Primary Suturing (Primary Wound Closure)

Definition & Context

Wound Closure Options

1. Primary closure — immediate closure at the time of injury
2. Delayed primary closure — closure at 4–5 days (96–120 hours after injury); reduces infection risk in contaminated wounds without changing overall healing time
3. Leave open — allow healing by secondary intention

Most wounds have a low risk of infection and can safely be closed primarily. Some wounds should never be closed primarily — e.g., human/animal bites to the hand, heavily contaminated wounds (grease/dirt). — Rosen's Emergency Medicine, 7e

Indications & Contraindications

• Safe for: clean lacerations, acute soft tissue defects, excision wounds
• Avoid primary closure in: heavily contaminated wounds, human/animal bites to the hand, wounds with devitalized tissue

Principles of Primary Closure

1. Careful tissue handling — avoid crushing wound margins with toothed forceps or hemostats
2. Meticulous hemostasis — blood or fluid under a closure disrupts healing
3. Closure without tension — tension causes microvascular compromise and dehiscence
4. Layered repair:
   • Deep absorbable sutures close dead space and relieve epidermal tension (dermis + subcutaneous tissue)
   • Skin sutures should use monofilament non-absorbable material (nylon or polypropylene)
5. Wound edge eversion — slightly everted edges produce less noticeable scarring
6. Drain placement — closed suction drain helps prevent fluid accumulation

Closing the deep and superficial fascia and the dermis in layers will almost effectively render a closed wound without any epithelial sutures. — Mulholland & Greenfield's Surgery, 7e

Tension Reduction Techniques

• Deep (subcutaneous) sutures — bring margins together, close dead space
  • Do NOT suture adipose tissue (risk of necrosis and infection)
  • Rarely used in hand/foot due to proximity of major structures
• Undermining — freeing the dermis from deeper attachments at the wound margin; preserves blood supply while allowing edges to approximate with less force

Suture Techniques

Simple Interrupted Sutures

• Most common method in emergency department laceration repair
• Needle enters at ~90° to skin, passes perpendicular on both sides
• Entry/exit equidistant from wound margin to avoid puckering
• Edges should be slightly everted and lightly touching
• Superior for curvilinear or jagged wounds — distributes tension properly; higher tensile strength

Running (Continuous) Suture

• Appropriate for linear lacerations under minimal tension with low infection risk
• Faster, uses less material; equivalent cosmetic result
• Not ideal for high-tension or irregular wounds

Intradermal (Buried) Sutures

• Absorbable; used in wounds under tension to approximate dermal margins and reduce skin-edge tension
• Knot must be buried deep to the skin surface
• Avoid in contaminated wounds — increase infection risk

Mattress Sutures

• Horizontal mattress: used for jagged/macerated wounds, e.g., scalp
• Provides strong eversion and tension distribution

Wound Closure Materials

Special Site Considerations

• Profuse bleeding due to dense connective tissue holding vessels open
• Check for galea defect (requires 3-0 or 4-0 absorbable deep repair to prevent cosmetic deformity)
• Staples are preferred for linear scalp lacerations — faster placement, earlier removal (1–3 days earlier), similar cosmesis
• Staples contraindicated if MRI will be needed

• Must use suture (tape/staples insufficient)
• Use layered closure with buried intradermal sutures to offload skin

Suture Removal Timing

The Doctor-Patient Relationship

Historical Evolution

• 4th century BC — The Hippocratic Oath established foundational ethics: patient confidentiality, avoiding harm (primum non nocere), and abstaining from sexual contact with patients.
• Late 19th–early 20th century — Growing recognition that patients have the right to actively influence their own care shifted the relationship from medical paternalism toward patient autonomy.
• 1914, Schloendorff v. Society of New York Hospital — Justice Cardozo ruled: "Every human being of adult years and sound mind has a right to determine what shall be done with his own body." This became the cornerstone of informed consent doctrine.
• 1957, Salgo v. Leland Stanford Jr. — Formally established the legal basis for informed consent and physician liability for inadequate risk disclosure.

The shift away from medical paternalism toward patient autonomy permitted a more appropriate balance within the therapeutic relationship. — Kaplan & Sadock's Comprehensive Textbook of Psychiatry

Models of the Relationship

Core Ethical Principles

1. Beneficence — Acting for the patient's medical benefit
2. Non-maleficence — First, do no harm
3. Patient autonomy — The right to make informed decisions about one's own body
4. Confidentiality — Patient information must be protected

Informed Consent

1. Physician's disclosure — diagnosis, proposed treatment, risks/benefits, alternatives, consequences of refusal
2. Patient's voluntariness — free from coercion
3. Patient's mental competence — capacity to understand and decide

Rapport: The Foundation of the Relationship

Even the most knowledgeable and skilled physician will have limited effectiveness if unable to develop rapport with patients. Rapport is not analyzed easily within any one body of knowledge. — Textbook of Family Medicine, 9e

• Instill confidence and trust by conveying sincerity and genuine interest
• Demonstrate compassion, thoroughness, and understanding
• Use eye contact, open posture, and appropriate physical presence
• Know the patient's name and its correct pronunciation before entering the room
• Reference prior visits — patients feel the physician is genuinely interested
• Brief non-medical conversation can make patients feel less rushed

Communication

More complaints against physicians result from a breakdown of the caring aspect of the doctor-patient relationship than from the technical quality of treatment. — Textbook of Family Medicine, 9e

• Listen carefully and take patient concerns seriously
• Be sensitive to what patients don't say — unvoiced concerns are common and lead to dissatisfaction
• "Hand-on-the-doorknob" phenomenon: patients often reveal their most important concern as they are leaving — always address it
• Avoid discussing patients within earshot of other patients — fragments of conversation can be distorted and fuel anxiety
• Make yourself accessible (phone, email, early appointment) without obstruction

• Lack of eye contact is perceived as lack of concern
• White coat + conventional dress projects more competence than scrubs alone
• Upright, energetic posture signals engagement and confidence
• A first impression forms in under 7 seconds

Patient Satisfaction

• Satisfaction correlates strongly with information provision — patients want to understand their illness
• Patients whose desire for information and emotional support is unmet are significantly less satisfied
• Greater satisfaction → greater compliance with treatment
• Spending even brief time on non-medical topics reduces the perception of being rushed
• Only ~4% of dissatisfied patients voice complaints — the rest simply do not return

Respect

• Take all complaints seriously — what seems trivial may reflect significant underlying pathology or depression
• Physicians who see more patients per session are more likely to label complaints as trivial
• Avoid negative statements about colleagues — this undermines the patient's confidence in the entire system
• Secure physicians admit the limits of their competence and seek consultation when needed without feeling threatened
• Recognize personal emotional reactions to difficult patients; unrecognized negative emotions become barriers to care

Threats to the Relationship

• Personal protective equipment obscures facial expression and human connection
• Fear of contagion and high workload reduce time with individual patients
• Emotional numbing as a coping mechanism