Managing Abrasions and Lacerations
Aaron Rubin, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 5 - MAY 98
In Brief: Abrasion and laceration management begins with controlling bleeding, assessing the wound site, and determining the patient's tetanus status. Abrasions are treated with thorough irrigation, a topical antibacterial agent, and an appropriate dressing. Laceration treatment includes anesthesia use and wound cleaning, suturing under sterile conditions, application of an appropriate dressing, and timely follow-up. Cyanoacrylate skin adhesives are a promising alternative to suturing for some wounds. Guidelines for return-to-play decisions are included.
Eleven million traumatic wounds are treated by emergency physicians each year in the United States (1). The skin, the largest organ in the body, is involved in most of these traumas. For example, cuts are the most frequent cause of nonfatal injuries in 10- to 17-year-olds (with an incidence of over 59 per 1,000), and they account for more than a third of nonfatal accidents, injuries, and poisonings in this population (2).
Sports participation puts the unprotected skin of athletes at risk of injury, not only in collision sports such as football and hockey but also in sports like basketball and soccer, where collision with another player or the playing surface often results in wounds. Skin injuries are among the most common injuries in bicycling, particularly off-road cycling (3).
Physicians who work with athletes need to quickly assess and treat skin wounds and make appropriate decisions about return to play, keeping in mind the need to minimize exposures to blood (see "Return to Play After an Abrasion or Laceration," below).
Cellular Events of Injury and Healing
The skin is divided into the epidermis and the dermis. The epidermis is the superficial layer that provides protection, while the dermis is the deeper layer that provides the firmness and elasticity of healthy skin. Beneath the skin is the subcutaneous tissue, which lies outside the fascia that generally covers muscle. The skin varies in thickness from 8 mm at the soles of the feet to 1 mm at the eyelid.
Abrasions are excoriations or circumscribed removals of the outer layer of skin or mucous membrane, usually caused by friction. Lacerations are either clean cuts caused by sharp trauma or torn, jagged wounds that occur when the patient's skin is split by being stretched over underlying bone.
Healing cascade. When skin is abraded or lacerated, a cascade of cellular and biochemical events begins. Hemostasis is initiated by the rupture of blood vessels and exposure of subendothelial collagen to platelets, which in turn activate the coagulation cascade. Chemotactic factors attract neutrophils followed by macrophages, fibroblasts, and lymphocytes. Each of these carries out roles in the initial inflammation stage and the later proliferation stage of wound healing, which is followed by the longer process of maturation.
Barriers to healing. This complicated series of events can be influenced by many factors. Bacterial infection, malnutrition, and poor tissue oxygenation, which may occur in anemia, hypoxemia, or poor perfusion, will interfere with wound healing. Medications such as systemic corticosteroids and cytotoxic and immunosuppressive agents blunt the inflammatory response. This blunted response may impair capillary budding, fibroblast proliferation, protein synthesis, and epithelialization and can delay and weaken healing (4). Wounds may also heal more slowly in diabetic and elderly patients.
Avoiding the above problems, of course, improves the healing process. Good nutrition status and general health can also speed a patient's recovery. However, physicians rarely control such conditions when they are treating acute skin injuries in the office or on the field. Nevertheless, they can take some steps to enhance healing and reduce the risk of complications.
Evaluating a wounded patient includes determining the wound's type, location, time of occurrence, and degree of contamination, examining for associated trauma, and assessing the patient's general medical condition and tetanus immune status. For on-site care during a sporting event, a well-stocked medical bag (table 1) facilitates treatment, the control of blood-borne pathogens, and decisions regarding temporary versus definitive treatment and return to play.
Controlling bleeding. For any wound, the bleeding must be controlled, usually by using direct pressure over the wound. Head and facial wounds tend to bleed more heavily than similar wounds in other locations. Universal precautions define all blood as a risk for disease transmission and require the use of gloves and other barriers to prevent contamination. If the wound occurs during an athletic event or practice, activity must be stopped immediately to allow removal of the athlete and cleaning of the playing surfaces.
The importance of location. The location of the wound will help determine the treatment. For example, facial wounds are cosmetically noticeable and require meticulous handling to prevent scar formation. Wounds over joints are under tension and need protection to prevent sutures from being pulled out. While minimum scarring is always the desired outcome, scar formation on the torso or extremities is generally more acceptable than on the face. Wounds at certain sites should be examined for associated trauma, such as a zygomatic fracture beneath a facial laceration or a tendon injury associated with a hand laceration; deep abrasions carry similar concerns.
Initial handling. The appearance of a wound site after healing is influenced by many factors. Some are outside a physician's control, including the age and race of the patient, the mechanism and location of the wound, and the patient's inherent ability to heal and tendency toward abnormal scar formation (5).
Others, such as initial wound management, can be controlled. Excessive scar formation can be minimized through gentle handling and careful cleaning of the injured tissue. Appropriate irrigation of wounds is extremely important in decreasing bacterial count and risk of infection. All wounds should be considered contaminated. This is especially true for human bite wounds, which generally should not be closed. The final appearance of other wounds can be enhanced if skin tension is minimized in closure.
