Stitches

I never cease to be amazed at the mechanisms people use to inflict lacerations upon themselves – most often not intentionally. Sharp instruments such as knives of every description, exposed sharp edges, chisels, screw drivers, power tools, broken glass and ceramics and so on. I have seen deep, neat lacerations on legs caused by the sharp edges of house bricks; nasty full-thickness tears caused by angle grinders and circular saws; rough lacerations caused by falling onto or against rough surfaces - to name but a few. One of the most severe I had to deal with was caused by a man falling, upright, through the top of an old tree stump and tearing open both legs exposing bone and muscle. I have seen severe facial lacerations on the faces of kids who have fallen off their bikes into bushes or onto broken glass or piles of broken bricks. Crush injuries often split the skin necessitating sutures.

A deep laceration, down to bone, on the shin of a young bricky. Caused when the sharp

edge of a brick he had dropped sliced his leg on the way to the ground. It required deep as well as skin stitches. >>>>>>>>>>>>>>>

A laceration is defined as, “A torn, ragged wound.” In practice we tend to describe any traumatic opening through the skin as a laceration. Lacerations most often need to be closed with stitches but, these days, we sometimes use glue, staples or adhesive strips to hold the skin edges together while healing takes place.

Steri-strips and glue are great for closing minor lacerations especially on kids. The use of needles to inject local anaesthetic, (which stings something cruel), can be avoided and the whole process becomes far less traumatic than it would be otherwise. (The glue stings too although it doesn’t worry most kids very much.) Most kids are up to date with their immunisations so a tetanus needle is not required. The parents of those who are not immunised will usually refuse permission to give it anyway.

It is difficult to predict how kids will react to injections of local anaesthetic if it must be used. It is wise to anticipate fear and do one’s best to allay that fear but without creating false expectations. The triage nurses will usually have filled the wound with local anaesthetic cream on arrival and this helps a lot. With toddlers, these days, we tend to use an intramuscular injection of a drug that renders them essentially unconscious but not deeply anaesthetised. This avoids the need to wrap the child in sheets and restrain it while an injection is given – a most undesirable situation. Most older kids will respond to the advice that we must give an injection into the wound, that it will sting for a short while but then it will all go numb. They will grit their teeth and grip Mum or Dad’s hand tightly while it is done. Some cry, some scream and some remain silent. Sometimes, this is a consequence of Mum or Dad fainting – happens often enough to be a nuisance and it is smart to keep an eye them.

Parents can be a bit of a nuisance in other ways too. A girl of about twelve was brought in by Mum late one afternoon. She had been riding a trail bike, without a crash hat, fallen off into bushes and a stick had penetrated and torn the skin along one eyebrow. She was remarkably composed and resigned to having a needle or two. Not so Mum who was in a state of hand-wringing remorse at letting the girl ride without the stack-hat. We were just about to start the local anaesthetic when Dad rocked up from work, took one look at the now-exposed wound and wanted to know if it might be better treated by a plastic surgeon. A fair enough question he was quite entitled to ask, and he was quite polite about it, but I had to stop what I was doing and discuss it with him, Mum and the daughter – who was quite happy to let me get on with it. In the end the parents accepted my assurance that I felt I could get a very satisfactory result and there would inevitable be some scarring but not ugly and would be masked by the eyebrow. I never did get to see the end result but had no follow-up complaint.

In the ED metal staples are rarely, if ever, used and then usually, only on the scalp. Surgeons sometimes use them to close wounds but they have not and are unlikely to ever replace the old fashioned stitches which, by the way, we describe as sutures just to maintain our superior position - of course.

And stitches ain’t just stitches! There are dozens of different stitches for different jobs and most come in different sizes. There are various sizes and shapes of needles – the business end of the stitch. Nowadays the stitches themselves are swaged onto the end of the needle. I can remember having to thread stitches through the eye of the needle. The stitch material may be absorbable or non-absorbable, monofilament or multifilament, dyed or not and coated or not.

For the skin there are a few to choose from. In days gone by BBS – Braided Black Silk was probably the most commonly used skin suture material. Haven’t seen it for donkey’s years now. Nowadays it is synthetics such as Vycril and Ethilon. My own preference is for Ethilon because I found its knots hold better than Vycril which tends to let them slip.

For repairing tissues under the skin the old fashioned cat gut is still used. (It is made from sheep intestine not cat’s.) It dissolves in the tissues and comes in plain and chromic types the latter taking longer to dissolve. The point is, “dissolving” stitches don’t just dissolve – they are foreign matter and trigger a reaction from the immune system that causes local inflammation, swelling and some pain. This can go on for 50 to 70 days before the stitch is completely broken down.

We use non-dissolving sutures in the skin. And most often we insert individual stitches rather than one continuous stitch. The reason being that, especially in traumatic wounds, infection of a stitch is not uncommon. If it occurs then the stitch must be removed otherwise the infection may extend into deeper tissues and into adjacent stitches. Removal of an infected continuous stitch usually compromises the integrity of the entire wound and it is likely to fall apart – dehisce is the techo term. However, we can often get away with the removal of one out of a series of stitches and retain the integrity of the repair. Infection of a stitch must not be confused with the normal inflammatory reaction on the skin against the foreign matter of the stitches. It results in the wound becoming red and itchy but without pus being present. It settles down rapidly after the stitches are removed at the proper time and the wound heals nicely.

Removing stitches is not painful - but little billy lids aren’t keen on having strangers approach them wearing rubber gloves and bearing stainless steel scissors and forceps and smelly antiseptics. This can present a challenge to the parents and nurses who usually perform the task. With the right approach it can usually be achieved without traumatising the child too much.

