Management of Traumatic Lacerations

N Engl J Med 1998; 338:474-476February 12, 1998

Article

To the Editor:

In their review of the evaluation and management of traumatic lacerations, Singer et al. (Oct. 16 issue)1 provide much helpful information, but the technique recommended for suture closure includes a dangerous surgical practice. In the diagrams of the placement of both a simple suture (Figure 1) and a deep suture (Figure 2), the surgeon everts the wound by retracting the edge of the skin to receive the suture with a finger. This puts the surgeon's finger in the path of the oncoming suture needle. The most common injury during surgery is a needle stick to the surgeon's nondominant index finger during suturing by doing exactly what is shown in these figures.2 In a survey of injuries to medical personnel during operating-room surgery, such a needle stick occurred in 4.9 percent of operations.3 Given the prevalence of blood-borne pathogens such as hepatitis viruses and the human immunodeficiency virus (HIV), this practice poses an unnecessary risk. The edge of the skin to be pierced by the oncoming needle can easily be everted by gentle downward pressure with a forceps. Once the needle is through the skin, the needle can easily be grasped with this same forceps. There is no advantage to the use of one's finger, and contaminated suture needles should be handled with instruments whenever possible.

James M. Spencer, M.D.
University of Miami, Miami, FL 33136

3 References

1
Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med 1997;337:1142-1148
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2
Spencer J, Katz BE. The potential role of simple dermatologic surgery techniques in transmitting HIV infection. Semin Dermatol 1995;14:219-227
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3
Panlilio AL, Foy DR, Edwards JR, et al. Blood contacts during surgical procedures. JAMA 1991;265:1533-1537
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To the Editor:

The figures in the article by Singer et al. depict practices that place the physician at increased risk for exposure to and infection with blood-borne pathogens such as HIV, hepatitis B, and hepatitis C. In the figures showing the placement of simple and deep sutures, a finger is being used to retract the edge of the skin. The finger lies directly in the path of the sharp needle and is likely to be punctured. In an observational study of skin contacts with blood during surgery, 80 of 620 hand contacts occurred during suturing.1

One of us maintains an ongoing surveillance data base on percutaneous injuries among health care personnel (the Exposure Prevention Information Network, or EPINet). From 1993 to 1996, in 77 hospitals nationwide, a total of 992 injuries entered in the data base occurred in emergency departments, 105 (10.6 percent) of which were caused by suture needles. Most of the needle-stick injuries (74 percent) occurred during suturing; a minority (26 percent) occurred after suturing or during disposal of the needle.

Suturing is a source of avoidable injuries to health care personnel. Skin can be retracted by techniques such as the use of instruments, thereby keeping the physician's fingers out of harm's way.2 This simple change in practice allows physicians to provide care without themselves becoming patients.

Scott Deitchman, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 30333

Janine Jagger, Ph.D.
University of Virginia, Charlottesville, VA 22908

2 References

1
Tokars JI, Culver DH, Mendelson MH, et al. Skin and mucous membrane contacts with blood during surgical procedures: risk and prevention. Control Hosp Epidemiol 1995;16:703-711
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2
Lewis FR Jr, Short LJ, Howard RJ, Jacobs AJ, Roche NE. Epidemiology of injuries by needles and other sharp instruments: minimizing sharp injuries in gynecologic and obstetric operations. Surg Clin North Am 1995;75:1105-1121
Web of Science | Medline

To the Editor:

. . . During wound assessment one must watch for persistent bleeding, even if the injury is not proximate to a major artery. Any wound that requires pressure for control of hemorrhage in order to close the skin must involve the laceration of an artery. At least once a year, my associates and I see a radial-artery false aneurysm resulting from forcible closure of a briskly bleeding puncture wound in the forearm. Singer et al. should also have emphasized that the presence of weak pulses distal to an injury or the absence of a pulse should never be attributed to spasm or adjacent swelling. This situation implies an arterial laceration, which should be assessed by a vascular surgeon.

