Wound Repair

See Also

History

History of injury
1. Identify if risk of Retained Foreign Body (e.g. dirt, wood, glass)
2. Identify contaminants (e.g. soiled knife)
3. Concurrent serious injury (e.g. Closed Head Injury)
Comorbid conditions
1. Human Immunodeficiency Virus Infection or AIDS
2. Diabetes Mellitus
3. Other immunocompromising condition (e.g. Chemotherapy, chronic Corticosteroids)
Medication allergies
1. Latex Allergy
2. Local Anesthesia allergy
3. Tape allergy
4. Antibiotic allergy
Tetanus Immunization status
1. Update with Td or Tdap if longer than 5-10 years since last Tetanus Vaccine

Exam

Obtain adequate Hemostasis on presentation (e.g. direct pressure)
1. See below for Hemostasis management
2. See Hemorrhage Management
3. See Topical Hemostatic Agent
Identify functional loss prior to injecting Anesthesia
Evaluate Muscle and tendon structures
Evaluate nerve structures
1. See Motor Exam
2. See Sensory Exam
Evaluate vascular structures
Evaluate underlying bone

Imaging

Indications
1. Fracture suspected
2. Retained Foreign Body
  1. See Radiopaque Foreign Body
Modalities
1. XRay
2. Bedside Ultrasound

Contraindications
Relative Contraindications to primary wound closure

Infected and inflamed wounds
Human Bite or Animal Bite
Serious crush wounds
Primary repair time constraints above not met

Indications
Surgical Consultation

Deep hand or Foot Wounds
Full-thickness Eyelid or canniculus Laceration
Consider for lip Lacerations, Ear Lacerations
Nerve, artery, or bone involvement
Traumatic Arthrotomy (joint involvement)
Penetrating wounds of unknown depth
Severe crush injuries
Wounds requiring drainage (severely contaminated)
Cosmetic outcome of significant issue

Risk Factors
Wound Infection

Age of Laceration Repair does not appear to significantly impact infection risk
Diabetes Mellitus
Laceration >5 cm
Lower extremity Laceration
Wound contamination
Quinn (2014) Emerg Med J 31(2): 96-100 [PubMed]

Preparation
Closure Approaches

Wound Closure by Primary Intention (standard Laceration Repair)
1. Immediate wound closure with Sutures, staples, surgical tape or Tissue Adhesive
Wound Closure by Secondary Intention
1. Wound not closed, but rather allowed to heal naturally
2. Typically used in badly contaminated wounds (e.g. Animal Bites, infected wounds)
Delayed Primary Wound Closure (closure by tertiary intention)
1. Delayed closure until after 3-5 days of observation for Wound Infection
2. May also be considered in late wound presentations (>24 hours)

Preparation
Closure Material

Suture Material
1. See Suture Material for Suture type and size selection
2. Deep (dermal or buried) Absorbable Sutures
  1. Vicryl is most commonly used for the deep layer, unless risk of infection (in which case use monofilament)
  2. Polyglecaprone 25 (Monocryl)
    1. Indicated for deep layer when wounds are higher risk of infection (Vicryl is contraindicated)
    2. Polydioxanone (PDS) is alternative to Polyglecaprone 25 (Monocryl) but has prolonged absorption
3. Superficial Sutures (e.g. simple interrupted, RunningSuture)
  1. Nonabsorbable Sutures (standard approach)
    1. Nylon (Ethilon) or Polypropylene (Prolene)
  2. Absorbable Sutures (Controversial)
    1. May be used effectively, and with similar cosmetic results in children to avoid Suture removal
    2. For facial Lacerations us fast Catgut, and for trunk or extremity use plain Catgut or Vicryl Rapide
    3. Alternatively, subcuticular skin closure technique may be used
Tissue Adhesive
1. See Tissue Adhesive
2. Avoid use around the eyes due to risk of Cyanoacrylate Eye Injury and risk of Periorbital Cellulitis
3. Limit to well-approximated, low tension, superficial Lacerations with linear edges
Tape closure (Steri-strip) with Benzoin
1. Remains attached for 4 days
2. Lower risk of Wound Infection
3. Place an extra steri-strip across each of strip ends
Staples
1. Indicated for Scalp Lacerations (tendons, nerves deep)
2. Higher risk of infection when used for post-operative orthopedic and cesarean skin closures
  1. Figueroa (2013) Obstet Gynecol 121(1):33-8 [PubMed]
  2. Smith (2010) J Bone Joint Surg Am 92(16):2732-2732 [PubMed]

