What happens when a laceration (cut) is deep through the bone and how is it managed?

From the Guidelines

Deep lacerations that extend through bone require immediate medical attention and typically surgical intervention, with the goal of preventing infection and promoting healing, as emphasized in the most recent study 1. Management of such injuries involves several key steps, including:

• Controlling bleeding and cleaning the wound to prevent infection
• Assessing the extent of damage to bone, surrounding tissues, nerves, and blood vessels
• Surgical debridement to remove contaminated and devitalized tissue, as recommended by the 2020 study 1
• Stabilizing the bone using internal fixation methods such as plates, screws, or pins, depending on the location and severity of the injury
• Administering intravenous antibiotics, such as cefazolin 1-2g every 8 hours or clindamycin 600-900mg every 8 hours for penicillin-allergic patients, to prevent infection, as bone exposure significantly increases infection risk 1
• Implementing pain management, typically including opioid analgesics initially, transitioning to non-opioid options as healing progresses
• Immobilizing the affected area, followed by physical therapy to restore function, as outlined in the 2020 study 1 These injuries often require multiple surgeries and extended rehabilitation periods, with the prognosis depending on the location, severity of bone damage, associated soft tissue injury, and presence of complications like infection or vascular compromise, as noted in the 2016 study 1. The use of local application of antimicrobials at the site of infection, such as gentamicin, tobramycin, vancomycin, and clindamycin, has also been recommended in the 2020 study 1, as it can achieve high local concentrations of antimicrobials with low systemic exposure, which is particularly useful in cases with impaired blood flow to the site of infection and necrotic bone tissue. Overall, the management of deep lacerations that extend through bone requires a comprehensive approach, incorporating surgical intervention, antibiotic therapy, pain management, and rehabilitation, with the goal of preventing infection, promoting healing, and optimizing outcomes, as emphasized in the most recent and highest quality study 1.

From the Research

Management of Deep Lacerations

When a laceration is deep and extends through the bone, management becomes more complex. The following points highlight the key considerations:

• The primary goal is to achieve hemostasis and optimal cosmetic results without increasing the risk of infection 2.
• There is no defined "golden period" for wound repair, and closure may be reasonable even 18 or more hours after injury, depending on the type of wound 2.
• Irrigation with potable tap water rather than sterile saline does not increase the risk of wound infection 2.
• The use of local anesthetic with epinephrine in a concentration of up to 1:100,000 is safe for use on digits, and 1:200,000 is safe for use on the nose and ears 2.
• Tissue adhesives and wound adhesive strips can be used effectively in low-tension skin areas 2.
• Wounds heal faster in a moist environment, and occlusive and semiocclusive dressings should be considered when available 2.
• Tetanus prophylaxis should be provided if indicated 2.
• Negative pressure wound therapy (NPWT) may be used to accelerate healing and prevent or treat wound infections 3.
• Antibiotic prophylaxis may be necessary to reduce the incidence of surgical wound infection, and the selection of antibiotics depends on the organism most commonly causing wound infection in the specific procedure 4.

Antibiotic Prophylaxis

The following points highlight the key considerations for antibiotic prophylaxis:

• Antibiotic prophylaxis is uniformly recommended for all clean-contaminated, contaminated, and dirty procedures 4.
• The first dose of antibiotics should be given before the procedure, preferably within 30 minutes before incision 4.
• Readministration of antibiotics at one to two half-lives is recommended for the duration of the procedure 4.
• Postoperative administration of antibiotics is not generally recommended 4.
• The selection of antibiotics depends on the organism most commonly causing wound infection in the specific procedure and the relative costs of available agents 4.