Transcript Suturing and splinting - Medicine is an art

Suturing and splinting
Presented by
Dr. Osama Kentab, M.D, FAAP, FACEP
Assistant Professor Pediatrics and Emergency Medicine
King Saud bin Abdulaziz University for Health silences
October 2014
Objectives
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Describe the principles of wound healing
Identify the various types and sizes of suture material.
Choose the proper instruments for suturing.
Identify the different injectable anesthetic agents and correct
dosages.
Demonstrate various biopsy methods: punch, excision, shave.
Demonstrate different types of closure techniques: simple
interrupted, continuous, subcuticular, vertical and horizontal
mattress, dermal
Demonstrate two-handed, one-handed, instrument ties
Recommend appropriate wound care and follow-up.
Critical Wound Healing Period
Tissue
Skin
5-7 days
Mucosa
5-7 days
Subcutaneous
7-14 days
Peritoneum
7-14 days
Fascia
14-28 days
0
5 7
14
21
Tissue Healing Time/Days
28
Model of Wound Healing
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(1) Hemostasis: within minutes post-injury, platelets aggregate at the
injury site to form a fibrin clot.
(2) Inflammatory: bacteria and debris are phagocytosed and removed,
and factors are released that cause the migration and division of cells
involved in the proliferative phase.
(3) Proliferative: angiogenesis, collagen deposition, granulation
tissue formation, epithelialization, and wound contraction
(4) Remodeling: collagen is remodeled and realigned along tension
lines and cells that are no longer needed are removed by apoptosis.
Wound Healing Concepts
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Patient factors
 Wound classification
 Mechanism of injury
 Tetanus/antibiotics/local anesthetics
 Surgical principles and wound prep
 Suture/needle/stitch choice
 Management/care/follow-up
Common Patient Factors
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Age
Blood supply to the
area
Nutritional status
Tissue quality
Revision/infection
Compliance
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Weight
Dehydration
Chronic disease
Immune response
Radiation therapy
CDC Surgical Wound Classification
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Clean: (1-5% risk of infection) uninfected operative wounds in
which no inflammation is encountered and the respiratory, alimentary,
genital, or uninfected urinary tracts are not entered. In addition, clean
wounds are primarily closed, and if necessary, drained with closed
drainage. Operative incisional wounds that follow nonpenetrating
(blunt) trauma should be included in this category if they meet the
criteria.
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Clean-contaminated: (3-11% risk) operative wounds in which
the respiratory, alimentary, genital, or urinary tract is entered under
controlled conditions and without unusual contamination. Specifically,
operations involving the biliary tract, appendix, vagina, and
oropharynx are included in this category, provided no evidence of
infection or major break in technique is encountered.
CDC Surgical Wound Classification
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Contaminated: (10-17% risk) open, fresh, accidental wounds,
operations with major breaks in sterile technique or gross spillage from
the gastrointestinal tract, and incisions in which acute, nonpurulent
inflammation is encountered.
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Dirty or infected: (>27% risk) old traumatic wounds with
retained devitalized tissue and those that involve existing clinical
infection or perforated viscera. This definition suggests that the
organisms causing postoperative infection were present in the
operative field before the operation.
