WHEN TO SUTURE LACERATIONS

WHEN TO SUTURE LACERATIONS

Part of the art of medicine is to know when to assist natural healing and when to leave well enough alone. This especially applies to suture closing of lacerations of the skin. Sometimes the actual suturing itself can leave undesirable scarring which wouldn’t have otherwise been there. One example would be a clean linear skin-deep laceration on the face. The best long-term closure might be gently applied steri-strip tapes to hold it together for a few days, leaving no needle marks and a tight barely noticeable scar.
Each type of laceration needs its own assessment of closure techniques. One would not think of suturing a paper cut, or a shaving cut. Proper technique would include proper cleaning, application of an antibacterial and some sort of covering. The more complex the mechanism of injury, the more wound closure techniques would be under consideration. Consider a laceration caused by a bicycle chain. The wound mechanism would include cutting and pinching of the skin. The pinching might leave an irregularly damaged wound edge which could be prone to infection. As in all wound treatments the initial step would be wound cleaning with an antibacterial like iodine soap. Then one would have to decide whether to cut away all the irregular macerations to leave smooth wound edges. The subcutaneous tissue would be pulled together with firm suture, individual and tied one-by-one. Then skin closure might be accomplished by more than one technique. It could be closed by individual sutures, side to side from the wound edges, each tied individually, or by subcuticular technique where absorbable suture is continuously used under the wound edges and tied only once at the end of the wound. As in all lacerations, one would have to insure that tetanus immunization was up to date, i.e., done in the last 3 to 5 years.
Another type of laceration is caused by a blow to the skin over an underlying bone. This literally causes the skin to split. This complicates matters as there is bruising to wound edges, possibly impeding the healing process. A typical example of a laceration of this type would be a scalp laceration. As usual the wound has to be thoroughly cleaned. There has to be visual and tactile examination to see if the underlying bone is fractured or depressed. A depressed skull fracture wouldn’t be assiduously closed because a specialist is possibly going to have to go back in there to treat the bony injury. If wound closure is deemed appropriate the sutures have to be placed in good (unbruised) skin to hold it closed. The scalp laceration is probably shaved, then closed with wide sutures or staples. Staples are a good choice because they are largely inert (don’t stir up an allergic reaction), and are easily removed when the laceration is healed. The shaving allows regular inspection to make sure whether any infection is occurring in the laceration.
Another type of laceration would be one caused by a puncture. This is where it gets a little tricky. Suppose you drove a pitch fork prong into your foot. Closing it with suture would look pretty at first, but it would probably be a disaster in a short time. Wounds like this simply aren’t sutured. They are cleaned as well as possible, and tetanus is given when needed. The proper treatment would be insertion of drains to remove infected and necrotic material, allowing the wound to heal from the inside out. Cultures of the drainage would be taken and appropriate antibiotics prescribed.
The mirror image of a puncture wound is the breakdown of skin into a laceration over a cyst or abscess. The treatment is the same as for a puncture wound: insertion of a drain to allow healing from the inside out and the prescription of antibiotics.
Once again, the art of medicine includes knowing when to leave a condition alone, and when to do something to assist the healing process. An example is knowing not to prescribe antibiotics for a viral infection. Another is knowing when and how to treat a laceration. It must be kept in mind that the objectives are minimal scarring and return of function to the area of injured skin. People had lacerations long before there were doctors. Many, if not most, healed with variable degrees of success, though some certainly were not very pretty. Modern medicine has an excellent track record in the repair of skin injuries, and its principles should be applied in the evaluation and treatment of skin lacerations