Approach to Laceration Repair

1. Clean the wound thoroughly: “The solution to pollution is dilution."

Normal saline is irrigant of choice.

Betadine decreases healing and is not necessary.

2. Inspect the wound thoroughly so that you know what you are dealing with.

Look for structures deep within the wound that need to be addressed.

Approximate the wound edges with your fingers. It shows you what tissue goes where. It gives you a sense of the elastic forces (tension/approximation). It helps you assess for any missing tissue.



3. Suture

Close the areas with the highest tension first!

This does not need to be approximated perfectly. Get the tissue about where it needs to be, to help take the tension off the remaining sutures. Then, go back and revise these early sutures at the end.

Piece together the corners early in the repair.

Local Anesthetic

For most urgent care repairs, there is no reason to use lidocaine with epinephrine. Plain lidocaine is sufficient.

Consider a 50/50 mix with bupivacaine: you get immediate anesthesia from lidocaine, and the patient remains pain-free when they go home, since bupivacaine lasts 6 hours.

you get immediate anesthesia from lidocaine, and the patient remains pain-free when they go home, since bupivacaine lasts 6 hours. A true allergy to lidocaine is very rare.

Patients may describe, “I was at the dentist’s office and my heart started racing when I got lidocaine.” This reaction is caused by the epinephrine, not the lidocaine.

Material

Monofilament (Monocryl) is preferred: because non-surgical wounds are dirtier and more prone to infection; monofilament is less likely than braided suture to get infected.

because non-surgical wounds are dirtier and more prone to infection; monofilament is less likely than braided suture to get infected. Using sub-dermal sutures takes tension off of the wound, which reduces scarring.

Absorbable vs non-absorbable sutures?

Non-absorbable is better because it is less likely to be­come infected and ensures that the patient gets adequate follow-up.

Absorbable sutures also have varying rates of degradation, so it is difficult to know when the sutures will be out.

Tejani C, et al. A comparison of cosmetic outcomes of lac­erations on the extremities and trunk using absorbable versus nonabsorbable sutures. Acad Emerg Med. 2014 Jun:21(6):637-43. PMID: 25039547.

Cosmetic outcomes were similar in the 2 groups, including the appearance of train tracks.

Vicryl Rapide had 11% incidence of infection vs only 1% incidence in prolene group.

Conclusion: don’t use absorbable sutures in laceration repair because they are at greater risk of infection.

Aftercare Instructions

Suture removal, generally speaking, is in 7-10 days. 5 days for the face or other cosmetic locations and under low tension. Up to 14 days for sutures in the hand or across a joint

Cleanse the wound thoroughly every day with either soap and water or 1/2 peroxide and 1/2 water to prevent scabbing: you want to be able to take the sutures out easily and not have to go digging.

Apply antibiotic ointment for 1-2 days.

Showering is ok, but no swimming until wound is healed (a few days after sutures are removed, and at least 1 week after injury).

Special Types of Lacerations

FACE

Use 6-0 nylon or prolene with a small needle.

Consider deep sutures (use 6-0 vicryl) if there is a lot of tension, to help take the elastic force off and allow you to close the outer layers without any tension.

Follow up the wound in 3 days.

Remove sutures in 5 days.

BITES

Use very thorough and vigorous irrigation. Tetanus vaccination for everyone!



for everyone! Start antibiotics early – the sooner you start the better. Cat or Dog bite: amoxicillin/clavulanate (Augmentin) 875mg/125mg PO q12hr x 3-5 days. Human bite: Augmentin as above or cephalexin (Keflex) 500mg PO q12hrs x 10 days. In general, it is best NOT to close these wounds: allow them to heal by secondary intention with revision at later date, if possible. NEVER close cat or human bites. You can consider closing dog bites only after very good irrigation. L oosely close with sutures farther apart than usual and give very close follow-up.



Three studies support this approach: Chen E, et al. Primary closure of mammalian bites. Ac Emerg Med. 2000 Feb:7(2):157-61. PMID: 10691074. Paschos NK, et al. Primary closure versus non-closure dog bite wounds. A randomized controlled trial. Injury. 201 Jan:45(1):237-40 PMID: 23916901. Medeiros I, et al. Antibiotic prophylaxis for mammali bites. Cochrane Database Syst Rev. 2001;(2):CD00173 PMID: 11406003.





Conclusions: it is safe to close dog bites, regardless location in patients who present within 8 hours of injury

Caveats: don’t close wounds to the hand: don’t close wound if patient is iimmunocompromised.



FRACTURES (i.e. tuft fractures or finger fractures with laceration)

Although usually most open fractures go to the operation room for wash out, these can be well-managed in the urge care setting.

The tendency is to use a lot of sutures to get things closed up, but all this does is cut off circulation and increase risk infection. So, use LESS SUTURE!

Irrigation, early antibiotics, and less suture are better help maintain circulation.

Tuft fractures that need to be pinned: close the skin and send to plastics/ortho within 5-7 days.

SUBUNGUAL HEMATOMAS

In the past, treatment involved removing the toenail in order suture the nail bed laceration.

Now, we treat symptomatically: trephinate to relieve pressure and prevent tissue necrosis. It is not necessary remove the toenail.

EAR INJURIES

Think of the external ear anatomy like a sandwich: skin both sides are the bread, cartilage is the filling on the inside.



Most ear lacerations are on the anterior surface involving t skin. Sometimes, they extend to cartilage. Rarely do ear lacerations involve all three layers.

Skin only laceration: irrigate, then place loose, interrupted , 5-0 or 6-0 prolene sutures. Thru-and-thru lacerations of the ear: irrigate very well, close loosely with chromic on the inside, and close skin on the front and back with prolene. Give antibiotics! Laceration through cartilage

Cartilage has poor circulation and hence greater chance of infection.



The greater amount of foreign body (suture)that you use in an area with poor circulation, the greater the chance of infection.



So, if the cartilaginous injury does not impair the stability of the ear, there is no need for sutures through the cartilage - just irrigate and close the skin.

NASAL FRACTURE

Most importantly, rule out a septal hematoma!





Can be sutured if needed and referred to ENT or facial plastics as an outpatient within 3-5 days (within 1 week if they need surgery).

Often Missed

There are 2 important things that are often missed with laceration repairs:

Retained foreign bodies Tendon Lacerations

Make sure you examine the injury in full range-of-motion. If you think there is a tendon injury but you cannot see it, repair the skin, place them in a splint, and refer to plastics or orthopedics for follow-up, because if tendon lacerations are not repaired properly, patients can have a lifetime of disability.

SUGGESTION for UC PROVIDERS: Find a plastic surgeon in your area who is willing to work with you and who you can call when you have a question about something. Once you get comfortable working with them, you will develop a rapport and an understanding of how he/she likes to handle different types of injuries.