II. History

  1. History of injury
    1. Identify if risk of Retained Foreign Body
    2. Identify contaminants (e.g. soiled knife)
    3. Concurrent serious injury (e.g. Closed Head Injury)
  2. Comorbid conditions
    1. Human Immunodeficiency Virus Infection
    2. Diabetes Mellitus
  3. Medication allergies
    1. Latex Allergy
    2. Local Anesthesia allergy
    3. Tape allergy
    4. Antibiotic allergy
  4. Tetanus Immunization status
    1. Update with Td or Tdap if longer than 5 years since last tetanus Vaccine

III. Exam

  1. Identify functional loss prior to injecting anesthesia
  2. Evaluate muscle and tendon structures
  3. Evaluate nerve structures
    1. See Motor Exam
    2. See Sensory Exam
  4. Evaluate vascular structures
  5. Evaluate underlying bone

IV. Contraindications: Relative Contraindications to primary wound closure

  1. Infected and inflamed wounds
  2. Human Bite or Animal Bite
  3. Serious crush wounds
  4. Primary repair time constraints above not met

V. Indications: Surgical Consultation

  1. Deep hand or Foot Wounds
  2. Full-thickness Eyelid, lip or ear Lacerations
  3. Nerve, artery, bone or joint involvement
  4. Penetrating wounds of unknown depth
  5. Severe crush injuries
  6. Wounds requiring drainage (severely contaminated)
  7. Cosmetic outcome of significant issue

VI. Risk Factors: Wound Infection

  1. Age of Laceration Repair does not appear to significantly impact infection risk
  2. Diabetes Mellitus
  3. Laceration >5 cm
  4. Lower extremity Laceration
  5. Wound contamination
  6. Quinn (2014) Emerg Med J 31(2): 96-100 [PubMed]

VII. Preparations: Closure Material

  1. Suture Material
    1. See Suture Material for Suture type and size selection
    2. Deep (dermal or buried) Absorbable Sutures
      1. Vicryl is most commonly used for the deep layer, unless risk of infection (in which case use monofilament)
      2. Polyglecaprone 25 (Monocryl)
        1. Indicated for deep layer when wounds are higher risk of infection (Vicryl is contraindicated)
        2. Polydioxanone (PDS) is alternative to Polyglecaprone 25 (Monocryl) but has prolonged absorption
    3. Superficial Sutures (e.g. simple interrupted, RunningSuture)
      1. Nonabsorbable Sutures (standard approach)
        1. Nylon (Ethilon) or Polypropylene (Prolene)
      2. Absorbable Sutures (Controversial)
        1. May be used effectively, and with similar cosmetic results in children to avoid Suture removal
        2. For facial Lacerations us fast Catgut, and for trunk or extremity use plain Catgut or Vicryl Rapide
        3. Alternatively, subcuticular skin closure technique may be used
  2. Tissue Adhesive
    1. See Tissue Adhesive
    2. Avoid use around the eyes due to risk of Cyanoacrylate Eye Injury and risk of Periorbital Cellulitis
    3. Limit to well-approximated, low tension, superficial Lacerations with linear edges
  3. Tape closure (Steri-strip) with Benzoin
    1. Remains attached for 4 days
    2. Lower risk of Wound Infection
    3. Place an extra steri-strip across each of strip ends
  4. Staples
    1. Indicated for scalp Lacerations (tendons, nerves deep)
    2. Higher risk of infection when used for post-operative orthopedic and cesarean skin closures
      1. Figueroa (2013) Obstet Gynecol 121(1):33-8 [PubMed]
      2. Smith (2010) J Bone Joint Surg Am 92(16):2732-2732 [PubMed]

VIII. Preparation: General

  1. Instrument pointers
    1. Use pickups with teeth (less crush injury)
  2. Gloves
    1. Sterile gloves not needed in uncomplicated repair
    2. Perelman (2004) Ann Emerg Med 43:362-70 [PubMed]
  3. Ruler
    1. Estimates of length without a ruler are inaccurate (although women estimate better than men)
    2. Measurement is key if billing and coding are based on lesion length
    3. Peterson (2014) Injury 45(1): 232-6 [PubMed]

