Laceration Repair: A Practical Approach: Randall T. Forsch, MD, MPH Sahoko H. Little, MD, PHD and Christa Williams, MD
Laceration Repair: A Practical Approach: Randall T. Forsch, MD, MPH Sahoko H. Little, MD, PHD and Christa Williams, MD
Laceration Repair: A Practical Approach: Randall T. Forsch, MD, MPH Sahoko H. Little, MD, PHD and Christa Williams, MD
RANDALL T. FORSCH, MD, MPH; SAHOKO H. LITTLE, MD, PhD; and CHRISTA WILLIAMS, MD
University of Michigan Medical School, Ann Arbor, Michigan
The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of
infection. Many aspects of laceration repair have not changed over the years, but there is evidence to support some
updates to standard management. Studies have been unable to define a “golden period” for which a wound can safely
be repaired without increasing risk of infection. Depending on the type of wound, it may be reasonable to close
even 18 or more hours after injury. The use of nonsterile gloves during laceration repair does not increase the risk of
wound infection compared with sterile gloves. Irrigation with potable tap water rather than sterile saline also does not
increase the risk of wound infection. Good evidence suggests that local anesthetic with epinephrine in a concentration
of up to 1:100,000 is safe for use on digits. Local anesthetic with epinephrine in a concentration of 1:200,000 is safe for
use on the nose and ears. Tissue adhesives and wound adhesive strips can be used effectively in low-tension skin areas.
Wounds heal faster in a moist environment and therefore occlusive and semiocclusive dressings should be considered
when available. Tetanus prophylaxis should be provided if indicated. Timing of suture removal depends on location
and is based on expert opinion and experience. (Am Fam Physician. 2017;95(10):628-636. Copyright © 2017 American
Academy of Family Physicians.)
A
More online pproximately 6 million patients pres- before further evaluation. Hemostasis con-
at http://www. ent to emergency departments for trols bleeding, prevents hematoma forma-
aafp.org/afp.
laceration treatment every year.1 tion, and allows for deeper inspection of
CME This clinical content
Although many patients seek care the wound.3 The next step is to determine
conforms to AAFP criteria
at emergency departments or urgent care cen- whether vessels, tendons, nerves, joints,
for continuing medical
education (CME). See ters, primary care physicians are an impor- muscles, or bones are damaged. Anesthe-
CME Quiz Questions on tant resource for urgent laceration treatment. sia may be necessary to achieve hemostasis
page 622. Many aspects of laceration repair have not and to explore the wound. Devitalized and
Author disclosure: No rel- changed, but there is evidence to support necrotic tissue in a traumatic wound should
evant financial affiliation. some updates to standard management. be identified and removed to reduce risk of
Patient information: infection.4,5
▲
A handout on this topic is Approach to the Wound If a foreign body (e.g., dirt particles, wood,
available at http://www. The goals of laceration repair are to achieve glass) is suspected but cannot be identified
aafp.org/afp/2008/1015/
p952.html.
hemostasis and optimal cosmetic results with- visually, then radiography, ultrasonography,
out increasing the risk of infection. Important or computed tomography may be needed.
considerations include timing of the repair, About one-third of foreign bodies may be
wound irrigation techniques, providing a missed on initial inspection.6
clean field for repair to minimize contamina- Injuries that require subspecialist con-
tion, and appropriate use of anesthesia. An sultation include open fractures, tendon or
article on wound care was previously pub- muscle lacerations of the hand, nerve inju-
lished in American Family Physician.2 ries that impair function, lacerations of the
salivary duct or canaliculus, lacerations of
EVALUATING THE WOUND the eyes or eyelids that are deeper than the
When a patient presents with a lacera- subcutaneous layer, injuries requiring seda-
tion, the physician should obtain a history, tion for repair, or other injuries requiring
including tetanus vaccination status, aller- treatment beyond the knowledge or skill of
gies, and time and mechanism of injury, and the physician.
then assess wound size, shape, and location.3
TIMING OF WOUND CLOSURE
If active bleeding persists after application
of direct pressure, hemostasis should be No randomized controlled trials (RCTs)
obtained using hemostat, ligation, or sutures have compared primary and delayed closure
628 American
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Laceration Repair
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Laceration Repair
Interrupted dermal Effective in accurate skin edge apposition and An optimal cosmetic result depends on
sutures wound eversion reapproximation of the vermilion border.
