Laceration Repair: A Practical Approach
Laceration Repair: A Practical ApproachRANDALL T. FORSCH, MD, MPH; SAHOKO H. LITTLE, MD, PhD; and CHRISTA WILLIAMS, MDUniversity of Michigan Medical School, Ann Arbor, MichiganThe goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk ofinfection. Many aspects of laceration repair have not changed over the years, but there is evidence to support someupdates to standard management. Studies have been unable to define a “golden period” for which a wound can safelybe repaired without increasing risk of infection. Depending on the type of wound, it may be reasonable to closeeven 18 or more hours after injury. The use of nonsterile gloves during laceration repair does not increase the risk ofwound infection compared with sterile gloves. Irrigation with potable tap water rather than sterile saline also does notincrease the risk of wound infection. Good evidence suggests that local anesthetic with epinephrine in a concentrationof up to 1:100,000 is safe for use on digits. Local anesthetic with epinephrine in a concentration of 1:200,000 is safe foruse on the nose and ears. Tissue adhesives and wound adhesive strips can be used effectively in low-tension skin areas.Wounds heal faster in a moist environment and therefore occlusive and semiocclusive dressings should be consideredwhen available. Tetanus prophylaxis should be provided if indicated. Timing of suture removal depends on locationand is based on expert opinion and experience. (Am Fam Physician. 2017;95(10):628-636. Copyright 2017 AmericanAcademy of Family Physicians.)More onlineat http://www.aafp.org/afp.CME This clinical contentconforms to AAFP criteriafor continuing medicaleducation (CME). SeeCME Quiz Questions onpage 622.Author disclosure: No relevant financial affiliation. Patient information:A handout on this topic isavailable at imately 6 million patients present to emergency departments forlaceration treatment every year.1Although many patients seek careat emergency departments or urgent care centers, primary care physicians are an important resource for urgent laceration treatment.Many aspects of laceration repair have notchanged, but there is evidence to supportsome updates to standard management.Approach to the WoundThe goals of laceration repair are to achievehemostasis and optimal cosmetic results without increasing the risk of infection. Importantconsiderations include timing of the repair,wound irrigation techniques, providing aclean field for repair to minimize contamination, and appropriate use of anesthesia. Anarticle on wound care was previously published in American Family Physician.2EVALUATING THE WOUNDWhen a patient presents with a laceration, the physician should obtain a history,including tetanus vaccination status, allergies, and time and mechanism of injury, andthen assess wound size, shape, and location.3If active bleeding persists after applicationof direct pressure, hemostasis should beobtained using hemostat, ligation, or suturesbefore further evaluation. Hemostasis controls bleeding, prevents hematoma formation, and allows for deeper inspection ofthe wound.3 The next step is to determinewhether vessels, tendons, nerves, joints,muscles, or bones are damaged. Anesthesia may be necessary to achieve hemostasisand to explore the wound. Devitalized andnecrotic tissue in a traumatic wound shouldbe identified and removed to reduce risk ofinfection.4,5If a foreign body (e.g., dirt particles, wood,glass) is suspected but cannot be identifiedvisually, then radiography, ultrasonography,or computed tomography may be needed.About one-third of foreign bodies may bemissed on initial inspection.6Injuries that require subspecialist consultation include open fractures, tendon ormuscle lacerations of the hand, nerve injuries that impair function, lacerations of thesalivary duct or canaliculus, lacerations ofthe eyes or eyelids that are deeper than thesubcutaneous layer, injuries requiring sedation for repair, or other injuries requiringtreatment beyond the knowledge or skill ofthe physician.TIMING OF WOUND CLOSURENo randomized controlled trials (RCTs)have compared primary and delayed 5, NumberMay 15,2017Downloadedfrom theAmericanFamily Physician website at www.aafp.org/afp.Copyright 2017 American Academy Volumeof Family Physicians.For 10the private,noncom mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