IX. Protocol: Repair timetable

  1. Age of Laceration does not appear to significantly impact infection risk
    1. Decision for primary closure should not solely be based on the age of Laceration ("golden period" for repair)
    2. Wounds involving nerves, blood vessels, tendons or bones have additional caveats
    3. Wounds <19 hours old heal better than those open for longer periods
      1. Berk (1988) Ann Emerg Med 17(5): 496-500 [PubMed]
    4. Bacterial count increase by 3 hours
      1. However Wound Infection risk is not directly correlated with age of Laceration
      2. See Risk Factors for infection as listed above
  2. Primary Repair
    1. See above precaution regarding no absolute cut-off for primary repair
    2. Face or Scalp: Repair within 24 hours (18 hours preferred)
    3. Body: Repair within 12-18 hours (6 hours preferred)
  3. Older wounds with infection risk
    1. Step 1: Initial Evaluation
      1. Option 1: Loose approximation with simple interrupted Suture
      2. Option 2: Pack wound with sterile wet to dry dressings changed twice daily
    2. Step 2: Reevaluation at 3-5 days
      1. No infection: Primary wound closure with Suture
      2. Infection: Treat infection and healing by second intention as below
    3. Alternative
      1. Consider loose closure with superficial, nonabsorbable monofilament Sutures (e.g. Nylon, Prolene)
      2. Consider scehduled wound recheck in 1-2 days, or in reliable patients, as needed follow-up for signs infection
      3. Remove Sutures if infection occurs
  4. Healing by second intention
    1. Pack wounds with sterile wet to dry dressing bid
    2. Granulation and Contraction risk without suturing

X. Protocol: Local Anesthesia

  1. Prepare skin with antiseptic prior to injection
    1. Betadine is not affective until it dries (hence hibiclens is often preferred)
    2. Avoid hibiclens near eyes (irritation) and inside ear canal (ototoxic)
  2. See Local Skin Anesthesia for pearls to decrease patient discomfort

XI. Protocol: Irrigation

  1. Saline is as effective as antiseptics (e.g. 1% betadine) for irrigation
  2. Tap water is as safe and effective as saline for irrigation (and more plentiful)
    1. Fernandez (2012) Cochrane Database Syst Rev (2): CD003861 +PMID:22336796 [PubMed]
    2. Weiss (2013) BMJ Open 3(1) +PMID:23325896 [PubMed]
  3. Moderate pressure irrigation is the key
    1. Irrigation with syringe provides approximately 7 psi
  4. Irrigate with minimum of 250 to 500 cc (use 1000 cc or more if contaminated)
    1. Normal Saline irrigation, compressible plastic bottles (250-500 cc) with plastic adapter OR
    2. Syringe 30-60 ml syringe (requires multiple refills)
  5. Avoid irrigation with tissue destructive agents
    1. Hydrogen peroxide (weak germacide)
    2. Betadine at stock concentration (9%)
      1. Always dilute betadine (1:10)

XII. Protocol: Wound Preparation

  1. Remove all foreign bodies with scrub brush on skin surface
  2. Do not apply Betadine or Hibiclens inside of wound
    1. Apply to wound edges prior to anesthesia injection (see Local Anesthesia as above)
  3. Drape widely to allow clear margins
  4. Scalp Wounds
    1. Slick surrounding hair down with K-Y Jelly
  5. Lacerations near the eye
    1. See Eyelid Laceration
    2. Avoid Tissue Adhesive if possible (risk of Cyanoacrylate Eye Injury and increased risk of Periorbital Cellulitis)
    3. Do not shave eyebrows
  6. Thin skin flaps (skin tears, especially in elderly)
    1. Patient must keep the area clean and dry, and not apply antibiotic ointment to prevent the steri-strips from sloughing
    2. Glue steri-strips parallel to wound edges
      1. Suture through the steri strips into skin
      2. Allows for greater strength at wound edge and prevents Suture from tearing through
      3. Pacifico (2009) J Plast Reconstr Aesthet Surg 62(12): e637-8 [PubMed]
    3. Glue steri-strips perpendicular to wound edge, across the Laceration (standard use)
      1. Suture through the steri-strips and traverse the wound as would be done normally
      2. Davis (2011) J Emerg Med 40(3): 322-3 [PubMed]
  7. Facial Nerve region
    1. Exercise caution in region of Facial Nerve, especially near Parotid Gland and mandubular branch
    2. Risk of permanent nerve injury
    3. Prevent excessive swelling that may compress Facial Nerve branches (consider wound drains)