Surgical Principles
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Incision
Dissection
Tissue handling
Hemostasis
Moisture/site
Remove infected,
foreign, dead areas
Length of time open
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Choice of closure
material/mechanism
Primary or secondary
Cellular responses
Eliminate dead space
Closing tension
Distraction forces and
immobilization/care
Suture Materials
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Criteria
– Tensile strength
– Good knot security
– Workability in handling
– Low tissue reactivity
– Ability to resist bacterial infection
Types of Sutures
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Absorbable or non-absorbable (natural or synthetic)
 Monofilament or multifilament (braided)
 Dyed or undyed
 Sizes 3 to 12-0 (numbers alone indicate progressively
larger sutures, whereas numbers followed by 0 indicate
progressively smaller)
 New antibacterial sutures
Absorbable
Non-absorbable
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Not biodegradable
and permanent
– Nylon (Ethilon)
– Prolene
– Stainless steel
– Silk (natural, can
break down over
years)
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Degraded via
inflammatory response
– Vicryl
– Monocryl
– PDS
– Chromic
– Cat gut (natural)
Natural Suture
Synthetic
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Biological
 Cause inflammatory
reaction
– Catgut (connective
from cow or sheep)
– Silk (from silkworm
fibers)
– Chromic catgut
Synthetic polymers
 Do not cause
inflammatory response
– Nylon
– Vicryl
– Monocryl
– PDS
– Prolene
Monofilament
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Multifilament (braided)
Single strand of suture
material
Minimal tissue trauma
Smooth tying but more
knots needed
Harder to handle due to
memory
Examples: nylon, monocryl,
prolene, PDS
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Fibers are braided or twisted
together
 More tissue resistance
 Easier to handle
 Fewer knots needed
 Examples: vicryl, silk,
chromic
Suture Materials
Suture Selection
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Do not use dyed sutures on the skin
Use monofilament on the skin as multifilament
harbor BACTERIA
Non-absorbable cause less scarring but must be
removed
Plus sutures (staph, monocryl for E. coli,
Klebsiella)
Location and layer, patient factors, strength,
healing, site and availability
Suture Selection
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Absorbable for GI, urinary or biliary
 Non-absorbable or extended for up to 6 mos
for skin, tendons, fascia
 Cosmetics = monofilament or subcuticular
 Ligatures usually absorbable
Suture Sizes
Surgical Needles
Wide variety with different company’s
naming systems
 2 basic configurations for curved needles
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– Cutting: cutting edge can cut through tough
tissue, such as skin
– Tapered: no cutting edge. For softer tissue
inside the body
Surgical Needles
Surgical Instruments
Scalpel Blades
Anesthetic Solutions
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Lidocaine (Xylocaine®)
– Most commonly used
– Rapid onset
– Strength: 0.5%, 1.0%, &
– Vasoconstriction
– Decreased bleeding
2.0%
– Maximum dose:
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– Prolongs duration
– Strength: 0.5% & 1.0%
5 mg / kg, or
300 mg
– Maximum individual
– 1.0% lidocaine = 1 g
lidocaine / 100 cc =
1,000mg/100cc
– 300 mg = 0.03 liter = 30
Lidocaine (Xylocaine®)
with epinephrine
dose:
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ml
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7mg/kg, or
500mg
Anesthetic Solutions
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CAUTIONS: due to its vasoconstriction
properties never use Lidocaine with epinephrine
on:
– Eyes, Ears, Nose
– Fingers, Toes
– Penis, Scrotum
Anesthetic Solutions
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BUPIVACAINE (MARCAINE):
– Slow onset
– Long duration
– Strength: 0.25%
– DOSE: maximum individual dose 3mg/kg
Local Anesthetics
Injection Techniques
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25, 27, or 30-gauge
needle
 6 or 10 cc syringe
 Check for allergies
 Insert the needle at the
inner wound edge
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Aspirate
 Inject agent into tissue
SLOWLY
 Wait…
 After anesthesia has
taken effect, suturing
may begin
Wound Evaluation
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Time of incident
 Size of wound
 Depth of wound
 Tendon / nerve involvement
 Bleeding at site
When to Refer
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Deep wounds of hands or feet, or unknown depth
of penetration
Full thickness lacerations of eyelids, lips or ears
Injuries involving nerves, larger arteries, bones,
joints or tendons
Crush injuries
Markedly contaminated wounds requiring
drainage
Concern about cosmesis
Contraindications to Suturing
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Redness
Edema of the wound margins
Infection
Fever
Puncture wounds
Animal bites
Tendon, nerve, or vessel involvement
Wound more than 12 hours old (body) and 24 hrs
(face)
Closure Types
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Primary closure (primary intention)
– Wound edges are brought together so that they are adjacent to each
other (re-approximated)
– Examples: well-repaired lacerations, well reduced bone fractures,
healing after flap surgery
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Secondary closure (secondary intention)
– Wound is left open and closes naturally (granulation)
– Examples: gingivectomy, gingivoplasty,tooth extraction sockets,
poorly reduced fractures
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Tertiary closure (delayed primary closure)
– Wound is left open for a number of days and then closed if it is
found to be clean
– Examples: healing of wounds by use of tissue grafts.
