Field Guide to Urgent & Ambulatory Care Procedures
1st Edition

Chapter 44
Repair of Lacerations
Lacerations are always a frequent presentation in the urgent care setting. Most are minor and are repairable by primary wound closure. Primary closure techniques strive to bring the wound edges together neatly and evenly, stop any bleeding, preserve function of the tissue, prevent infection, restore cosmetic appearance, and promote rapid healing. To assist in primary closure you may select from a variety of technologies, including dressings, sutures, staples, or glue.
Not all lacerations will lend themselves to primary closure in the urgent care setting. Wounds that have been grossly contaminated or infected or that have come to medical attention late may be allowed to begin healing after appropriate wound assessment and cleansing. These wounds may be suitable for delayed primary closure. For this repair the wound edges are recut (“freshened”) before being apposed. If a neglected wound is not suitable for delayed primary closure, it is appropriate to allow the wound to granulate closed (healing by secondary intention).
As a general rule, lacerations on any part of the body may be closed primarily for up to 12 hours after the laceration is made. The exception to this rule is facial wounds, which may be closed primarily up to 72 hours later (after appropriate cleansing and debridement). If there are any concerns about which wounds are suitable for primary closure, involve a surgical consultant early.
Facilities and available equipment may limit the lacerations you can repair safely. It is prudent to refer to a surgical consultant any laceration that you do not feel comfortable repairing. Lacerations that should be managed in an operating room under general anesthesia and with a surgical consultant include those associated with:
  • Excessive length or depth, potentially requiring a toxic dose of infiltrated anesthetic agent to obtain adequate analgesia
  • Severe contamination requiring extensive cleansing or debridement
  • Open fractures, tendon, nerve or major blood vessel injury
  • Complex structures requiring meticulous repair (as the eyelid)
Laceration repair involves a series of steps. These are wound assessment, local anesthesia, wound preparation, wound closure, and tetanus prophylaxis.
ASSESSMENT
All wounds require a brief history and physical examination. Most lacerations are caused by simple trauma; however, be wary of wounds caused by violent or unexpected trauma. Such wounds may have complexities that are not immediately apparent and preclude simple primary repair. The history may also provide clues as to any potential foreign material in the wound. Examine nerve function, vascular status, and motor function carefully; document these results. If there is any concern about a retained foreign body or underlying bony injury, obtain appropriate
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radiographs and discuss the case with a surgical consultant. If, after your assessment, you feel the wound is not amenable to primary closure because of your level of expertise or your facility’s lack of equipment, refer the patient to a surgical consultant early!
LOCAL ANESTHESIA
Please review Chapter 46 (“Regional Anesthetic Techniques”)for a full discussion of local anesthetics and anesthetic techniques.
WOUND PREPARATION
After assessment and anesthesia, the wound should be inspected thoroughlyfor foreign bodies and for damage to deeper tissues, tendons, nerves, and blood vessels.
If significant collateral damage is encountered at this stage, it may be best to refer the patient to a surgical consultant.
The wound should be cleansed thoroughly by mechanical and chemical means to remove gross particles of soil and to reduce bacterial contamination. Mechanical cleansing may be accomplished by using a surgical scrub brush with water to raise a good lather or by irrigating with saline. Use a 30- or 60-mL syringe with a 18- or 20-gauge needle to produce a “power-wash” spray. Irrigate with a minimum of 200 to 300 mL of saline. Chemical cleansing is probably less important than the mechanical cleansing. Use commercial antiseptic solutions such as Betadine, Savlon, or Hibiclens. These solutions are aided in effectiveness by allowing them to dry on the wound.
If the edges of the wound are ragged or dirty, they can be trimmed with iris scissors or a scalpel (after appropriate anesthesia) to give a fresh wound edge. A clean, fresh wound edge will promote a superior cosmetic result. A ragged or dirty edge will pucker or become infected after the closure.
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TETANUS PROPHYLAXIS
Check tetanus immunization status on all patients presenting with lacerations. If their immunization status has lapsed, administer the appropriate vaccine.
PRIMARY CLOSURE TECHNIQUES
Three standards should be held in any primary closure:
  • Closure of “dead” space to prevent accumulation of blood or tissue fluids
  • Accurate approximation of all involved tissue layers
  • Minimal tension on the wound edges required to keep them together
With these standards in mind, examine the wound again and decide which technique of wound closure is most appropriate.
