Lacerations and Soft Tissue Injuries

Do not use povidone iodine, hydrogen peroxide, or detergents, as they have been shown to impede healing (2)[B].

A fine-pore sponge may be used in cases of significant contamination or fine particulate matter.

Indications for removal of a foreign body include: Potential or actual injury to tendons, nerves, vasculature; toxic substance or reactive agent; source of pain

Retained foreign bodies in abrasions may result in “tattooing” of the skin.

Sterile saline and tap water have been found to have equivalent infection rates (3)[B].

Incidence of infection relates inversely to the amount of irrigation used (3). A “rule of thumb” is to use 50–100 mL of irrigant per centimeter of laceration.

All “clean” wounds can be closed primarily except puncture wounds not able to be adequately irrigated.

Wounds presenting for treatment after a delay, contaminated wounds, and noncosmetic animal bites should be irrigated, debrided, and have bleeding controlled.

Delayed primary closure can be performed after 3–5 days in order to allow the patient's immune system to decrease the bacterial load. The lowest approximate bacterial load will occur 96 hr after the initial injury (3).

Secondary closure is allowing a wound to heal by granulation. This is appropriate for partial-thickness avulsions, contaminated small wounds, and infected wounds (3).

Can be useful to treat abrasions, chaffing, and blisters as well as to further evaluate skin lacerations (4).

Options include 1% or 2% lidocaine jelly, LET (4% lidocaine, 0.1225% epinephrine, and 0.5% tetracaine), or EMLA (eutectic mixture of local anesthetics: 2.5% lidocaine and 2.5% prilocaine), or LMX (formerly known as Ela-Max-liposomal lidocaine) (3).

Preferred type of anesthesia for lacerations: Amide agents (lidocaine and bupivacaine) and ester agents (procaine) are the 2 basic types. Allergy to one group is not associated with allergy to anesthetic from the other group (3). Most allergies are caused by the preservatives used in the anesthetic, so a pure agent, such as cardiac lidocaine, could be used as an alternative (3). Intradermal diphenhydramine can be used for those patients allergic to the above anesthetics (2).

Epinephrine will improve the duration of injected anesthetics (5) and will promote vasoconstriction. Should be used with caution in fingers, toes, nose, ears, or the penis, as vasoconstriction may result in tissue necrosis. Can limit immune cell migration into the wound because of vasoconsrtiction.

Patient comfort can be increased by using a smaller gauge needle to inject, injecting subcutaneously through the open wound, using a slower injection rate, and with the addition of sodium bicarbonate to the anesthetic (1:10 of total volume injected).

Surgical tape: Advantages: Rapid application, patient comfort, lower infection rates, least tissue reactivity, low cost. Disadvantages: Can't apply to areas with hair, must remain dry, highest dehiscence rates, low tensile strength. Application: Use benzoin tincture, apply only to dry skin edges, ensure adequate approximation of skin edges.

Skin adhesives: Advantages: Rapid application, resists bacterial growth, no need for removal, no anesthesia needed, good cosmetic results, excellent for children. Disadvantages: Not adequate for moderate or heavy tension areas of the skin. Application: Apply on to dry skin edges, approximate skin edges.

Staples: Advantages: Rapid application, low tissue reactivity, low cost, can be used in areas with a lot of hair. Disadvantages: Inability to provide a meticulous closure, interference with imaging (CT or MRI), removal required. Application: Sterilize area, anesthesia, roughly approximate edges.

Sutures: Advantages: Meticulous closure, most tensile strength, lowest dehiscence rate. Disadvantages: Anesthesia required, slow application, most tissue reaction, removal required. Application: Determine single or multiple layer closure, remove foreign material or devitalized tissue, create sterile field.

Single layer can be performed with staples, adhesives, surgical tape, or sutures. Choice should depend on location of laceration.

Multiple layer closure: Closes deep tissue dead space; lessens tension at the epidermal level, improving the cosmetic result; absorbable suture should be used to close SC tissue.

Blisters <1 cm in size can be left intact and covered with a protective dressing or membrane (5).

Blisters >1 cm can be aspirated to prevent expansion, but the epidermal “roof” should be left intact (5). After drainage, they should be covered with a protective dressing or membrane.

Alternative dressings include Tegaderm, zinc oxide-impregnated gauze, and occlusive hydrocolloidal dressings such as Duoderm.

The initial dressing should be kept on for 48 hr following repair.

Athlete can shower within the 1st 24 hr, but should avoid prolonged exposure to water for 72 hr.

After 48 hr, dressing should be changed daily

Antibiotic ointment has not been proven to prevent infection, but may improve wound healing. Ointments should not be used more than 48 hr, as they may macerate the skin. White petrolatum ointment has been shown to be equally as effective as antibiotic ointment to prevent infection and promote healing (2)[B].