Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Suturing and splinting Presented by Dr. Osama Kentab, M.D, FAAP, FACEP Assistant Professor Pediatrics and Emergency Medicine King Saud bin Abdulaziz University for Health silences October 2014 Objectives Describe the principles of wound healing Identify the various types and sizes of suture material. Choose the proper instruments for suturing. Identify the different injectable anesthetic agents and correct dosages. Demonstrate various biopsy methods: punch, excision, shave. Demonstrate different types of closure techniques: simple interrupted, continuous, subcuticular, vertical and horizontal mattress, dermal Demonstrate two-handed, one-handed, instrument ties Recommend appropriate wound care and follow-up. Critical Wound Healing Period Tissue Skin 5-7 days Mucosa 5-7 days Subcutaneous 7-14 days Peritoneum 7-14 days Fascia 14-28 days 0 5 7 14 21 Tissue Healing Time/Days 28 Model of Wound Healing (1) Hemostasis: within minutes post-injury, platelets aggregate at the injury site to form a fibrin clot. (2) Inflammatory: bacteria and debris are phagocytosed and removed, and factors are released that cause the migration and division of cells involved in the proliferative phase. (3) Proliferative: angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction (4) Remodeling: collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis. Wound Healing Concepts Patient factors Wound classification Mechanism of injury Tetanus/antibiotics/local anesthetics Surgical principles and wound prep Suture/needle/stitch choice Management/care/follow-up Common Patient Factors Age Blood supply to the area Nutritional status Tissue quality Revision/infection Compliance Weight Dehydration Chronic disease Immune response Radiation therapy CDC Surgical Wound Classification Clean: (1-5% risk of infection) uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. Clean-contaminated: (3-11% risk) operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. CDC Surgical Wound Classification Contaminated: (10-17% risk) open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered. Dirty or infected: (>27% risk) old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation. Surgical Principles Incision Dissection Tissue handling Hemostasis Moisture/site Remove infected, foreign, dead areas Length of time open Choice of closure material/mechanism Primary or secondary Cellular responses Eliminate dead space Closing tension Distraction forces and immobilization/care Suture Materials Criteria – Tensile strength – Good knot security – Workability in handling – Low tissue reactivity – Ability to resist bacterial infection Types of Sutures Absorbable or non-absorbable (natural or synthetic) Monofilament or multifilament (braided) Dyed or undyed Sizes 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate progressively smaller) New antibacterial sutures Absorbable Non-absorbable Not biodegradable and permanent – Nylon (Ethilon) – Prolene – Stainless steel – Silk (natural, can break down over years) Degraded via inflammatory response – Vicryl – Monocryl – PDS – Chromic – Cat gut (natural) Natural Suture Synthetic Biological Cause inflammatory reaction – Catgut (connective from cow or sheep) – Silk (from silkworm fibers) – Chromic catgut Synthetic polymers Do not cause inflammatory response – Nylon – Vicryl – Monocryl – PDS – Prolene Monofilament Multifilament (braided) Single strand of suture material Minimal tissue trauma Smooth tying but more knots needed Harder to handle due to memory Examples: nylon, monocryl, prolene, PDS Fibers are braided or twisted together More tissue resistance Easier to handle Fewer knots needed Examples: vicryl, silk, chromic Suture Materials Suture Selection Do not use dyed sutures on the skin Use monofilament on the skin as multifilament harbor BACTERIA Non-absorbable cause less scarring but must be removed Plus sutures (staph, monocryl for E. coli, Klebsiella) Location and layer, patient factors, strength, healing, site and availability Suture Selection Absorbable for GI, urinary or biliary Non-absorbable or extended for up to 6 mos for skin, tendons, fascia Cosmetics = monofilament or subcuticular Ligatures