# Skin Suturing

## Overview

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

## Indications

1. Clean, minor skin wounds with minimal tissue loss

## Contraindications

1. Animal/human bite wounds or deep punctures (discuss with senior)

2. Wounds with skin loss where sutures would be under high tension (discuss with senior/plastic surgery)

3. Infected/grossly contaminated wounds (may require prior surgical debridement/washout)

4. Wounds with damage to underlying structures such as tendons or major blood vessels

5. Very

   vascular
   vascular

   Face, neck or scalp wounds

   wounds older than 24 hours, or other wounds older than 8 hours

## Patient information & 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

1. Patient notes

### Equipment

1. Non-sterile and

   sterile gloves
   sterile gloves

   Although it is considered best practice to use sterile gloves to perform minor procedures, there is mounting evidence that infection rates are similar for sterile and non-sterile glove use.

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. Irrigation equipment:

   1. At least 500 ml normal saline
   2. 20-60 ml syringe
   3. 16G or larger IV cannula
   4. A bowl and linen saver to catch irrigation fluid

5. Scissors to cut hair shorter if necessary

6. 1% solution of iodine, or chlorhexidine solution

7. A suture pack with prepacked

   instruments and cleaning consumables
   instruments and cleaning consumables
   1. Needle holder: hinged forceps with cross-hatched tips for holding a needle without damaging it
   2. Artery forceps: a hinged forceps or hemostat, with parallel grooves in the tips, for clamping bleeders not for holding the needle
   3. Thumb forceps: a toothed forceps for manipulating skin, and non-toothed forceps for manipulating viscera/deeper structures
   4. Dental syringe
   5. Scissors: straight-bladed suture scissors, and curved-bladed surgical scissors
   6. Bowl for skin disinfectant
   7. Drapes
   8. Sterile gauze

8. Sutures of the appropriate size and type

9. Lignocaine cartridges for dental syringe & dental needle

10. Suitable dressing and a crêpe bandage

## 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.

1. Perform hand hygiene.

2. Place the linen saver and bowl under the wound. Don non-sterile gloves to remove first aid dressings.

3. Open the suture pack and create a sterile field. If necessary, use spare forceps or sterile gauze to arrange your sterile field with the bowl uncovered and facing up.

4. Pour skin disinfectant into the bowl. Open syringe, IV cannula, sutures, and

   dental needle
   dental needle

   Not all dental needles come in sterile packaging. See Troubleshooting for how to deal with this.

   onto the sterile field. Drop non-sterile lignocaine cartridges into the iodine solution. Open a bottle of normal saline and place it beside the field.

5. Don sterile gloves.

6. Load the dental syringe and anaesthetise the wound edges. Wait 5-10 minutes.

7. Assess the wound for devitalised tissue, contamination, active haemorrhage and injury to underlying structures.

8. Cut adjacent

   hair
   hair

   Don't remove eyebrow hair -- use it as a guide for symmetrical closure.

   shorter with a razor/scissors if necessary.

9. Irrigate
   Irrigate

   Fill the large syringe with normal saline and connect the IV cannula (needle removed) to the syringe. Squirt normal saline into the wound, using the cannula tip. Repeat until the wound is clean.

   the wound.

10. Use gauze and iodine solution to

    clean the skin
    clean the skin

    Start at the wound edges and clean in circles moving outward, avoiding cleaning inside the wound. Skin disinfectants can cause tissue damage if applied inside a wound.

    around the wound, but not inside the wound. Drape the area.

11. Remove any remaining foreign bodies with forceps and cut away devitalised tissue.

12. Open the suture and suture the wound using one of the techniques described in Skin Closure Techniques.

13. Dispose of medical waste safely.

14. Dress the wound with a suitable dressing, then cover with gauze and a crêpe bandage.

15. Document the procedure. Advise the patient on wound care. Provide a topical antibiotic and

    analgesia
    analgesia

    5-7 days of paracetamol and ibuprofen is usually sufficient

    .

## 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

1. Bleeding, bruising, and pain at the site

2. Sharps injury to healthcare personnel

3. Wound infection

4. Scarring or keloids

5. Failure to heal (wound dehiscence)

6. Tetanus

7. Allergic reaction to local anaesthetic or skin antiseptic

## References

1. Newell KA. Wound Closure. In: Essential Clinical Procedures, Third Edition. Philadelphia: Elsevier; 2013. p. 250-272.

2. Lammers RL, Smith ZE. Methods of Wound Closure. In: Roberts and Hedges’ Clinical Procedures in Emergency Medicine, Sixth Edition. Philadelphia: Elsevier; 2014. p. 644-689.