Wound Closure

Part of First Aid

An open wound is an invitation for infection. Closing a wound brings the edges together, accelerates healing, reduces scarring, and creates a barrier against bacteria. But closing at the wrong time or in the wrong way can trap infection inside, turning a survivable injury into a fatal one.

The Critical Decision: Close or Leave Open

This is the single most important judgment call in wound management. Get it wrong and you kill the patient.

Close the wound if:

• The wound is less than 6-8 hours old (the “golden period” before bacterial colonization becomes established)
• It is a clean, sharp-edged laceration (knife cut, glass cut)
• You have irrigated it thoroughly with clean water
• There are no signs of contamination (dirt, rust, organic debris embedded in tissue)
• The wound edges can be brought together without excessive tension

Leave the wound OPEN if:

• The wound is older than 8 hours (contamination is likely established)
• It was caused by a bite (animal or human — extremely high infection risk)
• There is visible contamination you cannot fully irrigate out
• The wound shows any signs of infection (redness, warmth, swelling, pus, foul smell)
• It is a crush injury with significant tissue damage
• You are not confident in your ability to close it cleanly

Warning

The golden rule: a clean wound left open heals better than a dirty wound closed shut. When in doubt, leave it open, keep it clean, and let it heal by secondary intention (from the bottom up). It takes longer and scars more, but the patient lives.

Wound Closure Methods

From simplest to most complex:

1. Adhesive Strips (Butterfly Closures)

Best for: Shallow, clean cuts with straight edges. The simplest and lowest-risk closure method.

Improvised materials: Cut thin strips of adhesive tape, duct tape, or even electrical tape. Ideal strip size: 0.5-1 cm wide, 4-6 cm long.

Technique:

1. Dry the skin on both sides of the wound (adhesive will not stick to wet or bloody skin).
2. Place the first strip across the center of the wound, pulling the edges together.
3. Alternate sides from center outward, spacing strips 3-5 mm apart.
4. Do not cover the entire wound — leave small gaps between strips for drainage.
5. Apply a longitudinal strip along each side (parallel to the wound) over the ends of the crossing strips to anchor them.

Advantages: No needles, no suture material, minimal skill required, easy to remove. Limitations: Will not hold deep wounds, wounds under tension, or wounds in areas that move frequently.

2. Wound Closure Tape / Steri-Strips

If found in scavenged first aid kits, these are purpose-built adhesive strips. Use the same technique as butterfly closures. They are stronger and more adhesive than improvised strips.

3. Tissue Glue

Superglue (cyanoacrylate) can close shallow wounds. Standard superglue works but causes more tissue irritation than medical-grade formulations.

Technique:

1. Hold wound edges together with your fingers.
2. Apply a thin line of glue along the surface of the closed wound. Do NOT get glue inside the wound.
3. Hold the edges together for 60 seconds until the glue sets.
4. Apply 2-3 layers, allowing each to dry before the next.

Limitations: Shallow wounds only. Does not work on deep lacerations, high-tension areas, or wet wounds. The bond weakens in 5-7 days, which is usually enough for shallow cuts.

4. Suturing (Stitching)

The strongest and most reliable wound closure method. Requires materials and skill. See Suture Technique for detailed needle-and-thread instruction.

5. Staples

Medical staples from scavenged supplies. Fast and effective for scalp lacerations and long straight wounds. Position the staple across the wound and squeeze the stapler. Space staples 5-8 mm apart.

Preparing the Wound for Closure

No matter which method you use, preparation is the same:

Step 1 — Irrigate aggressively. Flush the wound with at least 500 ml of clean water under pressure. Squeeze water from a bottle or use a syringe if available. Mechanical flushing removes bacteria far more effectively than antiseptics alone.

Step 2 — Debride if necessary. Remove any dead tissue (grey, white, or black tissue that does not bleed when cut) and foreign material. Use a clean, sharp blade. Living tissue is pink or red and bleeds when disturbed.

Step 3 — Control bleeding. You cannot close a wound that is actively hemorrhaging. Apply pressure until bleeding is minimal. Small oozing is acceptable — it actually helps flush the wound.

Step 4 — Examine the wound depth. If you can see tendon, bone, or joint capsule, the wound needs specialized repair beyond basic closure. Close the skin layer only and seek someone with surgical knowledge. See Surgery.

Step 5 — Assess tension. Gently push the wound edges together with your fingers. If they come together easily, proceed. If the skin is under high tension (wound gapes open by more than 1-2 cm), do not try to force it closed. Options: leave open, use a series of partial closures over days as swelling decreases, or undermine the skin edges (an advanced technique).

Closure by Body Region

Region	Recommended Method	Notes
Scalp	Staples or sutures	Scalp bleeds profusely; closure stops bleeding. Hair can be used to tie wound edges together (hair apposition technique)
Face	Fine sutures or adhesive strips	Cosmetics matter less post-collapse, but face wounds heal well due to excellent blood supply
Arms and legs	Sutures or adhesive strips	High-movement areas; use sutures for anything over joint surfaces
Hands and fingers	Sutures	Complex anatomy; close skin only, avoid suturing tendons
Torso	Sutures for deep lacerations, strips for shallow	Low-tension area; heals well
Feet	Sutures	High-stress area; wound must hold against weight-bearing

Delayed Primary Closure

When a wound is too old or contaminated to close immediately but is not severely infected:

1. Clean and pack the wound with moist dressing (see Wound Packing)
2. Change the dressing daily, irrigating each time
3. At 3-5 days, if there are no signs of infection (no pus, no expanding redness, no fever), the wound can be closed
4. This approach gives you the benefits of closure while avoiding trapping infection

This technique was used extensively in military medicine during both World Wars and remains the safest approach for contaminated wounds.

Aftercare

1. Keep the closure dry for the first 24-48 hours to allow initial healing.
2. Inspect daily for signs of infection: increasing pain, redness spreading beyond 1 cm from the wound edge, warmth, swelling, discharge.
3. If infection develops: Remove some or all closures immediately to allow drainage. A closed infected wound can form an abscess or spread to the bloodstream.
4. Remove sutures or strips based on location:

Body Region	Remove Sutures After
Face	5 days
Scalp	7-10 days
Arms / trunk	7-10 days
Legs	10-14 days
Over joints	14 days
Feet / high-tension areas	14 days

5. Apply honey or antiseptic to the healing wound after suture removal. The suture holes themselves can become entry points for infection.

When Closure Goes Wrong

Signs that you need to open the wound:

• Pus draining from between sutures or from the wound itself
• Increasing pain after initial improvement
• Red streaks extending from the wound (lymphangitis — infection is spreading)
• Fever developing 2-5 days after closure
• The wound edges becoming grey or black (tissue death from excessive tension)

Remove enough sutures or strips to allow drainage, irrigate the wound, pack it open, and treat as an infected wound. Better to have an ugly scar than a dead patient.

Key Takeaways

• Never close a wound that is contaminated, older than 8 hours, or showing signs of infection — leave it open and clean
• Irrigate every wound with at least 500 ml of pressurized clean water before any closure attempt
• Adhesive strips and butterfly closures handle most shallow, clean lacerations without needing needle skills
• Delayed primary closure (clean-pack-wait 3-5 days-then close) is the safest approach for wounds you are unsure about
• Monitor every closed wound daily and be prepared to re-open it if infection develops