Suture Techniques in
Primary Care
Shawn A. Sutterlin, PA-C
Watauga Orthopaedics
Objectives
• Review wound types and classification
• Understand the principles of wound
healing
• Describe the 3 types of wound closure
• Overview of Suture materials
• Wound closure techniques
Wound Classification
• Four Classes
• Clean
• Clean-contaminated
• Contaminated
• Dirty/infected
Clean Wounds
• Most common is elective surgical
incision
• Primary closure
• 1-5% rate of infection
Clean Contaminated
• Wounds contaminated by local flora
despite aseptic technique
• Cholecystectomy, appendectomy and
hysterectomy
• 3-11% infection rate
Contaminated
• Open traumatic wounds in nonsterile
environment
• Open fractures
• Surgical procedures in which there is a
gross deviation from sterile technique
(emergent open cardiac massage)
• 10-17% infection rate
Dirty or Infected
• Gross/heavy contamination or active
infection
• Perforated viscera, abscess and
traumatic wounds
• >27% infection rate
Wound Healing
• Four Stages
• Hemostasis
• Inflammatory
• Proliferative
• Remodeling
Phase I: Hemostasis
• Vasoconstriction stimulated by
endothelial injury
• Platelet aggregation
• Coagulation cascade is activated and
fibrin clot formed
• Platelets release pro inflammatory
mediators and PDGF in preparation for
subsequent phases
Hemostasis
Phase II:
Inflammatory
• Inflammatory mediators released
• Vasodilation - provides increased blood
supply to injury site
• Increase vascular permeability - allows
plasma proteins, WBCs, into injured
tissue
• Migration of WBCs from circulation into
interstitium and phagocytose
debris/microbes
Inflammation
Phase III:
Proliferative
• Angiogenesis
• Granulation
• fibroblasts deposit extracellular matrix
including collagen/elastin
• Characteristic beefy red appearance
Phase III:
Proliferative
• Epithelialization
• keratinocytes
• Contraction
• Fibroblast release of actin
Phase IV:
Remodeling
• Collagen remodeled along tension lines
• Cells no longer needed are removed by
apoptosis
• May take many months
Patient factors
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Age
Weight
Nutrition
Dehydration
Blood supply
Immunocompromised
Chronic Disease
Wound Closure
• Primary closure
• Secondary closure
• Tertiary closure
Primary Closure
• Most common
• Preferred method when appropriate
• Wounds are re-approximated acutely
• Dermis-dermis apposition
• Best cosmetic outcome
Secondary Closure
• Known as healing by secondary
intention
• Wound edges are left un-approximated
• Granulation tissue formed
• Migration of keratinocytes provide reepithelialization over granulation
tissue
• Appropriate in wounds with soft tissue
loss or severe contamination not
closable by primary or tertiary means
Tertiary Closure
• Contaminated wound is I&D’d and left
open for several days
• Wound is then closed as in primary
closure when risk of complications
declines
• Preferred method for high energy and
highly contaminated wounds
Suture Materials
• Traits needed by suture
• Tensile Strength
• Knot security
• Ease of handling
• Low tissue reactivity
Characteristics
• Size
• Tensile Strength
• Monofiliment (nylon, prolene, monocryl)
• Multifiliment (vicryl, ethibond, Silk)
• Absorbable
• Non Absorbable
Characteristics
• Dyed
• Undyed
• Sizes 11-0 to 6
Suture Sizing
Absorbable
• Broken down in tissues by hydrolysis,
enzymes and inflammation
• Time to resorb varies by material and
diameter
• includes vicryl, monocryl, PDS, gut.
Non Absorbable
• Not broken down by hydrolysis or
inflammatory reaction
• Walled off in body by fibroblasts or
physically removed (skin sutures)
• Includes nylon, prolene, stainless steel,
silk, polyester (ethibond)
Suture
Size by Location
Needles
• Cutting - skin and other tough tissue
• Taper - softer tissues inside body
(bowel,vessels). Dilates tissues
• Blunt - felt to pose less risk of needle
sticks. Most useful in fascial closure.
Before Closing
• Hemostasis
• Evaluate
• Irrigate
• Debride devitalized/contaminated
tissues
• Should it be closed primarily?
