Closing the Deal: Mastering Suturing and Wound Closure in the ED

-Case-

A 28-year-old bartender walks into your ED with a deep laceration on her forearm after an unfortunate run-in with broken glass while working. The wound is actively bleeding, but the edges are clean. She’s concerned about scarring and whether she’ll be able to use her arm without issues in the future. 

When considering how best to close wounds in the ED, key factors include ensuring optimal healing, reducing risk of infection, and achieving the best cosmetic outcome.

-Evaluation-
So we have a cut; important keys on assessment are obvious signs of contamination, depth/size of the laceration, timing since the injury, and location of the wound.

First, assess the wound. Wounds over highly mobile areas (joints, hands) may require additional stabilization, while highly vascular areas like the face often heal well with minimal intervention. Contaminated wounds, particularly bite wounds or those older than 12 hours (or 24+ hours for the face), may require more aggressive irrigation and/or delayed closure to reduce infection risk.

After assessment, determine your closure technique. Primary closure (suturing, staples, or adhesive strips) is ideal for clean wounds with minimal contamination. On the other hand, delayed primary closure is used for contaminated wounds, allowing 48-72 hours for monitoring before closure. Secondary intention, or leaving the wound open to heal naturally, is reserved for infected or high-risk wounds.

-Techniques and Materials- 
When suturing, select the appropriate suture type and technique based on the location:

• Face and Cosmetic Areas: Use 6-0 or 5-0 nylon or polypropylene with simple interrupted or running sutures for a fine closure
• Extremities and Torso: 4-0 or 3-0 nylon or absorbable sutures for deeper wounds
• High-Tension Areas (Joints, Deep Wounds): Layered closure using absorbable deep sutures (e.g., 4-0 Vicryl) followed by non-absorbable skin sutures
• Scalp Wounds: Staples are quick and effective, especially for non-cosmetic areas
• Adhesives and Steri-Strips: Great for small, low-tension wounds, particularly on the face or in pediatric patients

-Best Practices-

• Irrigate, Irrigate, Irrigate: Use copious amounts of normal saline or sterile water to reduce bacterial load and debris
• Debride Necrotic Tissue: If present, remove devitalized tissue to promote healing
• Minimize Tension: Layered closures and buried sutures prevent wound dehiscence
• Infection Control: Consider antibiotics for contaminated wounds, bites, or immunocompromised patients
• Avoid Sun Exposure: For 1-2 months after closure, if possible, it’s best to have your patients keep the wound covered when outside! UV rays can damage skin and break down collagen, making scars more noticeable and long-lasting
• Imaging?: X-rays can be helpful to evaluate for retained foreign bodies when the mechanism of injury can lead to wound fragments (such as glass, wood, shrapnel, etc.)
• Tetanus Prophylaxis: Don’t forget to update if needed!

-Follow-Up and Removal-

Timing for suture removal of non-absorbable sutures often depends on location:

• Face: 5–7 days
• Scalp: 7–10 days
• Extremities and Trunk: 10–14 days
• High-Tension Areas (Joints, Hands): 14–21 days

-Fast Facts-

• The decision between primary vs delayed closure is widely based on wound contamination and infection risk
• Suture selection matters! The right material and technique prevents scarring and dehiscence
• Irrigation is your best friend; it reduces infection and improves healing outcomes. A good general rule of thumb is 100cc fluid irrigation per 1cm of lac
• Aim to minimize wound tension for better cosmesis and function

Wound closure is both an art and a science. Some lacerations may seem straightforward, but every wound has its own considerations. Choosing the right technique, material, and approach can mean the difference between a well-healed wound and complications down the line!

Want to read more about this topic? Click ✨here✨to read our in-depth study guide!

Cheers,

Tamir Zitelny, MD