Under this subheading, you’ll find archives of blog posts on novel techniques, controversial topics in wound care, and evidence-based practice recommendations (made palatable).
Wound Blog
The toenail “spork” technique
Recently I had an opportunity to perform one of my favorite techniques, the transverse figure-of-eight suture to secure a partially avulsed toenail. The patient was a young man who injured his toe kite boarding. Somehow he managed to lift the nail from its bed, miraculously had no underlying laceration to the bed (just a whole…
Dog Bite Dogma, Part II
Facial lacerations caused by a dog bite. The outline of the upper and lower jaws of the dog are visible in the wound. Though small, the wound crosses the vermillion border of the upper lip and is located in a highly cosmetic region of the patient’s face. A 19-year-old female presented to the Urgent Care…
Parallel Lacerations
Ever come across this problem? The two situations where I’ve seen it: (1) Cutters. The patient with borderline personality disorder, now on a psychiatric hold, who spent the good part of the day prior to arrival making fine lacerations across his/her forearm. Now, in order to be medically cleared for psychiatric hospitalization, you have to…
Eversion
We are taught the value of everting our wound edges from Day 1 in our surgery rotation in medical school. But just how important is it? Why do we do it? And can we cause harm when we fail to do it? Eversion Eversion is an axiom that has lost its source tag. The theorized…
The Perfect Simple Interrupted Suture
This short post will walk you through a mental exercise in simple interrupted suture placement. It aims to help junior learners develop good habits (and to help seasoned vets to break bad ones!). The technique as described focuses on how to achieve great eversion–a commonly accepted tenet of great wound edge approximation–although a forthcoming post will discuss the…
Not Your Mama’s Horizontal Mattress
The Locked Horizontal Mattress is an alternative to the traditional technique, conferring additional advantages such as better wound edge apposition. Think you know everything there is to know about placement of a horizontal mattress suture? Here are some variations on this tried-and-true technique to consider in specific acute traumatic wound care situations. The Locked Horizontal…
Spider Bites! Part I
A 30-year-old male presents to the emergency department with a swollen, tender red nodule on his right side for one week. ” How did it get there?,” you ask. “Oh– I was bitten by a spider,” he assuredly pronounces. Our 8-legged, somewhat creepy little friends are often blamed for soft tissue infections presenting to the ED…
The Set-Back Dermal Suture
If you are an EM:RAP listener, you may have had a chance to listen to the six-part series that myself, Dr. Jonathan Kantor, and Dr. Zack Shinar recorded on wound closure best practices, tips/tricks, and controversies. In our discussion, we hit on everything from the nuances of how to place the perfect simple interrupted suture…
Spider Bites! Part II
Spiders! Generally, they get blamed for much more morbidity than they are actually responsible for, but occasionally they can lead to some pretty nasty problems. In Part I, we discussed some general facts about venomous spiders relevant to humans. We then focused on the brown recluse spider and the stages of skin lesions that it…
Wound Preparation Series: Topical Anesthetics
In previous posts in this deep dive series on wound preparation, we discussed the best needle size and speed of injection for painless anesthesia delivery to an acute wound. In this next post, I’ll examine another thought: why inject at all? Perhaps the use of a topical anesthetic is a better approach. Many such preparations…
Wound Prep Series: Soap
So, you’ve managed to painlessly anesthetize your patient’s laceration, with a combination of topical and injected anesthetic. The wound has been irrigated with your solution of choice under optimal pressure. Now it’s time to prepare the field for your repair. You reach in to your wound supply cabinet and stare at the bottle of povidone-iodide (Betadine),…
Wound Preparation Series: Injectable Anesthetics
In a previous post, we discussed needle selection and injection speed as possible influences on a patient’s perceived pain. However, from an evidence-based and statistical standpoint, we ended up with some hand-waving rather than incontrovertible answers. So if it’s not the needle size nor the time it takes to inject that’s most affecting your…
Wound Preparation Series: Gloves
So, it’s time to glove up for your laceration repair. What gloves do you choose? I’ve mentioned it here before in one of my earliest posts on wound preparation: at least one ED-based study on laceration repair showed that for selected lacerations, the use of clean (but non-sterile) gloves seems reasonable. Recent Evidence More recently,…