usually absorbable Suture Sizes Surgical Needles Wide variety with different company’s naming systems 2 basic configurations for curved needles – Cutting: cutting edge can cut through tough tissue, such as skin – Tapered: no cutting edge. For softer tissue inside the body Surgical Needles Surgical Instruments Scalpel Blades Anesthetic Solutions Lidocaine (Xylocaine®) – Most commonly used – Rapid onset – Strength: 0.5%, 1.0%, & – Vasoconstriction – Decreased bleeding 2.0% – Maximum dose: – Prolongs duration – Strength: 0.5% & 1.0% 5 mg / kg, or 300 mg – Maximum individual – 1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc – 300 mg = 0.03 liter = 30 Lidocaine (Xylocaine®) with epinephrine dose: ml 7mg/kg, or 500mg Anesthetic Solutions CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: – Eyes, Ears, Nose – Fingers, Toes – Penis, Scrotum Anesthetic Solutions BUPIVACAINE (MARCAINE): – Slow onset – Long duration – Strength: 0.25% – DOSE: maximum individual dose 3mg/kg Local Anesthetics Injection Techniques 25, 27, or 30-gauge needle 6 or 10 cc syringe Check for allergies Insert the needle at the inner wound edge Aspirate Inject agent into tissue SLOWLY Wait… After anesthesia has taken effect, suturing may begin Wound Evaluation Time of incident Size of wound Depth of wound Tendon / nerve involvement Bleeding at site When to Refer Deep wounds of hands or feet, or unknown depth of penetration Full thickness lacerations of eyelids, lips or ears Injuries involving nerves, larger arteries, bones, joints or tendons Crush injuries Markedly contaminated wounds requiring drainage Concern about cosmesis Contraindications to Suturing Redness Edema of the wound margins Infection Fever Puncture wounds Animal bites Tendon, nerve, or vessel involvement Wound more than 12 hours old (body) and 24 hrs (face) Closure Types Primary closure (primary intention) – Wound edges are brought together so that they are adjacent to each other (re-approximated) – Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery Secondary closure (secondary intention) – Wound is left open and closes naturally (granulation) – Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly reduced fractures Tertiary closure (delayed primary closure) – Wound is left open for a number of days and then closed if it is found to be clean – Examples: healing of wounds by use of tissue grafts. Wound Preparation Most important step for reducing the risk of wound infection. Remove all contaminants and devitalized tissue before wound closure. – IRRIGATE w/ NS or TAP WATER (AVOID H2O2, POVIDONE-IODINE) – CUT OUT DEAD, FRAGMENTED TISSUE If not, the risk of infection and of a cosmetically poor scar are greatly increased Personal Precautions Basic Laceration Repair Principles And Techniques Langer’s Lines Principles And Techniques Minimize trauma in skin handling Gentle apposition with slight eversion of wound edges – Visualize an Erlenmeyer flask Make yourself comfortable – Adjust the chair and the light Change the laceration – Debride crushed tissue Types of Closures ● Simple interrupted closure – most commonly used, good for shallow ● ● ● ● ● ● wounds without edge tension Continuous closure (running sutures) – good for hemostasis (scalp wounds) and long wounds with minimal tension Locking continuous - useful in wounds under moderate tension or in those requiring additional hemostasis because of oozing from the skin edges Subcuticular – good for cosmetic results Vertical mattress – useful in maximizing wound eversion, reducing dead space, and minimizing tension across the wound Horizontal mattress – good for fragile skin and high tension wounds Percutaneous (deep) closure – good to close dead space and decrease wound tension Simple Interrupted Suturing Apply the needle to the needle driver – Clasp needle 1/2 to 2/3 back from tip Rule of halves: – Matches wound edges better; avoids dog ears – Vary from rule when too much tension across wound Simple Interrupted Suturing Rule of halves Simple Interrupted Suturing Rule of halves Suturing The needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees – Visualize Erlenmeyer flask – Evert wound edges Because scars contract over time Suturing Release the needle from the needle driver, reach into the wound and grasp the needle with the needle driver. Pull it free to give enough suture material to enter the opposite side of the wound. Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites. Rotate your wrist to follow the arc of the needle. Principle: minimize trauma to the skin, and don’t bend the needle. Follow the path of least resistance. Suturing Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2-inch suture strand protruding form the bites site. Release the needle from the needle driver and wrap the suture around the needle driver two times. Simple Interrupted Suturing Grasp the end of the suture material with the needle driver and pull the two lines across the wound site in opposite direction (this is one throw). Do not position the knot directly over the wound edge. Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap. Cut the ends of the suture 1/4-inch from the knot. The remaining sutures are inserted in the same manner Simple, Interrupted http://www.youtube.com/watch?v=PFQ5-tquFqY The trick to an instrument tie Always place the suture holder parallel to the wound’s direction. Hold the longer side of the suture (with the needle) and wrap OVER the suture holder. With each tie, move your suture-holding hand to the OTHER side. By always wrapping OVER and moving the hand to the OTHER side = square knots!! Continuous Locking and Nonlocking Sutures http://www.youtube.com/watch?v=xY4cAqk30K4 http://cal.vet.upenn.edu/projects/surgery/5000.htm http://www.youtube.com/watch?v=sgOaBojcX-c https://www.youtube.com/watch?v=hIqTDvofekM Vertical Mattress Good for everting wound edges (neck, forehead creases, concave surfaces) http://www.youtube.com/watch?v=824FhFUJ6wc Horizontal Mattress Good for closing wound edges under high tension, and for hemostasis. Horizontal Mattress http://www.youtube.com/watch?v=9DdaooEXshk http://www.youtube.com/watch?v=I7C7nsl5Tuk Suturing - finishing After sutures placed, clean the site with normal saline. Apply a small amount of Bacitracin or white petroleum and cover with a sterile non-adherent compression dressing (Tefla). Suturing - before you go… Need for tetanus globulin and/or vaccine? – Dirty (playground nail) vs clean (kitchen knife) – Immunization history (>10 yrs need booster or >5 yrs if contaminated) Tell pt to return in one day for recheck, for signs of infection (redness, heat, pain, puss, etc), inadequate analgesia, or suture complications (suture strangulation or knot failure with possible wound dehiscence) It should be emphasized to patients that they return at the appropriate time for suture removal or complications may arise leading to further scarring or subsequent surgical removal of buried sutures. Patient instructions and follow up care Wound care – After the first 24-48 hours, patients should gently wash the wound with soap and water, dry it carefully, apply topical antibiotic ointment, and replace the dressing/bandages. – Facial wounds generally only need topical antibiotic ointment without bandaging. – Eschar or scab formation should be avoided. – Sunscreen spf 30 should be applied to the wound to prevent subsequent hyperpigmentation. Suture Removal Average time frame is 7 – 10 days – – – – – – FACE: 3 – 5 d NECK: 5 – 7 d SCALP: 7 – 12 days UPPER EXTREMITY, TRUNK: 10 – 14 days LOWER EXTREMITY: 14 – 28 days SOLES, PALMS, BACK OR OVER JOINTS: 10 days Any suture with pus or signs of infections should be removed immediately. Suture Removal Clean with hydrogen peroxide to remove any crusting or dried blood Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin Pull the suture line through the tissue- in the direction that keeps the wound closed - and place on a 4x4. Count them. Most wounds have < 15% of final wound strength after 2 wks, so steri-strips should be applied afterwards. Topical Adhesives Indications: selection of approximated, superficial, clean wounds especially face, torso, limbs. May be used in conjunction with deep sutures Benefits: Cosmetic, seals out bacteria, apply in 3 min, holds 7 days (5-10 to slough), seal moisture, faster, clear, convenient, less supplies, no removal, less expensive Contraindicated with infection, gangrene, mucosal, damp