Is a hand laceration with exposed tendon at a higher risk for infection?

Hand Lacerations with Exposed Tendon Have Higher Infection Risk

Hand lacerations with visible tendon exposure are at significantly higher risk for infection and require more aggressive management compared to simple hand lacerations. While simple hand lacerations have an infection rate of approximately 5% 1, wounds with exposed tendons require specialized care due to their increased infection risk and potential for serious complications.

Infection Risk Factors in Hand Lacerations

• Tendon exposure: Visible tendon indicates deeper wound penetration, creating direct access for bacteria to colonize relatively avascular tendon tissue
• Anatomical considerations: Hand tendons have areas of relative hypovascularity, particularly near tendon insertions, making them more susceptible to infection once exposed 2
• Wound depth: Deeper wounds that reach tendon level have greater surface area for bacterial colonization and reduced blood supply for immune response
• Contamination potential: Exposed tendons can harbor bacteria that are protected from normal wound cleansing procedures

Management Algorithm for Hand Lacerations with Exposed Tendon

Initial Assessment

1. Evaluate wound characteristics:

   • Depth and extent of tendon exposure
   • Time since injury (though no definitive "golden period" has been established) 3
   • Presence of foreign bodies
   • Vascular and neurological status 4

2. Determine tendon injury extent:

   • Partial vs. complete laceration
   • Percentage of cross-sectional area affected
   • Functional impact

Treatment Protocol

1. For all hand lacerations with exposed tendon:

   • Thorough irrigation with tap water or sterile saline (100-1000 mL) 4
   • Consider referral to hand specialist or emergency hand unit for proper evaluation 5
   • Early specialist evaluation is critical as delayed treatment increases infection risk 4

2. For partial tendon lacerations:

   • Non-beveled lacerations affecting <95% of tendon cross-section may be managed without repair 6
   • Beveled lacerations >25% of cross-section should be repaired with simple sutures 6
   • Early mobilization is recommended regardless of repair decision 6

3. For complete tendon lacerations:

   • Surgical repair is necessary 7
   • Referral to hand surgery specialist

Infection Prevention Measures

1. Hand hygiene:

   • Proper hand hygiene is the cornerstone of infection prevention 2
   • Use alcohol-based hand rubs when hands are not visibly soiled 2
   • Wash hands with soap and water when visibly soiled 2

2. Wound care:

   • Apply clean occlusive dressing that maintains wound moisture 4
   • Consider topical antibiotics for minor wounds 4
   • Perform layered closure for deep wounds, identifying and reapproximating deep layers first 4

3. Antibiotic considerations:

   • Universal antibiotic prophylaxis is not recommended for all wounds 4
   • Reserve antibiotics for specific high-risk cases, including deep wounds with tendon exposure 4
   • For established infections with systemic signs, consider broad-spectrum coverage 4

Follow-up and Monitoring

1. Early follow-up within 24-48 hours to assess for signs of infection 4

2. Monitor for:

   • Increasing pain, swelling, redness
   • Purulent drainage
   • Fever or systemic symptoms
   • Limited range of motion

3. Patient education:

   • Keep wound clean and dry
   • Watch for signs of infection
   • Importance of follow-up appointments
   • Early mobilization protocols if appropriate

Key Considerations

• Hand lacerations with tendon exposure should be considered serious injuries requiring specialized evaluation
• The infection risk is significantly higher than the baseline 5% seen in simple hand lacerations 1
• Early specialist referral is critical for optimal outcomes
• Proper wound cleansing and appropriate closure techniques are essential for infection prevention
• Antibiotic use should be selective based on wound characteristics and patient risk factors

By following these guidelines, clinicians can minimize the risk of infection in hand lacerations with tendon exposure and optimize functional outcomes for patients.