XIII. Management: Hemostasis

  1. See Tourniquet (Pneumatic Tourniquet, Windlass Tourniquet)
  2. See Topical Hemostatic Agent
  3. See Hemorrhage Management
  4. Precautions
    1. Patient reports of spurting or pumping bleeding is arterial injury until proven otherwise
    2. Arterial injury may not be immediately obvious on Emergency Department presentation
      1. Arterial bleeding may stop briefly due to vasospasm and small thrombus formation
    3. Do not ligate named arteries
      1. Consult surgery if arterial injury is suspected
  5. Management of small artery bleeding
    1. Apply direct pressure
    2. Arteries <2mm
      1. Locally infiltrate Lidocaine with Epinephrine
      2. Consider electrocautery
    3. Small, unnamed arteries >2mm
      1. Ligation (if able to identify the bleeding vessel)
        1. Clamp the bleeding end and apply ligature (Suture)
      2. Figure of eight Suture (or horizontal mattress)
        1. Indicated for vessel that has retracted within tissue and cannot be clamped
        2. Imagine a square box around the bleeding source
          1. Each corner of the exposed square represents an entry or exit of the figure of eight Suture
          2. Tying the figure of eight compresses the tissue around the bleeding source

XIV. Protocol: Wound Repair

  1. Specific injury approaches
    1. See Finger Laceration
    2. See Scalp Repair
    3. See Wound Dressing for Transport
      1. Indicated if repair must be done elsewhere
  2. Debridement
    1. Recut wound for clean, fresh, surgical-incision edges
  3. Undermining
    1. May be required to ensure Dermis closure
  4. Suture technique
    1. Grasp Suture Needle with needle driver one third of way from Suture attachment (where needle becomes straight)
    2. Evert wound edges (do not dig a ditch, build a flask)
      1. Everted edges will flatten over time, inverted edges result in more prominent scars
      2. Needle should enter perpendicular to skin
      3. Direct the needle initially down and away from the Laceration edge
      4. Rotate the wrist and needle driver, following the needle curvature
      5. Exit perpendicular to the skin surface on the opposite side of the Laceration
    3. Reduce skin tension
      1. High skin tension results in a wound that may gape open with risk of Hypertrophic Scar
      2. If skin tension is high, use deep Sutures first to reduce surface skin tension
      3. Wound eversion is a good sign that skin tension has been reduced across the wound edge
    4. Interupted simple mneumonic
      1. Not too many
      2. Not too tight
      3. Not too wide
      4. Get them out
    5. References
      1. Lin, Kantor and Shinar in Herbert (2017) EM:Rap 17(4): 1
  5. Techniques
    1. Simple Interrupted Suture
      1. sutureSimpleInterruptedLabel.jpg
    2. Half-buried Horizontal Mattress Suture
      1. sutureHalfBuriedHorizontalMattressLabel.jpg
    3. Horizontal Mattress Suture
      1. sutureHorizontalMattressLabel.jpg
    4. Vertical Mattress Suture
      1. sutureVerticalMattressLabel.jpg
    5. Deep Suture
      1. sutureDeepLabel.jpg
    6. RunningSuture
      1. sutureRunningLabel.jpg
    7. Running Subcuticular Suture
      1. sutureRunningSubQLabel.jpg
  6. Suture Removal
    1. See Suture for timing of Suture removal

XV. Protocol: Bandages

  1. Moist Wound Healing is key
  2. Non-adherent slightly moist or Occlusive Dressing
  3. Ointment or Topicals (e.g. Bacitracin)
    1. Apply for first 3 days until epithelialization
    2. Reduces infection risk at minor wound sites
      1. Dire (1995) Acad Emerg Med 2(1): 4-10 +PMID:7606610 [PubMed]
    3. Precautions
      1. Avoid applying ointment over Skin Glue closure (e.g. Dermabond)
      2. Topical Antibiotics cause a irritant or Allergic Contact Dermatitis in up to 10% of cases
        1. Reactions are most common with neosporin (or triple antibiotic)
        2. Reactions may also occur with Bacitracin
  4. Consider debridement after epitheliazation (day 3)
    1. Initial use of Occlusive Dressings (first 3 days) prevent scab formation
    2. Carefully apply 50% hydrogen peroxide to scab
    3. Avoid prior to day 3 (delays Wound Healing)
    4. Scab removal may improve cosmesis

XVI. Protocol: Home Instructions

  1. Gentle compression
  2. Precautions about water exposure (e.g. bathing, getting wound wet)
    1. Previously, patients were warned not to get the lesion wet for first 24-48 hours after repair
    2. Early water exposure at a wound site does not appear to increase the risk of infection
      1. Heal (2006) BMJ 332(7549): 1053-6 +PMID:16636023 [PubMed]
    3. Patients should still avoid exposure to contaminated water (e.g. dish washing)

