Laceration, Simple

Presentation

Lacerations arise from either a cut with a sharp object or direct blunt trauma that exceeds the tensile strength of the skin. Consequently, lacerations may be linear ( Fig. 140.1 ) or stellate/complex with various amounts of tissue loss. The elderly and patients on chronic steroid therapy may present with “wet tissue paper” skin tears following relatively minor trauma.

What to Do

• A history should establish the approximate time of injury as well as the exact mechanism of injury. Traditional teaching associates increased risk with delayed closure, but this is not supported by data. There is no clear cutoff at which wounds are too high risk to repair. However, closure after 19 hours is associated with poorer wound healing. The location of the wound is more predictive of infectious risk, with lower extremity wounds being highest. This may in part be due to reduced circulation as well as bacteria from the anogenital region being washed over the wound during showers.

• Perform a distal neurovascular exam and assess tendon function on all extremity injuries. Put joints through both active and passive range of motion to assess for tendon injuries that may be temporarily outside the field of view. Test tendon function against resistance. Significant pain and/or lack of function indicates a partial or complete tendon laceration. Decreased or absent sensation suggests nerve injury. Tendon and nerve lacerations deserve specialty consultation.

• The following also require surgical consultation: joint capsule disruptions, vascular injuries, repair of specialized structures (e.g., parotid or lacrimal duct, eyelid margin, tarsal plate), extensive injuries, or those involving significant tissue loss.

• Provide either regional or local anesthesia prior to irrigation and wound repair. To help reduce the pain of injection , begin subdermally, inside the wound edge so as to avoid piercing intact skin. Inject slowly while repetitively pinching the skin, just behind the area being injected ( Fig. 140.2 ).

  

• Irrigation is the most important step in preventing infection. It is not necessary to use sterile water; tap water appears to be as efficacious in preventing infection.

• Two equally efficacious approaches to irrigation are available: high pressure/low volume (HP/LV) or low pressure/high volume (LP/HV).

  • HP/LV: Using a 60-cc syringe or a pressurized bag of intravenous fluid and an 18-gauge catheter creates an approximate pressure of 8 pounds per square inch (psi). No high-quality data are available regarding the optimal volume of irrigation solution with this technique, but a general guideline is to use 100 cc per centimeter of laceration length.

  • LP/HV: Using the pressure generated by the tap of a sink, the patient self-irrigates the wound with tap water. Again, no high-quality data exist regarding optimal volume and duration with this technique, but a general guideline is to irrigate for 1 minute per centimeter of laceration length.

• After irrigation and under hemostatic conditions, inspect for embedded foreign bodies and adherent debris. Keep in mind that with deeper lacerations, upper tissue layers may slide back in place and cover over hidden contaminants. Always use a gloved finger to explore the depth of any wound and expose any hidden debris. Consider bedside ultrasonography or radiographs if concern for foreign bodies persists. If a foreign body is seen, the risk of removal must be weighed against the risk of complications. Glass, metal, and plastic are generally inert, and their removal is not paramount but always recommended. Organic matter (e.g., wood, soil, other plant matter) can have highly immunogenic resin and serve as a nidus of infection. These contaminants must always be removed completely by further high- jet lavage, tissue abrasion with a wet surgical sponge or No. 10 scalpel blade, or sharp excision using forceps and scissors.

• Children may also benefit from a topical anesthetic agent, especially for scalp and facial lacerations. Lidocaine 4% plus epinephrine 1:1000 (0.1%) plus tetracaine 0.5% (LET) is safe, effective, and inexpensive. Put 3 mL on a cotton ball and press firmly into the wound for 20 to 30 minutes, either with tape or with the parent’s gloved hand.

• Cosmetic considerations will influence the degree to which facial lacerations are debrided. Excision of contaminated nonviable wound edges should be kept to a minimum on the face, with tissue preservation being of primary concern.

• Hair generally does not need to be removed. When necessary, shorten hair with scissors rather than shaving with a razor.

• Sterile gloves may be used for enhanced dexterity, but they are not necessary and do not reduce the risk of infection. Of course, routine protective vinyl gloves are required as an alternative.

• Ask about tetanus immunization status and provide prophylaxis where indicated (see Appendix G).

• In general, prophylactic systemic antibiotics are only indicated in heavily contaminated wounds, lacerations from bites, or in patients who are immunocompromised.

• After closing the wound with sutures, apply bacitracin antibiotic ointment and a sterile protective nonadherent dressing. While data are scarce, they suggest that topical application of bacitracin or neomycin reduces infection rates. However, neomycin is a highly allergenic compound, thus bacitracin is preferred.

• Give patients clear, specific discharge instructions that explain the potential complications of their injuries, and tell patients when and where to go for reevaluation and follow-up care.

• Schedule a wound check in 2 days if the patient is likely to develop any problems with infection, require dressing changes, or need continued wound care. After 48 hours, most sutured wounds can be redressed with a simple bandage that can be easily removed and replaced by the patient, allowing for a shower each day.

• The following discusses various suture and other wound closure techniques. They are meant to refresh memory but are not adequate as instruction for a novice provider.