Singer et al. state that deep sutures should be placed so that the knot is buried. This time-honored dictum is not supported by any study. Burying knots can be hard to do properly and is, in my opinion, generally useless with modern synthetic absorbable sutures.

Jeffrey L. Kaufman, M.D.
Baystate Medical Center, Springfield, MA 01199

To the Editor:

In their excellent article, Singer et al. should have mentioned the importance of seeking a foreign body and the need to perform x-ray imaging studies to detect such foreign bodies, which usually manifest themselves later with complications such as poor wound healing, infection, and neurovascular or tendon damage. The failure to identify a retained foreign body is one of the most common misdiagnoses attributed to emergency room physicians, and imaging studies are infrequently performed in such settings. In one series, imaging studies were performed in only 31 percent of urgent care patients later found to have a retained foreign body.1,2

Virtually all retained glass foreign bodies that are larger than 2 mm and are not overlying bone can be detected on a standard anteroposterior roentgenogram. Similarly, wooden fragments may be imaged with ultrasonography or computed tomography.2

C. William Kaiser, M.D.
Veterans Affairs Medical Center, Manchester, NH 03104

2 References

1
Risk management for emergency room physicians: complications of wound management. American College of Emergency Physicians Foresight. Issue 16. September 1990:3.

2
Kaiser CW, Slowick T, Spurling KP, Friedman S. Retained foreign bodies. J Trauma 1997;43:107-111
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To the Editor:

Singer et al. assert wrongly that “the use of vasoconstrictors should be avoided in areas with end arterioles, such as the fingers, toes, penis, and tip of the nose.” This advice enshrines the old medical school mnemonic device fingers, toes, penis, and nose — all extremities of a sort but not all containing end arteries. Ears and noses have a network pattern of vascularity without any end arteries. Rhinoplasties and otoplasties are carried out every day, and these procedures would be blood baths without the use of epinephrine-containing local anesthetics. Unless tissue is severely devitalized, vasoconstrictors should be recommended for the repair of nasal and ear wounds. As far as the penis is concerned, the skin circulation is essentially a random arterial network; only the deep vessels in the corpora are end arteries. Therefore, lacerations that do not penetrate deeply should be treated with the patient under local anesthesia with epinephrine.

Richard H.S. Karpinski, M.D.
200 Central Park South, New York, NY 10019

Author/Editor Response

The authors reply:

To the Editor: Dr. Spencer and Drs. Deitchman and Jagger correctly point out the risk of accidental puncture of the wound-retracting finger with the suture needle. If a finger is used to retract tissues, it should never be put in the potential pathway of the needle. Alternatively, tissues may be gently lifted with a fine forceps while care is taken not to cause any additional trauma to the tissues from crushing. The purpose of the figures was to illustrate the angle of needle entry during placement of sutures and not to mislead readers.

As we mentioned in our review, the possibility of any injury to underlying structures (such as arteries) must be ruled out before wound closure is attempted. We agree with Dr. Kaufman that if hemorrhage cannot be adequately controlled in the emergency room, operative exploration may be necessary to rule out arterial injury.

Failure to recognize the presence of foreign bodies in wounds may indeed have grave consequences, as Dr. Kaiser points out. Physicians can avoid this possibility by obtaining a detailed history of the mechanism of injury and, as we indicated, by thoroughly examining the wound. Appropriate imaging studies may be indicated in suspicious-appearing wounds.

We agree with Dr. Karpinski that under certain circumstances the use of a local vasoconstrictor in lacerations involving the nose and ears may be necessary. However, in our experience, most such wounds will have stopped bleeding by the time of wound closure. At that point, the use of vasoconstrictors would be unnecessary and could lead to further tissue devitalization.

Adam J. Singer, M.D.
State University of New York, Stony Brook, NY 11794

Judd E. Hollander, M.D.
University of Pennsylvania, Philadelphia, PA 19104

James V. Quinn, M.D.
University of Michigan, Ann Arbor, MI 48109

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