Primary Closure Using Dressings
Wounds that involve only the most superficial layers of the skin, that are not bleeding, and that have edges in close apposition before treatment may be suitable for closure using a dressing. These wounds should not be located on skin surfaces that are subject to significant tension (extensor or flexor surfaces of a joint) or constant friction (palms or soles).
The most convenient dressings to appose these minor lacerations are tape closure strips, such as Steri-strips or a similar product. After cleaning the wound, apply these tape closures and cover with a dressing of choice.
Primary Closure Using Tissue Glue
Superficial skin lacerations may also be closed using tissue glue, octylcyanoacrylate (Dermabond, or similar product). Using glue is generally painless, as there are no needle punctures from anesthetic or sutures. This makes glue an ideal technique for wound closure on young children or other patients who might not tolerate needle use. Suitable wounds for glue closure are those that involve the superficial skin layers (no deeper subcutaneous extension), have achieved hemostasis, and have edges that are already in close apposition.
Wounds in nearly any body area are suitable for glue use; exceptions are flexor or extensor surfaces of joints, wounds with extension into mucous membranes, or genital area wounds.
What You Need
Wound-cleansing materials
Dermabond or similar glue (even Krazy-glue will do in a pinch)
Wound apposition forceps (either disposable plastic ones, or Adson-type)
Paper or plastic tape
Dressing of choice
Clinical Technique
  • Obtain appropriate history of the laceration and perform a physical examination. Does the wound meet the criteria for glue closure? Discuss procedure with the patient and obtain consent.
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  • Cleanse wound in your usual fashion; ensure hemostasis.
  • Place strips of tape around all four edges of the wound, leaving 0.25 inch of exposed skin.
  • Use forceps to appose edges of wound by grasping the tape.
  • Apply a thin layer of glue over the apposed wound edges (Fig. 44.1).
    FIG. 44.1. Wound edges held together by special apposition forceps, followed by glue application.
  • Allow several moments for the glue to dry. Remove tape. Apply dressing of choice.
Follow-Up:
The laceration may be followed up by the primary care physician or surgical consultant in 4 to 5 days. The glue will slough off by that time.
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Primary Closure Using Sutures
Suture closure of lacerations is appropriate for wounds that extend into the deeper subcutaneous tissues and that are inappropriate for closure by the previous two techniques. Suturing is appropriate for the closure of lacerations of fascia, muscle, tendons, and subcutaneous tissues, as well as skin closure.
There are two broad categories of sutures, absorbable and nonabsorbable. Absorbable sutures include plain gut, chromic gut, braided polyglactin (Vicryl and Dexon), and the absorbable monofilaments polydioxanone (PDS) and polyglyconate (Maxon). Absorbable sutures on tapered needles are suitable for closure of deeper tissue layers and mucous membranes. Gut sutures will retain their strength for 5 to 10 days; Vicryl and Dexon, for 30 to 60 days; and the absorbable monofilaments for up to 90 days.
Nonabsorbable sutures include braided silk and the synthetic monofilaments Ethilon and Prolene. On a cutting needle, these sutures are generally used to close the external skin surfaces. Nonabsorbable sutures will need to be removed after 5 to 10 days to prevent scarring.
A single-layer closure refers to simply suturing the skin surface, whereas a layered closure involves deeper layers as well as the skin. By closing the deeper layers, the skin edges “fall” together with reduced tension, allowing for a superior cosmetic result. Closure of the deeper layers also prevents “dead space” from forming. This “dead space” may allow pockets of blood or serum to accumulate, which will impair wound healing and can lead to a wound infection.
What You Need
Wound-cleansing materials, irrigation materials
Suture set to include minimally: (a) needle holder of suitable size, (b) Adson-type forceps (both toothed and nontoothed), (c) iris scissors, (d) suture scissors, (e) hemostat, and (f) No. 15 blade and handle
Materials for local or regional anesthesia
Appropriate sutures for the laceration
Mask, gown, and sterile gloves
Sterile draping
Dressing of choice
Clinical Technique
  • Obtain history of the laceration and perform an appropriate physical examination. Can the laceration be closed primarily by you or is referral required? Does it require a single-layer or a layered closure? Discuss the procedure with the patient and obtain consent.
  • Wash your hands; don mask, gown, and gloves.
  • Anesthetize the wound with lidocaine or bupivicaine as appropriate.
