516 Emergency Medicine
time improves wound strength at the expense of cosmetic outcome. Most
sutures can be removed 7 days after placement. Sutures on the face should
be removed in 3 to 5 daysto prevent unsightly hatch markings. Sutures in
areas of high tension, such as arms, legs, hands, and feet require approxi-
mately 10 days.This patient’s laceration is large and in a high-tension area;
therefore, removing the sutures 10 days after placement is the best man-
agement.
Having this patient return in 3 days (a)would be too soon and 14 days
(c)would be too late. (d and e)There is no need to remove the sutures 2 days
after placement; especially since there are no signs of infection. Only if there
were signs of wound infection would suture removal be the appropriate
management.
467.The answer is a.(Knoop et al, p 162. Singer and Hollander, pp 35-37.)This
is a laceration of the face crossing the vermilion border (demarcation of the lip
mucosa and facial skin). The goal of repair in this case is approximation of the
vermilion borderwith less than 2 mm of displacement since significant
displacement is cosmetically unappealing. A nerve blockis required because
local anesthesia would distort tissue anatomy thereby limiting appropriate
approximation. The first stitch should focus on approximating the border prior
to closing the other aspects of the wound.
(b and d)Infiltration with local anesthesia will distort the tissue anatomy
and may make proper alignment unreliable. It should only be used if the
patient fails nerve block. Initial alignment of the dermis or mucosal aspects
of the laceration (c and d)may make approximation of the vermilion border
difficult. Tissue adhesive and Steri-Strips (e)should not be used to close
the lip as it is subject to pulling forces of facial movement. Wound separation
in this case could result in a cosmetically unappealing outcome.
468.The answer is c.(Tintinalli, p 327.)Puncture wounds owing to their
depth cannot be cleaned adequately. Delayed primary closurein these
wounds decreases the risk of abscess formation and wound infection.
(a)Approximately 5% of dog bites and 80% of cat bites become infected.
Copious irrigation is crucial in preventing wound infections. Most bite
wounds can be repaired with primary closure. (b)Puncture wounds, small
lacerations, and hand and foot wounds carry higher risks of infection and
therefore are best managed with delayed primary closure. Placing deep
sutures in this patient’s puncture wound would increase the risk of wound
infection.(d)Pasteurellais the most common organism in cat bites. Dog bites