Running Suture Technique for Linear Palmar Lacerations
For linear palmar lacerations, use a running (continuous) non-locking subcuticular suture technique with absorbable material, as this provides optimal pain reduction, cosmetic outcomes, and eliminates the need for suture removal in this high-function area.
Pre-Procedure Preparation
Anesthesia
- Apply topical anesthetic (lidocaine-epinephrine-tetracaine combination) for 20-30 minutes before repair to minimize procedural pain 1
- Alternatively, inject buffered lidocaine (mixed with bicarbonate) slowly using a small-gauge needle for nearly painless administration 1
- Warm the lidocaine before injection to further reduce discomfort 1
Wound Preparation
- Irrigate thoroughly under pressure to remove microscopic infectious agents and debris 2
- Examine for foreign bodies (note: not all are visible on plain radiographs) 2
- Debride devitalized tissue as needed 3
- Consider radiographic evaluation if foreign body suspected 3
Suture Technique: Step-by-Step
Key Principle
The dermis provides the skin's greatest tensile strength—accurate dermal approximation is essential, while epidermal coaptation provides cosmetic refinement but no structural support 3
Running Subcuticular Technique
Anchor the suture above the apex of the laceration in the deep dermis 1
Execute continuous non-locking passes through the deep dermal layer in a running fashion 1
- Pass the needle horizontally through the dermis on alternating sides
- Maintain uniform depth throughout (mid-to-deep dermal level)
- Keep passes equidistant (approximately 3-5mm apart)
Ensure proper wound edge eversion as you progress—this is critical for optimal healing 4
- The wound edges should slightly evert (turn outward), not invert
- This compensates for natural wound contraction during healing
Maintain even tension along the entire wound length 1
Complete the closure by anchoring the terminal end with a buried knot 1
Suture Material Selection
- Use absorbable suture material (5-0 Vicryl or similar) for palmar lacerations 5
- Absorbable sutures eliminate the need for removal—a significant advantage in the palm where suture removal can be painful 5
- Studies demonstrate equivalent scar quality at 6 months compared to non-absorbable sutures, with no difference in infection rates or complications 5
Critical Technical Points
Why Non-Locking Technique?
- Never use locking sutures—they create excessive tension leading to tissue ischemia, edema, and necrosis 1
- Non-locking continuous sutures reduce short-term pain and dyspareunia (relevant for perineal repairs, principle applies to all locations) 1
Why Subcuticular Placement?
- Subcuticular (deep dermal) placement avoids damaging nerve endings on the skin surface, significantly reducing postoperative pain 1
- This is superior to transcutaneous interrupted sutures for patient comfort 1
Palmar-Specific Considerations
- Full-thickness sutures may be safely used on palmar surfaces (unlike most other locations) due to the thick, durable nature of palmar skin 3
- However, subcuticular technique remains preferred for optimal cosmesis and comfort
Post-Repair Management
Immobilization
- Apply a splint or sling for extensive lacerations or those near joints to prevent tension on the repair 3
- This is particularly important in the palm given constant hand motion
Wound Monitoring
- Examine the wound 2-3 days post-repair for signs of infection 3
- Provide clear instructions for wound care and signs requiring urgent evaluation
Pain Control
- Recommend acetaminophen or ibuprofen as needed 6
- Apply ice packs in the first 24-48 hours to reduce pain and swelling 6
Common Pitfalls to Avoid
- Inadequate dermal approximation: Remember that epidermal closure alone provides no strength 3
- Using locking technique: This is the most common error leading to tissue necrosis 1
- Transcutaneous sutures: These damage superficial nerve endings and increase pain 1
- Uneven tension: Can lead to wound dehiscence or puckering 1
- Forgetting tetanus prophylaxis: Always assess and update as needed 2, 7