Skin Laceration

Introduction | Types of Lacerations | Clinical Presentation | Diagnosis | Management and Treatment | When to Refer | References

Introduction

Skin lacerations are common injuries that involve a tear or cut in the skin, often caused by sharp objects or trauma. Lacerations can vary significantly in depth, length, and severity, ranging from superficial cuts to deep wounds that involve underlying tissues such as muscles, tendons, or nerves. Proper management of lacerations is crucial to minimise the risk of infection, promote optimal healing, and reduce the likelihood of scarring.

Types of Lacerations

Lacerations can be classified into several types based on their cause and appearance:

• Clean Lacerations: Caused by sharp objects like knives or glass, resulting in smooth, clean-edged wounds that are easier to close and less likely to be contaminated.
• Contaminated Lacerations: Occur when the wound is exposed to dirt, debris, or bodily fluids, increasing the risk of infection. Often caused by dirty or rusty objects.
• Crush Lacerations: Result from blunt trauma, involving jagged edges and significant tissue damage, bruising, and swelling.
• Avulsion: A portion of the skin and underlying tissue is torn away, leading to a flap of skin that may remain partially attached or be completely detached.
• Puncture Wounds: Deep, narrow injuries caused by sharp, pointed objects like nails or needles. These wounds can be difficult to clean and are prone to infection.
• Degloving Injuries: A severe form of avulsion where the skin is peeled away from the underlying tissues, often requiring complex surgical management.
• Complex Lacerations: Involve multiple tissue layers, including nerves, tendons, or blood vessels, requiring specialist intervention.

Clinical Presentation

The presentation of a skin laceration varies depending on the severity and depth of the wound:

• Bleeding: Varies from minor oozing in superficial cuts to significant bleeding in deeper lacerations involving arteries or veins.
• Pain: Common in all lacerations, intensity varies with depth and involvement of nerve endings.
• Wound Edges: May be clean and smooth or irregular and jagged, indicating the mechanism of injury.
• Exposed Structures: Deeper lacerations may reveal underlying tissues such as fat, muscle, tendons, or bone.
• Contamination: Presence of dirt, debris, or foreign bodies increases infection risk.
• Swelling and Bruising: Particularly in crush injuries, may indicate underlying tissue damage.
• Loss of Function: If nerves, tendons, or muscles are involved, there may be weakness, numbness, or inability to move the affected area.
• Signs of Infection: Redness, warmth, swelling, pus, or fever may develop if the wound becomes infected.
• Shock: In severe cases with extensive blood loss, signs of hypovolemic shock may be present.

Diagnosis

The diagnosis of a skin laceration is primarily clinical, based on the appearance of the wound and the circumstances of the injury:

• History: Obtain a detailed history of the injury, including the mechanism, time of occurrence, environment, and any potential contaminants. Assess tetanus immunisation status and any allergies.
• Physical Examination:
  • Inspect the wound for depth, length, and presence of foreign bodies.
  • Assess for signs of infection: redness, warmth, swelling, or purulent discharge.
  • Check for underlying structural damage, such as tendon or bone involvement.
• Neurovascular Assessment: Evaluate motor and sensory function distal to the injury. Check pulses and capillary refill to assess blood flow.
• Imaging:
  • X-rays: Indicated if foreign bodies (e.g., glass, metal) are suspected or if there may be bone involvement.
  • Ultrasound: May help identify non-radiopaque foreign bodies like wood or plastic.
  • MRI/CT Scan: Rarely required but may be necessary for complex injuries involving deep structures.
• Laboratory Tests: Not routinely required but may include complete blood count if significant blood loss is suspected or wound cultures if infection is present.
• Photographs: With patient consent, photographs may be taken for medical records. Often done for secondary care opinion.

Management and Treatment

The management of skin lacerations aims to control bleeding, prevent infection, and promote optimal wound healing:

1. Initial Wound Care

• Control Bleeding: Apply direct pressure with a sterile dressing. Elevate the injured area above heart level if possible. Use tourniquets only as a last resort.
• Cleaning: Irrigate the wound thoroughly with sterile saline or clean water to remove debris and bacteria. High-pressure irrigation may be used for contaminated wounds.
• Debridement: Remove devitalised tissue and foreign material to reduce infection risk and promote healing.
• Anaesthesia: Local anaesthesia may be administered before cleaning and debridement to ensure patient comfort (done mostly in secondary care).

2. Wound Closure

• Primary Closure: Suitable for clean, uncontaminated wounds less than 6-12 hours old (up to 24 hours on the face). Methods include:
  • Sutures: Provide strength and precise wound edge approximation.
  • Staples: Quick method suitable for scalp or non-cosmetic areas.
  • Adhesive Strips (Steri-Strips): For small, superficial lacerations.
  • Tissue Adhesives (Skin Glue): Ideal for simple, clean cuts, particularly in children.
• Delayed Primary Closure: In contaminated wounds, closure is delayed for 3-5 days after initial cleaning and observation for infection signs.
• Secondary Intention: Wounds heal naturally without closure, suitable for heavily contaminated or infected wounds.
• Special Techniques: Complex wounds may require flaps or grafts by a specialist surgeon.

3. Antibiotic Therapy

• Prophylactic Antibiotics: Consider for high-risk wounds:
  • Contaminated wounds or those involving soil, faeces, or saliva.
  • Bite wounds from animals or humans.
  • Wounds involving joints, tendons, or bone.
  • Patients with diabetes, immunosuppression, or peripheral vascular disease.
• Empirical Antibiotics: If infection is suspected, start empirical therapy such flucloxacilin, targeting common skin pathogens like Staphylococcus aureus and Streptococcus pyogenes.
• Culture-Guided Therapy: if treatement failure, adjust antibiotics based on culture and sensitivity results if available.

4. Tetanus Prophylaxis

• Tetanus Immunisation:
  • Verify immunisation status.
  • Booster often given if more than 10 years since last dose for clean wounds, or more than 5 years for contaminated wounds.

5. Pain Management

• Analgesics:
  • Paracetamol: For mild to moderate pain.
  • NSAIDs: Ibuprofen for additional anti-inflammatory effect unless contraindicated.

6. Follow-Up Care

• Dressing Changes: Provide instructions on keeping the wound clean and when to change dressings.
• Suture or Staple Removal: Arrange for removal (you can ask to be booked with a nurse or yourself):
  • Face: 5-7 days.
  • Scalp: 7-10 days.
  • Limbs: 10-14 days.
  • Joints: 14 days.

When to Refer

Referral to a specialist or hospital may be necessary in the following situations:

• Complex or Deep Lacerations: Involvement of tendons, nerves, blood vessels, or bones.
• Facial Lacerations: Especially around the eyes, lips, or nose for optimal cosmetic and functional outcomes.
• Significant Tissue Loss: Wounds requiring reconstructive surgery, grafts, or flaps.
• Infected Wounds: Signs of severe infection, systemic symptoms, or failure to respond to initial treatment.
• Foreign Bodies: Retained foreign bodies not easily removable in a primary care setting.
• Immunocompromised Patients: Higher risk of complications requires specialist input.
• Non-Healing Wounds: Wounds that do not show signs of healing or worsen over time.
• Psychological Impact: Patients exhibiting signs of trauma, anxiety, or distress may benefit from mental health support.

References

1. British Association of Dermatologists (2024) Guidelines for the Management of Skin Lacerations. Available at: https://www.bad.org.uk (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Skin Lacerations: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng108 (Accessed: 26 August 2024).
3. British National Formulary (2024) Wound Management and Antibiotic Prophylaxis. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).
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