Tetanus status. Tetanus status should be determined for any athlete with an abrasion or laceration. If a patient is uncertain about having received the last dose of a primary series or a booster within the past 10 years, tetanus immunization should be given. If fewer than two doses of tetanus toxoid have been given and a wound is heavily contaminated, an athlete should also receive tetanus immune globulin (6).
Since bacteria introduced into abraded skin can cause infection that interferes with healing, abrasions must be thoroughly cleaned. Topical anesthesia is sometimes needed to decrease the pain caused by aggressive irrigation. To prevent contamination of the physician and others nearby, a face shield, gloves, and impermeable gown should be worn.
The wound is irrigated (figure 1) using a large syringe (30 to 60 mL) under pressure and sterile normal saline solution. The pressure may be increased by using an 18-gauge needle or angiocatheter. The wound should be irrigated until clean with at least 500 mL of solution. To prevent wound "tattooing," embedded material must be removed with a thumb forceps or hypodermic needle and the wound copiously irrigated.
Once clean, the wound should be covered with a topical anti-infective agent followed by an appropriate dressing. Generally, a nonstick dressing, such as Telfa (Kendall Health Care Products, Mansfield, Massachusetts) or Adaptic (Johnson & Johnson Medical, Inc, Arlington, Texas), is applied directly over the wound, and the dressing in turn is covered by absorbent gauze and roller gauze to hold it in place. An alternative dressing is a semipermeable film such as Tegaderm (3M Health Care Ltd, St Paul), which is a transparent polyurethane film that is permeable to oxygen and water vapor but impermeable to water and bacteria. Another alternative is an occlusive hydrocolloid such as Duoderm (Parkview Pharmacy and Home Health Care Supplies, Inc, Rancho Cucamonga, California), which is also impermeable to bacteria (7).
Treating a laceration involves bringing the edges of the skin together so that the healing process can close the wound. In superficial lacerations, this can be accomplished with skin tapes, but in lacerations into the dermal layer, suturing is necessary to eliminate dead space.
Anesthesia and irrigation. Before suturing, the laceration must be cleaned and anesthetized; early use of anesthesia allows for more aggressive cleaning. Anesthesia is accomplished by using a small-gauge needle to inject the anesthetic slowly in a fan-like pattern around the laceration and surrounding skin to be sutured. Anesthetics with epinephrine, however, should not be used in areas where the blood supply is limited, such as the nose, fingers, penis, and toes. Commonly used local anesthetics are listed in table 2 (not shown).
Once adequate anesthesia is obtained, the wound is inspected for foreign bodies and trauma to deeper structures, irrigated with normal saline (as described in the discussion of abrasions), and cleaned with an antiseptic such as hexachlorophene, chlorhexidine gluconate, or povidone-iodine.
Sterile drapes. Suturing must take place under sterile conditions with adequate surgical draping to prevent the introduction of bacteria into the wound from suture that has been dragged over contaminated surfaces. Maintaining such conditions during on-the-field suturing can be challenging, but most disposable suture kits contain sterile drapes (figure 2). If not, disposable drapes are available separately.
Deep suture. Before closing the wound, devitalized tissue must be debrided. If the wound edges cannot then be easily approximated, the wound may need to be undermined to allow the skin to be brought together without causing too much tension. Undermining is done by carefully dissecting the outer layer of skin from its dermal attachment to achieve decreased skin tension. If the wound is sufficiently deep, deep suturing, using an absorbable material such as polyglycolic acid, may be needed to eliminate "dead space" (figure 3) that could provide a site for hematoma or infection development. Any deep suturing will cause some reaction and therefore should be kept to a minimum.
Suture technique. The fundamentals of surgical wound closure include handling tissues gently with minimal debridement, ensuring hemostasis, keeping the skin edges relaxed, using fine suture, everting the wound edges, and removing the suture as early as possible (8).
Most wounds should be closed within 8 hours of occurrence, with the exception of facial wounds, which may be closed up to 24 hours later if they have adequate debridement, irrigation, and antibiotic coverage. The desired result is a fine-line scar that does not compromise function or appearance.
After the placement of deep suture, if needed, the skin may be closed with a nonabsorbable suture such as nylon. Good suture results depend on the proper handling of the needle driver and thumb forceps (figure 4) and careful manipulation of the wound edge to allow needle entry at 90° to the skin surface (figure 5). Good results also depend on choosing an appropriate suture technique for the wound site and on precise suture placement (figures 6 and 7). Unfortunately, traumatic lacerations do not always occur along tension lines of the skin and often result in an irregular wound opening, but proper suture placement (figure 8: not shown) can still produce a well-closed wound. Better results occur when the laceration or incision follows the skin's natural tension lines.