Laceration RepairPhysicians should wear protective gear, suchas a mask with shield, during irrigation.SORT: KEY RECOMMENDATIONS FOR PRACTICEClinical recommendationEvidenceratingReferencesB2, 7-9CLEAN VS. STERILE GLOVESUse of clean nonsterile examination gloves,rather than sterile gloves, during woundrepair has little to no impact on rate of subsequent wound infection. An RCT of 493patients undergoing skin excision with priA2, 10-12mary closure revealed that clean gloves werenot inferior to sterile gloves regarding infecA11, 18-20tion risk.18 A larger RCT with 816 patientsand good follow-up revealed no statistically significant difference in the incidenceB29, 30of infection between clean and sterile gloveuse.19 Smaller observational studies supportthese findings.11,20Lacerations are considered contaminatedat presentation, and physicians should makeA consistent, good-quality patient-oriented evidence; B inconsistent or limitedevery effort to avoid introducing additionalquality patient-oriented evidence; C consensus, disease-oriented evidence, usualbacteria to the wound. However, strict sterpractice, expert opinion, or case series. For information about the SORT evidencerating system, go to http://www.aafp.org/afpsort.ile techniques appear to be unnecessary.Sutures, needles, and other instrumentsthat touch the wound should be sterile, butof nonbite traumatic wounds.7 One systematic review everything else only needs to be clean.and a prospective cohort study of 2,343 patients foundthat lacerations repaired after 12 hours have no sig- ANESTHETIZING THE WOUNDnificant increase in infection risk compared with those Topical and injectable local anesthetics reduce pain durrepaired earlier.1 A case series of 204 patients found no ing treatment of lacerations and may be used alone or inincreased risk of infection in wounds repaired at less combination.21-23 Topical anesthetics (eTable A) are parthan 19 hours.8 Noninfected wounds caused by clean ticularly useful when treating children. Topical agentsobjects may undergo primary closure up to 18 hours commonly used in the United States include lidocaine/after injury. Head wounds may be repaired up to 24 epinephrine/tetracaine and lidocaine/prilocaine. Lidohours after injury.8 Factors that may increase the likeli- caine/prilocaine is not approved by the U.S. Food andhood of infection include wound contamination, lacera- Drug Administration for use on nonintact skin, althoughtion length greater than 5 cm, laceration located on the it has been used this way in numerous studies.lower extremities, and diabetes mellitus.9When using an injectable local anesthetic, the painassociated with injection can be reduced by using aWOUND IRRIGATIONhigh-gauge needle, buffering the anesthetic, warmingIrrigation cleanses the wound of debris and dilutes bac- the anesthetic to body temperature, and injecting theterial load before closure. However, there is no strong anesthetic slowly.24-28 Lidocaine may be buffered by addevidence that cleansing a wound increases healing or ing 1 mL of sodium bicarbonate to 9 mL of lidocaine 1%reduces infection.10 A Cochrane review and several (with or without epinephrine).27RCTs support the use of potable tap water, as opposedIf there is no concern for vascular compromise to anto sterile saline, for wound irrigation.2,10-13 To dilute appendage, then local anesthetic containing epinephthe wound’s bacterial load below the recommended 105 rine in a concentration of up to 1:100,000 is safe for useorganisms per mL,14 50 to 100 mL of irrigation solution in laceration repair of the digits, including for digitalper 1 cm of wound length is needed.15 Optimal pressure blockade.29,30 Local anesthetic containing epinephrinefor irrigation is around 5 to 8 psi.16 This can be achieved in a concentration of 1:200,000 is safe for lacerationby using a 19-gauge needle