Tom Terndrup, MD writes:
>> I used to suture all foot lacs. I am increasingly impressed
>> with healing facilitated by steri-strips, bulky dressings, and
>> non-weight bearing. Complaints about wound closures are sometimes
>> legitimate, sometimes not. Increasingly, I offer a choice to
>> the child and parent(s).
>> One principal reason for not suturing is the difficulty encountered
>> in providing local anesthesia. Local infiltration seems extremely
>> painful; topical seems largely ineffective; nerve blocks have been
>> effective, when they work. Anyone else have better results with
>> something else?
I completely agree! I, too, used to suture many foot lacs. Now I reserve that
easy and painless (sarcastic!) procedure for those patients with gaping wound
edges, with a desire to get back on their feet quickly, or with parents who
insist upon it. For small wounds with well-approximated edges, I often do
nothing other than irrigation and exploration for FB's. My experience with
steristrips has been mixed. They don't last long (because of tension and
When suturing is necessary, I have had a number of bad experiences with
anesthesia as well. Local infiltration seems very painful (compared to other
areas of the body) and frequently ineffective. Topical are useless. Nerve
blocks seem a drastic alternative. For those gaping sole wounds, I've started
placing a few deep absorbable sutures to bring the wound edges closer
together then let the skin heal by secondary intention. Putting deep sutures
doesn't hurt as much (and I can get away with minimal local anesthesia).
As far as repairing foot lacs, I also think of the poor soul (sometimes me)
who must care for the wound in follow-up. The big question is whether to use
non-absorbable sutures vs. absorbable ones. With the stress in the area, I'm
always afraid that absorbable suture will break early. Of course, absorbable
suture is perfect for those hard-to-reach areas that kids always seem to
lacerate (like the ventral crease at the base of toes) are nearly impossible
to put sutures into (much less try to remove the crusted remains a week or
What does everyone think?
As some of you probably have noticed, I've been away for a while (vacation
and then moving to another state). It took a while to read through all the
messages I missed, so I'm sorry that my reactions are a little late. But I'd
like to make a few comments:
-- concerning my original comments on giving no abx prophylaxis for dog bites
I did not mean to imply that I never give antibiotics for dog bites. I almost
always give abx for bites in high-risk areas (hands, for example) and in
high-risk circumstances (happened hours ago without proper irrigation). But
for those simple bites (frequently on the face) that I see right away and can
properly irrigate, I hold off on abx. The only infected dog bites I have seen
using this approach are those where sutures were placed several hours after
the bite. By the way, I don't suture bites unless they are on the face or
gaping (in which case, I just bring the edges closer together without sealing
-- concerning use of abx for viral URI's expecting that some pts. will
This is a crazy argument! I can't believe that some subscribe to this
position. It reminds me of the argument for the varicella vaccine that
focused on all the time parents miss from work (ignorning the potential
devastation that varicella might cause in an adult population with waning
vaccine immunity). In the ER, we always say "come back if it gets worse"
without blinking. Why does this apply to appendicitis and not to colds? Why
is giving abx to a patient with a clearly viral URI so as to prevent a second
visit in a few days different from having an abx vending machine in your
waiting room?!? The physician is using abx instead of education. Is the use
of abx so "benign" as to allow their indescriminant use. I don't think so.
Anyone who doubts the effect of widespread use of antibiotics on antibiotic
resistance needs only to look at the experience with the quinolones (Cipro,
etc.). When I was in medical school, they were just arriving on the scene.
They killed everything. It seemed liked a miracle drug. Then, it started to
be used as first-line for everything... and wouldn't you know it, quinolone
resistance is here (and it's only been a few short years). We've been using
PCN for 50 years. It's a miracle we've lasted this long. I'm afraid we're
heading for the day when previously-simple infections become life-threatening
I read an essay recently entitled "The Golden Age of Antibiotics" in which
the author (writing from an imaginary point in the future) reminisces on the
period in medical history when we could actually treat infectious disease
with antibiotics (a time that had long since passed). I hope that essay is
not the shape of things to come.
-- End of Sermon
Peace and happiness to all.
Jeff Hoffman, M.D.
(now in) Dayton, OH