Allows for minimal drainage Therefore, the first skin suture should be
Suited for closing clean wounds placed at this border. The border should be
Staples Fast, creates loose closure marked before anesthetic injection because
Allows for drainage the anesthetic may blur the border. The
Suited for unclean wounds muscle layer and oral mucosa should be
Should be avoided if cosmetic outcome is important repaired with 3-0 or 4-0 absorbable sutures,
and skin should be repaired with 6-0 or 7-0
Wounds adhesive Fast, no anesthesia required nylon sutures.
strips Used to approximate clean, simple, small lacerations
with little tension and without bleeding EYELID
Tissue adhesive Fast, no anesthesia required The patient should be referred to ophthal-
Used to approximate clean, simple, small lacerations mology if the laceration involves the eye
with little tension and without bleeding itself, the tarsal plate, or the eyelid margin,
or penetrates deeper than the subcutane-
NOTE:For a video of suture techniques, see https://www.youtube.com/watch? ous layer. Laceration through the portion of
v=-ZWUgKiBxfk. the upper or lower lid medial to the punc-
tum often damages the lacrimal duct or the
630 American Family Physician www.aafp.org/afp Volume 95, Number 10 ◆ May 15, 2017
Laceration Repair
EYEBROW
ILLUSTRATION BY RENEE CANNON
EAR
SCALP
May 15, 2017 ◆ Volume 95, Number 10 www.aafp.org/afp American Family Physician 631
Laceration Repair
Management of Acute Lacerations
Yes
Bleeding? Hemostasis (ligation or sutures)
No
Yes
Contaminated with debris or dirt, bite Irrigation, debridement,
wound, or concern for infection? removal of foreign body
No
No Yes
Repair of muscle/tendon Referral for deep injury of the hands, eyelids, and nose;
lacrimal duct injury; nerve injury; or open fracture
Skin repair: Simple interrupted, Simple interrupted, simple Simple interrupted, Simple interrupted,
Simple interrupted or simple simple running, horizontal running, horizontal mattress, simple running, simple running,
running sutures, surgical strips, mattress, vertical mattress vertical mattress sutures horizontal mattress, horizontal mattress
tissue adhesives sutures; staples; hair If the wound is clean with little basic lattice sutures; sutures
apposition technique tension, running subcuticular tissue adhesive;
If the wound is clean, double-
sutures, tissue adhesives surgical strips
layer with running subcuticular
or interrupted dermal sutures
Mucosal surface (lips, oral, genitalia) repair:
Simple interrupted or simple running sutures; absorbable
BITE WOUNDS
Up to 19% of bite wounds become infected. Cat bites are
much more likely to become infected compared with dog
or human bites (47% to 58% of cat bites, 8% to 14% of
dog bites, and 7% to 9% of human bites).43 The risk of
infection increases as time from injury to repair increases,
regardless of suture material.4 Evidence on optimal timing
of primary closure and antibiotic treatment is lacking.4,44
Cosmesis was improved with suturing compared with
no suturing in RCTs of patients with dog bites, although
ILLUSTRATION BY RENEE CANNON
632 American Family Physician www.aafp.org/afp Volume 95, Number 10 ◆ May 15, 2017
Laceration Repair
Table 2. Commonly Used Suture Materials
Absorbable
Chromic Reverse cutting 10 to 14 days Monofilament Mucosa, eye wounds
Glycolide/lactide polymer Conventional or 2 to 3 weeks Braided Deep dermal, muscle, fascia, oral mucosa,
(polyglactin 910 [Vicryl]) reverse cutting genitalia wounds
Poliglecaprone (Monocryl) Conventional and 7 to 10 days Monofilament Dermal, subcuticular wounds
reverse cutting
Polydioxanone (PDS II) Reverse cutting 4 weeks Monofilament Muscle, fascia, dermal wounds
Nonabsorbable
Nylon (Ethilon) Cutting edge > 10 years Monofilament Skin
Polypropylene (Prolene) Tapered point, Indefinite Monofilament Mostly used in vascular surgeries; can be
blunt tip used for skin, tendon, and ligaments,
depending on the needles
Silk Does not come 1 year Braided Used for hemostasis in ligation of vessels
with needle or for tying over bolsters
*—A variety of needles are available to order, but the most typical needles likely to be stocked are listed.
