Wound closure is a tricky business for doctors. There are many factors that go into ensuring that a surgical wound closes and a wound breakdown is avoided. The goal of wound closure is to promote wound healing and prevent wound breakdown. But sometimes, that simply doesn’t happen.
Let’s first take a look at how wounds are closed. There are thousands of suture materials that are available. There are thousands of needle choices for the sutures as well. But not only are there sutures, there are other types of wound closure methods that are available. Obviously, stitches are common. But also wound staples and skin glues are available also. The choice of what to use comes down to a number of factors. Usually, it relates to the location of the wound, how much tension is likely to be applied to that wound and the aesthetic appearance of the scar later on. For example, the choice of suture material opted for a internal stitch inside a shoulder is going to be vastly different to that on someone’s face. The tension inside that shoulder that is applied to that stitch is considerable. How it looks is irrelevant. The face, however, a different story – not a great deal of tension will be applied to that wound but the aesthetics is critical.
Next, doctors must consider patient factors. Age, other conditions (such as diabetes), risk of infection are going to sway their decision also. A young woman who is a stay at home mum with no other conditions is going to be at limited risk of having any major problems with wound breakdown. However, a 65 year old diabetic man who is a farmer and must continue to work shortly after the surgery will pose a much greater risk for wound breakdown. These factors need to be taken into consideration when choosing how to close wounds and avoid wound breakdown later down the road.
Sometimes, however, despite everything it’s a case of “best laid plans of mice and men”. Take Phill for example. He is young, fit and has no other medical conditions. His compliance with his therapies and his post-operative instructions were impeccable. The surgeon made a good choice for Phill’s sutures – good strong sutures for a forearm that would take on some degree of tension over the course of the first ten days but not a great deal. This allowed the surgeon to take aesthetics into consideration as the forearm will be visible. Nevertheless, Phill did have a wound breakdown.
The only chink in Phill’s armour, in regards to his wound, was the nature of his injury. A dirty pair of garden secateurs. He was very lucky that a full-blown wound infection didn’t eventuate. He had a course of antibiotics to ward that off and the surgeon washed out the wound well. There’s a saying amongst surgeons about dirty wounds: “The solution to pollution is dilution”. Which means sometimes litres of sterile water or saline are flushed through a dirty wound in an attempt to rid as much contaminant as possible. And this worked for Phill, mostly. The only problem with Phill’s “pollution” was that a little segment of his wound did not heal in time for the stitches to be removed.
In this Nurse on the Go Video, Phill has returned to the hand therapists at Day 18. The wound breakdown was discovered at hand therapy on Day 11 – the ideal time for sutures to be removed. They delayed suture removal until Day 15, but even then, the wound breakdown was not stable enough to be unsupported. Now at Day 18, these stitches simply must come out. The benefit that they are providing in wound support is quickly being surpassed by the risk of infection. The human body simply does not enjoy foreign bodies and soon, Phill’s body will start to fight these sutures that have outstayed their welcome. The hand therapist opts for some others ways to provide support to this wound breakdown other than sutures.
Nic Nash-Arnold has been nursing for twenty years. She has nursed thousands of patients, mainly in the operating theatre. Nicole has worked in both public and private hospitals in Queensland. Ten years ago, she left the “coal face” of nursing and moved into a Nurse Educator role and then a series of senior and executive hospital administration roles. Nic has always believed in the empowerment with education. That might be empowering nurses to provide better care or patients to take better care, but education is always the centre of the solution. Google