The major goal of wound closure is to restore the skin’s
integrity in order to reduce the risk of infection, scarring, and
impaired function. This may be achieved by one of three methods.
With primary closure, the wound is immediately closed by approximating
its edges. The main advantage of primary closure is a reduction
in healing time in comparison with other closure methods. Rapid
wound closure also may reduce bleeding and discomfort often associated
with open wounds. Secondary wound closure, in which the wound is
left open and allowed to close on its own, is particularly well
suited for highly contaminated or infected wounds as well as in
patients at high risk of infection. Although this method may reduce
the risk of infection, it is relatively slow and uncomfortable and
leaves a larger scar than primary closure. Delayed primary (or tertiary)
closure combines the advantages of both primary and secondary closure.
With this method, the wound is initially cleansed and then packed
with dry sterile gauze followed by a sterile covering. The dressing
is left undisturbed unless signs of infection develop: fever, purulent
exudate, or spreading cellulitis. After 4 to 5 days, the dressing
is removed and the wound edges can be closed if no infection has
supervened. This may be useful for highly contaminated wounds and
animal bites, especially with extensive wounds.
A small study of simple hand and finger lacerations challenges
the principle of primary closure for all lacerations.1 Small
(<2 cm) uncomplicated hand wounds randomized to
conservative treatment with antibiotic ointment and gauze dressing
(“secondary closure”) healed as fast and with
no notable differences in appearance or function as those closed primarily
with sutures.1 However, as this study was limited
to short, superficial hand lacerations, it cannot be widely recommended
for larger lacerations and in other sites.
Lacerations may be closed by one of four commonly available methods or
devices: sutures, staples, adhesive tapes, or tissue adhesives.
Each method has advantages and disadvantages (Table
45-1). Choice of the wound closure method
and timing should take into account both patient and wound characteristics
(Table 45-2). Cosmetic outcome is more closely
related to practitioner technique and the patient’s own
healing characteristics than to any specific closure method or device.
45-1 Advantages and Disadvantages of Wound Closure Devices |Favorite Table|Download (.pdf)
45-1 Advantages and Disadvantages of Wound Closure Devices
|Suture||Time-honored||Requires removal (if using nonabsorbable material)|
|Greatest tensile strength||Requires anesthesia|
|Lowest dehiscence rate||Risk of needle stick to physician|
|Greatest tissue reactivity|
|Staples||Rapid application||Less meticulous closure|
|Low tissue reactivity||May interfere with some imaging techniques
|Low risk of needle stick|
|Tissue adhesives||Rapid application||Lower tensile strength than 5-0 or larger
|Resistant to bacterial growth||Dehiscence over high-tension areas (joints)|
|No need ...|
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