XVII. Management: Adjuncts

  1. Prophylactic antibiotics possible indications
    1. Not routinely indicated in noncontaminated wounds
    2. Wounds at higher risk of secondary infection
      1. See secondary infection risk factors below
    3. Comorbidity with risk of distant site infection
      1. Endocarditis risk (see SBE Prophylaxis)
      2. Hip prosthesis
  2. Post-exposure Tetanus prophylaxis
    1. Unknown Immune Status or never immunized
      1. Tetanus Toxoid Containing Vaccine (e.g. Td, Tdap, TT) now, at 6 weeks and 6 months AND
      2. Tetanus Immune globulin 250 Units IM if Puncture Wound or contaminated wound
    2. Last Tetanus Toxoid containing Vaccine over 5-10 years prior
      1. Tetanus Toxoid Containing Vaccine (e.g. Td, Tdap, TT) now

XVIII. Management: Disposition

  1. Hospitalization Indications
    1. Failed outpatient therapy (especially if non-compliance with recommended management)
    2. Poorly controlled comorbidity (e.g. Diabetes Mellitus, Peripheral Vascular Disease)
    3. Immunocompromised state
    4. Severe or progressive Cellulitis (especially if deeper, regional or systemic signs)
    5. Necrotizing Fasciitis
  2. Referral Indications
    1. Wounds affecting joints, bones, tendons or nerves
    2. Wounds affecting large body regions
    3. Facial wounds
    4. Burn Injury
      1. See Burn Injury for referral/transfer criteria
      2. Severe or circumferential burns or
      3. Burns to the face, hands or feet

XIX. Complications: Secondary Wound Infection

  1. See Wound Infection for risk factors
  2. Occurs within 48 hours in most cases

XX. Course: Wound Healing

  1. See Wound

XXI. References

  1. Lin and Lin in Herbert (2014) EM:Rap 14(11): 8-10
  2. Mortiere (1996) Principles of Primary Wound Management
  3. Snell in Pfenninger and Fowler (1994) Procedures for Primary Care Physicians, Mosby, Chicago, p. 12-9
  4. Worster (2015) Am Fam Physician 91(2): 86-92 [PubMed]

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Ontology: Laceration (C0043246)

Definition (MSH) Torn, ragged, mangled wounds.
Concepts Injury or Poisoning (T037)
MSH D022125
SnomedCT 312608009, 210496003, 262543001, 157351009, 269347002, 35933005, 125671007
LNC LA7452-1, LA19042-3
English Laceration, Laceration NOS, Lacerations, Lacerations [Disease/Finding], lacerate, tearing, lacerated wound, lacerating, tear, lacerated, lacerated wounds, injury laceration, lacerates, lacerations, torn, Laceration NOS (disorder), LACERATION(S), Lacerated, Wound, lacerated, Tear, Tear - wound, Laceration - injury, Laceration (morphologic abnormality), Laceration - injury (disorder), laceration, Laceration, NOS, Tear, NOS
Italian Lacerazione, Lacerazioni
Japanese 裂傷, レッショウ
Czech tržná poranění, lacerace, Lacerace
Finnish Laseraatiot
Swedish Lacerationer
Spanish laceración - lesión traumática (trastorno), laceración -- lesión, laceración - lesión traumática, laceración -- lesión (trastorno), laceración, SAI, laceración, SAI (trastorno), desgarro - herida, desgarro, laceración (anomalía morfológica), laceración, Laceración, Laceraciones
Polish Rany szarpane
Hungarian Szakított seb
Norwegian Laceratio, Laserasjoner, Flerresår
Portuguese Laceração, Lacerações
Dutch inscheuring, Laceraties
French Déchirure, Lacérations, Dilacérations
German Risswunde, Lazerationen

Ontology: Closure of skin by suture (C0191408)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 265902003, 302409002, 61723005, 150347009, 415689009, 204780001, 391906003
English skin suture, Suture;laceration;skin, closure of skin by suture, skin sutures, Suturing - skin, Suture of skin (procedure), Suture of skin laceration, Skin repair (& suturing) (procedure), Closure of skin wound by suture, Suture of skin NOS, Skin/s.c. tissue repair, Suture of skin NOS (procedure), Skin repair (& suturing), Closure of skin laceration by suture, Suture of skin wound, Suture of skin, Closure of skin by suture (procedure), Closure of skin by suture, NOS, Suture of skin [Ambiguous], Closure of skin by suture, suture of skin laceration
Spanish sutura de una laceración en la piel, cierre de una laceración en la piel mediante sutura, sutura de piel, SAI (procedimiento), sutura de piel, SAI, cierre de una herida en la piel por sutura, cierre de una herida en la piel, sutura cutánea, SAI, sutura de piel, cierre de la piel por sutura (procedimiento), cierre de la piel por sutura