sutterlin - suture basics 2
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Suture Techniques
in Primary CareShawn A. Sutterlin, PA-CWatauga Orthopaedics
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Obecti!es
"#e!iew wound types and classi$cation
"%nderstand the principles o& woundhealing"'escribe the ( types o& wound closure
"O!er!iew o& Suture materials"Wound closure techniques
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Wound
Classi$cation")our Classes
"Clean"Clean-contaminated
"Contaminated"'irty*in&ected
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Clean Wounds
"+ost common is electi!e surgicalincision"Primary closure
"- rate o& in&ection
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Clean
Contaminated"Wounds contaminated by local
/ora despite aseptic technique
"Cholecystectomy, appendectomyand hysterectomy
"(- in&ection rate
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Contaminated
"Open traumatic wounds in nonsterileen!ironment
"Open &ractures"Surgical procedures in which there is
a gross de!iation &rom sterile
technique 0emergent open cardiacmassage1
"2-3 in&ection rate
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'irty or 4n&ected
"5ross*hea!y contamination oracti!e in&ection
"Per&orated !iscera, abscess andtraumatic wounds
"673 in&ection rate
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Wound 8ealing
")our Stages
"8emostasis"4n/ammatory
"Proli&erati!e"#emodeling
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Phase 49
8emostasis":asoconstriction stimulated byendothelial inury
"Platelet aggregation"Coagulation cascade is acti!ated
and $brin clot &ormed
"Platelets release pro in/ammatorymediators and P'5) in preparation&or subsequent phases
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8emostasis
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Phase 449
4n/ammatory"4n/ammatory mediators released":asodilation - pro!ides increased
blood supply to inury site
"4ncrease !ascular permeability -allows plasma proteins, W;Cs, into
inured tissue
"+igration o& W;Cs &rom circulationinto interstitium and phagocytose
debris*microbes
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4n/ammation
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Phase 4449
Proli&erati!e"Angiogenesis
"5ranulation"$broblasts deposit e
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Phase 4449
Proli&erati!e
"=pitheliali>ation
"?eratinocytes"Contraction
")ibroblast release o& actin
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Phase 4:9
#emodeling"Collagen remodeled along tension
lines
"Cells no longer needed areremo!ed by apoptosis
"+ay ta?e many months
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Patient &actors" Age
"Weight
"@utrition"'ehydration
" ;lood supply
" 4mmunocompromised" Chronic 'isease
" #adiation therapy
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Wound Closure
"Primary closure"Secondary closure
"Tertiary closure
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Primary Closure
"+ost common
"Pre&erred method when appropriate"Wounds are re-appro
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Secondary Closure
"nown as healing by secondary intention
"Wound edges are le&t un-approation o!er granulation tissue
"Appropriate in wounds with so&t tissueloss or se!ere contamination not closableby primary or tertiary means
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Tertiary Closure
"Contaminated wound is 4B'd andle&t open &or se!eral days
"Wound is then closed as in primaryclosure when ris? o& complicationsdeclines
"Pre&erred method &or high energyand highly contaminated wounds
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Suture +aterials
"Traits needed by suture
"Tensile Strength"not security"=ase o& handling
"Dow tissue reacti!ity
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Characteristics
"Si>e"Tensile Strength
"+ono$liment 0nylon, prolene,monocryl1
"+ulti$liment 0!icryl, ethibond, Sil?1"Absorbable"@on Absorbable
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Characteristics
"'yed"%ndyed
"Si>es -2 to E
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Suture Si>ing
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Absorbable
";ro?en down in tissues by
hydrolysis, en>ymes andin/ammation
"Time to resorb !aries by materialand diameter
"includes !icryl, monocryl, P'S, gut.
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@on Absorbable
"@ot bro?en down by hydrolysis or
in/ammatory reaction"Walled oF in body by $broblasts or
physically remo!ed 0s?in sutures1
"4ncludes nylon, prolene, stainlesssteel, sil?, polyester 0ethibond1
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Suture
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Si>e by Docation
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@eedles
"Cutting - s?in and other toughtissue
"Taper - so&ter tissues inside body0bowel,!essels1. 'ilates tissues
";lunt - &elt to pose less ris? o&needle stic?s. +ost use&ul in&ascial closure.