Wound Preparation
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Most important step for reducing the risk of wound
infection.
Remove all contaminants and devitalized tissue before
wound closure.
– IRRIGATE w/ NS or TAP WATER (AVOID H2O2,
POVIDONE-IODINE)
– CUT OUT DEAD, FRAGMENTED TISSUE
If not, the risk of infection and of a cosmetically poor scar
are greatly increased
Personal Precautions
Basic Laceration Repair
Principles And Techniques
Langer’s Lines
Principles And Techniques
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Minimize trauma in skin
handling
Gentle apposition with slight
eversion of wound edges
– Visualize an Erlenmeyer
flask
Make yourself comfortable
– Adjust the chair and the
light
Change the laceration
– Debride crushed tissue
Types of Closures
● Simple interrupted closure – most commonly used, good for shallow
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wounds without edge tension
Continuous closure (running sutures) – good for hemostasis (scalp
wounds) and long wounds with minimal tension
Locking continuous - useful in wounds under moderate tension or in
those requiring additional hemostasis because of oozing from the skin
edges
Subcuticular – good for cosmetic results
Vertical mattress – useful in maximizing wound eversion, reducing
dead space, and minimizing tension across the wound
Horizontal mattress – good for fragile skin and high tension wounds
Percutaneous (deep) closure – good to close dead space and decrease
wound tension
Simple Interrupted Suturing
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Apply the needle to the needle driver
– Clasp needle 1/2 to 2/3 back from tip
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Rule of halves:
– Matches wound edges better; avoids dog ears
– Vary from rule when too much tension across
wound
Simple Interrupted Suturing
Rule of halves
Simple Interrupted Suturing
Rule of halves
Suturing
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The needle enters the
skin with a 1/4-inch
bite from the wound
edge at 90 degrees
– Visualize Erlenmeyer
flask
– Evert wound edges
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Because scars contract
over time
Suturing
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Release the needle from the needle driver, reach into the
wound and grasp the needle with the needle driver. Pull it
free to give enough suture material to enter the opposite
side of the wound.
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Use the forceps and lightly grasp the skin edge and arc the
needle through the opposite edge inside the wound edge
taking equal bites.
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Rotate your wrist to follow the arc of the needle.
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Principle: minimize trauma to the skin, and don’t bend the
needle. Follow the path of least resistance.
Suturing
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Release the needle and grasp the portion of the
needle protruding from the skin with the needle
driver. Pull the needle through the skin until you
have approximately 1 to 1/2-inch suture strand
protruding form the bites site.
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Release the needle from the needle driver and
wrap the suture around the needle driver two
times.
Simple Interrupted Suturing
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Grasp the end of the suture material with the needle driver
and pull the two lines across the wound site in opposite
direction (this is one throw).
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Do not position the knot directly over the wound edge.
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Repeat 3-4 throws to ensuring knot security. On each
throw reverse the order of wrap.
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Cut the ends of the suture 1/4-inch from the knot.
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The remaining sutures are inserted in the same manner
Simple, Interrupted
http://www.youtube.com/watch?v=PFQ5-tquFqY
The trick to an instrument tie
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Always place the suture holder parallel to the
wound’s direction.
 Hold the longer side of the suture (with the
needle) and wrap OVER the suture holder.
 With each tie, move your suture-holding hand to
the OTHER side.
 By always wrapping OVER and moving the hand
to the OTHER side = square knots!!
