October 28, 2008 — Recommendations for best techniques for the primary care clinician to use when repairing skin lacerations are reviewed in the October 15 issue of American Family Physician.

"The goals of laceration repair are to achieve hemostasis, avoid infection, restore function to the involved tissues, and achieve optimal cosmetic results with minimal scarring," writes Randall T. Forsch, MD, MPH, from the Department of Family Medicine, University of Michigan Medical School in Ann Arbor. "Although the emergency department routinely treats acute trauma, family physicians should be prepared to manage acute lacerations. This requires knowledge of wound evaluation, preparation, and appropriate repair techniques; when to refer for surgical treatment; and how to provide follow-up care."

Immediately on presentation, a laceration should be evaluated, including careful exploration to assess severity and involvement of muscle, tendons, nerves, blood vessels, or bone. Direct pressure should be applied to control bleeding.

History should include when and how the injury occurred and personal health information, such as history of HIV; diabetes; tetanus immunization; and allergies to latex, local anesthesia, tape, or antibiotics. Before repair, examination should include baseline evaluation of neurovascular and functional status of the involved body part.

Because skin lacerations are frequently encountered in the primary care setting, knowing how to repair them is an important skill in family medicine. Although referral decisions should ultimately be based on the clinician's level of expertise, experience, and familiarity with managing lacerations, surgical consultation should be considered for some wounds.

These wounds include deep wounds of the hand or foot; full-thickness lacerations of the eyelid, lip, or ear; lacerations involving nerves, arteries, bones, or joints; penetrating wounds of unknown depth; severe crush injuries; severely contaminated wounds requiring drainage; and wounds for which the patient or clinician is strongly concerned about cosmetic outcome.

The optimal interval from injury to laceration repair is not clearly defined, and it is affected by anatomic location, patient health, type of injury, and wound contamination. Closure of noncontaminated wounds may be successful up to 12 hours after the injury, or even later in healthy patients with a clean laceration of well-vascularized tissue, such as the face and scalp.

In addition to the time since injury, extent and location of the wound, available laceration repair materials, and the skill of the treating clinician all affect definitive management of the laceration. Less severe wounds (eg, simple hand lacerations not longer than 2 cm) may heal well with conservative management, but those that expose underlying tissue or in which bleeding cannot be controlled should be repaired.

For skin laceration repair, suturing is the preferred method. Various options for outpatient repair of lacerations include sutures, tissue adhesives, staples, and skin-closure tapes. Clinicians should be competent in a range of suturing techniques, including simple, running, and half-buried mattress (corner) sutures.

For closure of gaping or high-tension wounds or wounds on fragile skin, the horizontal mattress technique may be preferred because it spreads the tension along the wound edge. In areas that tend to invert, such as the posterior aspect of the neck or concave skin surfaces, the vertical mattress technique allows eversion of the wound edges. A variation known as the half-buried mattress (corner) suture is ideal to close a triangular edge because it does not compromise the blood supply and may therefore reduce necrosis of the tip.

Long, low-tension wounds are best treated with a running ("baseball") suture. Small lacerations on the face or in other low skin-tension areas where cosmesis is an important consideration should be treated with a subcuticular running suture. Although the ends of this suture do not have to be tied, they may be secured with slip knots or tape.

Compared with sutures, tissue adhesives may be more cost effective and offer similar patient satisfaction, infection rates, and the risk for scarring in low skin-tension areas. For repair of scalp lacerations, the tissue adhesive hair apposition technique is also effective.

Using smaller-gauge needles, administering the injection slowly, and warming or buffering the anesthetic solution may reduce the stinging associated with local anesthesia injections. Tap water can be safely used for irrigation, and white petrolatum ointment is as effective as antibiotic ointment for postprocedure care. Furthermore, wetting the wound as early as 12 hours after repair does not increase the risk for infection, according to various studies. After laceration repair, the clinician must not neglect patient education and appropriate procedural coding.

