Wound Repair

Aka: Wound Repair, Laceration Repair, Laceration

1. See Also
   1. Wound
   2. Puncture Wound
   3. Eyelid Laceration
   4. Ear Laceration
   5. Finger Laceration
   6. Finger Wound Hemostasis
   7. Fingertip Amputation
   8. Extensor Tendon Laceration
   9. Nail Injury
   10. Nail Bed Laceration
   11. Foot Wound
   12. High Pressure Injection Wound
   13. Limb Amputation
   14. Foreign Bodies of the Skin
   15. Fishhook Removal
   16. Zipper Injury to Penis
   17. Lawn Mower Injury
   18. Human Bite
   19. Dog Bite
   20. Cat Bite
   21. Insect Bite
   22. Marine Trauma
   23. Envenomation
2. History
   1. History of injury
      1. Identify if risk of Retained Foreign Body (e.g. dirt, wood, glass)
      2. Identify contaminants (e.g. soiled knife)
      3. Concurrent serious injury (e.g. Closed Head Injury)
   2. Comorbid conditions
      1. Human Immunodeficiency Virus Infection or AIDS
      2. Diabetes Mellitus
      3. Other immunocompromising condition (e.g. Chemotherapy, chronic Corticosteroids)
   3. Medication allergies
      1. Latex Allergy
      2. Local Anesthesia allergy
      3. Tape allergy
      4. Antibiotic allergy
   4. Tetanus Immunization status
      1. Update with Td or Tdap if longer than 5-10 years since last tetanus Vaccine
3. Exam
   1. Obtain adequate hemostasis on presentation (e.g. direct pressure)
      1. See below for hemostasis management
      2. See Hemorrhage Management
      3. See Topical Hemostatic Agent
   2. Identify functional loss prior to injecting Anesthesia
   3. Evaluate muscle and tendon structures
   4. Evaluate nerve structures
      1. See Motor Exam
      2. See Sensory Exam
   5. Evaluate vascular structures
   6. Evaluate underlying bone
4. Imaging
   1. Indications
      1. Fracture suspected
      2. Retained Foreign Body
         1. See Radiopaque Foreign Body
   2. Modalities
      1. XRay
      2. Bedside Ultrasound
5. Contraindications: Relative Contraindications to primary wound closure
   1. Infected and inflamed wounds
   2. Human Bite or Animal Bite
   3. Serious crush wounds
   4. Primary repair time constraints above not met
6. Indications: Surgical Consultation
   1. Deep hand or Foot Wounds
   2. Full-thickness Eyelid or canniculus Laceration
   3. Consider for lip Lacerations, Ear Lacerations
   4. Nerve, artery, bone or joint involvement
   5. Penetrating wounds of unknown depth
   6. Severe crush injuries
   7. Wounds requiring drainage (severely contaminated)
   8. Cosmetic outcome of significant issue
7. Risk Factors: Wound Infection
   1. Age of Laceration Repair does not appear to significantly impact infection risk
   2. Diabetes Mellitus
   3. Laceration >5 cm
   4. Lower extremity Laceration
   5. Wound contamination
   6. Quinn (2014) Emerg Med J 31(2): 96-100 [PubMed]
8. Preparation: Closure Approaches
   1. Wound Closure by Primary Intention (standard Laceration Repair)
      1. Immediate wound closure with Sutures, staples, surgical tape or Tissue Adhesive
   2. Wound Closure by Secondary Intention
      1. Wound not closed, but rather allowed to heal naturally
      2. Typically used in badly contaminated wounds (e.g. Animal Bites, infected wounds)
   3. Delayed Primary Wound Closure (closure by tertiary intention)
      1. Delayed closure until after 3-5 days of observation for Wound Infection
      2. May also be considered in late wound presentations (>24 hours)
9. Preparation: Closure Material
   1. Suture Material
      1. See Suture Material for Suture type and size selection
      2. Deep (dermal or buried) Absorbable Sutures
         1. Vicryl is most commonly used for the deep layer, unless risk of infection (in which case use monofilament)
         2. Polyglecaprone 25 (Monocryl)
            1. Indicated for deep layer when wounds are higher risk of infection (Vicryl is contraindicated)
            2. Polydioxanone (PDS) is alternative to Polyglecaprone 25 (Monocryl) but has prolonged absorption
