Professional Documents
Culture Documents
Patient information: lthough the emergency department continue bleeding should be repaired,
A handout on taking care
of healing cuts, written by
routinely treats acute trauma, family although some less severe wounds (e.g.,
the author of this article, is physicians should be prepared simple hand lacerations that are less than
provided on page 952. to manage acute lacerations. This 2 cm long) may heal well with conservative
requires knowledge of wound evaluation, management.1
preparation, and appropriate repair tech- The goals of laceration repair are to achieve
niques; when to refer for surgical treatment; hemostasis, avoid infection, restore function
and how to provide follow-up care. to the involved tissues, and achieve optimal
cosmetic results with minimal scarring.
Wound Evaluation and Preparation Definitive laceration management depends
Immediately upon presentation, a lacera- on the time since injury, the extent and loca-
tion should be evaluated and the bleeding tion of the wound, available laceration repair
controlled using direct pressure. A patient materials, and the skill of the physician.
history should be obtained, including Guidelines for seeking surgical consultation
mechanism and time of injury and personal for laceration repair are presented in Table 1.
health information (e.g., human immu- The optimal time interval from injury to
nodeficiency virus and diabetes status; laceration repair is not clearly defined. Ana-
tetanus immunization history; allergies to tomic location of the wound, health of the
latex, local anesthesia, tape, or antibiotics). patient, mechanism of injury, and wound
A careful exploration of the laceration should contamination factor into the decision about
be performed to determine severity and when to repair the laceration. Noncon-
whether it involves muscle, tendons, nerves, taminated wounds have been successfully
blood vessels, or bone. Baseline neurovas- closed up to 12 hours post-injury.2 Clean
cular and functional status of the involved lacerations involving well-vascularized
body part should be evaluated before repair. tissue, such as the face and scalp, can be
Lacerations that expose underlying tissue or closed successfully even later in healthy
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SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
Saline or tap water may be used for wound irrigation, whereas povidone- B 3, 5
iodine, detergents, and hydrogen peroxide should be avoided.
The sting from a local anesthetic injection can be decreased by slow B 8
administration and buffering the solution.
Suturing is the preferred technique for skin laceration repair. C 5
Tissue adhesives are comparable with sutures in cosmetic results, A 14-17
dehiscence rates, and infection risk.
Applying white petrolatum to a sterile wound to promote wound healing B 25
is as effective as applying an antibiotic ointment.
946 American Family Physician www.aafp.org/afp Volume 78, Number 8 October 15, 2008
Laceration Repair
October 15, 2008 Volume 78, Number 8 www.aafp.org/afp American Family Physician 947
A
948 American Family Physician www.aafp.org/afp Volume 78, Number 8 October 15, 2008
ILLUSTRATION BY Renee Cannon
Figure 6. Proper technique for the applica-
tion of tissue adhesive in laceration repair.
Note the wound edge approximation and
thin layer of tissue adhesive. Figure 7. Hair apposition suture technique.
may be splinted temporarily for comfort and 30 seconds between applications. Full tensile
to promote healing. strength is achieved after 2.5 minutes. Anti-
biotic and white petrolatum ointments can
Tissue adhesives remove tissue adhesive; therefore, patients
Tissue adhesives, such as 2-octylcyanoacrylate must be instructed to avoid using them on
(Dermabond), are comparable with sutures in the repaired wound.
cosmetic results, dehiscence rates, and infec- The hair apposition technique (Figure 7)
tion risk.15-17 However, tissue adhesives can be may be used for closing scalp wounds. The
applied more quickly, require no anesthesia, technique is best for non-actively bleeding
and eliminate the need for follow-up because wounds that are less than 10 cm long when
they slough off spontaneously within five scalp hair is longer than 3 cm. Opposing
to 10 days. They form a protective barrier to strands of hair are brought together with
promote wound healing and may have anti- a simple twist and are secured with a drop
microbial effects.18 Although tissue adhesives of tissue adhesive. The technique can be
have a higher direct cost per unit than sutures, performed by nonphysicians and causes less
they are more cost-effective because of quick scarring, has fewer complications,21 and is
application and no follow-up.19 Tissue adhe- more cost-effective than a scalp suture.22
sives low tensile strength makes them inap-
Other Techniques
propriate for high-tension areas, such as over
joints, unless the area is immobilized. They Stainless steel or absorbable staples and skin-
may be ideal for simple lacerations under a closure strips (e.g., Steri-strips) are also com-
cast or splint. Tissue adhesives are contraindi- monly used to repair lacerations. Automatic
cated in patients at higher risk of poor heal- staplers, usually used in surgical wound
ing (e.g., those who are immunosuppressed repair, are recommended for closing thick
or have diabetes), and should not be used for skin on the extremities, trunk, and scalp, but
contaminated, complex, or jagged lacerations. not on the face, neck, hands, and feet. Stain-
They should also be avoided on mucosal sur- less steel staples should not be used for scalp
faces and areas that maintain moisture, such wounds if computed tomography or magnetic
as the groin or axillae.15 resonance imaging of the head is anticipated.