The Inverting Horizontal Mattress Suture, in action
When I show emergency physician colleagues the inverting horizontal mattress suture technique, most everyone finds it interesting; but most also have the question: When would I ever use this? In this post I feature two quick videos of real situations in the emergency department where this little technique made a big difference. Remember, the typical…
Read more The Inverting Horizontal Mattress Suture, in action
Dog Bite Dogma, Part I
Lacerations caused by a dog bite. The upper and lower jaws of the dog are perfectly outlined in this full thickness laceration; the lower laceration is stellate and crosses the vermillion border of the upper lip. A 19-year-old female presented to the Urgent Care for evaluation of a facial laceration due to a bite from…
Road Rash! Part I
A 9-year-old boy is brought in for evaluation of facial abrasions after falling down in the schoolyard. He unfortunately fell face first on pavement with loose gravel causing this painful abrasion around his left eye. The center of the wound is darkened with dirt and debris from the asphalt still embedded deeply in the wound.…
Road Rash! Part II
A 9-year-old boy was brought in for evaluation of facial abrasions after falling down in the schoolyard. He unfortunately fell face first on pavement with loose gravel, causing a painful abrasion around his left eye. The center of the wound was darkened with dirt and debris from the asphalt embedded deeply in the wound, but…
Preventable Lacerations: Epipen Auto-Injectors, Part I
I recently read a great article in the Annals of Emergency Medicine describing a case series of traumatic lacerations caused by epinephrine auto-injector devices. As a connossier of interesting and unique lacerations, I felt obliged to read the article. I have to admit I expected these injuries to be trivial, but I was SHOCKED by…
Read more Preventable Lacerations: Epipen Auto-Injectors, Part I
Epinephrine Autoinjector Injuries: Part II
A New Research Paradigm? In Part I of this post, we discussed a recent article in Annals of Emergency Medicine describing lacerations and embedded needle injuries caused by epinephrine auto-injector devices. The findings were interesting and I encourage you to read about them. Here in Part II, we’ll discuss the other unique aspect of this work: the…
Hypothenar Autografts for Dermal Avulsions
Case Discussion A few months ago I saw an interesting case of a young man with a small but deep avulsion wound to his dominant hand. He worked as a chef, but as luck would have it his injury occurred while cooking off-duty. As pictured, his wound involved the extensor surface of his second finger. A slipped knife…
Delayed Primary Closure, Part I
Since starting lacerationrepair.com, I have gotten many referrals of cases from people throughout the country with interesting questions regarding wound care. One such case I was recently referred* went like this: An otherwise healthy forty-year-old male presented to the ED 24 hours after sustaining a laceration to his forehead. The laceration was 4 cm, with macerated…
Delayed Primary Closure, Part II
In the first part of this post, I discussed a case of a referral of a patient for delayed primary closure*(DPC) which was deemed inappropriate by a consulting plastic surgeon. Here in Part II, we’ll address the answer to the second question this case posed: Question 2: What is the evidence for/against use of delayed primary…
The “Three-bite” dog ear correction
The “dog ear” is an infrequent but troublesome complication of wound closure. Asymmetric edges of a wound–which can be either iatrogenic, from a failure to align landmarks appropriately–or inevitable, from a traumatized wound with tissue loss and circular or asymmetric margins–leads to a closure conundrum in which one side of the wound is longer than…
Stock & Simplify your Suture Cart, Part I
I recently received an email from a practicing emergency physician posing the question: “I’ve been charged with revamping our suture supplies in a small critical access hospital. I’m a bit ashamed to be somewhat clueless as to needle types. I’ve always just viewed then in terms of “small versus big,” eyeballing them for the appropriate…
Stock & Simplify Your Suture Cart, Part II
I recently received an email from a practicing emergency physician posing the question: “I’ve been charged with revamping our suture supplies in a small critical access hospital. I’m a bit ashamed to be somewhat clueless as to needle types. I’ve always just viewed then in terms of “small versus big,” eyeballing them for the appropriate…
Achilles Tendon Laceration