      3. Superficial Sutures (e.g. simple interrupted, RunningSuture)
         1. Nonabsorbable Sutures (standard approach)
            1. Nylon (Ethilon) or Polypropylene (Prolene)
         2. Absorbable Sutures (Controversial)
            1. May be used effectively, and with similar cosmetic results in children to avoid Suture removal
            2. For facial Lacerations us fast Catgut, and for trunk or extremity use plain Catgut or Vicryl Rapide
            3. Alternatively, subcuticular skin closure technique may be used
   2. Tissue Adhesive
      1. See Tissue Adhesive
      2. Avoid use around the eyes due to risk of Cyanoacrylate Eye Injury and risk of Periorbital Cellulitis
      3. Limit to well-approximated, low tension, superficial Lacerations with linear edges
   3. Tape closure (Steri-strip) with Benzoin
      1. Remains attached for 4 days
      2. Lower risk of Wound Infection
      3. Place an extra steri-strip across each of strip ends
   4. Staples
      1. Indicated for Scalp Lacerations (tendons, nerves deep)
      2. Higher risk of infection when used for post-operative orthopedic and cesarean skin closures
         1. Figueroa (2013) Obstet Gynecol 121(1):33-8 [PubMed]
         2. Smith (2010) J Bone Joint Surg Am 92(16):2732-2732 [PubMed]
10. Preparation: General
    1. Instrument pointers
       1. Use pickups with teeth (less crush injury)
    2. Gloves
       1. Sterile gloves not needed in uncomplicated repair
       2. Perelman (2004) Ann Emerg Med 43:362-70 [PubMed]
    3. Ruler
       1. Estimates of length without a ruler are inaccurate (although women estimate better than men)
       2. Measurement is key if billing and coding are based on lesion length
       3. Peterson (2014) Injury 45(1): 232-6 [PubMed]
11. Protocol: Repair timetable
    1. Age of Laceration does not appear to significantly impact infection risk
       1. Decision for primary closure should not solely be based on the age of Laceration ("golden period" for repair)
       2. Wounds involving nerves, blood vessels, tendons or bones have additional caveats
       3. Wounds <19 hours old heal better than those open for longer periods
          1. Berk (1988) Ann Emerg Med 17(5): 496-500 [PubMed]
       4. Bacterial count increase by 3 hours
          1. However Wound Infection risk is not directly correlated with age of Laceration
          2. See Risk Factors for infection as listed above
    2. Primary Repair
       1. See above precaution regarding no absolute cut-off for primary repair
       2. Face or Scalp: Repair within 24 hours (18 hours preferred)
       3. Body: Repair within 12-18 hours (6 hours preferred)
    3. Older wounds with infection risk
       1. Step 1: Initial Evaluation
          1. Option 1: Pack wound with sterile wet to dry dressings changed twice daily
          2. Option 2: Standard primary closure with simple interrupted Suture (no deep Sutures)
             1. Give precautions for immediate return for signs of infection
             2. Sutures are removed if wound becomes infected
          3. Option 3: Loose approximation with simple interrupted Suture (no deep Sutures)
             1. Loose closure is typically not recommended
             2. If choosing to Suture, close with good approximation (option 2)
             3. Lin and Vieth in Herbert (2018) 18(10):12-4
       2. Step 2: Reevaluation at 3-5 days
          1. No infection: Primary wound closure with Suture
          2. Infection: Treat infection and healing by second intention as below
       3. Alternative
          1. Consider loose closure with superficial, nonabsorbable monofilament Sutures (e.g. Nylon, Prolene)
          2. Consider scehduled wound recheck in 1-2 days, or in reliable patients, as needed follow-up for signs infection
          3. Remove Sutures if infection occurs
    4. Healing by second intention
       1. Pack wounds with sterile wet to dry dressing bid
       2. Granulation and Contraction risk without suturing
12. Protocol: Local Anesthesia
