Laceration repair - WikEM (2024)

Overview

• This page is for general approach to lacerations and their repair.
  • See "See Also" section below for specific special laceration types.

Indications

• Skin or mucosal laceration.

Contraindications

• Body laceration >12 hours old
• Face/scalp wounds >24 hours old

When to Call a Consultant

• Signs of neurovascular or tendon injury
• Facial wounds that cross cosmetic boundaries
• Tissue loss

Equipment Needed

Suture Types

Laceration Areas and Their Common Suture Type and Duration

Note: consider use of Fast Absorbing Gut (5-0/6-0) on Ear, Eyelid, Eyebrow, Nose, Lip and Face if anticipated difficulty with suture removal

Note: Favor absorbable sutures for facial repair especially in children

Procedure

Wound Preparation

• Debridement is most important step in reducing infection/ promoting healing
• Avoid betadine/chlorhexadine in wound
• Not necessary to remove hair as this can increase chances of infection (if do, avoid using razor)
  • Can use antibiotic ointment to help keep hair out of the way

Anesthesia

• Can be topical or injected.
• Topical
  • LET for open wound, EMLA for intact skin
    • EMLA needs to be left on 1-2 hours ^[1]
    • LET onset is 20-30 minutes^[1], area will appear pale
• Evaluate motor/sensation before giving local anesthesia
• To decrease pain of injection:
  • Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine)
  • Inject slowly
• Consider nerve blocks to avoid tissue distortion for cosmetic areas such as vermillion border
  • Also helpful for extremities, sole of foot
  • Digital block for finger lacerations

Maximum Doses of Anesthetic Agents

Irrigation

• High pressure irrigation is best (can be achieved with 18 gauge syringe)
• Tap water is as effective as sterile water/ normal saline^[2][3][4]
  • Pressure from tap is ~45 psi, higher than syringe^[5]
• Irrigation optional for face/scalp wound as long as:
  • Not a bite wound
  • Not a contaminated wound
  • Not older than 6 hours
    • Often best to avoid irrigation of face and opt for cleaning with gauze to help prevent tissue distortion

Exploration

• See Soft tissue foreign body
• Explore to base of wound
• Ideally done in bloodless field
• Look for foreign bodies, tendon injury, or fracture
• Possible glass or metal in wound = get XR or US to evaluate

Suturing

• Simple Interrupted
  • Less potential for causing wound edema or impaired circulation
  • Allows for alignment adjustments
• Simple Running
  • Useful for long, linear wounds
  • Risk of dehiscence if suture ruptures
• Horizontal Mattress
  • Spreads tension over wound
  • Useful for high tension wounds
• Vertical Mattress
  • Great for wound eversion, closure of both superior and deep layers
  • Useful when there is a contraindication to deep sutures
• If laceration not closed immediately secondary to age of wound:
  • Irrigate and explore wound, then pack with non-adherent or vaseline gauze
  • Re-check in 3 days - may suture at that point if wound appears clean.

Steri-Strips

• Just as good a suturing according to this ^[6] and other articles. Picture on how to do it property from the same article ^[6] which is under CC BY-NC-SA 4.0 license:

Skin Glue

• Useful for areas of low tension and well approximated wounds
• Apply 3 layers allowing 30 seconds for first layer to dry
• Avoid in bite wounds, contaminated wounds, puncture wounds, mucosal surfaces, areas of high moisture (groin, axilla)
• Avoid antibiotic ointments which can prematurely dissolve glue
• If you accidentally glue the eyes shut use dexamethasone, neomycin, polymyxin B eyedrops (brand name Maxitrol in the U.S.) on the glue then gentle rubbing after 45 or 90 seconds ^[7]

Aftercare

• Consider antibiotics for
  • Wounds contaminated by debris or feces
  • Caused by punctures or bites
  • Tissue destruction or in avascular areas
  • Neglected wounds
  • Underlying systemic immunodeficiency (diabetes, HIV, chronic steroid use, etc)
  • Impaired local defenses, such as peripheral arterial disease or lymphedema
  • Retained foreign body

Wounds contaminated by fresh water and plantar puncture wounds through athletic shoes should include Pseudomonas coverage

• Splinting
  • Wounds over flexor surfaces or tension
• Tetanus prophylaxis
  • Tdap 0.5cc IM to patients >7y with no booster within 5 yr
  • Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given
    • Require follow up Tdap at 1mo & 1 yr; age>60 = high risk of poor immunization
• Dressing
  • Keep moist, not wet
    • Bandaid, xeroform, or ointment
• Wound check
  • 48-72 hrs ONLY if high risk wound
    • No point in checking before 48hr (takes this long for infection to occur)

Scar Minimization

• Preventing infection
  • Keep wound clean and covered
  • Apply antibiotic ointment twice daily
• Once healed, encourage daily sunscreen use and Vitamin E creams

Complications

Billing Considerations

Must document:

• Anatomical location of wound
• Size of wound
  • Length (cm) <2.5, 2.6-5.0, 5.1-7.5, 7.6-12.5, 12.5-20.0, 20.1-30.0, >30.0
• Complexity
  • Simple, intermediate, or complex (depends on debridement, layers, complex stitch, drain, etc.)
• Type and number of sutures

See Also

• Soft tissue foreign body
• LET

Special Lacerations by Body Part

• Head
  • Conjunctival laceration
  • Ear laceration
  • Eyelid laceration
  • Lip laceration
  • Scalp laceration
  • Tongue laceration
• Hand
  • Fingertip amputation
  • Nailbed laceration
• Other
  • Bites
  • General laceration repair (main)

External Links

• Merck Manual - How To Repair a Laceration With Simple Interrupted Sutures
• Merck Manual - How To Repair a Laceration With Horizontal Mattress Sutures
• Merck Manual - How To Repair a Laceration With Vertical Mattress Sutures

Videos

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References

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