Laceration repair: Difference between revisions
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==Overview== | |||
*This page is for general approach to lacerations and their repair. | |||
**See "See Also" section below for specific special laceration types. | |||
==Indications== | ==Indications== | ||
Skin or mucosal laceration. | *Skin or mucosal [[laceration]]. | ||
==Contraindications== | ==Contraindications== | ||
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*Face/scalp wounds >24 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}} | |||
{{Suture chart}} | |||
==Procedure== | |||
[[File:Suture, before and after, RMO.jpg|thumb|Wound before and after suture closure. The closure incorporates five simple interrupted sutures and one vertical mattress suture (center) at the apex of the wound.]] | |||
===Wound Preparation=== | ===Wound Preparation=== | ||
*Debridement is most important step in reducing infection/ promoting healing | *Debridement is most important step in reducing infection/ promoting healing | ||
*Avoid betadine/chlorhexadine in wound | *Avoid betadine/chlorhexadine in wound | ||
*Not necessary to remove hair (if do, avoid using razor) | *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=== | ===Anesthesia=== | ||
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*Topical | *Topical | ||
**LET for open wound, EMLA for intact skin | **LET for open wound, EMLA for intact skin | ||
***EMLA needs to be left on 1-2 hours <ref name=aafp>[https://www.aafp.org/afp/2002/0701/p99.html KUNDU S, et. al. Principles of Office Anesthesia: Part II. Topical Anesthesia Am Fam Physician. 2002 Jul 1;66(1):99-102.]</ref> | |||
***LET onset is 20-30 minutes<ref name=aafp></ref>, area will appear pale | |||
*Evaluate motor/sensation before giving local anesthesia | *Evaluate motor/sensation before giving local anesthesia | ||
*To decrease pain of injection: | *To decrease pain of injection: | ||
**Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine) | **Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine) | ||
**Inject slowly | **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}} | {{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<ref>Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007 May;14(5):404-9</ref><ref>Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013 Jan 16;3(1).</ref><ref>Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD003861. </ref> | |||
**Pressure from tap is ~45 psi, higher than syringe<ref>Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998 Nov;5(11):1076-80.</ref> | |||
*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=== | ===Exploration=== | ||
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*Ideally done in bloodless field | *Ideally done in bloodless field | ||
*Look for foreign bodies, tendon injury, or fracture | *Look for foreign bodies, tendon injury, or fracture | ||
*Possible glass in wound = get XR or US to evaluate | *Possible glass or metal in wound = get XR or US to evaluate | ||
===Suturing=== | ===Suturing=== | ||
[[File:Simple_Interrupted_Suture.png|thumb|Simple Interrupted]] | |||
[[File:Horizontal mattress suture.svg|thumb|Horizontal mattress]] | |||
[[File:Vertical mattress suture.svg|thumb|Vertical mattress]] | |||
*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: | *If laceration not closed immediately secondary to age of wound: | ||
**Irrigate and explore wound, then pack with non-adherent or vaseline gauze | **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. | **Re-check in 3 days - may suture at that point if wound appears clean. | ||
===Steri-Strips=== | |||
*Just as good a suturing according to this <ref name=Esmailian>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5887701/ Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds' Scar. Adv Biomed Res. 2018;7:49. Published 2018 Mar 27. doi:10.4103/abr.abr_148_16]</ref> and other articles. Picture on how to do it property from the same article <ref name=Esmailian></ref> which is under CC BY-NC-SA 4.0 license: | |||
[[File:Steri-strips.png|thumb|Steri-Strips]] | |||
===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 <ref>Liu et al. Inadvertent tissue adhesive tarsorrhaphy of the eyelid: a review and exploratory trial of removal methods of Histoacryl. Emerg Med J. 2020 Apr;37(4):212-216. doi: 10.1136/emermed-2019-209177. Epub 2020 Jan 9. https://www.ncbi.nlm.nih.gov/pubmed/31919233?dopt=AbstractPlus</ref> | |||
==Aftercare== | |||
*Consider antibiotics for | *Consider [[antibiotics]] for | ||
**Wounds contaminated by debris or feces | **Wounds contaminated by debris or feces | ||
**Caused by punctures or bites | **Caused by punctures or [[animal bites|bites]] | ||
**Tissue destruction or in avascular areas | **Tissue destruction or in avascular areas | ||
**Neglected wounds | **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 | Wounds contaminated by fresh water and plantar puncture wounds through athletic shoes should include Pseudomonas coverage | ||
*Splinting | *Splinting | ||
**Wounds over flexor surfaces or tension | **Wounds over flexor surfaces or tension | ||
*Tetanus | *[[Tetanus prophylaxis]] | ||
