# Skin Suturing

## Overview

This module describes how to close open skin wounds using sutures.

## Indications

## Contraindications

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I need to put in some stitches to close this wound so that it can heal. How long it takes to heal depends on many factors, such as how long ago it occurred, the type of injury, and even if you’ve put any medicines or substances on it.”

### What can my patient expect?

“I will give you an injection in or alongside the wound which will at first sting a little, then the wound will become numb. Putting in the stitches will not hurt. at all.”

### What is my patient’s role?

“Tell me when you had your last tetanus injection, and if you have any allergies. Fearing blood or needles is normal, but tell me if you have fainted from it. Stay very still. Let me know if you feel faint or have pain while I’m putting in the stitches. Afterwards, keep the bandage on for one day, and watch out for increasing pain, redness, swelling, and pus in the wound. Come back in x days so that we can remove the stitches.”

## Preparation

Consider the need for tetanus and rabies prophylaxis prior to starting the procedure, as rabies prophylaxis requires injection into the wound area.

Prepare a trolley with equipment.

### Documentation

### Equipment

## Site & Positioning

Ask the patient to sit or lie down with the wound exposed and within easy reach. Good lighting is essential.

## Procedure

Follow medical asepsis with sterile gloves. This procedure is performed using sterile gloves; however, due to the nature of traumatic wounds, complete sterility may not always be achievable.

## Troubleshooting

I am unsure of when to prescribe antibiotics.

While topical antibiotics are recommended, oral antibiotics are unnecessary, unless indicated for animal and human bites, heavily contaminated wounds, wounds in patients with valvular heart disease, and severely immunosuppressed patients.

There are no sterile dental needles.

While it is best practice to use sterile needles, you can try to submerge a non-sterile dental needle in skin disinfectant and dry it with sterile gauze. Alternatively, open a sterile syringe, blunt fill needle, and an injection needle onto the sterile field. Ask an assistant to hold up a bottle of lignocaine for you to draw up while you remain sterile.

The edges of the wound pucker when I approximate them.

There is too much tension on the wound edges. This might be because there has been tissue loss. Undermine the edges slightly with sharp dissection to loosen them up, and then try to approximate them.

If unsuccessful

If unsuccessful

Do not be tempted to close the wound under this tension as wound dehiscence will occur.

, call a senior.

The wound won’t stop bleeding.

Most venous oozing stops with pressure. If oozing continues or the bleed is from a visible vessel, clamp the vessel or tissue with artery forceps in a plane parallel to the skin. Tie an absorbable suture like chromic under the forceps, asking an assistant to partially release the forceps while you tighten the suture before the assistant tightens the grasp on the tissue or vessel again. Make another tie in the suture and ask the assistant to release the forceps, but only secure the knot when you are sure that haemostasis has been achieved. If unsuccessful, perform a figure-of-eight suture over the area where the bleeding is occurring.

The underlying limb is at risk of compartment syndrome

Loosely appose the wound edges without any tension in the sutures until the swelling has subsided. Then close the wound using one of the techniques described in Skin Closure Techniques.

The underlying limb has a fracture and needs to be placed in a POP or backslab until the patient is taken to theatre.

Follow the steps above to irrigate and clean the wound. Cover with a sterile, moist dressing such as saline soaked pads before placing the limb in a plaster cast or backslab as applicable. If a plaster cast is applied and the wound needs to be reviewed regularly, place a clear transparent dressing on the wound and cut a window into the plaster cast, roughly the size of the wound.

My mattress sutures have a tendency to be too tight.

You can place the tubing of a butterfly needle under your sutures as a spacer, then pull it out afterwards.

## Risks

## References