Management of Simple Lacerations
Simple lacerations are superficial wounds that can be managed effectively in general practice. The goal is to promote healing, reduce infection risk, and restore function with minimal scarring.
1. Initial Assessment
History:
- Mechanism of injury (sharp vs blunt, clean vs contaminated)
- Time since injury (>6–8 hours increases infection risk)
- Patient factors (diabetes, immunosuppression, anticoagulation)
- Tetanus vaccination status
Examination:
- Wound size, depth, and location (involvement of tendons, nerves, vessels?)
- Foreign bodies (glass, wood, gravel – consider X-ray for radio-opaque materials)
- Active bleeding (apply pressure; check for arterial involvement)
- Signs of infection (redness, swelling, pus, warmth)
2. Wound Preparation
Anaesthesia:
- Local infiltration with 1% lignocaine (± adrenaline for haemostasis, except in end-arterial areas like fingers, nose, ears, and penis)
- Buffering lignocaine with bicarbonate or using a small-gauge needle can reduce pain
Irrigation & Cleansing:
- Normal saline or tap water irrigation (high-pressure syringe preferred)
- Povidone-iodine or chlorhexidine (avoid deep tissue exposure due to cytotoxicity)
Debridement:
- Remove necrotic tissue, contaminants, or non-viable skin
3. Wound Closure
Choice of closure depends on wound location, size, tension, and contamination:
| Closure Method | Indications | Example Locations |
|---|---|---|
| Sutures | Deep wounds, areas of tension, gaping lacerations | Face, scalp, limbs |
| Adhesive strips (Steri-Strips™) | Superficial, low-tension wounds | Face, trunk |
| Tissue glue (Dermabond™) | Small, clean lacerations, low-tension wounds | Face, children’s wounds |
| Staples | Linear scalp and extremity wounds | Scalp, limbs |
Suture Choice:
- Face: 6-0 or 5-0 non-absorbable (nylon, polypropylene) for finer scars
- Scalp, extremities: 4-0 or 3-0 non-absorbable
- Deep dermal: Absorbable 4-0 Vicryl or Monocryl for layered closure
4. Post-Closure Care
- Dressing: Keep covered for 24–48 hours
- Tetanus prophylaxis if required
- Antibiotics: Generally not needed unless:
- Contaminated wounds (e.g., animal bites, farm injuries)
- Immunocompromised patients
- Deep puncture wounds (e.g., foot wounds from nails)
5. Follow-Up
- Suture Removal:
- Face: 5–7 days
- Scalp: 7–10 days
- Trunk, upper limbs: 7–10 days
- Lower limbs, high-tension areas: 10–14 days
- Scar care: Silicone gels, sun protection, massage after wound healing
- Infection monitoring: Redness, swelling, pus, pain
Management of Complex Lacerations
Complex lacerations involve deep tissue layers, nerves, blood vessels, tendons, or joints and require careful assessment and specialised management to prevent complications such as infection, loss of function, or poor healing.
1. Initial Assessment
History
- Mechanism of injury (e.g., knife, crush, avulsion, bite, glass)
- Time since injury (>6–8 hours increases infection risk)
- Contamination risk (soil, bites, human saliva, marine environment)
- Dominant hand (if on upper limb)
- Comorbidities (diabetes, immunosuppression, coagulopathy)
- Tetanus immunisation status
Examination
- Wound characteristics: Depth, size, location, contamination, presence of foreign bodies
- Haemostasis: Active bleeding suggests arterial involvement
- Neurological function: Sensory and motor testing for nerve injury
- Tendon function: Passive vs active movement
- Vascular supply: Capillary refill, pulses distal to the wound
- Foreign bodies: Consider X-ray (metal, glass), ultrasound (wood, organic material), or CT
2. Specific Considerations for Deep Structure Damage
1. Nerve Injury
Assessment
- Sensory function:
- Radial nerve → Loss of sensation over dorsum of thumb and inability to extend wrist
- Median nerve → Loss of sensation over palmar aspect of thumb, index, and middle fingers; weak thumb opposition
- Ulnar nerve → Loss of sensation over little finger and weak finger abduction
- Digital nerves (fingers): Test two-point discrimination (<6 mm normal)
- Motor function:
- Ask the patient to extend, flex, abduct, and adduct fingers
- OK sign test (anterior interosseous branch of median nerve)
