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==
*Do not close body wounds >12 hr old
*Skin or mucosal [[laceration]].
*Do not close face/scalp wounds >24 hr old
*If don't close, prepare wound as if going to close:
**Irrigate, explore, non-adherent or vaseline gauze to prevent wound edges from closing
**Wrap, consider oral abx
**On Day 3 remove packing, irrigate & suture if appears clean


==Wound Preparation==
==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 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===
*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===
*Can be topical or injected.
*Topical
**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
*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


==Irrigation==
{{Maximum doses of anesthetic agents}}
 
===Irrigation===
*High pressure irrigation is best (can be achieved with 18 gauge syringe)
*High pressure irrigation is best (can be achieved with 18 gauge syringe)
*Tap water is as effective as sterile water/ normal saline
*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:
*Irrigation optional for face/scalp wound as long as:
**Not a bite wound
**Not a bite wound
**Not a contaminated wound
**Not a contaminated wound
**Not older than 6 hours  
**Not older than 6 hours
***Often best to avoid irrigation of face and opt for cleaning with gauze to help prevent tissue distortion
==Anesthesia==
*NO epi if fingers, nose, toes, or penis
*Put LET in open wound, EMLA on intact skin (doesn't work in open wound)
*Check motor/sensory before give anesthesia


*Lidocaine 1% solution (10mg/mL)
===Exploration===
**Maximum safe dose = 4mg/kg (~300mg)
*See [[Soft tissue foreign body]]
*Lidocaine + epinephrine
*Explore to base of wound
**Maximum safe dose = 500mg
*Ideally done in bloodless field
**Delays healing, increases infection risk?
*Look for foreign bodies, tendon injury, or fracture
*Bupivicaine (0.25%)
*Possible glass or metal in wound = get XR or US to evaluate
**Maximum safe dose = 175mg
 
**Do not buffer with bicarbonate
===Suturing===
*Bupivicaine + epinephrine
[[File:Simple_Interrupted_Suture.png|thumb|Simple Interrupted]]
**Maximum safe dose = 225mg
[[File:Horizontal mattress suture.svg|thumb|Horizontal mattress]]
[[File:Vertical mattress suture.svg|thumb|Vertical mattress]]
*To decrease pain of injection:  
*Simple Interrupted
**Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine)
**Less potential for causing wound edema or impaired circulation
**Inject slowly
**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.


==Exploration==
===Steri-Strips===
*Look for foreign bodies or fracture
*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:
*Glass in wound = need for xray
[[File:Steri-strips.png|thumb|Steri-Strips]]


==Suturing==
===Skin Glue===
*See [[Sutures]]
*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==
==Aftercare==
*Consider [[antibiotics]] for
**Wounds contaminated by debris or feces
**Caused by punctures or [[animal bites|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
*Splinting
**Wounds over flexor surfaces or tension
**Wounds over flexor surfaces or tension
*Tetanus
*[[Tetanus prophylaxis]]
**Tdap 0.5cc IM to pts >7y w/ no booster w/in 5 yr
**Tdap 0.5cc IM to patients >7y with no booster within 5 yr
**Hypertet 250 u IM @ diff site from Tdap if NO Hx of Td
**Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given
***Require f/u Tdap @ 1mo & 1 yr; age>60 = high risk of poor immunization
***Require follow up Tdap at 1mo & 1 yr; age>60 = high risk of poor immunization
*Dressing
*Dressing
**Keep moist, not wet
**Keep moist, not wet
Line 60: Line 114:
**48-72 hrs ONLY if high risk wound
**48-72 hrs ONLY if high risk wound
***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)
===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==
==See Also==
*[[Sutures]]
*[[Soft tissue foreign body]]
*[[Bites]]
*[[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]


==Source==
==Videos==
*UpToDate
{{#widget:YouTube|id=TFwFMav_cpE}}


==References==
<references/>
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Procedures]]

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

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

Absorbable Sutures
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
Non Absorbable Sutures
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

Suture Usage
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 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

  • 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

Agent Without Epinephrine With Epinephrine Duration Notes
Lidocaine 5 mg/kg (max 300mg) 7 mg/kg (max 500mg) 30-90 min
  • 1% soln contains 10 mg/ml
  • 2% soln contains 20 mg/ml
Mepivicaine 7 mg/kg 8 mg/kg
Bupivicaine 2.5 mg/kg (max 175mg) 3 mg/kg (max 225mg) 6-8 hr
  • 0.5% soln contains 5 mg/ml
  • May cause cardiac arrest if injected intravascularly
  • Do not buffer with bicarbonate
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
Horizontal mattress
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:
    • 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:
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 [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

Special Lacerations by Body Part

External Links

Videos

{{#widget:YouTube|id=TFwFMav_cpE}}

References

  1. ↑ 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.
  2. ↑ 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
  3. ↑ 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).
  4. ↑ Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD003861.
  5. ↑ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998 Nov;5(11):1076-80.
  6. ↑ 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
  7. ↑ 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
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