To the Editor: In their review of the evaluation and managementof traumatic lacerations, Singer et al. (Oct. 16 issue)1 providemuch helpful information, but the technique recommended forsuture closure includes a dangerous surgical practice. In thediagrams of the placement of both a simple suture (Figure 1)and a deep suture (Figure 2), the surgeon everts the wound byretracting the edge of the skin to receive the suture with afinger. This puts the surgeon's finger in the path of the oncomingsuture needle. The most common injury during surgery is a needlestick to the surgeon's nondominant index finger during suturingby doing exactly what is shown in these figures.2 In a surveyof injuries to medical personnel during operating-room surgery,such a needle stick occurred in 4.9 percent of operations.3Given the prevalence of blood-borne pathogens such as hepatitisviruses and the human immunodeficiency virus (HIV), this practiceposes an unnecessary risk. The edge of the skin to be piercedby the oncoming needle can easily be everted by gentle downwardpressure with a forceps. Once the needle is through the skin,the needle can easily be grasped with this same forceps. Thereis no advantage to the use of one's finger, and contaminatedsuture needles should be handled with instruments whenever possible.
James M. Spencer, M.D. University of Miami Miami, FL 33136
References
Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med 1997;337:1142-1148. [Free Full Text]
Spencer J, Katz BE. The potential role of simple dermatologic surgery techniques in transmitting HIV infection. Semin Dermatol 1995;14:219-227. [Medline]
Panlilio AL, Foy DR, Edwards JR, et al. Blood contacts during surgical procedures. JAMA 1991;265:1533-1537. [Abstract]
To the Editor: The figures in the article by Singer et al. depictpractices that place the physician at increased risk for exposureto and infection with blood-borne pathogens such as HIV, hepatitisB, and hepatitis C. In the figures showing the placement ofsimple and deep sutures, a finger is being used to retract theedge of the skin. The finger lies directly in the path of thesharp needle and is likely to be punctured. In an observationalstudy of skin contacts with blood during surgery, 80 of 620hand contacts occurred during suturing.1
One of us maintains an ongoing surveillance data base on percutaneousinjuries among health care personnel (the Exposure PreventionInformation Network, or EPINet). From 1993 to 1996, in 77 hospitalsnationwide, a total of 992 injuries entered in the data baseoccurred in emergency departments, 105 (10.6 percent) of whichwere caused by suture needles. Most of the needle-stick injuries(74 percent) occurred during suturing; a minority (26 percent)occurred after suturing or during disposal of the needle.
Suturing is a source of avoidable injuries to health care personnel.Skin can be retracted by techniques such as the use of instruments,thereby keeping the physician's fingers out of harm's way.2This simple change in practice allows physicians to providecare without themselves becoming patients.
Scott Deitchman, M.D., M.P.H. Centers for Disease Control andPrevention Atlanta, GA 30333
Janine Jagger, Ph.D. University of Virginia Charlottesville,VA 22908
References
Tokars JI, Culver DH, Mendelson MH, et al. Skin and mucous membrane contacts with blood during surgical procedures: risk and prevention. Control Hosp Epidemiol 1995;16:703-11.
Lewis FR Jr, Short LJ, Howard RJ, Jacobs AJ, Roche NE. Epidemiology of injuries by needles and other sharp instruments: minimizing sharp injuries in gynecologic and obstetric operations. Surg Clin North Am 1995;75:1105-1121. [Medline]
To the Editor: . . . During wound assessment one must watchfor persistent bleeding, even if the injury is not proximateto a major artery. Any wound that requires pressure for controlof hemorrhage in order to close the skin must involve the lacerationof an artery. At least once a year, my associates and I seea radial-artery false aneurysm resulting from forcible closureof a briskly bleeding puncture wound in the forearm. Singeret al. should also have emphasized that the presence of weakpulses distal to an injury or the absence of a pulse shouldnever be attributed to spasm or adjacent swelling. This situationimplies an arterial laceration, which should be assessed bya vascular surgeon.
