Wound Closure Flashcards
What is primary wound closure?
Immediate closure of clean and clean-contaminated wounds
What do you want to minimize with closure?
Dead space
What is delayed primary wound closure?
Wound left ope for 2-5 days, but closed prior to visible granulation
Why would you use delayed primary closure?
If repeated lavage and debridement is necessary to convert to a clean-contaminated wound.
What is secondary closure?
Wound closure AFTER granulation tissue covers the wound.
Describe secondary closure with a deep, narrow wound.
Direct apposition over granulation tissue.
Describe secondary closure with a wide wound.
Mobilize skin edges and advance over granulation tissue.
NOTE: Dr. Pope will remove granulation tissue is he has enough skin to cover the wound.
What is second intention healing?
Contraction and granulation where granulation tissue is laid down and the wound contracts and gains an epithelial layer.
How well will a distal limb wound that is 25-33% the circumference heal?
Most heal well
How well will a distal limb wound that is 33-50% the circumference heal?
Probably heal, but with a wide scar. Consider facilitating closure.
How well will a distal limb wound that is >50% the circumference heal?
Consider reconstruction.
Extended heal time
What are 3 things that cause cessation of wound contraction?
Wound has healed
Tension exceeds pull of myofibroblasts
Collagen interferes with pull of myofibroblasts
What are 2 complications of second intention healing?
Epithelium is not very thick or adhered to the tissue below (bleeds and comes off easily)
Circular wounds just don’t heal well.
What is wound contracture?
Scar tissue formation that interferes with normal function .
When considering skin tension lines, do you want to cut parallel or perpendicular to the lines?
Parallel to the line ha less tension on the wound and allows for better healing.
If you have multiple suture lines meeting, how do you reduce the chance of necrosis?
Use an intradermal bite on the point to help edges meet up better.
If you have a wound with unequal sides lengths, how do you suture to help minimize “dog ears”?
Place sutures closer together on the short side, and farther apart on the long side.
What is primary contraction?
Retraction of the skin edge after tissue is cut.
What is a major concern with a patient that has a large, exudative wound?
Protein loss via exudate. Initial thought is to make wound smaller at least to minimize loss.
What 2 things influence ability to undermine skin?
Species (differences in blood supply)
Breed (loose skin vs. tight skin)
Under what structure should you be working to undermine skin and why?
Cutaneous trunci muscle, helps maintain good blood flow.
Why is it important to use blunt dissection when undermining skin?
Preserves direct cutaneous vessels
What happens to skin that has been pulled over to close a wound?
Tension results in stretching of the skin.
What are 3 purposes of a walking suture?
To advance/stretch skin over a wound
To distribute tension on the skin (helps avoid dehissance)
Decrease dead space
What type of suture would you use in a walking suture?
Absorbable monofilament
What must sutures engage to have enough holding power?
Dermis and fascia
What are 4 techniques for enhancing local skin movement?
Skin stretching
Releasing incisions
Multiple punctate relaxing incisions
Adjustable horizontal mattress sutures
What are 3 ways to stretch skin?
Skin expanders
Skin stretching devices (helps facilitate closure)
Presutureing
What is the purpose of presuturing?
Takes advantage of creep and stress relaxation of the skin
What does presuturing involve?
Mattress sutures with stents to distribute pressure
How long does the presuturing usually remain in place?
Usually <24 hours (placed day before surgery)
What are the 4 classifications of wound closure?
Primary
Delayed primary
Secondary
Contraction and Epithelialization (Second intention)
How well will a distal limb wound that is <25% circumference heal?
Should heal well
What is a good use for presuturing?
If you need to avoid making an incision over a pressure point like a joint, can stretch the skin beforehand so incision can be made to the side of the pressure point.
Why do you make multiple punctate relaxing incisions?
If skin edges of primary wound wont come together even after stretching.
What are the 3 steps to placing multiple punctate relaxing incisions?
Undermine skin
Place intradermal suture pattern
Make rows of staggered, full-thickness incisions (keep tension on intradermal suture
Isn’t it stupid to make MORE wounds with multiple punctate relaxing incisions that to just fix the primary wound?
Nope. Will aid in closure of primary wound, and secondary wounds will heal better than the primary wound would have.
When does adjustable horizontal mattress work best?
In wounds with established granulation tissue.
NOTE: reason is because skin edge is thicker and holds suture better
What materials do you need to do an adjustable horizontal mattress?
Monofilament suture
Buttons
Split-shot
What are the 3 steps to placing an adjustable horizontal mattress?
Continuous intradermal suture pattern
Buttons and split shot placed at one or both ends
Tighten suture each day to enhance wound closure
