Approach
History
• Time of event (>12 h → irrigate/heal by secondary intention or delayed primary closure, face/significant soft tissue defect → primary closure in <24 h), location (suture selection/time until removal), mechanism (↑ risk FB/contamination), tetanus (booster if >5 y)
Inspection
• FB, wound approximation
Palpation
• Pulses, strength, sensation distal to injury
Laceration
Definition
• Cut or tear to skin & soft tissues
History
• Penetrating or blunt trauma
Physical Findings
• Skin defect, ↓ pulses/sensation/motor (neurovascular injury)
Evaluation
• Plain films only if FB/fracture suspected
Treatment
• Hemostasis: Direct pressure, lidocaine w/ epinephrine if needed (avoid in digits, nose, ears, penis), hemostatic agents (eg, thrombin, Surgicel), proximal tourniquet
• Analgesia: Use regional blocks when possible (↓ wound distortion/amount of analgesic needed)
• Irrigation: >500 cc NS (no benefit over tap water) (Ann Emerg Med 1999;34:356), 8 psi of pressure (18 g IV catheter or Zerowet splash shield in 30–60 cc syringe), caution on delicate tissues (eye lids)
• Exploration (through a full ROM): FB, tendons (including in position of injury), fascial planes
• Repair:
• Abx: Not routinely required (must be given for certain bites)
Disposition
• Home
Pearls
• Scarring: Take up to 1 y to fully develop, apply sunscreen/keep covered even on cloudy days, apply Vit E
• Hand flexor tendon lacerations: Emergent primary repair by hand surgeon, splint (wrist 30° flexion, MP joint 70° flexion, DIP/PIP 10° flexion)
• Hand extensor tendon lacerations: Zone IV & VI repair primary in ED, splint, hand surgery f/u
Foreign Body
Definition
• Retained FB in wound (most common hand/foot) → ↑ risk delayed infection/granuloma/ formation/local compression of structures/embolization/ allergic rxns (reactive FBs: Wood, organic matter, clothing, skin fragments)
History
• Know FB, ↑ risk wounds: Stepping on glass/punching windows/MVC w/ glass exposure/fall on gravel/pain at IVD site/persistent wound infections/failure to heal (41% wounds caused by glass)
Physical Findings
• Visible/palpable FB
Evaluation
• Explore wound (adequate anesthesia/hemostasis/probe w/ instrument), plain films for radiopaque FBs (glass, metal, bone, teeth, graphite, gravel), US (use 100 cc bag of NS or other transducing material for superficial FB location)
Treatment
• Not all FB require removal (deep, small, inert, asymptomatic, away from vital structures), removal (significant pain, functional impairment, reactive, contamination, near vital structures, cosmetic concerns): May require wound extension, irrigation, fine tip forceps
Disposition
• D/C
Fingertip Wounds
Definition
• Amputations/laceration/crush to fingertip (skin/volar pulp/distal phalanx/nail/nail bed)
History
• Cutting/crushing injury
Physical Findings
• Amputation, nail bed lacerations, subungual hematoma
Evaluation
• Finger plain film (FB, fracture)
Treatment
• Amputation: Distal to DIP joint → wound care/secondary intention (may need to trim back bone/should always be covered by soft tissue)/abx, significant bone/soft tissue loss → emergent hand surgery consult
• Subungual hematoma: Large → nail trephination, small → no intervention
• Nail bed laceration: Primary repair → remove nail, repair w/ 6–0 absorbable suture, replace nail into nail fold (suture or secure w/ tape) to splint nail bed/maintain nail fold (nail growth → 70–160 d)
Disposition
• D/C