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A look at wound closure in primary care

Una Adderley
RGN DN BSc BA
Research Nurse Centre for Evidence Based Nursing
Department of Health Studies
University of York
District Nurse Scarborough and NE Yorks NHS Trust
E:una@adderleyspringfarm.fsnet.co.uk

Although most minor lacerations can be managed in primary care, any wounds involving arteries, nerves, muscles, tendons or bones should be referred immediately to secondary care. Most facial and lip lacerations (unless very minor), wounds requiring complicated suturing, those with suspected penetrating foreign bodies, and devitalised wounds requiring debridement before suturing should also be referred to secondary care for assessment and treatment.(1)
 
Assessing risk of infection
Once bleeding has been controlled, the wound should be thoroughly irrigated with sodium chloride 0.9% and examined for the presence of foreign bodies. The patient may require antibiotic or tetanus prophylaxis.
The clinician must then decide when and how to close the wound to achieve optimum healing. The risk of infection needs to be carefully considered when deciding how quickly to close a wound. Clean wounds that are at low risk of infection, such as surgical wounds or lacerations caused by clean objects such as a clean knife blade, should be closed as soon as possible or within 24 hours of the original injury.
Wounds that are at high risk of infection should not be closed if they are more than 6 hours old. High risk of infection may be due to contamination by soil, manure, saliva, vaginal secretions or faeces. Intraoral lacerations, foot wounds, stellate lesions, devitalised wounds and wounds in people with compromised healing (eg, due to diabetes mellitus or peripheral vascular disease) are also considered to be at high risk of infection. If there is no evidence of infection 3-5 days after the initial injury, closure should be attempted. Wounds that are clearly infected should not be closed until the infection has cleared.

Closure
The most common methods for wound closure include the use of sutures, sterile skin closure strips or tissue adhesives. Full-thickness lacerations that involve the dermis will require suturing. The sutured wound should be kept dry for 3 days and covered with a sterile nonadherent dressing. Facial sutures can be removed after 3-5 days, while sutures at other sites can be removed after 7-10 days.
Sterile skin closure strips can be useful when the laceration is less deep but the skin is too fragile to be sutured. Elderly patients who suffer "V" flap lacerations on the legs or arms may benefit from the application of sterile skin closure strips to enable the flap to heal similar to a skin graft. However, for best results the flap needs to be replaced and skin strips need to be applied as soon as possible after the injury. Sterile skin closure strips should not be used in areas subject to tension such as joints or on hairy skin. The wound must be kept dry until healing is achieved.
Tissue adhesives are a relatively recent introduction in primary care. They are perceived as having the advantages of being quick and painless to apply for the repair of simple clean wounds. It is advised that tissue adhesives should not be used on joints, hands, feet, lips, mucosa, infected wounds, puncture wounds, bites or stellate wounds.
A recent Cochrane systematic review examined and compared nine trials comparing tissue adhesives with standard wound closure for adults and children.(2) The review excluded wounds that were infected, heavily contaminated or devitalised, those crossing joints or mucocutaneous junctions and those on hairy skin.
The review found that tissue adhesives are as effective as standard wound closure for traumatic lacerations for cosmetic appearance. Tissue adhesives also reduced procedural pain and treatment time. However, the review also found a small but statistically significant increase in the rate at which wounds dehisced ­(spontaneously reopened).
Tissue adhesives should be applied by holding the skin edges together and applying the tissue adhesive in thin layers. The patient may feel a sensation of heat as the adhesive is applied: applying the adhesive in thin layers reduces this sensation. Adhesive should not leak into the wound as this impairs healing. The wound does not require a dressing as the tissue adhesive provides a sterile barrier between the wound and any potential contaminant.
Wounds that have been treated with tissue adhesive can come into contact with water, but prolonged immersion should be avoided. Tissue adhesives usually survive showering, but patients should not swim or bathe until full healing is achieved, which is usually after 7-10 days. Tissue adhesives do not require clinical removal as they usually slough off naturally as healing is achieved.
Tissue adhesives offer many potential benefits to both clinician and patient. The reduction in procedure-related pain and the length of procedure time are particularly beneficial in the treatment of children, who are likely to be less terrified of a tube of glue than of a needle and thread. There are also benefits for the GP practice. The procedure usually takes less time than suturing, and patients do not require a further appointment for removal of sutures.
Although the use of tissue adhesives can be beneficial for clinician and patient, they are unlikely to completely replace suturing and skin closure strips just yet. However, the recent evidence certainly supports the inclusion of tissue adhesives within the clinical repertoire of primary care clinicians.

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References

  1. Prodigy guidance. Lacerations. Available from URL: http://www. prodigy.nhs.uk/guidance.asp?gt=Lacerations
  2. Farion K, Somond MH, Hartling L, et al. Tissue ­adhesives for traumatic ­lacerations in children and adults (Cochrane review). In:The Cochrane Library. Issue 1. Oxford: Update Software; 2003.