with a 35-mL syringe or repair of the nose and ears.31 A systematic review docuby placing the wound under a running faucet.16,17 ments the safe use of lidocaine with epinephrine (in aNoninfected wounds caused by clean objectsmay undergo primary closure up to 18 hoursafter injury. Head wounds may be repairedup to 24 hours after injury.Using potable tap water instead of sterile salinefor wound irrigation does not increase the riskof infection.Use of clean nonsterile examination glovesrather than sterile gloves during wound repairdoes not significantly increase risk of infection.If there is no concern for vascular compromiseto an appendage, local anesthetic containingepinephrine in a concentration of up to1:100,000 is safe for use in laceration repairof the digits, including for digital blockade.May 15, 2017 Volume 95, Number 10www.aafp.org/afp American Family Physician 629
Laceration RepairWound RepairLaceration closure techniques are summarized in Table1. For a video of suturing techniques, see https://www.youtube.com/watch?v -ZWUgKiBxfk. There are nosignificant studies to guide technique choice. Comparedwith multilayer repair, single layer repair has similar cosmetic results for facial lacerations32 and is fasterand more cost-effective for scalp lacerations.33 Runningsutures reportedly have less dehiscence than interruptedsutures in surgical wounds.34 Mattresssutures (Figures 135 and 235) are effective forTable 1. Laceration Closure Techniqueseverting wound edges.36,37 Half-buried mattress sutures are useful for everting trianguTechniqueCommentslar edges in flap repair (Figure 3). Cosmeticoutcomes of facial wounds repaired withoutSimple interruptedGeneral tissue approximationdeep dermal sutures are similar to layeredsuturesCan be used for most woundsclosure.37 The approach to repair varies bySimple runningFast and effective for long lacerationswound location. Nonbite and bite woundssuturesAll sutures are lost if one suture is cut by mistakeare treated differently because of differencesor removed for drainagein infection risk. Figure 4 is an algorithm forthe management of lacerations.Horizontal mattressEffective for everting wound edgesconcentration up to 1:80,000) in more than 10,000 procedures involving digits without any reported incidenceof necrosis.30 Only two studies examined the safety ofepinephrine-containing anesthetics in patients withperipheral vascular disease. Although no patients hadischemic complications, the studies were small. Concernfor peripheral vascular compromise should be considered a contraindication to the use of an epinephrinecontaining anesthetic.sutures (Figure 1)Can cause skin necrosis and excessive scarsVertical mattresssutures (Figure 2)Most effective for everting wound edgesCan cause skin necrosis and excessive scarsHalf-buried mattresssutures (Figure 3)Most effective in everting triangular wound edgesin flap repairRunningsubcuticularsuturesFast and effective in accurate skin edge appositionDoes not allow for drainageSuited for closing clean wounds, such as surgicalwounds in the operating roomInterrupted dermalsuturesEffective in accurate skin edge apposition andwound eversionAllows for minimal drainageSuited for closing clean woundsStaplesFast, creates loose closureAllows for drainageSuited for unclean woundsShould be avoided if cosmetic outcome is importantWounds adhesivestripsFast, no anesthesia requiredUsed to approximate clean, simple, small lacerationswith little tension and without bleedingTissue adhesiveFast, no anesthesia requiredUsed to approximate clean, simple, small lacerationswith little tension and without bleedingFor a video of suture techniques, see https://www.youtube.com/watch? v -ZWUgKiBxfk.NOTE:630 American Family Physicianwww.aafp.org/afpFACIAL LACERATIONSDebridement of facial wounds should beconservative because of increased bloodsupply to the face. Removing subcutaneous fat may lead to depression of the scar.38Single layer 5-0 or 6-0 nylon sutures aresufficient.32LIP LACERATION THROUGH VERMILIONBORDERAn optimal cosmetic result depends onreapproximation of the vermilion border.Therefore, the first