Basics
Description
- A laceration is a disruption in skin integrity most often resulting from trauma.
- May be single or multiple layered
Etiology
Multiple causes
Diagnosis
Signs and Symptoms
Lacerations may be accompanied by:
- Bleeding
- Tissue foreign bodies
- Hematoma
- Pain or numbness
- Loss of motor function
- Diminished pulses, delayed capillary refill
History
- Mechanism and circumstances of injury
- Time of injury
- History of foreign body (glass, splinter, teeth)
- Tetanus immunization
- Comorbid condition or medications that may impede wound healing
Physical Exam
- Evaluate nerve and motor function.
- Document associated neurovascular injury.
- Assess presence of devitalized tissue, debris from foreign materials, bone or joint violation, tendon injury:
- Avoid digital exploration if the object is believed to be sharp.
Essential Workup
- Consider repair in OR if unable to be performed safely within the ED, especially for children requiring deep sedation.
- Consider surgical consultation for complex lacerations, especially involving eyes and face.
Assess for possible nonaccidental trauma.
Diagnosis Tests & Interpretation
Imaging
- Evaluation for possible foreign bodies
- Plain radiography:
- Soft-tissue views may aid in visualization.
- Objects with the same density as soft tissue may not be seen (wood, plants).
- US
- CT scan
- MRI with metal precautions
Differential Diagnosis
- Skin avulsion
- Contusion
- Abrasion
Treatment
Pre-Hospital
- Obtain hemostasis, or control of bleeding with direct pressure.
- Straighten any flaps of skin whose blood supply may be strangulated.
- Apply splint if needed.
- Universal precautions
Initial Stabilization/Therapy
- Airway, breathing, and circulation management (ABCs)
- Control hemostasis.
- Remove rings or jewelry if needed. Swollen fingers with rings can become ischemic.
Ed Treatment/Procedures
- Time of onset:
- Lacerations may be closed primarily ≤8 hr old in areas of poorer circulation.
- Lacerations may be closed ≤12 hr old in areas of normal circulation.
- On face, lacerations may be closed ≤24 hr if clean and well irrigated.
- If not closed, wound may heal by secondary intention or by delayed primary closure (DPC) in 3 " 5 days.
- Analgesia and conscious sedation:
- Adequate analgesia is crucial for good wound management.
- Conscious sedation may be required (see "Conscious Sedation " ).
- Local anesthetics:
- Topical:
- TAC (tetracaine, adrenaline, cocaine)
- EMLA (eutectic mixture, lidocaine, prilocaine)
- LET (lidocaine, epinephrine, tetracaine)
- Local/regional:
- Lidocaine, bupivacaine
- Epinephrine will cause vasoconstriction and improve duration of action of anesthetic.
- Avoid epinephrine in the penis, digits, toes, ears, eyelids, tip of nose, skin flaps (necrosis), and severely contaminated wounds (impairs defense).
- For patient comfort, inject slowly with small-gauge needle; buffer every 9 mL of 1% lidocaine with 1 mL 8.4% sodium bicarbonate.
- Consider a 1% diphenhydramine solution in the lidocaine-allergic patient.
- Exploration and removal of foreign body:
- Indications for removal of a foreign body include:
- Potential or actual injury to tendons, nerves, vasculature
- Toxic substance or reactive agent
- Continued pain
- Irrigation and debridement:
- Surrounding intact skin may be cleaned with an antiseptic solution (povidone-iodine, chlorhexidine):
- Do not use antiseptic solution within the wound itself because it may impair healing.
- Scrub with a fine-pore sponge only if significant contamination or particulate matter.
- Irrigation with ≥200 mL of normal saline (NS):
- Optimal pressure (5 " 8 psi) generated with 30-mL syringe through 18 " 20G needle
- Try to avoid shaving hair. Clip if necessary:
- Increased skin infection rate after shaving
- Never shave or clip eyebrow as it may not grow back with a normal appearance
- Debride devitalized and contaminated tissue.
- Wound repair:
- Universal precautions
- Wounds that cannot be cleaned adequately should heal by secondary intention or DPC.
- Reapproximate all anatomic borders carefully (e.g., skin " vermilion border of lip).
- Consider tissue adhesive for wounds with clean borders, low tension.
- Single-layered closure:
- Simple interrupted sutures:
- Avoid in lacerations under tension.
- Horizontal mattress sutures (running or interrupted):
- Edematous finger and hand wounds
- Ideal in skin flaps where edges at risk for necrosis
- Vertical mattress:
- For wounds under greater tension
- 1 stitch that provides both deep and skin closure
- Half-buried horizontal mattress sutures:
- Ideal for closing the vertex of a v- or y-shaped laceration where ischemia is a concern
- Multiple-layered closure:
- Closes deep tissue dead space
- Lessens tension at the epidermal level, improves cosmetic result
- Buried interrupted absorbable suture, simple or running nonabsorbable sutures for epidermis
- Dressing:
- Dress wound with antibiotic ointment and nonadherent semiporous dressing.
- Inform patient about scarring and risk for infection, use of sunscreen.
- Apply splint if needed.
- Antimicrobial agents:
- Uncomplicated lacerations do not need prophylactic antibiotics.
- If antibiotics are used, initiate before wound manipulation or as early as possible.