The skin will heal extremely well in most cases, provided the right conditions are established for nature to do its job of healing. Paramount among the right conditions is cleanliness. A dirty wound will inevitably become infected and not heal well if at all. Also, any foreign body or material must be removed. This can be difficult and sometimes require the use of scrubbing brushes and/or time consuming removal of small particles of dirt and debris, bit by bit, with forceps and swabs. And cleanliness must be maintained until the wound has healed.

Old habits die hard and one of mine is to shave the edges of skin wounds on hairy areas. The idea is to prevent hairs getting caught up in the wound and acting as a foreign body or a conduit for bacteria to enter the wound. Nurses frequently advise me this is not necessary but I thank them politely for their advice, grin and proceed to shave the area anyway. One exception is the eyebrow. Eyebrows are prominent features giving form to the face. Remove one or part of one and it stands out like a warehouse in the desert. With care, the coarse hairs of the eyebrow can be excluded from the wound during suturing. They also mask the presence of the wound and sutures. Teenage girls, and young ladies, in particular are always grateful for this little courtesy.

Every wound must be assessed properly before any attempt is made to repair it. It is critical to exclude or define any damage to blood vessels, nerves, muscles, tendons and bones. The simplest, neatest cut to a finger with a very sharp knife can conceal a severed nerve or tendon requiring micro-surgery under general anaesthetic. Crush injuries very often require x-rays to determine if bones have been damaged. Careful assessment of sensation by testing both light touch and pin prick, (and sometimes other methods), is mandatory with every laceration especially of hands and fingers. Modern surgical techniques now enable the repair of even the extremely fine nerves supplying the fingertips with sensation. Similarly, there is no excuse for failing to diagnose a severed tendon in any part of the body and the fingers in particular. They can be repaired with restoration of normal appearance and function.

There is quite a knack to inserting sutures that will not only make the wound look neat, tidy and professionally repaired but will heal with minimal scarring. Its important that the needle enters the skin at right angles to the surface before being rotated out through the wound then reinserted into the wound and emerging through the skin, at right angles, on the other side. Tying the knot is usually done using the needle holder and just enough tension applied to draw the wound edges together with a little eversion. Sutures should be placed as far apart as the exposed length of stitch after tying and cutting – that is they form a square. It is always tempting to young players to put the first stitch across the middle of the wound and draw the edges together. This results in too much tension on the stitch and compromises the blood supply to that area of skin. I usually start at one end and work my way down to the other or alternate the stitches end to end with the last one in the middle of the wound. Each stitch then has equal, minimal tension.

When I have finished stitching a wound I like to clean the wound and adjacent skin of any blood or dirt then paint the wound and stitches with old fashioned, but still readily available, Friars Balsam aka as Tincture of Benzoin Compound. It seals the wound edges and the stitch entry and exit points keeping out bacteria and dirt. Then a dressing is applied with the advice to leave it in place for a day or so.

Once the skin sutures are in they must be removed – after the wound is sufficiently healed and before they cause cross-hatching, inflammation or infection becomes established. The skin of the face, especially in children, heals rapidly and we like to get these sutures out after three to five days. The back of an elderly person is a different kettle of fish and we would be unlikely to remove them within ten days. Given that most wounds have very little tensile strength within five days it is necessary to leave sutures over joints, especially the knee, in place for ten days or even more. This because flexion of the joins stretches the wound and may cause it to fall apart and require re-suturing.

A dirty laceration on the hairy leg of an adult male. Caused by the sharp edge

of a sheet of roofing iron.

The same wound after cleaning, shaving and inserting six stitches then

applying Friars Balsam.

Potato peelers are nasty little instruments that can inflict very nasty wounds when used carelessly. The simplest wounds they inflict are simply the peeling off of a small piece of skin, usually partial thickness, without damaging underlying tissues. These we just clean and dress, offer tetanus booster and allow the skin to repair itself. However, I have seen potato peeler wounds, over knuckles, that have extended into the joint space and even severed a tendon over a knuckle. Severed tendons require surgery to repair and months of immobilisation to heal. Seemingly innocuous wounds can have serious, unforeseen consequences. A surgeon acquaintance once presented with a wound over a knuckled inflicted when he was kindly assisting his wife to prepared dinner and the potato peeler attacked him. It took out a full-thickness, sizeable piece of skin but, fortunately did not cause other damage. However, it was not suitable for stitching and had to be covered with a dressing while it healed itself and that would take at least two weeks. And he needed to take a course of antibiotics. That’s all very well and good but – he had operating sessions booked over the next few weeks and surgeons cannot operate with bandaids or wounds on their fingers.

The appalling act of smashing drinking glasses or bottles into the faces of others has become so commonplace that it has attracted its own, disgusting, euphemism – “glassing”. It is not an entirely knew phenomenon – I spent most of one Saturday night in about 1977 in the then local hospital stitching up the face of a teenage boy victim. Fortunately all the lacerations were superficial and all missed his eyes. Not so for the all-too-common victims these days. And many were, previously, pretty young women and many are the victims of attacks by another woman. “Go figure” as the Americans would say. But these poor people require the services of plastic surgeons and often eye surgeons and/or fascio-maxillary surgeons and, even so, are never the same again.

At the other end of the spectrum, in the context of glassing, are the “tissue paper” lacerations of the elderly. The “tissue paper” description is my own but that is exactly what they resemble. They occur when an elderly person traumatises a limb by falling or by catching it on an object. Because their skin is so fragile the trauma causes the epidermis, or outer layer, to peel off. We usually see a triangular area of raw skin with what looks like a roll of wet tissue paper at one end. Stitching these wounds is an unnecessary waste of time. After carefully cleaning the wound the epidermis can be gently stretched back over the raw area and held in place with a dressing. They usually heal up nicely within ten days.