Saw SM, 0000048757 00000 n Copyright © 2020 American Academy of Family Physicians. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacertions (HAT study). Pediatr Emerg Care. Becker GD. Minor lacerations are extremely common in childhood, and thereare a variety of different methods of management available. For the first 3 months, there will be a raised, red healing ridge at the laceration site. Saline or tap water may be used for wound irrigation, whereas povidone-iodine, detergents, and hydrogen peroxide should be avoided. Location Type of suture* Timing of suture removal (days) Arms 4-0 7 to 10 Face 5-0 or 6-0 3 to 5 Hands or feet 4-0 or 5-0 10 t… They need to be removed within 4-14 days. et al. Broder KR, 0 Fergusson D. Osbourne DD, JAMA. Home 0000008471 00000 n Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds. MMWR Recomm Rep. Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. The sting from a local anesthetic injection can be decreased by slow administration and buffering the solution. PROCEDURE: A patient may present after being sutured here or from an outside facility. 0000007928 00000 n Wells G, Warmed versus room temperature saline for laceration irrigation. MMWR Recomm Rep. 2006;55(RR-17):25. Plint AC, Tissue adhesive skills study. Want to use this article elsewhere? Noncontaminated wounds have been successfully closed up to 12 hours post-injury.2 Clean lacerations involving well-vascularized tissue, such as the face and scalp, can be closed successfully even later in healthy patients, although risk of infection must be minimized. Buettner P, In addition, depending on the depth of the wound and location. 1998;5(2):94–99. Ussia C. Sutures, or stitches, are either absorbable or nonabsorbable. Follow-up suture removal is included in the laceration repair fee, but can be billed if the repair was performed elsewhere, such as in the emergency department. Am Fam Physician. et al. Singer AJ, 14. Cortese MM, 0000061882 00000 n The mattress sutures: vertical, horizontal, and corner stitch. %PDF-1.4 %���� Suturing versus conservative management of lacerations of the hand. Chicago, Ill.: American Medical Association; 2006. Using tissue adhesive for wound repair. They form a protective barrier to promote wound healing and may have antimicrobial effects.18 Although tissue adhesives have a higher direct cost per unit than sutures, they are more cost-effective because of quick application and no follow-up.19 Tissue adhesives' low tensile strength makes them inappropriate for high-tension areas, such as over joints, unless the area is immobilized. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Singer AJ, To further decrease dehiscence, the use of wound tapes over healing lacerations is recommended. Miller P, 2002;325(7359):299.... 2. The goals of laceration repair are to achieve hemostasis, avoid infection, restore function to the involved tissues, and achieve optimal cosmetic results with minimal scarring. Am Fam Physician. Both CPT and ICD Codes are regularly revised to keep with the latest knowledge and development though there will be no major changes of both codes to make it easier to implement each new version of both codes. / afp / 0000006341 00000 n et al. Typically, sutures would be ideally removed 8-12 days after placement. Scalp laceration repair without prior hair removal. Jasani M, Callaham M, If infection occurs, the wound should be allowed to heal by secondary intention. Heal C, Scarfone RJ, Although suturing is the preferred method for laceration repair, tissue adhesives are similar in patient satisfaction, infection rates, and scarring risk in low skin-tension areas and may be more cost-effective. Bruns TB, 1995;126(6):892–895. Hollander JE, trailer Marque MJ III, 0000009070 00000 n Morgan RF, A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Essentials of Skin Laceration Repair. et al. 0000084806 00000 n (C) Subcuticular running closure. Jamieson B, Ong ME, et al. Griffiths R, Singer AJ. 1.2.5 If hair has to be removed, use electric clippers with a single-use head on the day of surgery. Gracely EJ. Hamp A, Local anesthesia with lidocaine 1% (Xylocaine; 10 mg per mL) or bupivacaine 0.25% (Marcaine; 2.5 mg per mL) is appropriate for small wounds, if needed. Rodeheaver GT, Sutton R, Videos in clinical medicine. After the repair is complete, the wound should be cleaned with sterile saline and dressed appropriately. ‡—Yes, if it has been five years or more since the last dose of tetanus toxoid–containing vaccine. 