Preparation
General

Instrument pointers
1. Use Adson's forceps ("pickups") with teeth (less crush injury)
2. Grasp the needle driver (clamp) in palm of hand (without fingers in handle) for better control
3. Use adson's forceps or similar (not fingers) to feed needle to needle driver
Gloves
1. Sterile gloves not needed in uncomplicated repair
2. Perelman (2004) Ann Emerg Med 43:362-70 [PubMed]
Ruler
1. Estimates of length without a ruler are inaccurate (although women estimate better than men)
2. Measurement is key if billing and coding are based on lesion length
3. Peterson (2014) Injury 45(1): 232-6 [PubMed]

Protocol
Repair timetable

Age of Laceration does not appear to significantly impact infection risk
1. Decision for primary closure should not solely be based on the age of Laceration ("golden period" for repair)
2. Wounds involving nerves, blood vessels, tendons or bones have additional caveats
3. Wounds <19 hours old heal better than those open for longer periods
  1. Berk (1988) Ann Emerg Med 17(5): 496-500 [PubMed]
4. Bacterial count increase by 3 hours
  1. However Wound Infection risk is not directly correlated with age of Laceration
  2. See Risk Factors for infection as listed above
Primary Repair
1. See above precaution regarding no absolute cut-off for primary repair
2. Face or Scalp: Repair within 24 hours (18 hours preferred)
3. Body: Repair within 12-18 hours (6 hours preferred)
Older wounds with infection risk
1. Step 1: Initial Evaluation
  1. Option 1: Pack wound with sterile wet to dry dressings changed twice daily
  2. Option 2: Standard primary closure with simple interrupted Suture (no deep Sutures)
    1. Give precautions for immediate return for signs of infection
    2. Sutures are removed if wound becomes infected
  3. Option 3: Loose approximation with simple interrupted Suture (no deep Sutures)
    1. Loose closure is typically not recommended
    2. If choosing to Suture, close with good approximation (option 2)
    3. Lin and Vieth in Herbert (2018) 18(10):12-4
2. Step 2: Reevaluation at 3-5 days
  1. No infection: Primary wound closure with Suture
  2. Infection: Treat infection and healing by second intention as below
3. Alternative
  1. Consider loose closure with superficial, nonabsorbable monofilament Sutures (e.g. Nylon, Prolene)
  2. Consider scehduled wound recheck in 1-2 days, or in reliable patients, as needed follow-up for signs infection
  3. Remove Sutures if infection occurs
Healing by second intention
1. Pack wounds with sterile wet to dry dressing bid
2. Granulation and Contraction risk without suturing

Protocol
Local Anesthesia

See Local Skin Anesthesia (includes pearls to decrease patient discomfort)
Prepare skin with antiseptic prior to injection
1. Betadine is not affective until it dries (hence Hibiclens is often preferred)
2. Avoid Hibiclens near eyes (irritation) and inside ear canal (ototoxic)
Consider Topical Anesthetics, especially in children (e.g. LET Anesthesia)
Epinephrine is safe in areas previously contraindicated (fingers, toes, ears, nose)
1. Exercise caution in Peripheral Vascular Disease
2. Digits (even Digital Block): 1:100,000 Epinephrine concentration
  1. Shridharani (2014) Eur J Plast Surg 37(4): 183-8 [PubMed]
3. Nose/Ears: 1:200,000 Epinephrine concentration
  1. Hafner (2005) J Dtsch Dermatol Ges 3(3): 195-9 [PubMed]