Continuous Locking and Nonlocking Sutures
http://www.youtube.com/watch?v=xY4cAqk30K4
http://cal.vet.upenn.edu/projects/surgery/5000.htm
http://www.youtube.com/watch?v=sgOaBojcX-c
https://www.youtube.com/watch?v=hIqTDvofekM
Vertical Mattress
Good for everting wound edges
(neck, forehead creases, concave surfaces)
http://www.youtube.com/watch?v=824FhFUJ6wc
Horizontal Mattress
Good for closing wound edges under high tension,
and for hemostasis.
Horizontal Mattress
http://www.youtube.com/watch?v=9DdaooEXshk
http://www.youtube.com/watch?v=I7C7nsl5Tuk
Suturing - finishing
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After sutures placed, clean the site with
normal saline.
 Apply a small amount of Bacitracin or
white petroleum and cover with a sterile
non-adherent compression dressing (Tefla).
Suturing - before you go…
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Need for tetanus globulin and/or vaccine?
– Dirty (playground nail) vs clean (kitchen knife)
– Immunization history (>10 yrs need booster or >5 yrs if
contaminated)
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Tell pt to return in one day for recheck, for signs of infection
(redness, heat, pain, puss, etc), inadequate analgesia, or suture
complications (suture strangulation or knot failure with possible
wound dehiscence)
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It should be emphasized to patients that they return at the
appropriate time for suture removal or complications may arise
leading to further scarring or subsequent surgical removal of
buried sutures.
Patient instructions and follow up care
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Wound care
– After the first 24-48 hours, patients should gently wash
the wound with soap and water, dry it carefully, apply
topical antibiotic ointment, and replace the
dressing/bandages.
– Facial wounds generally only need topical antibiotic
ointment without bandaging.
– Eschar or scab formation should be avoided.
– Sunscreen spf 30 should be applied to the wound to
prevent subsequent hyperpigmentation.
Suture Removal
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Average time frame is 7 – 10 days
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FACE: 3 – 5 d
NECK: 5 – 7 d
SCALP: 7 – 12 days
UPPER EXTREMITY, TRUNK: 10 – 14 days
LOWER EXTREMITY: 14 – 28 days
SOLES, PALMS, BACK OR OVER JOINTS: 10 days
Any suture with pus or signs of infections should be
removed immediately.
Suture Removal
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Clean with hydrogen peroxide to remove any
crusting or dried blood
 Using the tweezers, grasp the knot and snip the
suture below the knot, close to the skin
 Pull the suture line through the tissue- in the
direction that keeps the wound closed - and place
on a 4x4. Count them.
 Most wounds have < 15% of final wound
strength after 2 wks, so steri-strips should be
applied afterwards.
Topical Adhesives
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Indications: selection of approximated, superficial, clean
wounds especially face, torso, limbs. May be used in
conjunction with deep sutures
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Benefits: Cosmetic, seals out bacteria, apply in 3 min,
holds 7 days (5-10 to slough), seal moisture, faster, clear,
convenient, less supplies, no removal, less expensive
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Contraindicated with infection, gangrene, mucosal, damp
or hairy areas, allergy to formaldehyde or cryanoacrylate,
or high tension areas
Dermabond®
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A sterile, liquid topical skin
adhesive
Reacts with moisture on skin
surface to form a strong, flexible
bond
Only for easily approximated
skin edges of wounds
– punctures from minimally
invasive surgery
– simple, thoroughly cleansed,
lacerations
Dermabond®
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Standard surgical wound prep and dry
Crack ampule or applicator tip up; invert
Hold skin edges approximated horizontally
Gently and evenly apply at least two thin layers on
the surface of the edges with a brushing motion
with at least 30 s between each layer, hold for 60 s
after last layer until not tacky
Apply dressing
http://www.youtube.com/watch?v=oa13wriWTus&feature=related
http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1
Follow Up Care with Adhesives
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No ointments or medications on dressing
May shower but no swimming or scrubbing
Sloughs naturally in 5-10 days, but if need to remove use
acetone or petroleum jelly to peel but not pull apart skin
edges
Pt education and documentation
EBM Take Home Points
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Suturing is preferred technique for skin laceration repair
LOE SORT C
Saline or tap water should be used for wound irrigation
LOE SORT B
Use of white petrolatum to promote wound healing is as
effective as antibiotic ointment LOE SORT B
Tissue adhesives show comparable results with regards to
cosmetic, infection or dehisence rates LOE SORT A
References
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http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf
Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct.