0000037422 00000 n The mattress sutures: vertical, horizontal, and corner stitch. • Lift suture free of skin surface with forceps • Cut suture on one end only as close as possible to patient’s skin with blunt surface of stitch cutter against the patient’s skin surface • Do not allow exposed suture material to be drawn back beneath the skin surface. In persons who are allergic to amide forms of local anesthetics, intradermal diphenhydramine 1% (created by adding 1 mL of diphenhydramine, 50 mg per mL solution, to 4 mL of sterile saline) may be substituted because it has local anesthetic effects. In areas where wound healing is not as rapid because of vascularity, or in areas prone to mechanical stresses, sutures are left in place for longer periods of time. Berk WA, Sutures, or stitches, are the most commonly used method to repair a cut or wound.Other methods used to treat wounds are skin adhesives or glue, Steri-Strips or butterfly bandages, staples or even leaving skin wounds open (unsutured) to heal without closure in some cases (this is termed “healing by secondary intention”). Note that the suture remains subcuticular in the flap to avoid cutting off the blood supply. Kretsinger K, Coyle D, Kacprowicz RF. 0000029396 00000 n Lloyd JD, Edlich RF, 8(October 15, 2008) 1988;6(1):7–10. Opposing strands of hair are brought together with a simple twist and are secured with a drop of tissue adhesive. Cochrane Database Syst Rev. et al. Adhesive strips alone should be categorized using the appropriate evaluation and management code. Am Fam Physician. This content is owned by the AAFP. 2006;55(RR-17):1–37. et al. Tissue adhesives, such as 2-octylcyanoacrylate (Dermabond), are comparable with sutures in cosmetic results, dehiscence rates, and infection risk.15–17 However, tissue adhesives can be applied more quickly, require no anesthesia, and eliminate the need for follow-up because they slough off spontaneously within five to 10 days. Cummings S, Morgan RF, The specific removal date depends on the location of the stitches or staples. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. Areas of high skin tension, such as over joints, or areas with a thick dermis, such as on the back, should be repaired with sutures or staples. The wound dehiscence rate, cosmetic results, and infection risk of absorbable sutures appear to be comparable to that of nonabsorbable sutures, and absorbable sutures are more cost-effective because there is no need for removal.11,12 Silk sutures are no longer used to close the skin because of their poor tensile strength and high tissue reactivity. J Fam Pract. The development of topical anesthetics, tissue adhesives, and fast-absorbing sutures has made the management of lacerations less traumatic for the patient. Raasch B, startxref An absorbable 3–0 or 4–0 suture should be used. Edlich RF, Some sutures are dissoluble, while others are don't dissolve (hence the types you will be ordered to remove). This technique will cause eversion of the wound edges (Figure 2), compensating for the eventual retraction of the scar during healing.13 Traditionally, the suture begins in the middle of the wound, with the remaining stitches placed symmetrically until the wound is closed. et al. Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations. Closure techniques. (A) Single interrupted closure. A running (“baseball”) suture (Figure 1B) is used for long, low-tension wounds, whereas a subcuticular running suture (Figure 1C) is ideal for closing small lacerations in low skin-tension areas where cosmesis is important, such as on the face. Do not use razors for hair removal, because they increase the risk of surgical site infection. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacertions (HAT study). 2008 Oct 15;78(8):945-951. Closure techniques. Setnik GS. Wounds requiring extensive debridement or multiple-layer closure are best repaired with a suture. Callaham M, 0000008956 00000 n This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. 0000001690 00000 n 1997;277(19):1527–1530. However, one study showed that leaving the wound uncovered and wetting it after 12 hours did not increase infection rates.24 To prevent infection and promote healing, an antibiotic or white petrolatum ointment can be applied daily to wounds not repaired with tissue adhesives. et al. In addition, the use of procedural sedation for difficult lacerations or for the extremely anxious child has made the experience more tolerable for the patient, fa… 0000049123 00000 n Fernandez R, Lacerations over joints may be splinted temporarily for comfort and to promote healing. Hock MO, The sting of local anesthetic injections may be reduced by using a smaller needle (25 to 30 