1887

Decision-making in wound closure

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Abstract

Wound closure and reconstruction should aim to return the patient to normal function as soon as possible. To achieve this aim, the key questions in decision-making are when and how a particular wound should be closed. To answer these, the veterinary surgeon must take into account a number of factors such as the overall condition of the patient, how the wound was caused, and the degree of trauma at the site of the wound. Failure to take such factors into account may not only lead to local wound complications and dehiscence but, with severe trauma, the consequences to the patient could be catastrophic. Essentially there are two key areas of management: the whole patient; and the local wound environment. Assessment and stabilization; Timing of wound closure; Basic closure techniques; Reconstructive techniques; Orthopaedic injuries; Basic principles of reconstructive oncological surgery; and Planning management and reconstruction are all considered.

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Figures

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3.3 Contaminated open wound in the hindlimb of a German Shepherd Dog following a collision with a train. (© CSH Sale)
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3.5 Firearm wound. A high-velocity ballistic wound involving the forelimb of a dog that was shot by a 0.223 calibre military weapon. The entry wound is small, round and regular with little indication of the underlying trauma. The size of the exit wound emphasizes the conical shape of the wound caused by the shockwave of the impacting ballistic. The distal two-thirds of the radius and ulna had been removed by the shockwave through the exit wound. (© RAS White)
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3.6 An open fracture managed by early application of an external fixator and continued open wound management. (© CSH Sale)
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3.8 Thin hairless skin of a chronically managed wound on a cat’s leg. Chronic wound contraction in the inguinal area of a cat.
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3.9 Suture apposition of deep tissue layers using buried absorbable suture material. Note that the knot is placed deep in the tissue. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.10 The reconstructive ladder. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.11 Continuous intradermal or subcuticular suture, showing an Aberdeen knot. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.12 Simple interrupted sutures, placed 3–5 mm from wound edges and spaced at intervals of about 5 mm. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.13 Creating slight eversion of the wound edge by a combination of instrument (skin hook (illustrated above) or fine thumb forceps) and ensuring a wider bite at the deeper part of the wound. Note the curved path taken by the needle on passing through the wound edges. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.14 Incorrect suture placement will lead to poorer wound healing. Adjustment of the suture allows more accurate wound apposition. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.15 Ford interlocking (continuous) suture pattern.
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3.16 Tension-relieving sutures. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.17 Vertical mattress suture. These are placed at a distance from the wound margin so there is less tendency to reduce circulation. They are generally used in combination with simple interrupted sutures. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.18 Horizontal mattress suture pattern. If not placed correctly, this will lead to marked eversion of the wound edges and damage to the local blood supply. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.19 Suturing corners. Flap tip necrosis due to suture strangulation. Bunching of the flap tip from incorrect suture placement. The three-point suture technique. The dotted lines show the intradermal portion of the suture. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.20 Stapling. When applied, the staple closes to evert the wound edges slightly and also allows some space for drainage of wound oedema. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.21 A stapled axillary fold flap. (© Alison L. Moores)
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3.22 The staple remover bends staples in the middle to release them from the skin. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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3.23 Presuturing a wound by placement of mattress sutures. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.

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