Severe Wound Closure

          Primary closure works well in this situation; no extensive wound care is needed and the wound will reach a healed state quickly

          Hemorrhage can be controlled without difficulty in most wounds by using pressure, cauterization, or ligation. Wound cannot be closed if it is still bleeding because the hematomas act as a barrier to the healing. Hematomas must first be drained before closure can occur. Small hematomas may allow for secondary closure, whereas larger hematomas usually require primary closure

          Foreign bodies and necrotic tissue must first be removed before closure. Most foreign bodies and necrotic tissue can be removed without difficulty either manually or with high-pressure saline irrigation. For more firmly embedded foreign bodies, surgical excision can be used for removal. For foreign material that was injected, such as paint or grease injected under pressure, radiographs can help determine the spread of material in the target area. Radiopaque materials, such as metals or leaded glass, can also be detected with a radiograph. For other materials that cannot be easily visualized, techniques to use include xeroradiography, magnified radiographs and CT scans.

         Side Note: For burn wounds, it extremely difficult to assess tissue damage because the injury may become worse in the few days after the burn. This is the reason why closure of burn wounds is often delayed

Once the wound is ready to be closed, the appropriate type of closure method must be chosen. The major methods of wound closure are:

         The first step to take before wound closure is proper anesthesia. The most commonly used anesthetic is lidocaine (0.5% or 1.0%) because of its fast-acting capability, rare instances of allergic reactions, and the 1-2 hours of local anesthesia it provides which is usually enough time for most wound closures. Often combined with lidocaine is epinephrine, which makes the anesthetic effective for a longer time and helps with hemostasis

         Irrigation with a high-pressure spray is necessary to reduce the number of bacteria that may be present. Commonly used irrigants include 0.9% saline solution and Pluronic F-68, which has surfactant properties that improve wound cleaning. Antibiotics can be added in order to remove more bacteria if necessary

         The surrounding tissue should be prepared with an antibacterial solution, a common one being povidone-iodine. Foreign matter and necrotic tissue should be removed to reduce chances of infection. If conditions allow, wound edges should be made smooth and level using incisions

       For wounds, regaining strength takes a long time. Collagen fibers are usually growing by the third day of injury but the skin wound has no tensile strength. Blood vessels cross the wound by 8 days, as well as epithelial cells and fibrinous coagulum. The skin gains strength from 8-21 days and continues to gain for 4 months. It is sometimes difficult to make the balance between maintaining wound strength and cosmetic appearance. Currently no wound closure techniques accomplish all the requirements for ideal wound closure. The requirements always have to be balanced depending on the situation

 Sutures are commonly used when the wound is small and clean enough that the wound edges can be brought together without deformation. Suture material should be chosen based on:

Two general classes of sutures are absorbable (rapidly degrade and lose tensile strength within 60 days) and nonabsorbable (maintain strength for more than 60 days). The type must be chosen depending on the type of wound

Polyamides - Nylon, high tensile strength and low reactivity but relatively large degradation rate in vivo (12.5% per year). Pliable and easy to handle, favored for interrupted percutaneous sutures