Laceration

“Does this need stitches?” The key word here is “need,” and for perspective I’ll start with a story. About 20 years ago I was an exhausted medical student on my gynecology/oncology rotation “prerounding.” Those are the rounds you do at 4am before the more painful actual rounds where you’re the dumbest bug in the swarm. My job was to gather vital signs, lab and X-ray results, and remove post-op staples to replace them with steri strips. One extremely obese patient was 2 weeks post-op and had a foot-long vertical abdominal incision with staples theoretically ripe for removal. I got to the last staple and then, to my horror, watched a centimeter gap turn into a fully unzipped incision. (Lesson for med students – Apply steri strips as you unstaple.) Luckily, she was too large to see the wound, and it was too dark for her to see my expression.

I ran to my resident. We returned to apply some dressings and I was told the wound would heal “by secondary intention.” I was amazed to find out I wasn’t fired, and the rounding team was actually quite reassuring. Because of her size and her need for chronic steroids nobody seemed surprised. I was skeptical. But they were confident, and over time I came to realize they were probably right. The human body is just incredibly good at closing itself up… kids especially. So back to “need.” Technically the answer is “rarely.” Far more important than stitching is cleansing.

Red Flags:

• Exposed bone, cartilage, tendon, ligaments
• 
Open fracture
• Animal bite
• 
Probable joint penetration
• 
Dirty or anything embedded (gravel, wood, metal, fish bones… organic matter being worst)
• Arterial bleeding (though this usually stops with pressure too)
• 
Lost sensation or strength suggesting ruptured tendon, muscle, nerve
• Frail, diabetic, immunocompromised etc.

Happy Words

• Clean
• Shallow
• Otherwise healthy
• No circulatory, sensory, motor loss

The happy words describe the large majority of wounds that find the ER. As I said, by far the most useful thing we do is cleanse. But believe or not, high flow tap water has been shown to be as effective as our high tech solutions, probably because the mechanical removal of debris and microbes is most important. In fact, high concentration solutions like Betadine can actually inhibit wound closure. (So for anyone who calls me at home with an “owie,” my first suggestion is to get it under the running sink or shower.)

Back to the opening question… The decision whether or not to suture is based largely on likelihood for infection vs. desire for smaller scars and faster healing. If we use glue, steri strips, sutures or staples, that means we’re confident that the wound is sufficiently clean, and we’re unlikely to be trapping anything that may cause infection. If not clean, then no closing. In 3-4 days, we may consider “delayed primary closure.” As for bacitracin, I’ve a hunch it’s one of the best placebos we peddle. At the very least it keeps bandages from sticking.

And don’t forget Tetanus! I’ve only come across it from a distance in Haiti. If you’ve had a booster in the last 5-10 years, no worries. If not, we can help there as well.

In summary, if you’re on the fence about a wound, feel free to give a call or text me an image. If you’re even considering whether or not to get help, my bet is you won’t “need” much.

More here on wound care.

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