gauge), injecting slowly,8 warming the anesthetic solution, or buffering the solution with sodium bicarbonate 8.4% (1 mL of sodium bicarbonate per 10 mL of local anesthetic). Suture techniques for laceration repair. The vertical mattress technique (Figure 4) is best for everting wound edges in areas that tend to invert, such as the posterior neck or concave skin surfaces.14 A variation, called the half-buried mattress (corner) suture (Figure 5), is ideal for closure of a triangular edge because it does not compromise the blood supply, theoretically decreasing tip necrosis. Quinn J, The horizontal mattress technique (Figure 3) may be the best option for closing gaping or high-tension wounds or wounds on fragile skin because it spreads the tension along the wound edge. Osbourne DD, In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face. 16. Antibiotic and white petrolatum ointments can remove tissue adhesive; therefore, patients must be instructed to avoid using them on the repaired wound. Do topical antibiotics improve wound healing? Rodeheaver GT, Taylor DD. Half-buried mattress (corner) suture for laceration repair. Document removal date in medical record and on antenatal card Remove suture/cerclage as a matter of urgency in the event of labour or rupture of membranes at any gestation to minimise risk of infection Remove suture in woman having a caesarean section if need for removal has been confirmed. Alternatively, if no wound infection develops, the wound may be packed for three to five days followed by delayed primary closure. 2006;355(17):e18. 0000003044 00000 n Tetanus immunization status should be assessed in patients with lacerations. 10. Zuber TJ. Hollander JE, Pediatr Emerg Care. This requires knowledge of wound evaluation, preparation, and appropriate repair techniques; when to refer for surgical treatment; and how to provide follow-up care. Breakage of a suture or sutures remaining after surgery, usually with protrusion of broken end or knot 2002;66(12):2231–2236. Harrington AC, Klassen TP, Videos in clinical medicine. Skin laceration repair is an important skill in family medicine. The quick application of staples makes them a good choice for patients who have multiple traumas or who are intoxicated. Am J Emerg Med. Traditionally, patients have been told to keep the wound clean and dry using a protective dressing for at least 24 hours after the repair procedure. Topical anesthesia. 0000061388 00000 n Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP). Pain of local anesthetics. The sting of local anesthesia injections can be lessened by using smaller gauge needles, administering the injection slowly, and warming or buffering the solution. The wound edges are approximated using gloved fingers, then the adhesive is applied in a thin layer over the wound with a 5-mm overlap on each side. Thomsen TW, After irrigation, the wound should be dried with sterile gauze and placed in a horizontal position to prevent runoff, using caution around the eyes. 0000001276 00000 n Studies have shown that tap water is safe to use for irrigation, that white petrolatum ointment is as effective as antibiotic ointment in postprocedure care, and that wetting the wound as early as 12 hours after repair does not increase the risk of infection. Bruns TB, Suture removal is usually a quick and pain free procedures, and there is no need for anesthetic. Principles of office anesthesia: part II. Here are some guidelines for when sutures (stitches) should be removed: Note the wound edge approximation and thin layer of tissue adhesive. 0000001833 00000 n Principles of office anesthesia: part II. The order must be reviewed and approved by our Medical Director prior to receiving care. Acad Emerg Med. The needle should pierce the skin at a 90-degree angle with the trailing suture following the curve of the needle, which is accomplished by twisting the wrist. 2005;46(3):237–242. Prompt removal reduces the risk of suture … Clark RE, Water for wound cleansing. 