A laceration is a break in the skin caused by trauma. Although common, proper evaluation is essential because wounds can hide deeper injuries such as nerve, tendon, vessel, or joint involvement. Certain mechanisms—like bites, glass injuries, or contaminated wounds—significantly change management.
Your uploaded chart outlines a structured, practical approach widely used in emergency care.
This article expands that information into a detailed learning resource.
Red Flags in Laceration
These signs require heightened caution:
Concerning Features
- Actively bleeding wound
- Human/animal bite
- Deep wound or puncture
- Diabetic or immunocompromised patient
- Possible nerve/tendon/vessel injury
- Contaminated wound (dirt, rust, feces, bite)
- Foreign body sensation (glass, metal, wood)
- High-tension areas (joints, hands, scalp)
Always update tetanus status as part of initial management.
Initial Steps in Laceration Management
✔ Step #1 – Update Tetanus
Follow CDC guidelines based on wound type and vaccination history.
✔ Step #2 – Neurovascular (NV) Exam
Document before anesthesia:
- Sensation: SILT (sensation intact to light touch)
- Motor: Full ROM across joints
- Discrimination: 2-point discrimination (especially in digits)
- Perfusion: Capillary refill
This is crucial for medical-legal protection.
Timing of Wound Closure
Timing matters because infection risk increases with delayed repair.
| Time Since Injury | Recommendation |
|---|---|
| < 6 hours | Repair almost all wounds |
| 6–24 hours | Depends on wound type (face more likely to repair; hands/feet dirty wounds less likely) |
| > 24 hours | Generally avoid closure; consider delayed closure if needed |
The face has excellent blood supply → low infection risk.
The feet, hands, intertriginous areas → higher risk.
Size & Suture Type Selection
✔ Skin Adhesive
- For small, linear, bloodless wounds
- Not for joints, hands, or hair-bearing areas
✔ Suture Guidelines
- Face: 6-0 nylon or skin adhesive (best cosmetic result)
- Joints: Larger sutures, always nylon
- Hands: 5-0 or 4-0 (use 4-0 for high tension)
- Everywhere else: 4-0 or 3-0 nylon
Absorbable sutures are useful in patients unlikely to return for follow-up.
Special Situations
Eyelid Margin
- Always consult ophthalmology
- Perform visual acuity and eye exam
Lip Lacerations
- For vermillion border → perfect alignment is essential
- Consider oral and maxillofacial surgery consult
Hands/Feet
- High suspicion for tendon involvement
- Always perform NV exam with 2-point discrimination
Scalp
- Staples preferred
- Evaluate for head injury
Bite Wounds
- Cat > human > dog (in terms of infection risk)
- Suture only when necessary—many should be left open
- Consider prophylactic antibiotics
Deep Wounds
- Use a few large, deep absorbable sutures to reduce dead space
- Avoid absorbables in hands (risk of infection)
Penetration of Joint Capsule
- Rule out joint involvement → irrigation, imaging
- Orthopedic consult
Shattered Glass / Foreign Body Suspicion
Low threshold for X-rayUnreliable Follow-Up
Prefer absorbable suturesWound Closure Mechanics (Step-by-Step)
A. Anesthesia
- 1% lidocaine with epinephrine
- Consider special blocks: digital block, flexor sheath block, nerve block
Areas to avoid epinephrine: tips of nose, penis, toes, ears, fingers (classic teaching—use your local institutional guidelines).
B. Irrigation
- The most important step in preventing infection
- Use copious high-pressure saline
- Minimum: 5 minutes under running sink OR 250–500 mL via syringe
C. Wound Edge Preparation
- Evert wound edges → prevents depressed scars
- First suture should be in the center (“bisect method”)
D. Suture Technique
- Enter/exit at 90°
- Continue until edges are approximated—not strangulated
E. Dressing
- Apply bacitracin + sterile dressing
- Avoid bacitracin if skin adhesive was used
Pearls & Pitfalls (from the chart)
✔ Don’t make the bite of your suture too small
→ Weak closure, poor approximation
✔ Don’t tie sutures too tight
→ Causes tissue ischemia
✔ Irrigation reduces infection more than antibiotics
→ Meticulous cleaning is essential
✔ Give tetanus immunoglobulin if patient is unvaccinated
Wounds contaminated by dirt, feces, or typically rusty objects require immunoglobulin.
✔ Avoid epinephrine in high-risk anatomical tips
(Nose, penis, fingers, toes, ear—follow institutional protocols)
✔ Splints help if laceration crosses joint
→ Prevents wound dehiscence
✔ Staples for scalp wounds
Fast and effective
✔ Cosmetic outcome less important in large, poorly aligned wounds
→ Consider leaving open or using absorbables
Documentation Essentials
General
- Time since injury
- Mechanism (glass, knife, bite, fall)
- Environment (dirty, metal, animal)
Neuro/Wound Exam
- Sensation intact
- Full ROM
- 2-point discrimination
- No foreign bodies
- No exposed tendon/bone
Procedure Note Example
“Anesthesia with 1% lidocaine and epinephrine. Irrigated with 500 mL pressurized saline. No foreign body seen. Wound edges approximated using 5-0 nylon simple interrupted sutures. Dressed with bacitracin. Patient tolerated well.”
Discharge Instructions
- Keep dry for 24 hours
- Clean daily with soap/water after
- Watch for signs of infection: redness, swelling, pain, fever, pus
Suture Removal Timing
- Face: 5 days
- High-tension areas: 10–14 days
- Everywhere else: 7–10 days
- (Skin adhesives/absorbables do NOT need removal)
Quick Summary Table
| Component | Key Points |
|---|---|
| Tetanus | Update in all traumatic wounds |
| NV Exam | SILT, ROM, 2-pt discrimination |
| Closure Timing | <6h repair; 6–24h selective; >24h avoid |
| Sutures | Face 6-0; hands 5-0/4-0; elsewhere 4-0/3-0 |
| Irrigation | High-pressure, abundant |
| Special Cases | Eyelid, lip, bites, joints, glass, tendons |
| Documentation | Mechanism, NV exam, irrigation, sutures, follow-up |
FAQs About Laceration Management
1. Do all lacerations need antibiotics?
No. Only select wounds—bites, deep contaminated wounds, immunocompromised patients.
2. When should imaging be ordered?
If there is foreign body sensation, glass injury, or high-force trauma.
3. Should bite wounds be sutured closed?
Often no—especially cat bites. Human bites also carry high risk.
4. Is skin adhesive better than sutures?
For small, linear, low-tension wounds: yes.
For high-tension areas: no.