  • Cleanse the wound using mechanical and chemical methods. Irrigate well with saline (200 to 300 mL saline minimum). Are there any foreign bodies?
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  • Drape the wound to define a sterile field.
  • Debride and recut wound edges if necessary. Hold skin edges together. Do they come together with little or no tension? Undermine skin edges (Fig. 44.2) if wound closes only with tension. Undermining allows the skin and dermis to “float” over the deeper tissues without undue tension. Use a No. 15 blade or the iris scissors to undermine at the dermal-subcutaneous tissue junction.
    FIG. 44.2. Undermining of skin edges to reduce tension during wound closure.
  • Select appropriate suture(s) for closure (see Table 44.1 for suggestions).
    TABLE 44.1. Suture Selection and Wound Closure Technique for Selected Wounds
  • Use appropriate suture technique.
Interrupted Stitch
The interrupted stitch is a basic suture technique that may be used at any tissue level to close a wound. Figure 44.3 demonstrates the technique on the skin surface. Notice that the suture incorporates a broad base of tissue on either side of the laceration. This has the effect of slightly “everting” the wound edges, which promotes healing. For skin, use a monofilament nonabsorbable on a cutting needle.
FIG. 44.3. The simple interrupted suture. Note the broad, even base of tissue incorporated in the stitch, and notice the knot is tied on ONE SIDE.
If dead space needs to be closed, use an absorbable suture on a taper needle. Tie the knot so that it is “buried” in the deeper tissues (Fig. 44.4). Closing dead space also brings the superficial wound edges together under less tension. This in turn allows for an easier skin repair.
FIG. 44.4. The basic interrupted suture used to close dead space. Notice that the knot is buried in the deeper tissues.
If the wound will be under some tension or is on thicker skin, such as the palms or soles, consider a mattress suture technique. This technique has the advantage of additional strength (two lengths of suture for each tie), and it everts the wound edges nicely. Use a nonabsorbable suture on a cutting needle. The mattress suture may be horizontally or vertically inserted (Fig. 44.5 and Fig. 44.6); the choice of which one to use is left to personal preference.
FIG. 44.5. The horizontal mattress suture.
FIG. 44.6. The vertical mattress suture. Note how the first loop of suture is pulled upward to “tent” the tissue for the next deeper loop.
A running continuous suture is suitable for longer, linear wounds on the extremities or the trunk (Fig. 44.7). Use a nonabsorbable monofilament suture on a cutting needle.
FIG. 44.7. The running continuous suture.
If the wound is linear, small (less than 5 cm), and under minimal tension, or is on the face or neck, using an intracuticular running suture provides an excellent
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cosmetic result. You may tie the ends over a gauze bolster or simply tape them onto the skin to maintain tension in the stitching. Removal is accomplished by cutting the “escape loop” in the middle and pulling on the two exposed ends of the suture (Fig. 44.8). Use a nonabsorbable suture on a cutting needle.
FIG. 44.8. The intracuticular running suture with “escape loop.”
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If you have a laceration with an acute corner, use the three-point corner stitch to appose the skin edges. The three-point corner stitch is an intradermal stitch where the needle is initially inserted into the skin on the nonflap portion of the laceration at the mid-dermal level. The stitch is then passed through the apex of the flap at the intradermal level and then returned on the opposite side of the wound, paralleling the point of entrance (Fig. 44.9).
FIG. 44.9. The three-point corner stitch.
Follow-Up:
  • Use dressing of choice over the wound.
  • Have patient see their primary physician or surgical consultant for suture removal. Remove facial sutures in 3 to 5 days; sutures on other areas in 10 days. Sutures on the palms or soles, or other areas under tension should be removed at 14 days.
Primary Closure Using Staples
Skin closure using surgical steel staples is a rapid and effective wound management technique. A specialized stapler prefilled with staples is required for the procedure. The steel staple is in the form of a wide, inverted U, and as the staple is inserted the cross arm is bent. This directs the legs of the staple into the skin. This elevates, everts, and approximates the skin enclosed by the staple.
Skin stapling is appropriate for wounds on the scalp, trunk, or extremities. Having an assistant hold the wound edges together with forceps often aids in the procedure.
Follow-Up:
Skin staples should be removed by the primary care physician or surgical consultant within 7 to 10 days. A special staple removal instrument is required.
Table 44.1 lists suggestions for suture selection and closure methods for a variety of wounds.