or hairy areas, allergy to formaldehyde or cryanoacrylate, or high tension areas Dermabond® A sterile, liquid topical skin adhesive Reacts with moisture on skin surface to form a strong, flexible bond Only for easily approximated skin edges of wounds – punctures from minimally invasive surgery – simple, thoroughly cleansed, lacerations Dermabond® Standard surgical wound prep and dry Crack ampule or applicator tip up; invert Hold skin edges approximated horizontally Gently and evenly apply at least two thin layers on the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky Apply dressing http://www.youtube.com/watch?v=oa13wriWTus&feature=related http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1 Follow Up Care with Adhesives No ointments or medications on dressing May shower but no swimming or scrubbing Sloughs naturally in 5-10 days, but if need to remove use acetone or petroleum jelly to peel but not pull apart skin edges Pt education and documentation EBM Take Home Points Suturing is preferred technique for skin laceration repair LOE SORT C Saline or tap water should be used for wound irrigation LOE SORT B Use of white petrolatum to promote wound healing is as effective as antibiotic ointment LOE SORT B Tissue adhesives show comparable results with regards to cosmetic, infection or dehisence rates LOE SORT A References http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct. 355: 17. Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988. www.uptodateonline.com; 2009, topic lacerations, etc. http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf http://www.mnpa.us/handouts/Session%2005%20%20%20%20Basic%20Suturing%20%202010%20MNPA.pdf http://www.practicalplasticsurgery.org/docs/Practical_01.pdf http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE87EB5D06CE8DF/0/wound_healing_manual.pdf Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family Physicians. AAFP Scientific Assembly. 2010. http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/asse mbly/2010handouts/071.Par.0001.File.tmp/071-072.pdf Splinting and Casting Immediate Treatment of Orthopedic Injury • One primary goal – Reduction of swelling • PRICE – Protection – Rest – Ice – Compression – Elevation Cold Application • • • • Decreases pain Produces vasoconstriction Controls hemorrhage and edema Decreases local cell metabolism – Decreases tissues’ need for oxygen – Reduces hypoxia • Sensations- Cold, burning, aching, numb Emergency Splinting • Two vital principles – Splint from one joint above the fracture to one joint below the fracture – Splint the injury in the position it is found Indications for Splinting • • • • • • • Fractures Sprains Joint infections Tenosynovitis Acute arthritis / gout Lacerations over joints Puncture wounds and animal bites of the hands or feet Splinting Equipment • Plaster of Paris – Made from gypsum - calcium sulfate dihydrate – Exothermic reaction when wet - recrystallizes (can burn patient) – Warm water - faster set, but increases risk of burns – Fast drying - 5 - 8 minutes to set – Extra fast-drying - 2 - 4 minutes to set - less time to mold – Can take up to 1 day to cure (reach maximum strength) – Upper extremities - use 8-10 layers – Lower extremities - 12-15 layers, up to 20 if big person (increased risk of burn!) Splinting Equipment • Ready Made Splinting Material – Plaster (OCL) • 10 -20 sheets of plaster with padding and cloth cover – Fiberglass (Orthoglass) • • • • Cure rapidly (20 minutes) Less messy Stronger, lighter, wicks moisture better Less moldable Splinting Equipment • Stockinette • protects skin, looks nifty (often not necessary) • cut longer than splint • 2,3,4,8,10,12-in. widths • Padding - Webril • 2-3 layers, more if anticipate lots of swelling • Extra over elbows, heels • Be generous over bony prominences • Always pad between digits when splinting hands/feet or when buddy taping • Avoid wrinkles • Do not tighten - ischemia! • Avoid circumfrential use • Ace wraps Specific Splints and Orthoses Upper Extremity Lower Extremity • Elbow/Forearm • Knee – Long Arm Posterior – Double Sugar - Tong • Forearm/Wrist – Volar Forearm / Cockup – Sugar - Tong • Hand/Fingers – – – – Ulnar Gutter Radial Gutter Thumb Spica Finger Splints – Knee Immobilizer / Bledsoe – Bulky Jones – Posterior Knee Splint • Ankle – Posterior Ankle – Stirrup • Foot – Hard Shoe Long Arm Posterior Splint • Indications – – – – Elbow and forearm injuries: Distal humerus fx Both-bone forearm fx Unstable proximal radius or ulna fx (sugar-tong better) • Doesn’t completely eliminate supination / pronation -either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx. Double Sugar Tong • Indications – Elbow and forearm fx prox/mid/distal radius and ulnar fx. – Better for most distal forearm and elbow fx because limits flex/extension and pronation / supination. 