What should I assess and report when evaluating an injury laceration?

Assessment and Documentation of Lacerations

When evaluating a laceration injury, you should systematically assess and document specific characteristics to ensure proper management and optimal healing outcomes.

Essential Assessment Components

• Mechanism of injury: Document what caused the laceration, when it occurred, and how it happened to identify potential complications affecting wound healing, tendon function, and long-term outcomes 1

• Position of the finger/body part at the time of injury to assess potential tendon involvement 1

• Presence of crushing component which may affect tissue viability and healing 1

• Foreign body sensation or known foreign material in the wound to assess infection risk 1, 2

• Functional assessment: Document ability to move the affected area through full range of motion to evaluate tendon function 1

• Neurovascular status: Check for numbness, tingling, or color changes (pallor, cyanosis) to assess nerve and vascular involvement 1

• Pain with movement to identify potential complications 1

• Medical history including diabetes, peripheral vascular disease, or other conditions affecting circulation that may impair wound healing 1, 2

Physical Examination Findings to Document

• Wound characteristics:

  • Location and orientation of the laceration 3
  • Length, width, and depth measurements 2
  • Tissue layers involved (epidermis, dermis, subcutaneous tissue, muscle, tendon) 4
  • Wound edge appearance (clean, jagged, contused) 3

• Contamination assessment:

  • Presence of visible foreign bodies 1, 2
  • Degree of contamination 5
  • Time elapsed since injury (affects infection risk) 2

• Functional assessment:

  • Range of motion of affected area 1
  • Tendon integrity through specific functional testing 1
  • Neurovascular status (sensation, capillary refill) 1

Special Considerations for Specific Anatomical Areas

• For perineal lacerations: Document the degree of laceration using standardized classification (first through fourth degree) 3

• For abdominal/thoracic lacerations: Assess for potential involvement of underlying organs or diaphragm 3

• For hand/finger lacerations: Document specific tendon function and digital nerve integrity 1

Documentation of Management

• Wound preparation technique: Document irrigation method and cleaning agents used 5

• Closure method: Document type of closure (primary suturing, adhesive, no closure) 6, 7

• Materials used: Document suture type, size, and technique if applicable 6, 4

• Antibiotic prophylaxis: Document if administered and rationale 6, 2

• Tetanus prophylaxis: Document vaccination status and if booster was administered 5

Follow-up Instructions

• Signs of infection to monitor for (increasing pain, redness, swelling, purulent drainage) 2

• Wound care instructions (keeping clean and dry initially, then appropriate cleaning) 6

• Activity restrictions based on location and severity 6, 4

• Follow-up timing for suture removal or wound reassessment 4

Common Pitfalls to Avoid

• Failure to perform adequate wound exploration may miss deep structure involvement or retained foreign bodies 1, 5

• Inadequate documentation of neurovascular status before and after repair can miss important complications 1

• Not documenting pre-existing functional limitations may lead to confusion about injury-related deficits 1

• Overlooking the need for specialist consultation for complex wounds involving tendons, nerves, or joints 1, 4

• Incomplete tetanus history documentation may lead to inadequate prophylaxis 5