PROCEDURE

� Timing

Wound healing occurs by primary, secondary, or tertiary

intention. Primary intention is the most common method

of repair and involves the approximation of wound edges

soon after the injury with the use of sutures, staples, tape, or

tissue adhesive. In secondary intention, the wound is

cleaned but left open and allowed to heal spontaneously.

This method is used when the risk of infection after primary

closure is high. Tertiary intention (delayed primary closure)

decreases infection rate in highly contaminated wounds. It is

performed by cleaning and debriding contaminated wounds

acutely, then suturing the wound after 3-5 days.

� Wound Preparation

First, ensure adequate lighting and hemostasis to allow for

a complete evaluation. A thorough neurovascular examination is required for all wounds before administration of

local anesthesia. Tendon function must also be assessed,

when appropriate. Wound exploration may detect foreign

bodies and diagnose injuries to deeper structures. If the

depth of the wound is not easily appreciated and a foreign

body is suspected (ie, patient fell on broken glass), then a

plain radiograph is recommended. Glass fragments >2 mm

are almost universally visualized on plain radiographs.

Plastic and wood foreign bodies are not radiopaque and

may require further imaging (computed tomography scan,

ultrasound, or magnetic resonance imaging).

Lacerations through hair-covered surfaces require further preparation before proceeding with repair. Clipping

hair to 1-2 mm (but not shaving) or applying antibacterial

ointment to part hair away from wound edges will allow

better visualization during wound closure and decrease

risk of infection. Do not remove hair from eyebrows or the

hairline, as this can lead to impaired or abnormal regrowth.

The edges of the wound are prepped with povidoneiodine solution. Care should be taken not to get the solution

in the wound itself, as this inhibits healing. Draw up 1 o/o

lidocaine into a syringe and prepare to infiltrate using a 25-

or 27-gauge needle. Pain of injection can be reduced by

buffering the lidocaine with bicarbonate. To do this, mix

1 mL of sodium bicarbonate with 9 mL of 1 o/o lidocaine; this

solution must be used promptly. Lidocaine is infiltrated

within the wound edges and around the entire wound (field

block). In contaminated wounds, puncture the skin around

the laceration (theoretical lower risk of infection); in clean

wounds, puncture the wound edge within the wound itself

(decreases pain of injection). Remember, the maximum

dose of lidocaine without epinephrine is 4 mg!kg. This

equates to 280 mg in a 70-kg (154 lb) man or 28 mL of

1 o/o lidocaine ( 10 mgfmL). Lidocaine with epinephrine has a

maximum dose of 7 mg!kg. Other advantages of adding

epinephrine include decreased bleeding and increased dura ­

tion of anesthetic. Traditional teaching dictates that caution

should be used with epinephrine in end-arterial fields (eg,

fingers, toes) for patients with vascular injury or a history of

vascular disease; however, little evidence exists supporting

this practice.