Choice of suture color may facilitate suture removal (figure 9), especially when the wound occurs in a hairy area. An alternative to suture on the scalp or extremities is the use of skin staples specifically designed for this purpose.
Dressings. Sterile tapes should be placed over the wound to reduce tension on the suture line, because preventing tension has been shown to decrease scar formation. The sutured wound is then covered with sterile dressings. In athletes, additional support and padding to a sutured laceration may be necessary to allow a safe return to participation. One technique is to cover the sutured wound with a semipermeable dressing and gauze sponges for padding and bind the whole with flexible tape.
Follow-up. The wound area should be kept dry and inspected daily by the patient for signs of infection such as redness, swelling, warmth, tenderness, or drainage. Sutures should generally be removed 3 to 5 days after repair of facial lacerations, 7 to 8 days after closure of scalp and extremity wounds not over a mobile joint, and 10 to 14 days following stitching of wounds over mobile joints and on the soles, palms, or back. The wound should be rechecked by a medical professional 2 to 3 days after suture.
Since repaired skin is not as strong as intact skin, an athlete may need to use some type of protection, such as a padded bandage, over the wound. In some sports, an athlete may consider using a splint or protective padding over an injured area.
Cyanoacrylate adhesives, commonly known as "super glues," polymerize on application to form a strong bond. Butylcyanoacrylate skin adhesives are commercially available but are not approved by the US Food and Drug Administration for use in the United States. A newer adhesive, octylcyanoacrylate, has been approved by Health Canada for use in closing skin wounds. It forms a stronger, more flexible bond than n-2-butylcyanoacrylate (histoacryl blue, or HAB).
Research findings. Using adhesives offers clear advantages, especially during athletic events. Treatment time and patient pain are reduced. No dressing is required. No needles are used, thus decreasing the risk of inadvertent needle sticks. In addition, studies (9,10) suggest that the cost of treating wounds with adhesives is about 80% lower than the cost of suturing.
In a recent randomized trial (1), octylcyanoacrylate worked as effectively as suture in closing lacerations and was also a faster and less painful method of repair. After debridement and placement of deep sutures, if needed, the wounds were randomly sutured or glued. The appearance of the wounds was similar when they were evaluated at 3 to 5 days (facial wounds), or 10 to 14 days (extremity and torso wounds), and also when reevaluated 3 months later by a plastic surgeon blinded to the type of closure.
When patients rated the pain of repair on a 100-point scale—100 being the worst pain—the glue group averaged 7.2 compared with 18.0 for the suture group. The average time of repair was 3.6 minutes in the glue group vs 12.4 minutes in the suture group. Three of 50 patients in the glue group had a wound that dehisced, vs 1 of 48 in the suture group.
The main concern with adhesives is the decreased tensile strength of the wound closure. According to one study (11), the tensile strength of wounds closed with butylcyanoacrylate adhesive was significantly lower at 4 days than that of wounds closed with suture.
Adhesive application. Tissue adhesives can be used to close lacerations on the face, torso, and extremities. However, they should not be applied to heavily contaminated wounds, puncture, bite or scratch wounds, or wounds on the hands or feet, over a joint, or at a mucocutaneous junction. Other contraindications include pregnancy and a history of peripheral vascular disease, diabetes mellitus, or prolonged corticosteroid use.
To close the wound with adhesive, the physician first irrigates and debrides the wound, and if necessary, places deep suture as described above (see "Suture Substitutes: Using Skin Adhesives," April, page 115). Then he or she manually approximates the wound edges, paints the wound line with octylcyanoacrylate—being careful to avoid introducing the adhesive into the wound or touching the glue—and holds the skin edges together for 30 seconds. If adhesive is introduced into the wound, it can form a barrier to healing.
The patient should examine the wound daily for signs of infection. Further follow-up is usually not required, but clinical judgment should be the guide.
Whether skin adhesives offer a viable alternative to traditional suture depends on the approval and availability of products that overcome problems such as tensile strength. Meanwhile, physicians familiar with the basics of abrasion and laceration treatment can help active patients and athletes who have these injuries resume sports participation as soon as possible.
Return to Play After an Abrasion or Laceration
When an athlete involved in a game or practice has a laceration or abrasion, the team physician must decide whether the wound is significant enough for the athlete to be excluded from play. Such decisions are not always clear-cut, especially if they must be made during a game or competition.
The general guiding principle, of course, is the well-being of the athlete—including the final appearance of the wound—and others involved in the activity. Specific return-to-play considerations include:
Dr Rubin thanks Virginia Huang, MD, and Norman Sogioka, MD, for their aid in manuscript preparation.
Dr Rubin is director of the Kaiser Permanente Sports Medicine Fellowship in Fontana, California, and a member of the editorial board of The Physician and Sportsmedicine. He is a fellow of the American Academy of Family Physicians and the American College of Sports Medicine. Address correspondence to Aaron Rubin, MD, Kaiser Fontana Family Medical Residency Program, 9961 Sierra Ave, Fontana, CA 92335.
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