Pediatric emergency medicine trisk 846

skin can be pulled more tightly than elsewhere. Firm, but not strangulating,
apposition of the wound will also help with hemostasis.
To ensure proper alignment, the first suture may be placed at the midpoint of
the wound, with subsequent sutures then placed in a bisecting fashion lateral to
the midpoint. Use of noncrushing forceps to hold tissue should be encouraged
because this allows the operator to precisely pass the needle through the desired
points alongside the wound edge. However, forceps use should be kept to a
minimum during the repair to avoid tissue damage.
Skin wounds can generally be repaired using interrupted sutures. To place a
simple interrupted suture, the needle is held pointing down toward the skin and
the wrist is pronated as the needle enters the skin at a 90-degree angle. The needle
tip will then move farther away from the wound margin and penetrate deeply.
Thus, more tissue is at the depth of the wound, and this causes the wound to
evert. Sutures should be placed about 2 mm apart and 2 mm from the wound edge
on delicate areas such as the face. More sutures placed closer together decrease
wound tension and leave a less noticeable scar. Larger bites should be used for
body parts where cosmesis is less important.

FIGURE 110.3 A: The buried subcutaneous suture. B: The horizontal dermal stitch.

Use an instrument tie to secure the suture ( Fig. 110.4 ). The knots should
ideally be placed on one side of the wound. Knots placed directly over the wound
increase inflammation and scar formation. On the first throw, the provider should
wrap the needle holder twice to create a surgeon’s knot and then wrap subsequent


throws a single time. The first and second throws should be snug enough to
approximate the wound edges, but not so tight that tissue is strangulated. All
subsequent knots are squared to maintain the closure. Four or five throws are
usually required to keep the knot from unraveling. A “loop knot” is effective in
apposing the wound edge with minimal tension. This involves placing a surgeon’s

knot, using the instrument tie, followed by a loop. The surgeon’s knot will “give”
slightly should edema develop subsequently. The loop knot allows easier, painless
removal of sutures because it creates a free space between the suture and the skin
( Fig. 110.5 ).
Running or continuous sutures can be applied rapidly to close large, straight
wounds or multiple wounds. With this technique, the suture is not cut and tied
with each stitch. The first suture is placed at one end of the wound and a knot is
tied, cutting only the end of thread not attached to the needle. The next loop is
placed a few millimeters away and continuous loops of equal bites are made to
close the wound. On the final loop, because the suture is not completely pulled
through, a small loop remains on the opposite side of the wound. Now, the knot
can be tied using the preceding loop of suture ( Fig. 110.6 ). This type of stitch is
more likely to leave suture marks if not removed in 5 days. Apposition of the
edges and eversion are more difficult to achieve with running sutures, and the
entire suture line can unravel if the suture breaks anywhere along the repair.
However, the technique gives the advantage of having equal tension on the
wound edges.

FIGURE 110.4 Simple interrupted skin suture secured with instrument tie.


FIGURE 110.5 Placement of a “loop knot” in conjunction with simple sutures of the skin using
an eversion technique. A: The needle enters the skin at a right angle in a way that allows
somewhat less skin and more subcutaneous tissue to be caught in the passage of the needle. The
needle should incorporate the same amount of skin and subcutaneous tissue on each side. The
ideal suture material for placing a “loop knot” is 4-0 nylon. One can also use 5-0 nylon. B: The
first knot should be a surgeon’s knot drawn down gently to barely coapt the skin edges. C: The
second tie should be placed to produce a square knot but should be drawn to produce an
approximate 2- to 3-mm loop. D: The third tie should be placed to produce a square knot. This
third tie can be secured tightly against the second tie, preserving the loop and allowing for some

spontaneous loosening of the surgeon’s knot as later edema develops.


FIGURE 110.6 Continuous skin sutures. A: The simple continuous running stitch. B: The
continuous interlocking skin stitch. C: The running lateral mattress stitch or continuous halfburied horizontal mattress stitch.

FIGURE 110.7 A–E: The vertical mattress suture. After initially placing a simple interrupted
stitch with a somewhat larger bite, make a backhand pass across the wound, taking small,
superficial bites. When the knot is tied, the edges of the laceration should evert slightly. (From
Grisham J. Wound care. In: Dieckmann RA, Fiser DH, Selbst SM, eds. Illustrated Textbook of
Pediatric Emergency & Critical Care Procedures . St. Louis, MO: Mosby; 1997:676, reprinted
with permission.)

The vertical mattress stitch is useful for deep wounds in which it may be
difficult to tie a simple, deep, interrupted suture. It reduces tension on the wound
and may close dead space within the wound. It essentially combines a deep and
superficial stitch in one suture. The needle is placed deep within the wound
(about 3 mm from the wound edge) and brought out to the opposite skin surface.
It is then brought across the epidermis to approximate the epidermal edges ( Fig.
110.7 ). This stitch takes more time to accomplish and produces more cross
marks, but it provides excellent, exaggerated wound eversion and apposition of
the wound edge. Too tight of a knot can pucker the wound.
The horizontal mattress stitch reinforces the subcutaneous tissue and
effectively relieves tension from the wound edges. It does not provide woundedge approximation as well as the vertical mattress stitch. The needle is passed ½