355: 17.
Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988.
www.uptodateonline.com; 2009, topic lacerations, etc.
http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf
http://www.mnpa.us/handouts/Session%2005%20%20%20%20Basic%20Suturing%20%202010%20MNPA.pdf
http://www.practicalplasticsurgery.org/docs/Practical_01.pdf
http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE87EB5D06CE8DF/0/wound_healing_manual.pdf
Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family
Physicians. AAFP Scientific Assembly. 2010.
http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/asse
mbly/2010handouts/071.Par.0001.File.tmp/071-072.pdf
Splinting and Casting
Immediate Treatment of
Orthopedic Injury
• One primary goal
– Reduction of swelling
• PRICE
– Protection
– Rest
– Ice
– Compression
– Elevation
Cold Application
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Decreases pain
Produces vasoconstriction
Controls hemorrhage and edema
Decreases local cell metabolism
– Decreases tissues’ need for oxygen
– Reduces hypoxia
• Sensations- Cold, burning, aching,
numb
Emergency Splinting
• Two vital principles
– Splint from one joint above the fracture to
one joint below the fracture
– Splint the injury in the position it is found
Indications for Splinting
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Fractures
Sprains
Joint infections
Tenosynovitis
Acute arthritis / gout
Lacerations over joints
Puncture wounds and animal
bites of the hands or feet
Splinting Equipment
• Plaster of Paris
– Made from gypsum - calcium sulfate dihydrate
– Exothermic reaction when wet - recrystallizes (can
burn patient)
– Warm water - faster set, but increases risk of burns
– Fast drying - 5 - 8 minutes to set
– Extra fast-drying - 2 - 4 minutes to set - less time to
mold
– Can take up to 1 day to cure (reach maximum
strength)
– Upper extremities - use 8-10 layers
– Lower extremities - 12-15 layers, up to 20 if big
person (increased risk of burn!)
Splinting Equipment
• Ready Made Splinting Material
– Plaster (OCL)
• 10 -20 sheets of plaster with padding and cloth
cover
– Fiberglass (Orthoglass)
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Cure rapidly (20 minutes)
Less messy
Stronger, lighter, wicks moisture better
Less moldable
Splinting Equipment
• Stockinette
• protects skin, looks nifty (often not necessary)
• cut longer than splint
• 2,3,4,8,10,12-in. widths
• Padding - Webril
• 2-3 layers, more if anticipate lots of swelling
• Extra over elbows, heels
• Be generous over bony prominences
• Always pad between digits when splinting hands/feet or when
buddy taping
• Avoid wrinkles
• Do not tighten - ischemia!
• Avoid circumfrential use
• Ace wraps
Specific Splints and Orthoses
Upper Extremity
Lower Extremity
• Elbow/Forearm
• Knee
– Long Arm Posterior
– Double Sugar - Tong
• Forearm/Wrist
– Volar Forearm / Cockup
– Sugar - Tong
• Hand/Fingers
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–
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Ulnar Gutter
Radial Gutter
Thumb Spica
Finger Splints
– Knee Immobilizer / Bledsoe
– Bulky Jones
– Posterior Knee Splint
• Ankle
– Posterior Ankle
– Stirrup
• Foot
– Hard Shoe
Long Arm Posterior Splint
• Indications
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Elbow and forearm injuries:
Distal humerus fx
Both-bone forearm fx
Unstable proximal radius or
ulna fx (sugar-tong better)
• Doesn’t completely eliminate
supination / pronation -either
add an anterior splint or use
a double sugar-tong if
complex or unstable distal
forearm fx.
Double Sugar Tong
• Indications
– Elbow and forearm fx prox/mid/distal radius and
ulnar fx.