Protocol
Irrigation

Personal Protection Equipment
1. Wear a mask with eye shield during irrigation
Saline is as effective as antiseptics (e.g. 1% Betadine) for irrigation
1. Antseptics should be avoided inside the wound due to tissue injury
Tap water is as safe and effective as saline for irrigation (and more plentiful)
1. Fernandez (2012) Cochrane Database Syst Rev (2): CD003861 +PMID:22336796 [PubMed]
2. Weiss (2013) BMJ Open 3(1) +PMID:23325896 [PubMed]
Moderate pressure irrigation is the key
1. Irrigation with syringe provides approximately 5-8 psi
Irrigate with minimum of 250 to 500 cc, or 50-100 ml/cm wound length (use 1000 cc or more if contaminated)
1. Normal Saline irrigation, compressible plastic bottles (250-500 cc) with plastic adapter OR
2. Syringe 30-60 ml syringe (requires multiple refills) OR
3. Placing wound under Running tap water
Avoid irrigation with tissue destructive agents
1. Hydrogen Peroxide (weak germacide)
2. Betadine at stock concentration (9%)
  1. Always dilute Betadine (1:10)

Protocol
Wound Preparation

Remove all surface foreign bodies with scrub brush on skin surface
Do not apply Betadine or Hibiclens inside of wound
1. Apply to wound edges prior to Anesthesia injection (see Local Anesthesia as above)
Drape widely to allow clear margins
Scalp Wounds
1. Slick surrounding hair down with K-Y Jelly
Lacerations near the eye
1. See Eyelid Laceration
2. Avoid Tissue Adhesive if possible (risk of Cyanoacrylate Eye Injury and increased risk of Periorbital Cellulitis)
3. Do not shave eyebrows
Thin Skin Flaps (Skin Tears, especially in elderly)
1. See Skin Tear
Facial Nerve region
1. Exercise caution in region of Facial Nerve, especially near Parotid Gland and mandubular branch
2. Risk of permanent nerve injury
3. Prevent excessive swelling that may compress Facial Nerve branches (consider wound drains)

Management
Hemostasis

See Tourniquet (Pneumatic Tourniquet, Windlass Tourniquet)
See Topical Hemostatic Agent
See Hemorrhage Management
Precautions
1. Patient reports of spurting or pumping bleeding is arterial injury until proven otherwise
2. Arterial injury may not be immediately obvious on Emergency Department presentation
  1. Arterial bleeding may stop briefly due to vasospasm and small thrombus formation
3. Do not ligate named arteries
  1. Consult surgery if arterial injury is suspected
Management of small artery bleeding
1. Apply direct pressure
2. Arteries <2mm
  1. Locally infiltrate Lidocaine with Epinephrine
  2. Consider electrocautery
3. Small, unnamed arteries >2mm
  1. Ligation (if able to identify the bleeding vessel)
    1. Clamp the bleeding end and apply ligature (Suture)
  2. Figure of eight Suture (or horizontal mattress)
    1. Indicated for vessel that has retracted within tissue and cannot be clamped
    2. Imagine a square box around the bleeding source
      1. Each corner of the exposed square represents an entry or exit of the figure of eight Suture
      2. Tying the figure of eight compresses the tissue around the bleeding source

