54.3 Some bitter lessons from early suture

Here are two cases where the indications for primary suture were not observed.

IBRAHIM (6 years) was admitted in severe shock with a gross open fracture of his tibia and a bad laceration of his anus. His wound was carefully toileted, and his leg amputated below his knee. The stump was closed by primary suture and drained. His anus was treated by wound toilet, and a proximal defunctioning colostomy was done. He was given antibiotics, but his amputation stump became so badly infected that his leg had later to be amputated above his knee.

MUSTAFA (46 years) had a minor fracture of his fibula, and a wound over the medial side of his ankle, away from the fracture. A wound toilet was done and the wound was stitched, as the doctor who was caring for him said ’to convert a compound fracture into a simple one’. He was then transferred to another hospital and was given antibiotics. Nevertheless, sepsis had spread within his ankle joint so severely that its ligaments sloughed, it fell open and the surrounding bone necrosed. He required five more operations, including sequestrectomy, drainage, and skin grafts. Finally, he was left with an ankylosed ankle.

What were the mistakes? Both patients had a social toilet and a surgical toilet. The most probable mistake was to suture their wounds too early. The boy would probably not have lost his knee if his original amputation stump had been closed by delayed primary or secondary suture. Sutures inevitably damage the blood supply a little, and kill some tissue, which may tip the delicate balance towards the spread of infection. Both wounds should have been left open, and only closed when they showed signs of healing. Here, by contrast, are some patients whose wounds were left open.

KAMAU (35 years) had a bad injury to his right hand. He was treated in another hospital but discharged himself when he was told ‘when the suppuration is over we will amputate your hand’. His hand was indeed seriously injured, with its palm torn open. It was toileted under a tourniquet and bleeding controlled with packs. His wound was then left wide open under a gauze pack. Within 6 days it was granulating well and was ready for grafting. The grafts took and he is now using his hand normally.

NJOROGE (25 years) was a bus driver with a severely torn forearm. Lacerated tendons, crushed muscle, bruised torn fat, and damaged ischaemic skin lay ingrained with mud in the depths of his dirty ragged wound. All damaged tissue was cut away, and even some of his tendons, until only healthy bleeding muscle, viable skin, and fat were left in his wound. Packs took 20 minutes to control bleeding, but only a few small arteries needed tying. His wound was left widely open under a gauze dressing, and it, too, was ready for grafting in 6 days. All the grafts took and he is now driving his bus.

JACK (51 years) was standing in cattle manure and slurry when he had his legs torn off by a farm machine. Manure was deeply ingrained in what was left of his calf muscles. A social toilet was done using about 15 litres of water. This was followed by a thorough surgical toilet, and below knee amputations, using long flaps and delayed primary suture. Both knee joints were saved and he is now walking on bilateral below knee prostheses.

Although these are only a few cases, they are examples of a very effective way of managing wounds. A patient usually needs no antibiotics, if he does need one, penicillin is usually enough. If you are in any doubt how to close a wound, wait to see what happens. Delay in closing it will not lengthen a patient’s stay in hospital, but an unwise’decision to close it immediately may cause disaster.