Wound Repair

Aka: Wound Repair, Laceration Repair, Laceration

1. See Also
   1. Wound
   2. Marine Trauma
   3. Puncture Wound
2. History
   1. Comorbid conditions
      1. Human Immunodeficiency Virus Infection
      2. Diabetes Mellitus
   2. Medication allergies
      1. Latex Allergy
      2. Local Anesthesia allergy
      3. Tape allergy
      4. Antibiotic allergy
3. Exam
   1. Evaluate muscle and tendon structures
   2. Evaluate nerve structures
      1. See Motor Exam
      2. See Sensory Exam
   3. Evaluate vascular structures
   4. Evaluate underlying bone
4. Contraindications: Relative Contraindications to primary wound closure
   1. Infected and inflamed wounds
   2. Human Bite or Animal Bite
   3. Serious crush wounds
   4. Primary repair time constraints above not met
5. Indications: Surgical consultation
   1. Deep hand or Foot Wounds
   2. Full-thickness Eyelid, lip or ear Lacerations
   3. Nerve, artery, bone or joint involvement
   4. Penetrating wounds of unknown depth
   5. Severe crush injuries
   6. Wounds requiring drainage (severely contaminated)
   7. Cosmetic outcome of significant issue
6. Preparation: Materials
   1. See Suture Material
   2. See Tissue Adhesive
   3. 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
   4. Staples
      1. Indicated on scalp and Abdomen (tendons, nerves deep)
   5. Instrument pointers
      1. Use pickups with teeth (less crush injury)
   6. Gloves
      1. Sterile gloves not needed in uncomplicated repair
      2. Perelman (2004) Ann Emerg Med 43:362-70
7. Protocol: Repair timetable
   1. Primary Repair (bacterial count increased by 3 hours)
      1. Face or Scalp: Repair within 24 hours (18 hours preferred)
      2. Body: Repair within 12-18 hours (6 hours preferred)
   2. Older wounds with infection risk
      1. Step 1: Initial Evaluation
         1. Option 1: Loose approximation with simple interrupted Suture
         2. Option 2: Pack wound with sterile wet to dry dressings changed twice daily
      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. Healing by second intention
      1. Pack wounds with sterile wet to dry dressing bid
      2. Granulation and Contraction risk without suturing
8. Protocol: Anesthesia Pearls to decrease patient discomfort
   1. See Local Skin Anesthesia
9. Protocol: Irrigation
   1. Saline as efficacious as 1% betadine for irrigation
   2. Tap water may be more efficacious than saline (more plentiful)
   3. Moderate pressure irrigation is the key
      1. Irrigation with syringe provides approximately 7 psi
      2. Use 35 ml syringe with 19 gauge needle
      3. Irrigate with minimum of 500 to 1000 cc
   4. Avoid irrigation with tissue destructive agents
      1. Hydrogen peroxide (weak germacide)
      2. Betadine at stock concentration (9%)
         1. Always dilute betadine (1:10)
10. Protocol: Wound Preparation
    1. Remove all foreign bodies with scrub brush
    2. Do not apply Betadine or Hibiclens inside of wound
       1. May apply to wound edges
       2. Avoid hibiclens near eyes
    3. Drape widely to allow clear margins
    4. Scalp Wounds
       1. Slick surrounding hair down with K-Y Jelly
    5. Eyebrow region wounds
       1. Do not shave eyebrows
11. Protocol: Wound Repair
    1. 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
    2. Debridement
       1. Recut wound for clean, fresh, surgical-incision edges
    3. Undermining
       1. Ensures Dermis closure
    4. Suture technique: Interupted simple mneumonic
       1. Not too many
       2. Not too tight
       3. Not too wide
       4. Get them out
    5. Techniques
       1. Simple Interrupted Suture
          1. 
       2. Half-buried Horizontal Mattress Suture
          1. 
       3. Horizontal Mattress Suture
          1. 
       4. Vertical Mattress Suture
          1. 
       5. Deep Suture
          1. 
       6. RunningSuture
          1. 
       7. Running Subcuticular Suture
          1. 
    6. Bandages: Moist Wound Healing is key
       1. Non-adherent slightly moist dressings
       2. Ointment or Topicals (e.g. Bacitracin)
          1. Apply for first 3 days until epithelialization
       3. Consider debridement after epitheliaztion (day 3)
          1. Carefully apply 50% hydrogen peroxide to scab
          2. Avoid prior to day 3 (delays Wound Healing)
          3. Scab removal may improve cosmesis
       4. Gentle compression
       5. Limited bathing may begin >24 hours after repair
12. Protocol: Suture Removal
    1. See Suture for timing of Suture removal
13. Management: Adjuncts
    1. Prophylactic antibiotics possible indications
       1. See secondary infection risk factors below
       2. Endocarditis risk (see SBE Prophylaxis)
       3. Hip prosthesis
       4. Not routinely indicated in noncontaminated wounds
    2. Tetanus Toxoid booster
       1. Unknown Immune Status or never immunized
          1. Tetanus Toxoid 0.5 nl now, at 6 weeks and 6 months
          2. Tetanus Immune globulin 250 U if dirty wound
       2. Last Tetanus Toxoid over 5-10 years prior
          1. Tetanus Toxoid 0.5 ml
14. Complications: Secondary wound infection
    1. Occurs within 48 hours
    2. Risk factors
       1. Contaminated wound (manure, dirt, rust)
       2. Bite Injury
       3. Crush Injury
       4. High risk site (hand or foot)
       5. Prolonged time to skin closure (see above)
       6. Underlying medical condition
          1. Diabetes Mellitus
          2. Chemotherapy
          3. Corticosteroids
          4. Malnutrition
          5. Lymphedema
          6. Peripheral Vascular Disease
15. Course: Wound Healing
    1. See Wound