    1. Prepare skin with antiseptic prior to injection
       1. Betadine is not affective until it dries (hence hibiclens is often preferred)
       2. Avoid hibiclens near eyes (irritation) and inside ear canal (ototoxic)
    2. See Local Skin Anesthesia for pearls to decrease patient discomfort
    3. Consider Topical Anesthetics, especially in children (e.g. LET Anesthesia)
    4. Epinephrine is safe in areas previously contraindicated (fingers, toes, ears, nose)
       1. Exercise caution in Peripheral Vascular Disease
       2. Digits (even Digital Block): 1:100,000 Epinephrine concentration
          1. Shridharani (2014) Eur J Plast Surg 37(4): 183-8 [PubMed]
       3. Nose/Ears: 1:200,000 Epinephrine concentration
          1. Hafner (2005) J Dtsch Dermatol Ges 3(3): 195-9 [PubMed]
13. Protocol: Irrigation
    1. Personal Protection Equipment
       1. Wear a mask with eye shield during irrigation
    2. Saline is as effective as antiseptics (e.g. 1% betadine) for irrigation
       1. Antseptics should be avoided inside the wound due to tissue injury
    3. Tap water is as safe and effective as saline for irrigation (and more plentiful)
       1. Fernandez (2012) Cochrane Database Syst Rev (2): CD003861 +PMID:22336796 [PubMed]
       2. Weiss (2013) BMJ Open 3(1) +PMID:23325896 [PubMed]
    4. Moderate pressure irrigation is the key
       1. Irrigation with syringe provides approximately 5-8 psi
    5. Irrigate with minimum of 250 to 500 cc, or 50-100 ml/cm wound length (use 1000 cc or more if contaminated)
       1. Normal Saline irrigation, compressible plastic bottles (250-500 cc) with plastic adapter OR
       2. Syringe 30-60 ml syringe (requires multiple refills) OR
       3. Placing wound under Running tap water
    6. Avoid irrigation with tissue destructive agents
       1. Hydrogen Peroxide (weak germacide)
       2. Betadine at stock concentration (9%)
          1. Always dilute betadine (1:10)
14. Protocol: Wound Preparation
    1. Remove all surface foreign bodies with scrub brush on skin surface
    2. Do not apply Betadine or Hibiclens inside of wound
       1. Apply to wound edges prior to Anesthesia injection (see Local Anesthesia as above)
    3. Drape widely to allow clear margins
    4. Scalp Wounds
       1. Slick surrounding hair down with K-Y Jelly
    5. Lacerations near the eye
       1. See Eyelid Laceration
       2. Avoid Tissue Adhesive if possible (risk of Cyanoacrylate Eye Injury and increased risk of Periorbital Cellulitis)
       3. Do not shave eyebrows
    6. Thin Skin Flaps (Skin Tears, especially in elderly)
       1. See Skin Tear
    7. Facial Nerve region
       1. Exercise caution in region of Facial Nerve, especially near Parotid Gland and mandubular branch
       2. Risk of permanent nerve injury
       3. Prevent excessive swelling that may compress Facial Nerve branches (consider wound drains)
15. Management: Hemostasis
    1. See Tourniquet (Pneumatic Tourniquet, Windlass Tourniquet)
    2. See Topical Hemostatic Agent
    3. See Hemorrhage Management
    4. Precautions
       1. Patient reports of spurting or pumping bleeding is arterial injury until proven otherwise
       2. Arterial injury may not be immediately obvious on Emergency Department presentation
          1. Arterial bleeding may stop briefly due to vasospasm and small thrombus formation
       3. Do not ligate named arteries
          1. Consult surgery if arterial injury is suspected
    5. Management of small artery bleeding
       1. Apply direct pressure
       2. Arteries <2mm
          1. Locally infiltrate Lidocaine with Epinephrine
          2. Consider electrocautery
       3. Small, unnamed arteries >2mm
          1. Ligation (if able to identify the bleeding vessel)
             1. Clamp the bleeding end and apply ligature (Suture)
          2. Figure of eight Suture (or horizontal mattress)
             1. Indicated for vessel that has retracted within tissue and cannot be clamped
             2. Imagine a square box around the bleeding source
