Closure of minor skin wounds with staples

INTRODUCTION — Almost 12 million wounds are treated annually in emergency departments in the United States [1]. Management of minor wounds has two goals: hemostasis and achievement of a functional scar that is cosmetically acceptable [2]. Suturing is the most common method of wound closure for minor lacerations; stapling and tissue adhesives (eg, Dermabond) are acceptable alternatives.

The use of staples for wound closure is reviewed here. Wound preparation and other wound closure methods and the assessment and management of scalp lacerations are discussed separately. (See "Minor wound evaluation and preparation for closure" and "Skin laceration repair with sutures" and "Minor wound repair with tissue adhesives (cyanoacrylates)" and "Assessment and management of scalp lacerations".)

INDICATIONS — For many minor wounds, suturing is the standard method of closure. Staples are an acceptable alternative for linear lacerations through the dermis that have straight, sharp edges and are located on the scalp, trunk, arms, and legs [3-6]. The table describes key aspects of wounds that impact the selection of a wound closure method (table 1).

Scalp lacerations are particularly suitable for closure with staples. For these injuries, randomized trials suggest that closure of scalp wounds with staples is faster and less costly than with similar infection rates, healing time, and cosmetic outcomes when compared to sutures. (See "Assessment and management of scalp lacerations", section on 'Surgical staples'.)

Because staples can be placed more rapidly than can sutures [7,8], they are especially useful in mass casualty situations [1,3]. In such situations, staples may be safer because the risk of accidental needle-stick injury is eliminated [9].

CONTRAINDICATIONS — Because staples do not permit meticulous cosmetic repair, the clinician should avoid staple use on the face or neck [1,5,6]. Also, discomfort makes staples a poor choice for wound closure in the hands or feet. Staples should not be used in patients who may require computed tomography or magnetic resonance imaging as part of their acute care because they produce scan artifacts and may be avulsed by the powerful magnetic field.

PREPARATION

Analgesia — Local anesthesia using topical agents (eg, lidocaine-epinephrine-tetracaine [LET] gel) and/or infiltrative anesthesia (eg, buffered lidocaine) provides adequate pain control in most patients. In children, anxiety and pain response may often be decreased with distraction techniques and use of a child life specialist. (See "Subcutaneous infiltration of local anesthetics", section on 'Lidocaine' and "Clinical use of topical anesthetics in children", section on 'Lidocaine-epinephrine-tetracaine (LET)'.)

Wound assessment and irrigation — Wound irrigation, foreign body removal, and necrotic tissue debridement should occur prior to staple placement. Hair need not be removed prior to stapling. Lubrication to comb the hair away from wound margins or simple clipping with scissors is all that is necessary in most cases. Shaving to skin level increases the risk of infection and can leave small particles in the wound. (See "Minor wound evaluation and preparation for closure", section on 'Hair removal'.)

The preparation of a skin wound for closure is discussed in greater detail separately. (See "Minor wound evaluation and preparation for closure".)

Materials — Assemble the following materials:

●Sterile gloves for the provider

●Sterile 4 x 4 inch gauze, tubular gauze bandage, and tape for dressing

●Sterile drapes (optional)

●Irrigation solution (eg, sterile normal saline)

●30 to 60 mL syringe with 18 to 19 gauge IV catheter or irrigation device with splash shield (eg, Zerowet)

●Staple device

●Adson forceps (forceps with teeth)

●Antibiotic ointment (eg, bacitracin)

●Staple remover

Many stapling devices are commercially available. Units which hold between 5 and 25 staples can be purchased. The 10-staple unit suffices for most lacerations.

PROCEDURE — After wound assessment and preparation with appropriate local anesthesia, the clinician performs staple closure as follows (figure 1) (see "Minor wound evaluation and preparation for closure" and 'Analgesia' above) [10]:

●Approximate the adjacent skin margins with eversion of the skin edges using Adson forceps (forceps with teeth) or the thumb and forefinger. Eversion is necessary to avoid the tendency of the stapler to invert the edges of the wound, which can cause a less aesthetically pleasing scar. Eversion of the wound edges by an assistant may permit more accurate staple positioning.

●Place the stapler firmly on the skin surface but without indenting the skin.

●Align the center mark on the stapler with the center of the wound margin.

●Gently squeeze the stapler handle to eject the staple into the skin.

●If the stapler does not automatically release, then release the staple from the stapler by pulling the stapler back. When properly placed, the crossbar of the staple is elevated a few millimeters above the skin surface.