Information from references 50 and 51.
CHOOSING THE APPROPRIATE SUTURE MATERIAL Tissue adhesive should not be applied to misaligned
Physicians should use the smallest suture that will give wound edges. Care should be taken to avoid getting tissue
sufficient strength to reapproximate and support the adhesive into the wound or accidentally adhering gauze
healing wound.50,51 Commonly used sutures are included or instruments to the wound. If tissue adhesive is misap-
in Table 2 50,51; however, good evidence is lacking regard- plied, it should be wiped off quickly with dry gauze. To
ing the appropriate suture size for laceration repair. The remove dry adhesive, petroleum-based ointment should
5-0 or 6-0 sutures should be used for the face, and 4-0 be applied and wiped away after 30 minutes.
sutures should be used for most other areas. The 3-0 Wound adhesive strips can also be used. One analy-
sutures work well for the thicker skin on the back, scalp, sis suggests that wound adhesive strips are the most
palms, and soles.50,51 cost-effective method of closure for appropriate low-
A meta-analysis of 19 studies of skin closure for surgi- tension wounds.56 The strips are applied perpendicular
cal wounds and traumatic lacerations found no signifi- to the vector of the wound to approximate and secure
cant difference in cosmetic outcome, wound infection, the edges. One study found the same cosmetic outcomes
or wound dehiscence between absorbable and nonab-
sorbable sutures.52,53 A systematic review did not show
any advantage of monofilament sutures over braided Table 3. Criteria for Use of Tissue Adhesives
sutures with regard to cosmetic outcome, wound infec-
tion, or wound dehiscence.54 Wound less than 12 hours old
Linear (not stellate)
USE OF TISSUE ADHESIVE OR WOUND ADHESIVE STRIPS
Hemostatic
The two types of tissue adhesive available in the United Not crossing a joint
States are n-butyl-2-cyanoacrylate (Histoacryl Blue, Not crossing a mucocutaneous junction
PeriAcryl) and 2-octyl cyanoacrylate (Dermabond, Sur- Not in a hair-bearing area (unless hair apposition technique
giseal). Table 3 shows the criteria for tissue adhesive use. is being used)
A Cochrane review found these adhesives to be com- Not under significant tension (or tension relieved with deep
parable in cosmesis, procedure time, discomfort, and absorbable sutures)
complications.55 They work well in clean, linear wounds Not grossly contaminated
that are not under tension. They are not generally used Not infected
in hair-bearing areas (except in the hair apposition tech- Not devitalized
nique). There is a slightly higher likelihood of wound Not a result of mammalian bite
dehiscence with tissue adhesives than with sutures, with No chronic condition that might impair wound healing
a number needed to harm of 25 for tissue adhesives.52,53
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Laceration Repair
had lower rates of infection when antibiotic *—Examples are wounds contaminated with dirt, feces, soil, or saliva; deep punc-
ture wounds; avulsions; and wounds resulting from missiles, crushing injury, burns,
ointment was applied rather than petroleum or frostbite.
jelly. The lowest rate of infection occurred †—Tdap is preferred over Td for adults who have never received Tdap. Single-antigen
with the use of an ointment containing tetanus toxoid is no longer available in the United States.
bacitracin and neomycin.59 Therefore, topi- ‡—Yes, if it has been more than 10 years since the last dose of a tetanus toxoid–
containing vaccine.
cal antibiotic ointment should be applied to §—Yes, if it has been more than 5 years since the last dose of a tetanus toxoid–
traumatic lacerations repaired with sutures containing vaccine.
unless the patient has a specific antibiotic Adapted from Tetanus. In: Hamborsky J, Kroger A, Wolfe C, eds. Epidemiology and
allergy. A meta-analysis did not show ben- Prevention of Vaccine-Preventable Diseases. Atlanta, Ga.: Centers for Disease Control
efit with the use of prophylactic systemic and Prevention; 2015:344.