**Tdap 0.5cc IM to patients >7y with no booster within 5 yr | **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 | **Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given | ||
Line 68: | Line 115: | ||
***No point in checking before 48hr (takes this long for infection to occur) | ***No point in checking before 48hr (takes this long for infection to occur) | ||
==Billing== | ===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 | *Anatomical location of wound | ||
*Size of wound | *Size of wound | ||
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==See Also== | ==See Also== | ||
*[[Soft | *[[Soft tissue foreign body]] | ||
*[[LET]] | *[[LET]] | ||
{{Special lacerations see also}} | |||
==External Links== | |||
*[https://www.msdmanuals.com/professional/injuries-poisoning/how-to-care-for-wounds-and-lacerations/how-to-repair-a-laceration-with-simple-interrupted-sutures?query=how%20to%20repair%20a%20laceration Merck Manual - How To Repair a Laceration With Simple Interrupted Sutures] | |||
*[https://www.msdmanuals.com/professional/injuries-poisoning/how-to-care-for-wounds-and-lacerations/how-to-repair-a-laceration-with-horizontal-mattress-sutures?query=how%20to%20repair%20a%20laceration Merck Manual - How To Repair a Laceration With Horizontal Mattress Sutures] | |||
*[https://www.msdmanuals.com/professional/injuries-poisoning/how-to-care-for-wounds-and-lacerations/how-to-repair-a-laceration-with-vertical-mattress-sutures?query=how%20to%20repair%20a%20laceration Merck Manual - How To Repair a Laceration With Vertical Mattress Sutures] | |||
==Videos== | |||
{{#widget:YouTube|id=TFwFMav_cpE}} | |||
==References== | ==References== |
Latest revision as of 19:25, 1 March 2023
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
Suture Type | Days of Tensile Strength | Complete Absorption | Descriptions |
---|---|---|---|
Chromic Gut | 7-21 days | 90 days | Chromium treated to decrease tissue reactivity |
PDS (Polydioxone) | 14 days | 180-240 days | Monofilament synthetic absorbable suture |
Vicryl (Polyglactin) | 21 days | 90 days | Synthetic |
Vicryl Rapid | 10 days | 42 days | Synthetic with radiation treatment for increased absorption |
Suture Type | Tensile Strength | Body Reactivity | Filament |
---|---|---|---|
Nylon | High | Low | Monofilament |
Silk | Low | High | Multifilament |
Prolene (Polypropylene) | Moderate | Low | Monofilament stiff |
Laceration Areas and Their Common Suture Type and Duration
Area | Size | Type | Days to Removal |
---|---|---|---|
Scalp | Staples or 4-0 or 5-0 | non absorbable | 7 |
Ear | 6-0 | non absorbable (absorbable for cartilage repair) | 5-7 |
Eyelid | 6-0 or 7-0 | absorbable or nonabsorbable | 5-7 |
Eyebrow | 5-0 or 6-0 | absorbable or nonabsorbable | 5-7 |
Nose | 6-0 | absorbable or nonabsorbable | 5-7 |
Lip | 6-0 | absorbable | NA |
Oral mucosa | 5-0 | absorbable | NA |
Other face / forehead | 6-0 | absorbable or nonabsorbable | 5 |
Chest/abdomen | 4-0 or 5-0 | non absorbable | 12-14 |
Back | 4-0 or 5-0 | non absorbable | 7-10 |
Extremities | 4-0 or 5-0 | non absobrable | 7-10 |
Hand | 5-0 | non absorbable | 7-10 |
Foot / Sole | 4-0 | non absorable | 12-14 |
Joint (Extensor) | 4-0 | non absorable | 10-14 |
Joint (Flexor) | 4-0 | non absorbable | 7-10 |
Vagina | 4-0 | absorbable | NA |
Penis | 5-0 | non absorbable | 7-10 |
Scrotum | 5-0 | non absorbable | 7-10 |
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
- 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
Agent | Without Epinephrine | With Epinephrine | Duration | Notes |
Lidocaine | 5 mg/kg (max 300mg) | 7 mg/kg (max 500mg) | 30-90 min |
|
Mepivicaine | 7 mg/kg | 8 mg/kg | ||
Bupivicaine | 2.5 mg/kg (max 175mg) | 3 mg/kg (max 225mg) | 6-8 hr |
|
Ropivacaine | 3 mg/kg | |||
Prilocaine | 6 mg/kg | |||
Tetracaine | 1 mg/kg | 1.5 mg/kg | 3hrs (10hrs with epi) | |
Procaine | 7 mg/kg | 10 mg/kg | 30min (90min with epi) |
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
- Keep moist, not wet
- Wound check
- 48-72 hrs ONLY if high risk wound
- No point in checking before 48hr (takes this long for infection to occur)
- 48-72 hrs ONLY if high risk wound
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
Special Lacerations by Body Part
- Head
- Hand
- 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
{{#widget:YouTube|id=TFwFMav_cpE}}
References
- ↑ 1.0 1.1 KUNDU S, et. al. Principles of Office Anesthesia: Part II. Topical Anesthesia Am Fam Physician. 2002 Jul 1;66(1):99-102.
- ↑ Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007 May;14(5):404-9
- ↑ Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013 Jan 16;3(1).
- ↑ Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD003861.
- ↑ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998 Nov;5(11):1076-80.
- ↑ 6.0 6.1 Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds' Scar. Adv Biomed Res. 2018;7:49. Published 2018 Mar 27. doi:10.4103/abr.abr_148_16
- ↑ Liu et al. Inadvertent tissue adhesive tarsorrhaphy of the eyelid: a review and exploratory trial of removal methods of Histoacryl. Emerg Med J. 2020 Apr;37(4):212-216. doi: 10.1136/emermed-2019-209177. Epub 2020 Jan 9. https://www.ncbi.nlm.nih.gov/pubmed/31919233?dopt=AbstractPlus