Wound Closure Classification
Why Use
The type and timing of wound closure in traumatic or contaminated wounds play a role in the incidence of surgical site infections. Surgical site infections are a source of significant morbidity to the patient and increased health care costs.
When to Use
Patients with open wounds after traumatic injuries. The types of wound closure will differ depending on the wound’s etiology and pattern of injury, morphology, contamination classification, and complexity.
Formula
Pearls / Pitfalls
The types of wound closure are clearly described; however, patient-specific characteristics, such as risk factors and nutritional status, in addition to the quality of the wound itself, will make every clinical scenario different. Surgeon experience and judgment often dictate type and timing of closure. Has limited application in abdominal and orthopedic wounds. Multiple studies (of varying levels of evidence) have compared primary versus delayed primary closure of contaminated or infected abdominal wounds, and of traumatic open orthopedic wounds, in the context of reducing surgical site infections— currently no definitive evidence-based consensus exists on the optimal time of primary skin closure for either abdominal or orthopedic wounds.
Management
For the management of open fractures, ACS TQIP guidelines , which are based on expert opinion due to lack of evidence, recommend that skin defects overlying open fractures should be closed at the time of initial debridement. For open fractures associated with wounds requiring coverage with skin grafting or soft tissue transfers (in other words, Gustilo type IIIB), it is recommended that coverage be completed within seven days from the time of the injury.
Advice
Management will depend on the diagnosed pathology or injury, and wound closure will differ depending on the clinical scenario. Surgeon experience and judgment will generally dictate the type and timing of closure. Multiple studies of varying levels of evidence have compared primary versus delayed primary closure of contaminated or infected abdominal wounds in the context of reducing surgical site infections, with no definite conclusions.
More Information
Classification Description Management* Primary Healing by primary or first intention. Wound is mechanically closed by approximation of wound edges. Closure ideally performed within 6-8 hours of trauma. If well-vascularized, may be closed up to 24 hours after trauma. Secondary Healing by secondary or second intention. Wound is left open to heal largely by the formation of granulation tissue and contraction. No surgical closure. Daily dressing changes. Consider negative pressure vacuum therapy. Tertiary Healing by tertiary or third intention. Delayed closure of a wound after a variable period of time for which it has been left open. Thoroughly explore, irrigate, and debride. Observe for 3-7 days before surgical closure or skin grafting. May benefit from negative pressure vacuum therapy. From Kugler et al 2016 , Vargo 2012 , Kaushik et al 2017 , Cherubino et al 2017 .