Here is an interesting case of a great laceration I recently saw. For medical students, a basic principle of wound evaluation and a neat trick in evaluating this particular wound is discussed. This case is posted with consent of the patient. A 25-year-old healthy female who works as a stage actress was dressing in front…
Subcuticular Suturing Pearls
Last week I received an email from Rajiv, an EM resident at the University of Toledo Medical Center. He was curious about whether non-absorbable sutures like prolene can be used in a running subcuticular fashion with intent for removal later. And if so, what technical considerations go in to placing these sutures in an easy-to-remove…
Absorbable Sutures, Revisited
In a previous post, I gave my take on the evidence in support of using absorbable sutures for superficial wound closure. A study published in 2014 adds to this body of literature. It’s generated some buzz that’s worth a brief discussion. In this new study by Tejani et al, the use of absorbable sutures was compared with non-absorbable…
Three things you didn’t know about gluing skin
Have you ever applied Dermabond to a simple laceration in your ED, and had the patient react like this: “Really? You are just using super glue? I could have bought that at a hardware store and done that myself.” Think for a moment. How would you respond to a comment like that? I had an interaction…
The Golden Period
Extensive forehead laceration, with large delay in presentation due to patient’s poor mobility. On a recent shift, I cared for an elderly patient with a fairly extensive and cosmetically deforming facial laceration. The patient was found down in her home, and due to inability to seek medical help was delayed in presenting to our ER for…
Laceration Aftercare
The other day while I was suturing a patient’s laceration in the ED, he began to ask me some great questions about the aftercare for his injury. While I had a standard set of “canned” answers to give, it made me realize that I wasn’t quite so sure about the legitimacy of my responses. Most…
Toddler Whispering
This 3 year old presented to our ED with a a tough laceration. It’s too splayed open for steri-strips or glue, but too small to justify sedation for suturing. What would you do? When it comes to lac repairs, a lot of people believe that the only thing that the patient (or parent of the patient,…
Absorbable Sutures
Sometimes, a patient may put you in a circumstance that forces you to get creative about your wound management. Young man with a facial laceration. This and all subsequent images used with patient permission. Take this case for example. I met this young man as a patient in the ER earlier this year. He got…
Wound Preparation
Last week, I worked as a volunteer doctor at San Francisco’s Outside Lands Music Festival. We saw quite a few hand lacerations in what we presumed were “fence jumpers.” For the uninitiated, these are the unticketed patrons who decided to try their luck scaling the barbed fences to get in to the show. They…
Anyone ever use skin adhesive over absorbable interrupted sutures in kids to prevent premature removal by those little scrappers?
Interesting thought. I have actually come across this situation before. The difficulty is that the residual glue can make suture removal exceedingly difficult on the backend. This can be a big problem when you are talking about kids, who are already apprehensive about the process of getting their sutures out. Just something to take into consideration. Thanks for your comment!
Thanks! I use plain gut for suturing so removal isn’t necessary. The drawback is they don’t handle much toddler abuse. I was thinking the glue should come off about the time the sutures are absorbed.
Tissue Adhesive: I do a lot of wound closure and was speaking with a pediatrician from the old school who was cursing a blue streak about adhesives – they always pop open and then leave a worse scar – even on low tension areas. Gee , I thought- that wasn’t my experience. Sure enough later that day I get a call from an ENT whose daughter had a small chin lac that was well apporximated and she told me that the the duaghter woke up with blood coming out of the wound and it had opened.
Again, I do not remeber this happening much – what do your readers have to say?
Hi Yosef, thank you for your question. Another way to think about this is that Teacher he’s a glue, like any medical treatment we render, has a number needed to harm. In this case the “harm“ is dehiscence of the wound. The NNH is commonly quoted at around 40, meaning about one in every forty wounds closed with tissue adhesive glue will open up. Incidentally, that’s also the NNH for a running subcuticular closure. I think providing your patient with that kind of framing can help them better understand the risks of using this technique for closure.