increases the risk of contamination and subsequent infection. On the fourth or fifth day, the wound can be undressed and inspected. In the absence of infection (no purulence or erythema beyond the edges of the wound) and devitalized tissue, the wound edges can be approximated with minimal risk of infection. 2

Closure by secondary intention is allowing the wound to heal without mechanical closure. Over a period of time the tissue slowly granulates, forming a slightly larger scar than that would be seen with primary wound closure yet less of a scar than would be seen if a sutured wound became infected.

Once it is decided to close the wound, a closure technique must be selected that allows the most accurate and secure approximation of the skin edges. Suturing is the oldest and most commonly used method. However, alternative techniques—including skin staples, skin-closure tapes, and tissue adhesives—can be used in selected patients. The short-term goal of any closure method is to hold tissue in apposition until the tensile strength of the wound is sufficient to withstand stress. The long-term goal of wound closure is to accurately reapproximate wound edges with the most esthetically pleasing results.

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