Protocol
Wound Repair

Specific injury approaches
1. See Finger Laceration
2. See Scalp Repair
3. See Wound Dressing for Transport
  1. Indicated if repair must be done elsewhere
4. Lip Laceration
  1. Reapproximation of vermillion border is critical to optimal cosmetic result
  2. Place first Suture to reapproximate vermillion border
  3. Use skin marker at border before Anesthetic injection
  4. Repair deeper Muscle and Oral Mucosa with 4-0 Absorbable Suture
  5. Repair skin with 6-0 nylon (e.g. Ethilon)
5. Deep injuries with full thickness muscle Lacerations
  1. Muscle does not hold Sutures well
  2. Attempt to close Muscle with 2-0 or 3-0 Absorbable Suture, using Horizontal Mattress Suture
  3. Consider closing fascia above and below Muscle
  4. Lin, Shinar and Kantor in Herbert (2017) EM:Rap 17(8): 1-2
Debridement
1. Recut wound for clean, fresh, surgical-incision edges
Undermining
1. May be required to ensure Dermis closure and decreased skin tension
2. Best dissection plane is between dermal layer and connective tissue, subcutaneous fat
3. Insert closed scissors on lateral wound margin, and then spread open
  1. Repeat for opposite lateral wound margin
Suture technique
1. General pearls
  1. Grasp Suture Needle with needle driver one third of way from Suture attachment (where needle becomes straight)
  2. Tie the knot with two square knots (4 ties, or for narrow Suture use 5 to 6 ties)
    1. The first knot should have 2 loops or throws around the needle driver to "set" the knot
  3. Cut Suture to 3-5 mm length
2. Evert wound edges (do not dig a ditch, build a flask)
  1. Everted edges will flatten over time, inverted edges result in more prominent scars
  2. Needle should enter perpendicular to skin
  3. Direct the needle initially down and away from the Laceration edge
  4. Rotate the wrist and needle driver, following the needle curvature
  5. Exit perpendicular to the skin surface on the opposite side of the Laceration
3. Reduce skin tension
  1. High skin tension results in a wound that may gape open with risk of Hypertrophic Scar
  2. Avoid tying knots too close to the wound (increases skin tension)
  3. Wound eversion is a good sign that skin tension has been reduced across the wound edge
  4. Avoid subcuticular closure as sole repair method
  5. Techniques to reduce skin tension
    1. Use deep Sutures first, before superficial closure
    2. Undermine skin edges
    3. In contaminated wounds use simple interrupted Suture or Vertical Mattress Suture
4. Interrupted simple mnemonic
  1. Not too many
  2. Not too tight
  3. Not too wide
  4. Get them out
5. References
  1. Lin, Kantor and Shinar in Herbert (2017) EM:Rap 17(4): 1
Techniques
1. See Wound Closure with Staples
2. Simple Interrupted Suture
  1. Work-horse of Laceration Repair (appropriate for nearly all repairs)
3. Half-buried Horizontal Mattress Suture
  1. Indicated in triangular flap Laceration (does not compromise blood supply to tip of corner)
4. Horizontal Mattress Suture
  1. Everts wound edges, but risk of skin necrosis and scar
5. Vertical Mattress Suture
  1. Everts wound edges, but risk of skin necrosis and scar
6. Deep Suture (interrupted dermal Sutures)
  1. May use in clean wounds to better approximate wound edges and reduce wound edge tension
7. RunningSuture
  1. Fast technique for long Lacerations, but risk of dehiscence if Suture breaks anywhere along its length
8. Running Subcuticular Suture
  1. May use in clean wounds (surgical wounds) for close wound edge apposition (but does not allow drainage)
Suture Removal
1. See Suture for timing of Suture removal

Protocol
Bandages

Moist Wound Healing is key
Non-adherent slightly moist or Occlusive Dressing
Ointment or Topicals (e.g. Bacitracin, vaseline)
1. Apply for first 3 days until epithelialization
2. Reduces infection risk at minor wound sites
  1. Dire (1995) Acad Emerg Med 2(1): 4-10 +PMID:7606610 [PubMed]
3. Precautions
  1. Avoid applying ointment over Skin Glue closure (e.g. Dermabond)
  2. Vaseline alone is sufficient without risk of reaction and without higher rate of Wound Infections
  3. Topical Antibiotics cause a irritant or Allergic Contact Dermatitis in up to 10% of cases
    1. Reactions are most common with neosporin (or triple Antibiotic)
    2. Reactions may also occur with Bacitracin
Consider Debridement after epitheliazation (day 3)
1. Initial use of Occlusive Dressings (first 3 days) prevent scab formation
2. Carefully apply 50% Hydrogen Peroxide to scab
3. Avoid prior to day 3 (delays Wound Healing)
4. Scab removal may improve cosmesis