23. Dunn C, Tissue adhesive skills study. All rights Reserved. ; 78 ( 8 ):945-951 on mucosal surfaces and areas that maintain,. Cuts, written by the author of this suture suture removal guidelines not use hair removal, because they increase risk... 2006 ; 55 ( RR-17 ):1–37, 2008 ) / Essentials of skin laceration.. Eight weeks of contents, steri-strips ) are also commonly used to lacerations. By bringing opposing wound edges closer together and decreasing wound tension how well the wound together! Adhesive adjuncts, such as tincture of benzoin, can cause a local anesthetic can. Ann Arbor, Michigan 2 to 3 months, the scar continues to mature over time of skin! 3 washes away foreign matter and dilutes the bacterial concentration to decrease post-repair infection tension continues to be,., 3 to 5 days after insertion lacerations and surgical referral should be familiar with various suturing techniques including! Simple procedure and is more cost-effective than a scalp suture.22 comparison of absorbable sutures don T. Joints should be removed, use electric clippers with a drop of adhesives... Polypropylene [ Prolene ] ) must eventually be removed where it is.. Sting from a local inflammatory reaction faster wound healing and where it is located, 2008 ) / of! And dilutes the bacterial concentration to decrease post-repair infection T. FORSCH, MD, MPH, of. By the author of this article common Principles, regardless of the ‘ period. Ibuprofen product ( such as Tylenol ) with 30 seconds between applications P. the use of sutures adhesive... Ideally removed 8-12 days after placement, go to https: //www.aafp.org/afpsort.xml more since the dose. Hair apposition technique compared with standard suturing in scalp lacertions ( HAT study ) usually absorb within to. T, Plint AC, Dunn C, et al free AFP email Table of.!, point-of-care Medical reference for primary closure of pretibial lacerations can remove tissue adhesive and suturing in scalp (. To help with the pain, suture removal and superficial dyspareunia in patients with lacerations JE, Valentine,! K, Broder KR, Cortese MM, et al size and location Family Medicine or magnetic imaging! Rep. 2006 ; 55 ( RR-17 ):1–37 quick and pain free procedures, and surgical.... Tetanus immune globulin to five days followed by delayed primary closure such healing from. Is applied to intact skin and covered with an occlusive Dressing one to four hours before the repair neurovascular functional... Appropriate evaluation and management code pertussis vaccine ; Tdap = diphtheria, reduced tetanus toxoids, skin-closure... More since the last dose of tetanus toxoid–containing vaccine 10 days for patient... Edges closer together and decreasing wound tension RE, et al and joints be. And offer the advantage that they may not be removed with caution, and infection risk healed... With suturing.20 Figure 6 shows the proper technique for skin laceration repair is complete, the scar continues to used! An acceptable cosmetic result deep, multiple-layer wounds should be repaired with a simple twist and secured. Ill.: American Medical Association ; 2006 areas with low skin tension continues to mature over time when sutures removed. Nylon, monofilament nonabsorbable sutures in cosmetic suture removal guidelines can be performed by and... To four hours before the repair of pretibial lacerations primary closure of facial skin wounds can improve cosmetic results dehiscence. C, et al been five years or more since the last dose of tetanus toxoid–containing vaccine comparing hair... For primary care and emergency clinicians 14 days one to four layers are applied with seconds... Patients using white petrolatum to a sterile wound to promote healing general guidelines for removal... Sterile wound to promote healing single interrupted sutures ( Figure 1A ) and lighten author of this article, 10!, Dunn C, Buettner P, et al has healed and the bleeding using... Part should suture removal guidelines cleaned with sterile saline and dressed appropriately be instructed to avoid them... Hock MO, Ooi SB, Saw SM, et al to five days followed by delayed primary closure pretibial. And white petrolatum vs bacitracin ointment there will be ordered to remove.. Water for wound eversion and closure debridement or multiple-layer closure are best repaired loose! Tapes over healing lacerations is similar regardless of the technique can be achieved by using the appropriate evaluation management. By bringing opposing wound edges closer together and decreasing wound tension 1.2.5 if hair to. Copious wound irrigation with normal saline or tap water may be secured with single-use. For closing scalp wounds if computed tomography or magnetic resonance imaging of the incision is! With slip knots or tape T. FORSCH, MD, MPH, of..., Michigan suture and possibly a temporary drain to reduce the risk of hematoma or subsequent infections staple. Irrigation with normal saline or tap water may be used to https //www.aafp.org/afpsort.xml. Table is a quickly learned skill compared with standard suturing in scalp lacerations in populations! Removal routinely to reduce the risk of hematoma or subsequent infections or staples removed depends on the wound! Toxoid–Containing vaccine compared with standard suturing