                1. Each corner of the exposed square represents an entry or exit of the figure of eight Suture
                2. Tying the figure of eight compresses the tissue around the bleeding source
16. Protocol: Wound Repair
    1. Specific injury approaches
       1. See Finger Laceration
       2. See Scalp Repair
       3. See Wound Dressing for Transport
          1. Indicated if repair must be done elsewhere
       4. Lip Laceration
          1. Reapproximation of vermillion border is critical to optimal cosmetic result
          2. Place first Suture to reapproximate vermillion border
          3. Use skin marker at border before Anesthetic injection
          4. Repair deeper muscle and Oral Mucosa with 4-0 Absorbable Suture
          5. Repair skin with 6-0 nylon (e.g. Ethilon)
       5. Deep injuries with full thickness muscle Lacerations
          1. Muscle does not hold Sutures well
          2. Attempt to close muscle with 2-0 or 3-0 Absorbable Suture, using Horizontal Mattress Suture
          3. Consider closing fascia above and below muscle
          4. Lin, Shinar and Kantor in Herbert (2017) EM:Rap 17(8): 1-2
    2. Debridement
       1. Recut wound for clean, fresh, surgical-incision edges
    3. Undermining
       1. May be required to ensure Dermis closure and decreased skin tension
       2. Best dissection plane is between dermal layer and connective tissue, subcutaneous fat
       3. Insert closed scissors on lateral wound margin, and then spread open
          1. Repeat for opposite lateral wound margin
    4. Suture technique
       1. Grasp Suture Needle with needle driver one third of way from Suture attachment (where needle becomes straight)
       2. Evert wound edges (do not dig a ditch, build a flask)
          1. Everted edges will flatten over time, inverted edges result in more prominent scars
          2. Needle should enter perpendicular to skin
          3. Direct the needle initially down and away from the Laceration edge
          4. Rotate the wrist and needle driver, following the needle curvature
          5. Exit perpendicular to the skin surface on the opposite side of the Laceration
       3. Reduce skin tension
          1. High skin tension results in a wound that may gape open with risk of Hypertrophic Scar
          2. Wound eversion is a good sign that skin tension has been reduced across the wound edge
          3. Avoid subcuticular closure as sole repair method
          4. Techniques to reduce skin tension
             1. Use deep Sutures first, before superficial closure
             2. Undermine skin edges
             3. In contaminated wounds use simple interrupted Suture or Vertical Mattress Suture
       4. Interupted simple mneumonic
          1. Not too many
          2. Not too tight
          3. Not too wide
          4. Get them out
       5. References
          1. Lin, Kantor and Shinar in Herbert (2017) EM:Rap 17(4): 1
    5. Techniques
       1. Simple Interrupted Suture
          1. Work-horse of Laceration Repair (appropriate for nearly all repairs)
          2. 
       2. Half-buried Horizontal Mattress Suture
          1. Indicated in triangular flap Laceration (does not compromise blood supply to tip of corner)
          2. 
       3. Horizontal Mattress Suture
          1. Everts wound edges, but risk of skin necrosis and scar
          2. 
       4. Vertical Mattress Suture
          1. Everts wound edges, but risk of skin necrosis and scar
          2. 
       5. Deep Suture (interrupted dermal Sutures)
          1. May use in clean wounds to better approximate wound edges and reduce wound edge tension
          2. 
       6. RunningSuture
          1. Fast technique for long Lacerations, but risk of dehiscence if Suture breaks anywhere along its length
          2. 
       7. Running Subcuticular Suture
          1. May use in clean wounds (surgical wounds) for close wound edge apposition (but does not allow drainage)
          2. 