Before Closing
• Evaluate the wound
• Time of injury
• Size and shape of wound
• Soft tissue loss
• Gross contamination/foreign body
Before Closing
• Wound depth
• Nerve, tendon, vascular involvement
• Bone involvement (open Fx)
• Uncontrolled hemorrhage
Wound Preparation
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Single most important step in preventing
complications
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Control bleeding
Remove all debris and devitalized tissue
Irrigate copiously with NS
Do not use iodine or hydrogen peroxide in the
wound
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When to Consult
Specialist
Deep wounds to hands/feet, thorax, abdomen, or
pelvis
Full thickness lac to eyelids, lips or ears
Lacerations which involve bone, joint, tendon, artery,
muscle or nerve
Markedly contaminated wounds
Crush injuries
Concerns about cosmesis
When to Not Close
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Active infection
Erythema/induration
Puncture wounds
Human/animal bites
Delayed onset of treatment
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12 hours for body
24 hours for face
Anesthesia
• General/spinal Anesthesia
• Used for large wounds and more
invasive procedures
• Regional Anesthesia
• Lidocaine/bupivicaine infiltrated near
peripheral nerve to produce
anesthesia distally in extremity
• Digital, wrist and ankle blocks most
common
Anesthesia
• Local
• Anesthetic agent infused directly into
the tissues being treated
• Most common method in outpatient
setting
Lidocaine
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Most common
1% should be adequate for most procedures
Sodium channel blocker
Rapid onset
Relatively short duration of action
Available with epinephrine
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helps control bleeding
Bupivicaine
• Longer duration of action
• Useful in prolonged procedures as well
as post procedure pain control
• Also available with epinephrine
Local Anesthetics
Caution!!
• Do not use local anesthetic with
epinephrine on structures with limited
circulation
• ears, nose, fingers, toes, penis
Equipment
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General
Considerations
Handle tissues as little as possible
Limit the time and force used in retracting tissues
Do not pinch tissues with forceps, Gently lift wound
edges to place suture
Irrigate frequently to minimize contaminants and
maintain moist wound bed
Approximate, don’t strangulate
Needle
Position
Needle should be secured 1/2
- 2/3 down the length needle
from the tip
Always cross skin at 90
degree angle
Rule of Halves
• Allows better approximation of tissues
• Avoids “dog ears”
Rule of Halves
3
1
2
The Instrument Tie
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How to tie a perfect square knot every time
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Place needle driver parallel to and directly over
incision
Always wrap needle end over driver toward tail
When tightening each throw, move needle driver
to opposite side of incision.
The key is to always wrap OVER needle driver
and to always alternate sides
Basic Suture
Methods
• Simple interrupted
• Simple running
• locked running
• Horizontal mattress
• Vertical mattress
• Running Subcuticular
• Subcutaneous (buried knot)
Simple Interrupted
• Most common closure performed
• Used in superficial wounds with minimal
tension.
• Nylon or prolene
• Be careful of knot security
Simple Interrupted
Simple Continuous
• Rapid
• Best in short lacerations with no tension
• Helps with hemostasis
• If one knot fails, the entire closure is
compromised
• Contraindicated in infected tissues as
infection can propagate along suture
line
Locked Continuous
• Used in wounds closed with moderate
tension
• Helpful in obtaining hemostasis
• Similar concerns with knot security and
integrity of closure
Horizontal Mattress
• For fragile tissue
• Distributes tension over wider area
• Helps evert skin edges
Horizontal Mattress
Vertical Mattress
• Used for maximal edge eversion
• Minimizes deadspace in deeper tissues
• Helps minimize tension
Vertical Mattress
Running Subcuticular
• Provides optimum cosmetic results
• Not for contaminated or infected
wounds
Running Subcuticular
Subcutaneous
• Buries the knot
• Useful for minimizing deadspace in
deeper wounds
• Helps relieve tension on skin closure
• May be used in dermis as well
Subcutaneous
After Closure
• Apply antibiotic ointment
• Non adherant sterile dressing
• Splint if appropriate
• Tetanus
• Antibiotics
• Schedule follow up 2-3 days
Suture Removal
• Face: 3-5 days
• Scalp: 7 days
• Chest and extremities: 8-10 days
• Joints, palms, soles: 10-14 days