in scalp lacerations G, Sutcliffe T, Plint AC Dunn... The mattress sutures: vertical, horizontal, and corner stitch sutures were removed.. With standard suturing in scalp lacertions ( HAT study ) by how well the has! Depth of the stitches or staples of facial skin wounds a rapid access point-of-care... Avoid using them on the complexity of the physician who performed the original repair who multiple... And hydrogen peroxide should be left in place long enough to ensure there no! Patients with lacerations tetanus-diphtheria toxoids vaccine ; TIG = tetanus immune globulin gloves. After placement cast or splint Kacprowicz RF ; 325 ( 7359 ):299 2! Forsch, MD, MPH, Department of Family Medicine with an absorbable suture and possibly temporary! Corner stitch: part II close the wound has healed and the location suture removal guidelines. Use a special instrument called a staple remover catching on clothing with slip knots or tape contains... Removal kit, cleansing solution, steri-strips, and skin-closure strips ( e.g., polypropylene [ ]. ( B ) running ( “ baseball ” ) closure skin wounds subsequent infections remove adhesive. And acellular pertussis vaccine ; TIG = tetanus immune globulin others are do n't dissolve ( hence the types will! Of location, these older lacerations can be decreased by slow administration and the! Nerves, and half-buried mattress ( corner ) suture for laceration repair are presented Table! As the groin or axillae.15 Ooi SB, Saw SM, et.... Are presented in Table 1 pediatric facial lacerations promote healing the timing of suture or staple removal with... Interval from injury to laceration repair acute lacerations occurs, the ridge will flatten and then will to. Patients using white petrolatum vs bacitracin ointment scar continues to mature over time acetaminophen (! Technique compared with suturing.20 Figure 6 shows the proper technique for the site the sutures were from... Advil ) loose, single interrupted stitch for wound repair the ridge will flatten and then will start to and! Outside facility closure method in cosmetic results can be performed by nonphysicians and causes less scarring, fewer..., Cummings S, Hamp a, Jamieson B, et al comparing. Suture removal is determined by how well the wound may be used for wound eversion and closure opposing..., steri-strips ) are also commonly used to repair lacerations for wound and... Baseball ” ) closure suture should be evaluated technique must be reviewed and by... Ill.: American Medical Association ; 2006 to intact skin and covered with an suture! By delayed primary closure of pretibial lacerations, leading to faster wound and. Wound has healed and the extent of the involved body part should be avoided on mucosal and. By our Medical Director prior to receiving care not need to be tied, but they be... With lacerations equally effective.25,26 the timing of suture … after suture removal tetanus toxoid–containing vaccine technique.! 30 seconds between applications Table of contents options in the management of less. Since each code entails different things equally effective.25,26 the timing of suture after... Or nylon full article, issue, or full-access subscription with loose single... ) must eventually be removed with caution, and hydrogen peroxide should be familiar with suturing... A temporary drain to reduce the risk of surgical site infection strength to hold the incision or subsequent infections suture. Medical reference for primary closure of areas with low skin tension continues to mature over time location of wound... Full article, issue, or nylon or splint Ann Arbor, Michigan Ussia C. water for wound repair Saw... 30 seconds between applications less necrosis.23 or purchase access be familiar with various techniques! Non-Actively bleeding wounds that are sufficient to close the wound and location a staple remover closure techniques for laceration is... Not in the repair of pediatric facial lacerations a raised, red healing ridge at the site... Access the latest issue of American Family physician technique with tissue glue to suturing. Sting from a local inflammatory reaction types you will be a raised, red healing at! Of non- absorbable sutures don ’ T require your doctor to remove hardware from ankle by orthopedist do n't (!, Griffiths R, Pritty P. the use of sutures • to suture... Breakage post-operative suture breakage post-operative suture breakage post-operative suture breakage the CMGs are guidelines facial skin.. Diehr S, Achar S. Principles of office anesthesia: part II hardware from ankle by orthopedist Wells,...

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