Effective application of tissue adhesives The quick application of staples makes them
is a quickly learned skill compared with a good choice for patients who have multiple
suturing.20 Figure 6 shows the proper tech- traumas or who are intoxicated.
nique. After irrigation, the wound should Although skin-closure strips can be effec-
be dried with sterile gauze and placed in a tive for small, simple lacerations in low-
horizontal position to prevent runoff, using tension areas with well-approximated edges,
caution around the eyes. The wound edges their lack of tensile strength can lead to
are approximated using gloved fingers, then wound dehiscence. Also, adhesive adjuncts,
the adhesive is applied in a thin layer over such as tincture of benzoin, can cause a
the wound with a 5-mm overlap on each local inflammatory reaction. However, skin-
side. Three to four layers are applied with closure strips have a role in the repair of
October 15, 2008 Volume 78, Number 8 www.aafp.org/afp American Family Physician 949
Laceration Repair
pretibial lacerations, leading to faster wound procedure. However, one study showed that
healing and less necrosis.23 leaving the wound uncovered and wetting
it after 12 hours did not increase infection
Follow-up Care and Billing rates.24 To prevent infection and promote
Follow-up for repaired lacerations is healing, an antibiotic or white petrolatum
similar regardless of the technique used. ointment can be applied daily to wounds not
Traditionally, patients have been told to keep repaired with tissue adhesives. Antibiotic and
the wound clean and dry using a protective white petrolatum ointments are equally effec-
dressing for at least 24 hours after the repair tive.25,26 The timing of suture or staple removal
varies with wound location (Table 2).
Tetanus immunization status should be
assessed in patients with lacerations. Table 3
Table 2. Timing of Suture
summarizes the Centers for Disease Control
or Staple Removal
and Prevention guidelines for tetanus pro-
phylaxis in these patients.27 After laceration
Wound location Timing of removal (days)
repair, patients should receive instructions
Face Three to five on signs of infection and when follow-up
Scalp Seven to 10 should be performed (see accompanying
Arms Seven to 10 patient education handout).
Trunk 10 to 14 Billing for laceration repair depends on
Legs 10 to 14 the size and location of the wound and
Hands or feet 10 to 14 on the complexity of the repair. Table 4
Palms or soles 14 to 21 includes codes for common procedures.28
Sutures, staples, and tissue adhesives are
Table 3. Guidelines for Tetanus Prophylaxis in Adults Table 4. CPT Codes for
Receiving Routine Wound Management Laceration Repairs
950 American Family Physician www.aafp.org/afp Volume 78, Number 8 October 15, 2008
Laceration Repair
all billable methods. Adhesive strips alone 11. Parell GJ, Becker GD. Comparison of absorbable with
nonabsorbable sutures in closure of facial skin wounds.
should be categorized using the appropri-
Arch Facial Plast Surg. 2003;5(6):488-490.
ate evaluation and management code. Sim- 12. Al-Abdullah T, Plint AC, Fergusson D. Absorbable versus
ple laceration repair includes superficial, nonabsorbable sutures in the management of traumatic
single-layer closures with local anesthesia; lacerations and surgical wounds. Pediatr Emerg Care.