Specific recommendations for clinical practice regarding laceration repair, and their accompanying level of evidence rating, are as follows:

• Although wounds may be irrigated with saline or tap water, povidone iodine, detergents, and hydrogen peroxide should be avoided (level of evidence, B).
• Slow administration and buffering of anesthetic solution can reduce the sting from a local anesthetic injection (level of evidence, B).
• For skin laceration repair, suturing is the preferred technique (level of evidence, C).
• Compared with sutures, tissue adhesives are comparable in cosmetic results, rates of dehiscence, and the risk for infection (level of evidence, A).
• To promote wound healing, applying white petrolatum to a sterile wound is as effective as applying an antibiotic ointment (level of evidence, B).

"Tetanus immunization status should be assessed in patients with lacerations," Dr. Forsch concludes. "After laceration repair, patients should receive instructions on signs of infection and when follow-up should be performed. Billing for laceration repair depends on the size and location of the wound and on the complexity of the repair."

Dr. Forsch has disclosed no relevant financial relationships.

Am Fam Physician. 2008;78:945-951.

Clinical Context

Study Highlights

• Wound irrigation can reduce the risk for infection after repair. Tap water appears as safe and effective as normal saline as an irrigation fluid, and warmed liquid is more comfortable for the patient. Povidone-iodine solution, hydrogen peroxide, and detergents should be avoided because they inhibit wound healing.
• Large wounds on the extremities may require a regional anesthetic block to avoid toxic doses of local anesthetic, defined by the following doses:
  • More than 3 to 5 mg/kg of lidocaine without epinephrine
  • More than 7 mg/kg of lidocaine with epinephrine
  • More than 1 to 2 mg/kg of bupivacaine without epinephrine
  • More than 3 mg/kg of bupivacaine with epinephrine
• In patients with an allergy to amide forms of local anesthetic, intradermal diphenhydramine may be effective.
• Areas of high skin tension, such as over joints, or areas with a thick dermis, such as the back, should be closed with sutures or staples. Areas with low skin tension, such as the face, shin, and dorsal hand, may be repaired with tissue adhesives.
• Absorbable sutures usually dissolve within 4 to 8 weeks. Rates of wound dehiscence and infection appear similar between absorbable and nonabsorbable sutures, and cosmetic results are also similar between these 2 types of suture.
• Regarding the size of the suture, optimal cosmetic results depend on using the finest (smallest-diameter) suture. A 3-0 or 4-0 suture (larger diameter) is appropriate for the trunk, a 4-0 or 5-0 suture (smaller diameter) is usually best for the extremities, and a 5-0 or 6-0 suture (smallest diameter) is appropriate for the face.
• A horizontal mattress suture is usually best for high-tension wounds or wounds with fragile skin, and the vertical mattress technique is best for everting wound edges in anatomic locations which tend to invert, such as the posterior aspect of the neck.
• A half-buried mattress suture can close triangular wounds without compromising their blood supply.
• Subcuticular running suture is ideal for low-tension, cosmetically important wounds.
• Tissue adhesive is convenient and may be cost effective because no follow-up for suture removal is necessary. Patients at a higher risk of poor healing, including patients with diabetes, should not receive tissue adhesive.
• For scalp lacerations less than 10 cm long, strands of hair at least 3 cm in length from opposing sides of the wound may be twisted and fixed with a drop of tissue adhesive to close the laceration.
• Although many patients are told to keep the sutured laceration dry for 24 hours, research has demonstrated that wetting the area after only 12 hours does not increase the risk for infection.
• White petrolatum appears as effective as topical antibiotics in preventing wound infection after laceration repair.
• Sutures may usually be removed at the following times for different anatomic locations:
  • Face: 3 to 5 days
  • Scalp: 7 to 10 days
  • Arms: 7 to 10 days
  • Trunk: 10 to 14 days
  • Legs: 10 to 14 days
  • Hands or feet: 10 to 14 days
  • Palms or soles: 14 to 21 days

Pearls for Practice

• Warm tap water or normal saline is ideal for wound irrigation before laceration repair. Povidone-iodine solution, hydrogen peroxide, and detergents should be avoided because they inhibit wound healing.
• A horizontal mattress suture is usually best for high-tension wounds or wounds with fragile skin, and the vertical mattress technique is best for everting wound edges in anatomic locations which tend to invert, such as the posterior aspect of the neck. A half-buried mattress suture can close triangular wounds without compromising their blood supply. A subcuticular running suture is ideal for low-tension, cosmetically important wounds.

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