Singer et al. state that deep sutures should be placed so thatthe knot is buried. This time-honored dictum is not supportedby any study. Burying knots can be hard to do properly and is,in my opinion, generally useless with modern synthetic absorbablesutures.
Jeffrey L. Kaufman, M.D. Baystate Medical Center Springfield,MA 01199
To the Editor: In their excellent article, Singer et al. shouldhave mentioned the importance of seeking a foreign body andthe need to perform x-ray imaging studies to detect such foreignbodies, which usually manifest themselves later with complicationssuch as poor wound healing, infection, and neurovascular ortendon damage. The failure to identify a retained foreign bodyis one of the most common misdiagnoses attributed to emergencyroom physicians, and imaging studies are infrequently performedin such settings. In one series, imaging studies were performedin only 31 percent of urgent care patients later found to havea retained foreign body.1,2
Virtually all retained glass foreign bodies that are largerthan 2 mm and are not overlying bone can be detected on a standardanteroposterior roentgenogram. Similarly, wooden fragments maybe imaged with ultrasonography or computed tomography.2
C. William Kaiser, M.D. Veterans Affairs Medical Center Manchester,NH 03104
References
Risk management for emergency room physicians: complications of wound management. American College of Emergency Physicians Foresight. Issue 16. September 1990:3.
Kaiser CW, Slowick T, Spurling KP, Friedman S. Retained foreign bodies. J Trauma 1997;43:107-111. [Medline]
To the Editor: Singer et al. assert wrongly that "the use ofvasoconstrictors should be avoided in areas with end arterioles,such as the fingers, toes, penis, and tip of the nose." Thisadvice enshrines the old medical school mnemonic device fingers,toes, penis, and nose — all extremities of a sort butnot all containing end arteries. Ears and noses have a networkpattern of vascularity without any end arteries. Rhinoplastiesand otoplasties are carried out every day, and these procedureswould be blood baths without the use of epinephrine-containinglocal anesthetics. Unless tissue is severely devitalized, vasoconstrictorsshould be recommended for the repair of nasal and ear wounds.As far as the penis is concerned, the skin circulation is essentiallya random arterial network; only the deep vessels in the corporaare end arteries. Therefore, lacerations that do not penetratedeeply should be treated with the patient under local anesthesiawith epinephrine.
Richard H.S. Karpinski, M.D. 200 Central Park South New York,NY 10019
The authors reply:
To the Editor: Dr. Spencer and Drs. Deitchman and Jagger correctlypoint out the risk of accidental puncture of the wound-retractingfinger with the suture needle. If a finger is used to retracttissues, it should never be put in the potential pathway ofthe needle. Alternatively, tissues may be gently lifted witha fine forceps while care is taken not to cause any additionaltrauma to the tissues from crushing. The purpose of the figureswas to illustrate the angle of needle entry during placementof sutures and not to mislead readers.
As we mentioned in our review, the possibility of any injuryto underlying structures (such as arteries) must be ruled outbefore wound closure is attempted. We agree with Dr. Kaufmanthat if hemorrhage cannot be adequately controlled in the emergencyroom, operative exploration may be necessary to rule out arterialinjury.
Failure to recognize the presence of foreign bodies in woundsmay indeed have grave consequences, as Dr. Kaiser points out.Physicians can avoid this possibility by obtaining a detailedhistory of the mechanism of injury and, as we indicated, bythoroughly examining the wound. Appropriate imaging studiesmay be indicated in suspicious-appearing wounds.
We agree with Dr. Karpinski that under certain circumstancesthe use of a local vasoconstrictor in lacerations involvingthe nose and ears may be necessary. However, in our experience,most such wounds will have stopped bleeding by the time of woundclosure. At that point, the use of vasoconstrictors would beunnecessary and could lead to further tissue devitalization.
Adam J. Singer, M.D. State University of New York Stony Brook,NY 11794
Judd E. Hollander, M.D. University of Pennsylvania Philadelphia,PA 19104
James V. Quinn, M.D. University of Michigan Ann Arbor, MI 48109
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