●Place staples about 0.5 to 1 cm apart.

●Place enough staples to allow for proper apposition of the wound edges.

AFTERCARE — Aftercare of wounds closed with staples is similar to wounds closed with sutures and includes (see "Skin laceration repair with sutures", section on 'Aftercare'):

●Tetanus prophylaxis – Tetanus prophylaxis for all wounds as indicated (table 2). Tetanus prophylaxis for pregnant women depends upon their immunization history and is discussed in detail separately. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

●Wound care and bathing – After the wound is stapled, apply an antibiotic ointment to minimize dressing adherence and either cover the wound with a sterile dressing (eg, leg, arm, and trunk wounds) or leave it open to the air (eg, scalp wounds). The patient may remove the dressing and gently clean the wound in 24 to 48 hours. The patient may then continue wound care until the staples are removed as follows:

•Apply antibiotic ointment daily to the wound.

•Apply a dressing to the wound unless it was originally left open.

•Do not soak the wound (eg, swimming or bathing), although showering is acceptable.

STAPLE REMOVAL — The interval between application and removal of the staple is the same as that for standard suture placement and removal, although healing is more rapid (see "Skin laceration repair with sutures", section on 'Suture removal'):

●Scalp – 7 to 10 days

●Trunk and upper extremities – 7 days

●Lower extremities – 8 to 10 days

The procedure for staple removal is as follows (figure 2):

●Position both prongs of the staple remover under the staple.

●Depress the handle of the staple remover so that the staple is bent outward in the midline, easing it out of the skin.

Some patients describe a pinching sensation during removal [4].

If the patient is following up elsewhere for staple removal, provide a staple remover to the patient to ensure that the follow-up provider has the proper equipment.

COMPLICATIONS — Complications related to staple closure occur infrequently and at a rate that appears equivalent to that of sutured wounds [7,9].

●Scarring – As with sutures, staples can cause scarring. In patients who scar easily, the scar that results from staples may be more pronounced than one produced by sutures, particularly if the staples are left in place for prolonged periods (>5 to 15 days, depending upon the location) [3,11].

●Difficult removal – Embedding of the staples in the skin and rotation of the staples may lead to difficulty in removal. Proper depth and symmetry of initial staple placement, as well as timely removal, should avoid this problem in most patients [12].

For partially embedded staples, the remover can be placed as far under the staple as possible and toggled back and forth until the staple loosens. On occasion, it is easier to grasp and toggle the staple with a hemostat.

Rarely, staples may become completely lodged within the skin. In this situation, radiographs may be necessary to determine the orientation of the buried staple. After local anesthesia, an incision can be made over the buried staple so that removal can occur.

●Wound dehiscence – Wound dehiscence may occur if hemostasis is not ensured prior to staple placement or if the wound is not apposed completely during closure [13].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Minor wound management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Stitches and staples (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Indications – Staples are suitable for closure of linear lacerations through the dermis that have straight, sharp edges and are located on the scalp, trunk, arms, or legs. (See 'Indications' above.)

●Contraindications – Because staples do not permit meticulous cosmetic repair, the clinician should avoid staple use on the face or neck. Also, discomfort makes staples a poor choice for wound closure in the hands or feet. In addition, staples should not be used in patients who may require computed tomography or magnetic resonance imaging as part of their acute care. (See 'Contraindications' above.)

●Preparation – Proper wound preparation prior to stapling requires appropriate analgesia, wound assessment, irrigation, and debridement and does not differ significantly from the approach to wounds undergoing suture placement. (See 'Analgesia' above and "Minor wound evaluation and preparation for closure".)

●Procedure – The needed materials and procedure for staple placement, wound care, and staple removal are described above (figure 1). (See 'Materials' above and 'Procedure' above.)

●Aftercare – Aftercare of wounds closed with staples does not differ significantly from wounds closed with nonabsorbable sutures and includes:

•Tetanus prophylaxis for all wounds as indicated (table 2).

•Routine wound care consisting of daily application of topical antibiotics, wound dressing (eg, leg, arm, and trunk wounds), or wound left open to the air (eg, scalp wounds)

•Avoid soaking the wound (eg, swimming or bathing), although showering is acceptable

●Staple removal – Timing of staple removal is based on the site of placement (figure 2):

•Scalp – 7 to 10 days

•Trunk and upper extremities – 7 days

•Lower extremities – 8 to 10 days

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Rana Kronfol, MD, who contributed to an earlier version of this topic review.