634 American Family Physician www.aafp.org/afp Volume 95, Number 10 ◆ May 15, 2017
Laceration Repair
This article updates previous articles on this topic by Forsch35 and by Zuber.64 to suturing:a prospective, double-blind, randomised, controlled clinical
trial. BMJ Open. 2013;3 (1).
Data Sources: The authors used an Essential Evidence summary based 14. Marshall KA, Edgerton MT, Rodeheaver GT, Magee CM, Edlich RF. Quan-
on the key words facial laceration, laceration, and tissue adhesives. The titative microbiology:its application to hand injuries. Am J Surg. 1976;
search included relevant POEMs, Cochrane reviews, diagnostic test data, 131(6):730-733.
and a custom PubMed search. Key words were skin laceration, skin repair,
15. Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edilich RF. Side-
local anesthesia, sterile technique, sterile gloves, and wound irrigation.
effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143(5):
Search dates: April 2015 and January 5, 2017. 775-778.
16. Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with
The Authors tap water. Acad Emerg Med. 1998;5 (11):1076-1080.
17. Singer AJ, Hollander JE, Subramanian S, Malhotra AK, Villez PA. Pres-
RANDALL T. FORSCH, MD, MPH, is an assistant professor in the Depart- sure dynamics of various irrigation techniques commonly used in the
ment of Family Medicine at the University of Michigan Medical School in emergency department. Ann Emerg Med. 1994;24(1):36-40.
Ann Arbor. 18. Heal C, Sriharan S, Buttner PG, Kimber D. Comparing non-sterile to
sterile gloves for minor surgery:a prospective randomised controlled
SAHOKO H. LITTLE, MD, PhD, is an assistant professor in the Department
non-inferiority trial. Med J Aust. 2015;202(1):27-31.
of Family Medicine at the University of Michigan Medical School. She is
also an attending physician at the Comprehensive Wound Care Clinic, Uni- 19. Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G.
versity of Michigan. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in
the emergency department:a randomized controlled trial. Ann Emerg
CHRISTA WILLIAMS, MD, is a clinical lecturer in the Department of Family Med. 2004;43(3):362-370.
Medicine at the University of Michigan Medical School. 20. Creamer J, Davis K, Rice W. Sterile gloves:do they make a difference?
Am J Surg. 2012;204(6):976-979.
Address correspondence to Randall T. Forsch, MD, MPH, University
21. Adler AJ, Dubinisky I, Eisen J. Does the use of topical lidocaine, epineph-
of Michigan Medical School, 1301 Catherine, Ann Arbor, MI 48109-
rine, and tetracaine solution provide sufficient anesthesia for laceration
5624 (e-mail: rforsch@umich.edu). Reprints are not available from the
repair? Acad Emerg Med. 1998;5 (2):108-112.
authors.
22. Ernst AA, Marvez-Valls E, Nick TG, Weiss SJ. LAT (lidocaine-adrenaline-
tetracaine) versus TAC (tetracaine-adrenaline-cocaine) for topical anesthe-
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636 American Family Physician www.aafp.org/afp Volume 95, Number 10 ◆ May 15, 2017
Laceration Repair
Onset of Duration
Agent Forms Recommended age Dosage Application action of action
NOTE: Topical anesthetics are used for lacerations less than 5 cm long and are most effective on the scalp and face. They should be avoided on the
digits, nose, and ear lobes.
*—Lidocaine/prilocaine is not approved by the U.S. Food and Drug Administration for nonintact skin, although it has been used this way in numer-
ous studies.
Information from Young KD. What’s new in topical anesthesia. Clin Pediatr Emerg Med. 2007;8(4):232-239.