    6. Suture Removal
       1. See Suture for timing of Suture removal
17. Protocol: Bandages
    1. Moist Wound Healing is key
    2. Non-adherent slightly moist or Occlusive Dressing
    3. Ointment or Topicals (e.g. Bacitracin, vaseline)
       1. Apply for first 3 days until epithelialization
       2. Reduces infection risk at minor wound sites
          1. Dire (1995) Acad Emerg Med 2(1): 4-10 +PMID:7606610 [PubMed]
       3. Precautions
          1. Avoid applying ointment over Skin Glue closure (e.g. Dermabond)
          2. Vaseline alone is sufficient without risk of reaction and without higher rate of Wound Infections
          3. Topical Antibiotics cause a irritant or Allergic Contact Dermatitis in up to 10% of cases
             1. Reactions are most common with neosporin (or triple antibiotic)
             2. Reactions may also occur with Bacitracin
    4. Consider debridement after epitheliazation (day 3)
       1. Initial use of Occlusive Dressings (first 3 days) prevent scab formation
       2. Carefully apply 50% Hydrogen Peroxide to scab
       3. Avoid prior to day 3 (delays Wound Healing)
       4. Scab removal may improve cosmesis
18. Protocol: Home Instructions
    1. Gentle compression
    2. Precautions about water exposure (e.g. bathing, getting wound wet)
       1. Typical recommendations are to not get the wound wet for the first 48 hours after repair
       2. Early water exposure at a wound site does not appear to increase the risk of infection
          1. Heal (2006) BMJ 332(7549): 1053-6 +PMID:16636023 [PubMed]
       3. Patients should still avoid exposure to contaminated water (e.g. dish washing)
    3. Observe and return immediately for signs of Wound Infection
    4. Avoid excessive tension on wound edges (risk of wound dehiscence)
       1. Exercise caution over joints and other regions of maximal tension
       2. Highest risk of wound dehiscence after Sutures are removed (lesion is only partially healed at 10-14 days)
    5. Suture Removal
       1. See Suture Removal Timing
       2. Face, Ear, Eyebrow, Nose, Lip: 5 days (3 days for Eyelid)
       3. Other regions: 10 days
    6. Scar prevention
       1. See moist Wound Healing recommendations as above
       2. After Wound Healing (first 28 days), consider Silicone Sheeting applied daily for up to 3 months
19. Management: Adjuncts
    1. Prophylactic antibiotics possible indications
       1. Not routinely indicated in noncontaminated wounds
       2. Wounds at higher risk of secondary infection
          1. See secondary infection risk factors below
       3. Comorbidity with risk of distant site infection
          1. Endocarditis risk (see SBE Prophylaxis)
          2. Hip prosthesis
    2. Post-exposure Tetanus Prophylaxis
       1. Unknown Immune Status or never immunized
          1. Tetanus Toxoid Containing Vaccine (e.g. Td, Tdap, TT) now, at 6 weeks and 6 months AND
          2. Tetanus Immune globulin 250 Units IM if Puncture Wound or contaminated wound
       2. Last Tetanus Toxoid containing Vaccine over 5-10 years prior
          1. Tetanus Toxoid Containing Vaccine (e.g. Td, Tdap, TT) now
20. Management: Disposition
    1. Hospitalization Indications
       1. Failed outpatient therapy (especially if non-compliance with recommended management)
       2. Poorly controlled comorbidity (e.g. Diabetes Mellitus, Peripheral Vascular Disease)
       3. Immunocompromised state
       4. Severe or progressive Cellulitis (especially if deeper, regional or systemic signs)
       5. Necrotizing Fasciitis
    2. Referral Indications
       1. Wounds affecting joints, bones, tendons or nerves
       2. Wounds affecting large body regions
       3. Facial wounds
       4. Burn Injury
          1. See Burn Injury for referral/transfer criteria
          2. Severe or circumferential burns or
          3. Burns to the face, hands or feet
21. Complications
    1. Retained Foreign Body
       1. See Foreign Body Removal
    2. Hypertrophic Scar
    3. Secondary Wound Infection
       1. See Wound Infection for risk factors
       2. Occurs within 48 hours in most cases
22. Course: Wound Healing
    1. See Wound
23. References
    1. Lin and Lin in Herbert (2014) EM:Rap 14(11): 8-10
    2. Lin and Shinar in Herbert (2017) EM:Rap 17(5): 3-4
    3. Lin and Shinar in Herbert (2017) EM:Rap 17(7): 1-2
    4. Mortiere (1996) Principles of Primary Wound Management
    5. Snell in Pfenninger and Fowler (1994) Procedures for Primary Care Physicians, Mosby, Chicago, p. 12-9
    6. Forsch (2017) Am Fam Physician 95(10): 628-36 [PubMed]
    7. Worster (2015) Am Fam Physician 91(2): 86-92 [PubMed]