10 90 Forearm Volar Splint aka ‘Cockup’ Splint • Indications – Soft tissue hand / wrist injuries - sprain, carpal tunnel night splints, etc – Most wrist fx, 2nd -5th metacarpal fx. – Most add a dorsal splint for increased stability ‘sandwich splint’ (B). – Not used for distal radius or ulnar fx - can still supinate and pronate. Forearm Sugar Tong • Indications – Distal radius and ulnar fx. • Prevents pronation / supination and immobilizes elbow. Hand Splinting • • • • • The correct position for most hand splints is the position of function, a.k.a. the neutral position. This is with the the hand in the “beer can” position (which may have contributed to the injury in the first place) : wrist slightly extended (10-25°) with fingers flexed as shown. When immobilizing metacarpal neck fractures, the MCP joint should be flexed to 90°. Have the patient hold an ace wrap (or a beer can if available) until the splint hardens. For thumb fx, immobilize the thumb as if holding a wine glass. Radial and Ulnar Gutter •Indications •Fractures, phalangeal and metacarpal, and soft tissue injuries of the little and ring fingers. •Indications •Fractures, phalangeal and metacarpal, and soft tissue injuries of index and long fingers. Thumb Spica • Indications – Scaphoid fx - seen or suspected (check snuffbox tenderness) – De Quervain tenosynovitis. • Notching the plaster (shown) prevents buckling when wrapping around thumb. • Wine glass position. Finger Splints • Sprains - dynamic splinting (buddy taping). • Dorsal/Volar finger splints - phalangeal fx, though gutter splints probably better for proximal fxs. Jones Compression Dressing - aka Bulky Jones • Indications – Short term immobilization of soft tissue and ligamentous injuries to the knee or calf. • Allows slight flexion and extension - may add posterior knee splint to further immobilize the knee. • Procedure – Stockinette and Webril. – 1-2 layers of thick cotton padding. – 6 inch ace wrap. Posterior Ankle Splint • Indications – Distal tibia/fibula fx. – Reduced dislocations – Severe sprains – Tarsal / metatarsal fx • Use at least 12-15 layers of plaster. • Adding a coaptation splint (stirrup) to the posterior splint eliminates inversion / eversion - especially useful for unstable fx and sprains. Stirrup Splint • Indications – Similiar to posterior splint. – Less inversion /eversion and actually less plantar flexion compared to posterior splint. – Great for ankle sprains. – 12-15 layers of 4-6 inch plaster. Other Orthoses • Knee Immobilizer – Semirigid brace, many models – Fastens with Velcro – Worn over clothing • Bledsoe Brace – Articulated knee brace – Amount of allowed flexion and extension can be adjusted – Used for ligamentous knee injuries and post-op • AirCast/ Airsplint – Resembles a stirrup splint with air bladders – Worn inside shoe • Hard Shoe – Used for foot fractures or soft tissue injuries Complications • Burns – Thermal injury as plaster dries – Hot water, Increased number of layers, extra fast-drying, poor padding - all increase risk – If significant pain - remove splint to cool • Ischemia – Reduced risk compared to casting but still a possibility – Do not apply Webril and ace wraps tightly – Instruct to ice and elevate extremity – Close follow up if high risk for swelling, ischemia. – When in doubt, cut it off and look – Remember - pulses lost late. • Pressure sores – Smooth Webril and plaster well • Infection – Clean, debride and dress all wounds before splint application – Recheck if significant wound or increasing pain Any complaints of worsening pain Take the splint off and look!