2007;23(5):339-344.
intermediate laceration repair includes
13. Thomsen TW, Barclay DA, Setnik, GS. Videos in clinical
multiple-layer closures or extensive clean- medicine. Basic laceration repair. N Engl J Med. 2006;
ing; and complex laceration repair includes 355(17):e18.
multiple-layer closures, debridement, and 14. Zuber TJ. The mattress sutures: vertical, horizontal, and
other wound preparation (e.g., undermin- corner stitch. Am Fam Physician. 2002;66(12):2231-
2236.
ing of skin for better wound edge closure). 15. Bruns TB, Worthington JM. Using tissue adhesive for
Follow-up suture removal is included in the wound repair. Am Fam Physician. 2000;61(5):1383-
laceration repair fee, but can be billed if the 1388.
repair was performed elsewhere, such as in 16. Quinn J, Wells G, Sutcliffe T, et al. A randomized trial
comparing octylcyanoacrylate tissue adhesive and
the emergency department. sutures in the management of lacerations. JAMA.
1997;277(19):1527-1530.
The Author 17. Singer AJ, Hollander JE, Valentine SM, et al. Prospec-
tive, randomized, controlled trial of tissue adhesive (2-
RANDALL T. FORSCH, MD, MPH, is an assistant professor octylcyanoacrylate) vs standard wound closure tech-
in the Department of Family Medicine at the University niques for laceration repair. Stony Brook Octylcyano-
of Michigan Medical School, Ann Arbor. He received his acrylate Study Group. Acad Emerg Med. 1998;5(2):
medical degree from Wayne State University School of 94-99.
Medicine, Detroit, Mich., and completed the University of 18. Lloyd JD, Marque MJ III, Kacprowicz RF. Closure tech-
Michigan Family Medicine Residency. niques. Emerg Med Clin North Am. 2007;25(1):73-81.
Address correspondence to Randall T. Forsch, MD, MPH, 19. Osmond MH, Klassen TP, Quinn JV. Economic com-
Chelsea Health Center, 14700 E. Old U.S. 12, Chelsea, MI parison of tissue adhesive and suturing in the repair
of pediatric facial lacerations. J Pediatr. 1995;126(6):
48118 (e-mail: rforsch@umich.edu). Reprints are not
892-895.
available from the author.
20. Lin M, Coates WC, Lewis RJ. Tissue adhesive skills study.
Author disclosure: Nothing to disclose. Pediatr Emerg Care. 2004;20(4):219-223.
21. Hock MO, Ooi SB, Saw SM, et al. A randomized con-
REFERENCES trolled trial comparing the hair apposition technique
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1. Quinn J, Cummings S, Callaham M, et al. Suturing (HAT study). Ann Emerg Med. 2002;40(1):19-26.
versus conservative management of lacerations of the
22. Ong ME, Coyle D, Lim SH, et al. Cost-effectiveness
hand. BMJ. 2002;325(7359):299.
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golden period for wound repair. Ann Emerg Med. 2005;46(3):237-242.
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23. Sutton R, Pritty P. The use of sutures or adhesive tapes
3. Fernandez R, Griffiths R, Ussia C. Water for wound cleans- for primary closure of pretibial lacerations. Br Med J
ing. Cochrane Database Syst Rev. 2002;(4):CD003861. (Clin Res Ed). 1985;290(6482):1627.
4. Ernst AA, Gershoff L, Miller P, et al. Warmed versus 24. Heal C, Buettner P, Raasch B, et al. Can sutures get wet?
room temperature saline for laceration irrigation. South BMJ. 2006;332(7549):1053-1056.
Med J. 2003;96(5):436-439.
25. Smack DP, Harrington AC, Dunn C, et al. Infection
5. Hollander JE, Singer AJ. Laceration management. Ann and allergy incidence in ambulatory surgery patients
Emerg Med. 1999;34(3):356-367. using white petrolatum vs bacitracin ointment. JAMA.
6. Edlich RF, Rodeheaver GT, Morgan RF, et al. Principles 1996;276(12):972-977.
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1988;17(12):1284-1302. ics improve wound healing? J Fam Pract. 2007;56(2):
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prior hair removal. Am J Emerg Med. 1988;6(1):7-10. 27. Kretsinger K, Broder KR, Cortese MM, et al. Preventing
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thetics. Ann Emerg Med. 1998;31(1):36-40. tetanus toxoid, reduced diphtheria toxoid and acellular
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10. Singer AJ, Quinn JV, Clark RE, et al. Closure of lacerations 28. Beebe M, Dalton JA, Espronceda M, et al. Current Pro-
and incisions with octylcyanoacrylate. Surgery. 2002; cedural Terminology (CPT) 2007. Chicago, Ill.: American
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