- Lacerations with high likelihood of infection:
- Animal, human bites, especially to hand (see "Hand Infection " )
- Contaminated with dirt, bodily fluids, feces
- Tetanus immunization
Medication
- See "Conscious Sedation. "
- Tetanus (Tdap/Td for adolescents " adults, DTap for peds): 0.5 mL IM
- Local anesthetics:
- Topical, applied directly to wound with cotton, gauze:
- EMLA (eutectic mixture, 5% lidocaine, and prilocaine): Apply for 60 min. Note: each g of EMLA contains 2.5 g of lidocaine, do not exceed 3 mg/kg lidocaine
- TAC (0.5% tetracaine, 1:2,000 adrenaline, 11.8% cocaine): Apply for 20 " 30 min. Apply from 2 " 5 mL to wound
- LET (4% lidocaine, 1:1,000 epinephrine, 0.5% tetracaine): Apply for 20 " 30 min. Apply 1 " 3 mL. Do not exceed 3 mg/kg lidocaine.
- Injected:
- Bupivacaine (max.: 2 mg/kg; duration 3 " 10 hr)
- Lidocaine (max.: 4.5 mg/kg; duration 1.5 " 3.5 hr)
- Suture materials:
- Absorbable:
- For use in mucous membranes and buried muscle/fascial layer closures
- Natural: Dissolve <1 wk, poor tensile strength, local inflammation: Plain gut, chromic gut, fast-absorbing gut (for certain facial lacerations where cosmesis is important)
- Synthetic braided: Tensile strength diminishing over 1 mo, mild inflammation: Polyglycolic acid (Dexon), polyglactin 910 (Vicryl)
- Synthetic monofilament: Tensile strength 70% at 1 mo: Polydioxanone (PDS), polyglyconate (Maxon)
- Nonabsorbable:
- Greatest tensile strength
- Monofilament: Nylon (Ethilon, Dermalon), polypropylene (Prolene), polybutester (Novafil) can stretch with wound edema, polyethylene (stainless steel)
- Multifilament: Cotton, Dacron, silk (local inflammation)
- Needle types:
- Cutting (cuticular and plastic) types are most often used in outpatient wound repair.
- Staples:
- For linear lacerations of scalp, torso, extremities
- Avoid in hands, face, and areas requiring CT or MRI.
- Adhesive tapes (Steri-Strips):
- For lacerations that are clean, small, and under minimal tension
- Avoid in wounds that have potential to become very swollen.
- Pretreat wound edges with tincture of benzoin to improve adhesion.
- Tissue adhesives:
- Good cosmetic results have been achieved in simple lacerations with low skin tension.
- An alternative to sutures/staples, especially in children
Follow-Up
Disposition
Admission Criteria
- Few lacerations by themselves necessitate admission unless they require significant debridement or ongoing IV antibiotics, or are complicated by extensive wound care issues or comorbid processes (head injury, abdominal trauma).
- It is unsafe for a child to return home when nonaccidental trauma is suspected.
Discharge Criteria
- Wounds at risk for infection or poor healing require a wound check within 48 hr.
- Time of suture removal dependent on location and peripheral perfusion:
- Scalp: 7 " 10 days
- Face: 3 " 5 days
- Oral: 7 days
- Neck: 4 " 6 days
- Abdomen, back, chest, hands, feet: 7 " 10 days
- Upper extremity: 7 " 10 days
- Lower extremity: 10 " 14 days
- Overlying joints: 10 " 14 days
Issues for Referral
- Lacerations of the eye where tear duct injury is suspected require immediate referral.
- Complicated lacerations (tendon involvement) may require further repair in the outpatient surgical office.
- Be sure to discuss temporary skin closure and splinting with your surgical consultant.
- Specific follow-up should be arranged prior to patient discharge.
Additional Reading
- Beam JW. Tissue adhesives for simple traumatic lacerations. J Athl Train. 2008;43(2):222 " 224.
- Chisolm C, Howell JM. Soft tissue emergencies. Emerg Med Clin North Am. 1992;10(4):665 " 705.
- Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999;34(3):356 " 367.
- Roberts PA, Lamacraft G. Techniques to reduce the discomfort of paediatric laceration repair. Med J Aust. 1996;164(1):32 " 35.
- Trott A. Wounds and Lacerations: Emergency Care and Closure. 4th ed. Philadelphia, PA: Saunders, Elsevier; 2012.
See Also (Topic, Algorithm, Electronic Media Element)
Hand Infection
Codes
ICD9
- 879.8 Open wound(s) (multiple) of unspecified site(s), without mention of complication
- 882.0 Open wound of hand except finger(s) alone, without mention of complication
- 883.0 Open wound of finger(s), without mention of complication
- 873.40 Open wound of face, unspecified site, without mention of complication
- 873.50 Open wound of face, unspecified site, complicated
- 879.9 Open wound(s) (multiple) of unspecified site(s), complicated
- 882.1 Open wound of hand except finger(s) alone, complicated
- 883.1 Open wound of finger(s), complicated
- 883.2 Open wound of finger(s), with tendon involvement
ICD10
- S61.219A Laceration w/o fb of unsp finger w/o damage to nail, init
- S61.419A Laceration without foreign body of unsp hand, init encntr
- T14.8 Other injury of unspecified body region
- S01.81XA Laceration w/o foreign body of oth part of head, init encntr
- S01.82XA Laceration w foreign body of oth part of head, init encntr
- S61.229A Laceration w fb of unsp finger w/o damage to nail, init
- S61.429A Laceration with foreign body of unsp hand, init encntr
SNOMED
- 312608009 Laceration - injury (disorder)
- 274172008 Laceration of finger (disorder)
- 284549007 Laceration of hand (disorder)
- 370247008 Facial laceration (disorder)
- 211463006 Foreign body in skin wound (disorder)
- 301453009 tendon laceration (disorder)