Management
- Sharp, clean-cut nerve injuries: Consider referral for primary repair if within 72 hours
- Blunt or crush injuries: Often require delayed repair by a hand surgeon
- If referral is delayed, close the wound loosely and refer for secondary repair
2. Blood Vessel Injury
Assessment
- Capillary refill time > 2 seconds
- Cool, pale limb
- Absent or weak pulses (compare to the contralateral limb)
- Doppler ultrasound if pulses are not easily palpable
Management
- Direct pressure for bleeding control
- Do NOT clamp suspected arteries blindly → risk of nerve damage
- If arterial injury is suspected → urgent referral to vascular surgery
- If venous bleeding → elevate the limb, apply pressure dressing
3. Tendon Injury
Assessment
- Flexor tendons (palm/fingers): Ask patient to actively flex fingers
- Extensor tendons (dorsal hand): Ask patient to extend fingers and wrist
- Isolated tendon tests:
- Jersey sign → Unable to flex distal phalanx (Flexor Digitorum Profundus injury)
- Boutonnière deformity → Central slip injury of extensor tendon
- Mallet finger → Inability to extend distal phalanx
Management
- Complete tendon laceration: Requires urgent surgical referral for repair
- Partial tendon laceration: May be managed conservatively with splinting, but refer for hand therapy
- Splint in a functional position (e.g., flexor tendon injuries require wrist flexion and finger immobilisation in a splint until repair)
3. Wound Management
Anaesthesia
- Regional nerve block (e.g., digital block) preferred over local infiltration to avoid tissue distortion
- Lignocaine 1% ± adrenaline (except in end-arterial areas like fingers, nose, ears, penis)
Wound Preparation
- Irrigation: High-pressure saline irrigation to remove contaminants
- Debridement: Remove necrotic tissue, devitalised skin, or obvious foreign material
- Foreign body removal: Use imaging (X-ray, ultrasound, CT) if suspected
Closure Methods
- Primary closure: Clean wounds <6 hours old
- Delayed primary closure: Contaminated wounds, bite wounds (close in 3–5 days after ensuring no infection)
- Secondary intention: Highly contaminated or deep irregular wounds
| Closure Method | Indications | Example Locations |
|---|---|---|
| Sutures | Deep wounds, high-tension areas | Scalp, limbs, face |
| Staples | Large scalp wounds | Scalp |
| Tissue adhesive (glue) | Small, superficial wounds | Face, low-tension areas |
| Sterile strips | Linear, low-tension wounds | Face, trunk |
4. Additional Considerations
Antibiotic Prophylaxis
- Indications:
- Contaminated wounds
- Bites (human, animal, marine exposure)
- Diabetic or immunocompromised patients
- Deep wounds involving bone, joint, or tendon
| Wound Type | First-Line Antibiotic | Alternative (Penicillin Allergy) |
|---|---|---|
| Human bite | Augmentin (Amoxicillin-Clavulanate) 875/125mg BD | Doxycycline + Metronidazole |
| Dog/Cat bite | Augmentin 875/125mg BD | Doxycycline + Metronidazole |
| Saltwater wounds | Doxycycline + Ciprofloxacin | Azithromycin |
| Freshwater wounds | Fluoroquinolone (Ciprofloxacin) | TMP-SMX + Clindamycin |
Tetanus Prophylaxis
| Wound Type | Vaccination Status | Action |
|---|---|---|
| Clean, minor wound | ≥3 doses, last dose <10 years | No tetanus booster needed |
| Clean, minor wound | ≥3 doses, last dose >10 years | Give dT vaccine |
| Dirty wound | ≥3 doses, last dose <5 years | No booster needed |
| Dirty wound | ≥3 doses, last dose >5 years | Give dT vaccine |
| Dirty wound | <3 doses or unknown | Give dT + tetanus immunoglobulin (TIG) |
5. Follow-Up and Wound Monitoring
- Suture Removal Timing:
- Face: 5–7 days
- Scalp: 7–10 days
- Trunk, upper limbs: 7–10 days
- Lower limbs, high-tension areas: 10–14 days
- Signs of infection: Increased pain, erythema, pus, swelling
- Referral if complications arise (wound dehiscence, delayed healing, loss of function)
Key Takeaways
- Neurovascular assessment is crucial in deep wounds
- Flexor tendon injuries require urgent repair and splinting
- Vascular injury → urgent referral to vascular surgery
- Consider foreign bodies and imaging if needed
- Antibiotics for bites, high-risk wounds, or immunocompromised patients