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;e&ore Closing
"8emostasis
"=!aluate"4rrigate"'ebride de!itali>ed*contaminated
tissues
"Should it be closed primarilyG
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;e&ore Closing
"=!aluate the wound
"Time o& inury"Si>e and shape o& wound"So&t tissue loss
"5ross contamination*&oreignbody
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;e&ore Closing
"Wound depth
"@er!e, tendon, !ascularin!ol!ement
";one in!ol!ement 0open )
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Wound Preparation
" Single most important step in pre!entingcomplications
"Control bleeding"#emo!e all debris and de!itali>ed tissue
" 4rrigate copiously with @S
"'o not use iodine or hydrogen pero
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When to Consult
Specialist"'eep wounds to hands*&eet, thora
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When to @ot Close
" Acti!e in&ection
" =rythema*induration
" Puncture wounds
"8uman*animal bites
"'elayed onset o& treatment
" 7 hours &or body
" 7I hours &or &ace
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Anesthesia
"5eneral*spinal Anesthesia"%sed &or large wounds and more
in!asi!e procedures
"#egional Anesthesia"Didocaine*bupi!icaine in$ltrated
near peripheral ner!e to produceanesthesia distally in e
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Anesthesia
"Docal
"Anesthetic agent in&used directlyinto the tissues being treated
"+ost common method inoutpatient setting
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Didocaine"+ost common
" should be adequate &or most procedures
" Sodium channel bloc?er" #apid onset
" #elati!ely short duration o& action
"A!ailable with epinephrine
" helps control bleeding
" prolong duration o& action
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"Donger duration o& action"%se&ul in prolonged procedures aswell as post procedure pain control
"Also a!ailable with epinephrine
;upi!icaine
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Docal Anesthetics
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"'o not use local anesthetic withepinephrine on structures withlimited circulation
"ears, nose, $ngers, toes, penis
CautionJJ
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=quipment
5 l
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5eneral
Considerations"8andle tissues as little as possible" Dimit the time and &orce used in retracting
tissues
"'o not pinch tissues with &orceps, 5ently li&twound edges to place suture
" 4rrigate &requently to minimi>e contaminantsand maintain moist wound bed
" Appro
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@eedlePosition
@eedle should be secured*7 - 7*( down the length
needle &rom the tip
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Always cross s?in at K2degree angle
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#ule o& 8al!es
"Allows better appro
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#ule o& 8al!es
7(
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The 4nstrument Tie"8ow to tie a per&ect square ?not e!ery time
" Place needle dri!er parallel to and directlyo!er incision
"Always wrap needle end o!er dri!er towardtail
"When tightening each throw, mo!e needledri!er to opposite side o& incision.
"The ?ey is to always wrap O:=# needledri!er and to always alternate sides
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; i S t
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;asic Suture
+ethods"Simple interrupted"Simple running"loc?ed running"8ori>ontal mattress
":ertical mattress"#unning Subcuticular
"Subcutaneous 0buried ?not1
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Simple 4nterrupted
"+ost common closure per&ormed
"%sed in super$cial wounds withminimal tension.
"@ylon or prolene";e care&ul o& ?not security
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Simple 4nterrupted
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Simple Continuous
"#apid";est in short lacerations with no tension"8elps with hemostasis"4& one ?not &ails, the entire closure is
compromised
"Contraindicated in in&ected tissues asin&ection can propagate along suture line
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"%sed in wounds closed withmoderate tension
"8elp&ul in obtaining hemostasis
"Similar concerns with ?not securityand integrity o& closure
Doc?ed Continuous
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8ori ontal
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8ori>ontal
+attress
")or &ragile tissue"'istributes tension o!er wider area
"8elps e!ert s?in edges
8ori>ontal
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8ori>ontal
+attress
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:ertical +attress
"%sed &or mae tension
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:ertical +attress
#unning
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#unning
Subcuticular
"Pro!ides optimum cosmetic results"@ot &or contaminated or in&ected
wounds
#unning
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#unning
Subcuticular
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Subcutaneous
";uries the ?not
"%se&ul &or minimi>ing deadspace indeeper wounds"8elps relie!e tension on s?in
closure"+ay be used in dermis as well
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Subcutaneous
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A&ter Closure
"Apply antibiotic ointment
"@on adherant sterile dressing
"Splint i& appropriate"Tetanus
"Antibiotics"Schedule &ollow up 7-( days
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Suture #emo!al
")ace9 (- days"Scalp9 3 days"Chest and e
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