Protocol
Home Instructions

Gentle compression
Precautions about water exposure (e.g. bathing, getting wound wet)
1. Typical recommendations are to not get the wound wet for the first 48 hours after repair
2. Early water exposure at a wound site does not appear to increase the risk of infection
  1. Heal (2006) BMJ 332(7549): 1053-6 +PMID:16636023 [PubMed]
3. Patients should still avoid exposure to contaminated water (e.g. dish washing)
Observe and return immediately for signs of Wound Infection
Avoid excessive tension on wound edges (risk of wound dehiscence)
1. Exercise caution over joints and other regions of maximal tension
2. Highest risk of wound dehiscence after Sutures are removed (lesion is only partially healed at 10-14 days)
Suture Removal
1. See Suture Removal Timing
2. Face, Ear, Eyebrow, Nose, Lip: 5 days (3 days for Eyelid)
3. Other regions: 10 days
Scar prevention
1. See moist Wound Healing recommendations as above
2. After Wound Healing (first 28 days), consider Silicone Sheeting applied daily for up to 3 months

Management
Adjuncts

Prophylactic Antibiotics possible indications
1. Not routinely indicated in noncontaminated wounds
2. Wounds at higher risk of secondary infection
  1. See secondary infection risk factors below
3. Comorbidity with risk of distant site infection
  1. Endocarditis risk (see SBE Prophylaxis)
  2. Hip prosthesis
Post-exposure Tetanus Prophylaxis
1. Unknown Immune Status or never immunized
  1. Tetanus Toxoid Containing Vaccine (e.g. Td, Tdap, TT) now, at 6 weeks and 6 months AND
  2. Tetanus Immune globulin 250 Units IM if Puncture Wound or contaminated wound
2. Last Tetanus Toxoid containing Vaccine over 5-10 years prior
  1. Tetanus Toxoid Containing Vaccine (e.g. Td, Tdap, TT) now

Management
Disposition

Hospitalization Indications
1. Failed outpatient therapy (especially if non-compliance with recommended management)
2. Poorly controlled comorbidity (e.g. Diabetes Mellitus, Peripheral Vascular Disease)
3. Immunocompromised state
4. Severe or progressive Cellulitis (especially if deeper, regional or systemic signs)
5. Necrotizing Fasciitis
Referral or Consultation Indications
1. Wounds affecting joints, bones, tendons or nerves
2. Wounds affecting large body regions
3. Facial wounds
4. Burn Injury
  1. See Burn Injury for referral/transfer criteria
  2. Severe or circumferential burns or
  3. Burns to the face, hands or feet

Complications

Retained Foreign Body
1. See Foreign Body Removal
Hypertrophic Scar
Secondary Wound Infection
1. See Wound Infection for risk factors
2. Occurs within 48 hours in most cases

Course
Wound Healing

See Wound

References

Lin and Lin in Herbert (2014) EM:Rap 14(11): 8-10
Lin and Mason in Herbert (2022) EM:Rap 22(6): 12-14
Lin and Shinar in Herbert (2017) EM:Rap 17(5): 3-4
Lin and Shinar in Herbert (2017) EM:Rap 17(7): 1-2
Mortiere (1996) Principles of Primary Wound Management
Snell in Pfenninger and Fowler (1994) Procedures for Primary Care Physicians, Mosby, Chicago, p. 12-9
Forsch (2017) Am Fam Physician 95(10): 628-36 [PubMed]
Worster (2015) Am Fam Physician 91(2): 86-92 [PubMed]