Laceration repair
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
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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