skin suture should beplaced at this border. The border should bemarked before anesthetic injection becausethe anesthetic may blur the border. Themuscle layer and oral mucosa should berepaired with 3-0 or 4-0 absorbable sutures,and skin should be repaired with 6-0 or 7-0nylon sutures.EYELIDThe patient should be referred to ophthalmology if the laceration involves the eyeitself, the tarsal plate, or the eyelid margin,or penetrates deeper than the subcutaneous layer. Laceration through the portion ofthe upper or lower lid medial to the punctum often damages the lacrimal duct or theVolume 95, Number 10 May 15, 2017
Laceration Repairmedial canthal ligament and requires referral to an ophthalmologist or plastic surgeon. Laceration of upper orlower eyelid skin can be repaired with 6-0 nylon sutures.ILLUSTRATION BY RENEE CANNONEYEBROWThe edges of the eyebrow serve as landmarks, so theeyebrow should not be shaved. Placing a single suture ateach margin first ensures good alignment.37EARFigure 1. Horizontal mattress sutures.Reprinted with permission from Forsch RT. Essentials of skin lacerationrepair. Am Fam Physician. 2008;78(8):948.Cartilage has poor circulation and is prone to infectionand necrosis. It needs to be covered with skin to heal. Asingle bite with reverse cutting needle or tapered needle(6-0 polypropylene sutures) should be used to approximate skin and perichondrium simultaneously. Eartrauma often causes a hematoma, and applying a pressure dressing can be difficult. Fluffed gauze under a circumferential head wrap can achieve adequate pressure toprevent a hematoma.ILLUSTRATION BY RENEE CANNONSCALPFigure 2. Vertical mattress sutures.Reprinted with permission from Forsch RT. Essentials of skin lacerationrepair. Am Fam Physician. 2008;78(8):948.A rich blood supply to the scalp causes lacerations tobleed significantly. After ruling out intracranial injury,bleeding should be controlled with direct pressure foradequate exploration of the wound. Shaving the areais rarely necessary. If the galea is lacerated more than0.5 cm it should be repaired with 2-0 or 3-0 absorbablesutures.39 Skin can be repaired using staples; interrupted,mattress, or running sutures, such as 3-0 or 4-0 nylonsutures; or the hair apposition technique (Figure 5 35).Staples are faster and more cost-effective than sutureswith no difference in complications.40 The hair apposition technique using tissue adhesive has the lowest costand highest patient satisfaction for scalp repair.41 A videoof the hair opposition technique is available at https://laceration r epair.com /alternative-wound-closure /hair-apposition-technique/.ILLUSTRATION BY RENEE CANNONHANDS AND FOREARMFigure 3. Half-buried mattress sutures.May 15, 2017 Volume 95, Number 10Lacerations of the fingers, hands, and forearms can berepaired by a family physician if deep tissue injury isnot suspected. These lacerations are repaired with 4-0or 5-0 nylon sutures. Any suspicion of injury involvingtendon, nerve, muscle, vessels, bone, or the nail bed warrants immediate referral to a hand surgeon. Traditionally, a large subungual hematoma involving more than25% of the visible nail indicated nail removal for nailbed inspection and repair, but a recent review concludedthat a subungual hematoma without significant fingertipinjury can be treated with trephining (drainage througha hole) alone.42www.aafp.org/afp American Family Physician 631
Laceration RepairManagement of Acute LacerationsBleeding?YesHemostasis (ligation or sutures)NoYesContaminated with debris or dirt, bitewound, or concern for infection?Irrigation, debridement,removal of foreign bodyNoDeep tissue injuries?NoYesRepair of muscle/tendonReferral for deep injury of the hands, eyelids, and nose;lacrimal duct injury; nerve injury; or open fractureManagement of skin lacerationLeave skin open; patient shouldbe seen within 24 hours of injuryFaceScalpTrunkUpper extremitiesLower extremitiesSkin repair:Simple interrupted,simple running, horizontalmattress, vertical mattresssutures; staples; hairapposition techniqueSimple interrupted, simplerunning, horizontal mattress,vertical mattress