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

- Half-buried Horizontal Mattress Suture
- Indicated in triangular flap Laceration (does not compromise blood supply to tip of corner)

- Horizontal Mattress Suture
- Everts wound edges, but risk of skin necrosis and scar

- Vertical Mattress Suture
- Everts wound edges, but risk of skin necrosis and scar

- Deep Suture (interrupted dermal Sutures)
- May use in clean wounds to better approximate wound edges and reduce wound edge tension

- RunningSuture
- Fast technique for long Lacerations, but risk of dehiscence if Suture breaks anywhere along its length

- Running Subcuticular Suture
- May use in clean wounds (surgical wounds) for close wound edge apposition (but does not allow drainage)

- Suture Removal
- See Suture for timing of Suture removal
- Protocol: Bandages
- Moist Wound Healing is key
- Non-adherent slightly moist or Occlusive Dressing
- Ointment or Topicals (e.g. Bacitracin, vaseline)
- Apply for first 3 days until epithelialization
- Reduces infection risk at minor wound sites
- Dire (1995) Acad Emerg Med 2(1): 4-10 +PMID:7606610 [PubMed]
- Precautions
- Avoid applying ointment over Skin Glue closure (e.g. Dermabond)
- Vaseline alone is sufficient without risk of reaction and without higher rate of Wound Infections
- Topical Antibiotics cause a irritant or Allergic Contact Dermatitis in up to 10% of cases
- Reactions are most common with neosporin (or triple antibiotic)
- Reactions may also occur with Bacitracin
- Consider debridement after epitheliazation (day 3)
- Initial use of Occlusive Dressings (first 3 days) prevent scab formation
- Carefully apply 50% hydrogen peroxide to scab
- Avoid prior to day 3 (delays Wound Healing)
- Scab removal may improve cosmesis
- Protocol: Home Instructions
- Gentle compression
- Precautions about water exposure (e.g. bathing, getting wound wet)
- Typical recommendations are to not get the wound wet for the first 48 hours after repair
- Early water exposure at a wound site does not appear to increase the risk of infection
- Heal (2006) BMJ 332(7549): 1053-6 +PMID:16636023 [PubMed]
- Patients should still avoid exposure to contaminated water (e.g. dish washing)
- Observe and return immediately for signs of Wound Infection
- Avoid excessive tension on wound edges (risk of wound dehiscence)
- Exercise caution over joints and other regions of maximal tension
- Highest risk of wound dehiscence after Sutures are removed (lesion is only partially healed at 10-14 days)
- Suture Removal
- See Suture Removal Timing
- Face, Ear, Eyebrow, Nose, Lip: 5 days (3 days for Eyelid)
- Other regions: 10 days
- Scar prevention
- See moist Wound Healing recommendations as above
- After Wound Healing (first 28 days), consider Silicone Sheeting applied daily for up to 3 months
- Management: Adjuncts
- Prophylactic antibiotics possible indications
- Not routinely indicated in noncontaminated wounds
- Wounds at higher risk of secondary infection
- See secondary infection risk factors below
- Comorbidity with risk of distant site infection
- Endocarditis risk (see SBE Prophylaxis)
- Hip prosthesis
- Post-exposure Tetanus prophylaxis
- Unknown Immune Status or never immunized
- Tetanus Toxoid Containing Vaccine (e.g. Td, Tdap, TT) now, at 6 weeks and 6 months AND
- Tetanus Immune globulin 250 Units IM if Puncture Wound or contaminated wound
- Last Tetanus Toxoid containing Vaccine over 5-10 years prior
- Tetanus Toxoid Containing Vaccine (e.g. Td, Tdap, TT) now
- Management: Disposition
- Hospitalization Indications
- Failed outpatient therapy (especially if non-compliance with recommended management)
- Poorly controlled comorbidity (e.g. Diabetes Mellitus, Peripheral Vascular Disease)
- Immunocompromised state
- Severe or progressive Cellulitis (especially if deeper, regional or systemic signs)
- Necrotizing Fasciitis
- Referral Indications
- Wounds affecting joints, bones, tendons or nerves
- Wounds affecting large body regions
- Facial wounds
- Burn Injury
- See Burn Injury for referral/transfer criteria
- Severe or circumferential burns or
- Burns to the face, hands or feet
- Complications
- Retained Foreign Body
- See Foreign Body Removal
- Hypertrophic Scar
- Secondary Wound Infection
- See Wound Infection for risk factors
- Occurs within 48 hours in most cases
- Course: Wound Healing
- See Wound
- References
- Lin and Lin in Herbert (2014) EM:Rap 14(11): 8-10
- Lin and Shinar in Herbert (2017) EM:Rap 17(5): 3-4
- Lin and Shinar in Herbert (2017) EM:Rap 17(7): 1-2
- Mortiere (1996) Principles of Primary Wound Management
- Snell in Pfenninger and Fowler (1994) Procedures for Primary Care Physicians, Mosby, Chicago, p. 12-9
- Forsch (2017) Am Fam Physician 95(10): 628-36 [PubMed]
- Worster (2015) Am Fam Physician 91(2): 86-92 [PubMed]