– Better for most distal
forearm and elbow fx
because limits
flex/extension and
pronation / supination.
10
90
Forearm Volar Splint aka ‘Cockup’ Splint
• Indications
– Soft tissue hand / wrist
injuries - sprain, carpal
tunnel night splints, etc
– Most wrist fx, 2nd -5th
metacarpal fx.
– Most add a dorsal splint for
increased stability ‘sandwich splint’ (B).
– Not used for distal radius or
ulnar fx - can still supinate
and pronate.
Forearm Sugar Tong
• Indications
– Distal radius and
ulnar fx.
• Prevents pronation /
supination and
immobilizes elbow.
Hand Splinting
•
•
•
•
•
The correct position for most hand splints
is the position of function, a.k.a. the
neutral position.
This is with the the hand in the “beer can”
position (which may have contributed to
the injury in the first place) : wrist slightly
extended (10-25°) with fingers flexed as
shown.
When immobilizing metacarpal neck
fractures, the MCP joint should be flexed
to 90°.
Have the patient hold an ace wrap (or a
beer can if available) until the splint
hardens.
For thumb fx, immobilize the thumb as if
holding a wine glass.
Radial and Ulnar Gutter
•Indications
•Fractures, phalangeal and
metacarpal, and soft tissue
injuries of the little and ring
fingers.
•Indications
•Fractures, phalangeal and
metacarpal, and soft tissue
injuries of index and long
fingers.
Thumb Spica
• Indications
– Scaphoid fx - seen or
suspected (check snuffbox
tenderness)
– De Quervain tenosynovitis.
• Notching the plaster (shown)
prevents buckling when
wrapping around thumb.
• Wine glass position.
Finger Splints
• Sprains - dynamic
splinting (buddy
taping).
• Dorsal/Volar finger
splints - phalangeal
fx, though gutter
splints probably
better for proximal
fxs.
Jones Compression Dressing
- aka Bulky Jones
• Indications
– Short term immobilization
of soft tissue and
ligamentous injuries to the
knee or calf.
• Allows slight flexion and
extension - may add posterior
knee splint to further
immobilize the knee.
• Procedure
– Stockinette and
Webril.
– 1-2 layers of thick
cotton padding.
– 6 inch ace wrap.
Posterior Ankle Splint
• Indications
– Distal tibia/fibula fx.
– Reduced dislocations
– Severe sprains
– Tarsal / metatarsal fx
• Use at least 12-15 layers of
plaster.
• Adding a coaptation splint
(stirrup) to the posterior splint
eliminates inversion /
eversion - especially useful
for unstable fx and sprains.
Stirrup Splint
• Indications
– Similiar to posterior splint.
– Less inversion /eversion
and actually less plantar
flexion compared to
posterior splint.
– Great for ankle sprains.
– 12-15 layers of 4-6 inch
plaster.
Other Orthoses
• Knee Immobilizer
– Semirigid brace, many models
– Fastens with Velcro
– Worn over clothing
• Bledsoe Brace
– Articulated knee brace
– Amount of allowed flexion and extension can be adjusted
– Used for ligamentous knee injuries and post-op
• AirCast/ Airsplint
– Resembles a stirrup splint with air bladders
– Worn inside shoe
• Hard Shoe
– Used for foot fractures or soft tissue injuries
Complications
• Burns
– Thermal injury as plaster dries
– Hot water, Increased number of
layers, extra fast-drying, poor
padding - all increase risk
– If significant pain - remove splint
to cool
• Ischemia
– Reduced risk compared to
casting but still a possibility
– Do not apply Webril and ace
wraps tightly
– Instruct to ice and elevate
extremity
– Close follow up if high risk for
swelling, ischemia.
– When in doubt, cut it off and look
– Remember - pulses lost late.
• Pressure sores
– Smooth Webril and plaster well
• Infection
– Clean, debride and dress all
wounds before splint
application
– Recheck if significant wound or
increasing pain
Any complaints of
worsening pain Take the splint off
and look!