suturesSimple interrupted,simple running,horizontal mattress,basic lattice sutures;tissue adhesive;surgical stripsSimple interrupted,simple running,horizontal mattresssuturesSimple interrupted or simplerunning sutures, surgical strips,tissue adhesivesIf the wound is clean, doublelayer with running subcuticularor interrupted dermal suturesIf the wound is clean with littletension, running subcuticularsutures, tissue adhesivesMucosal surface (lips, oral, genitalia) repair:Simple interrupted or simple running sutures; absorbableFigure 4. Algorithm for the management of acute lacerations.Up to 19% of bite wounds become infected. Cat bites aremuch more likely to become infected compared with dogor human bites (47% to 58% of cat bites, 8% to 14% ofdog bites, and 7% to 9% of human bites).43 The risk ofinfection increases as time from injury to repair increases,regardless of suture material.4 Evidence on optimal timingof primary closure and antibiotic treatment is lacking.4,44Cosmesis was improved with suturing compared withno suturing in RCTs of patients with dog bites, althoughthe infection rate was the same.44,45 Therefore, dog bitewounds should be repaired, especially facial woundsbecause they are less prone to infection.4,46 Cat bites, withhigher infection rates, have better outcomes without primary closure, especially when not located on the face orscalp. Bite wounds with a high risk of infection, such ascat bites, deep puncture wounds, or wounds longer than3 cm,43 should be treated with prophylactic amoxicillin/clavulanate (Augmentin).47,48 Clindamycin may be usedin patients with a penicillin allergy.49632 American Family PhysicianILLUSTRATION BY RENEE CANNONBITE WOUNDSFigure 5. Hair apposition technique for laceration closure.Opposing strands of hair are brought together with a simple twist and are secured with a drop of tissue adhesive.Reprinted with permission from Forsch RT. Essentials of skin lacerationrepair. Am Fam Physician. 2008;78(8):949.www.aafp.org/afpVolume 95, Number 10 May 15, 2017
Laceration RepairTable 2. Commonly Used Suture e polymer(polyglactin 910 [Vicryl])Poliglecaprone (Monocryl)Polydioxanone (PDS II)NonabsorbableNylon (Ethilon)Polypropylene (Prolene)SilkCommon needletype*Time to lose50% strengthConfigurationTypical useReverse cuttingConventional orreverse cuttingConventional andreverse cuttingReverse cutting10 to 14 days2 to 3 weeksMonofilamentBraided7 to 10 daysMonofilamentMucosa, eye woundsDeep dermal, muscle, fascia, oral mucosa,genitalia woundsDermal, subcuticular wounds4 weeksMonofilamentMuscle, fascia, dermal woundsCutting edgeTapered point,blunt tip 10 yearsIndefiniteMonofilamentMonofilamentDoes not comewith needle1 yearBraidedSkinMostly used in vascular surgeries; can beused for skin, tendon, and ligaments,depending on the needlesUsed for hemostasis in ligation of vesselsor for tying over bolsters*—A variety of needles are available to order, but the most typical needles likely to be stocked are listed.Information from references 50 and 51.CHOOSING THE APPROPRIATE SUTURE MATERIALPhysicians should use the smallest suture that will givesufficient strength to reapproximate and support thehealing wound
increase the risk of wound infection. Good evidence suggests that local anesthetic with epinephrine in a concentration of up to 1:100,000 is safe for use on digits.
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007-1 allogeneic bone marrow transplant 9.0159 23.0 41 007-2 allogeneic bone marrow transplant 13.1525 36.3 96 . coma 1 hr or no coma 0.8786 2.6 5 056-2 brain contusion/laceration & complicated skull fx, coma 1 hr or no coma 1.4162 3.8 9 056-3 brain contusion/laceration & complicated skull fx, coma 1 hr or no coma 2.8989 10.3 27 .
A two-phase mechanical test was designed to quantify laceration injury risk of individual cleats. Phase one represents initial impact and phase two represents the subsequent raking motion as observed in the biomechanical study. Each phase is based on the impact parameters of observed stamping impacts. The developed test method has the
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