Splints & Wound Closure

Question 1

Volar Wrist Splint

Answer 1

• For stable wrist fractures
• Restricts wrist flexion and extension
• Splint to the MCP level leaving fingers free

Question 2

Sugar Tong Splint

Answer 2

• For forearm fractures
• Restricts elbow motion
• Restricts wrist flexion and extension
• Restricts pronation and supination

Question 3

Short Leg Splint

Answer 3

• For ankle fractures, dislocations, ankle sprains, calcaneus and talus fractures, achilles tendon injury
• splint ankle at 90 degrees

Question 4

When is wound closure contraindicated? (3)

Answer 4

1. in wounds older than 12 hrs (24 hrs for facial wounds)
2. Bite wounds (exception: if gaping or on the face)
3. Puncture wounds

Question 5

What are the 3 phases of wound healing?

Answer 5

1. Initial lag phase (days 0-4)
2. Fibroplasia phase (days 5-14)
3. Final healing phase (day 15 to completed healing)

Question 6

What types of wounds should be closed by “secondary intention”?

Answer 6

• active infx/inflammation
• stab/puncture wounds
• contaminated wounds
• wounds presented after significant period of time since injury
• abscess cavities
• animal bites

Question 7

What are the goals of wound closure? (4)

Answer 7

• Hemostasis
• Cosmesis
• Infx prevention
• minimize discomfort

Question 8

What to give for pasturella prophylaxis?

Answer 8

Augmentin 875mg PO BID x7 days

Question 9

When to give antibiotics for a wound?

Answer 9

• Obesity
• Diabetes with LE wound
• Immunocompromised patient
• areas of higher bacteria (e.g. axilla, groin, mouth, etc.)
• significant wound contamination
• chronic steroid use

Question 10

When to give tetanus?

Answer 10

• If less than 3 tetanus doses given
• If last dose given was more than 10 years ago (for minor wounds)
• If last dose given was more than 5 years ago (all other wounds)

Question 11

Ulnar Gutter Splint

Answer 11

• For Boxer’s fracture, ulnar metacarpal injuries
• Splint MCP joints at 90 degrees, intrinsic plus position (as if holding a baseball)

Question 12

When to consult/refer for wounds?

Answer 12

• Deep wounds of hands or foot
• full-thickness lacerations of eyelid, lip, ear
  > Lip lacerations involving the vermilion border
  > Ear cartilage wounds! ** prevent cauliflower ear
  > Wounds to the eyelid that involve the tarsal plate
• Lacerations involving nerves, arteries, bones, joints
• Severe crush injuries
• Penetrating wounds of unknown depth
• Severely contaminated wounds requiring drainage
• Wounds leading to a strong concern about cosmetic outcome
• Anything makes you feel uncomfortable as a provider treating the wound

Question 13

How long do local anesthetics take for onset and how long do they last?

Answer 13

• Lidocaine w/o epi
  onset: 1 min
  lasts: 0.5-1 hr
• Lidocaine w/ epi
  onset: 5 min
  lasts: 2-6 hrs
• Bupivacaine w/out epi
  onset: 5 min
  lasts: 2-4 hrs
• Bupivacaine w/ epi
  onset: 5 min
  lasts: 3-7 hrs

Question 14

When is epinephrine in local anesthetic contraindicated?

Answer 14

In large wounds in patients with comorbid conditions:
- hyperthyroid
- CAD
- severe HTN (some epi is absorbed systemically)
- PAD

Question 15

What are the benefits to adding epinephrine to local anesthetic? (3)

Answer 15

• decreases bleeding
• reduces systemic absorption of the anesthetic
• prolongs the duration of action of the anesthetic

Question 16

What topical preparations can be used to numb the skin before injecting local anesthetics? (3)

Answer 16

1. EMLA cream
2. ethyl chloride
3. LET gel

Question 17

What can be added as a buffer to lidocaine?

Answer 17

1ml sodium bicarb per 10ml lidocaine
(neutralizes the pH)

Question 18

What does suture size refer to? How to select size of suture?

Answer 18

Suture size refers to the thickness of the suture material.

Choose suture size based on skin thickness and wound tension, as well as anatomical location of the wound.
** the smaller the number, the thicker the suture size (such as with needle gauges)

3-0 or 4-0 on trunk
4-0 or 5-0 on extremities, scalp
5-0 to 7-0 on face

Question 19

Clinical pearls about suture material?

Answer 19

• Braided (silk, polyester) are stronger, but can harbor bacteria. Avoid in contaminated wounds
• Monofilament (Prolene, nylon/ethilon) have a lower infx risk but are weaker
• Absorbable sutures (Vicryl) are good for deep multi-layer lacerations and mucosal lacerations (mouth, tongue, genitals) and absorb within 4-8 weeks

Question 20

When to choose horizontal mattress sutures vs vertical mattress sutures?

Answer 20

Horizontal:
- Good for fragile skin
(elderly, chronic corticosteroid use)
- Good for hemostasis, gaping, high tension wounds

Vertical:
- Good in areas where skin tends to invert
- deep, deep, up, up

Question 21

How many ties recommended when suturing?

Answer 21

3 ties

Question 22

Surgeon’s knot?

Answer 22

1 double or triple throw
+ 3 single throws

Question 23

Patient education tips for suture care?

Answer 23

• No shower x24 hours after sutures applied
• No pools, tubs, or natural bodies of water throughout healing
• Review symptoms of infection
• Scarring: Daily cleansing, petroleum or bacitracin, sunscreen

Question 24

When to remove sutures?

Answer 24

** No longer than 14 days (skin will grow over sutures)

• Eyelids 3 days
• Neck 3-4 days
• Face 5 days
• Scalp 7-14 days
• Trunk and UE 7 days
• LEs 8 to 10 days