Management of Open Macerated Hand Lacerations
For an open macerated hand laceration, thorough irrigation with sterile saline or tap water, proper debridement, and appropriate wound closure are essential, with antibiotic prophylaxis reserved for high-risk wounds. 1, 2
Initial Wound Assessment and Preparation
- Assess the wound for depth, contamination, involvement of deeper structures (tendons, nerves, vessels, bone), and time since injury 3
- Remove rings, watches, and bracelets before beginning wound care to allow proper assessment and prevent complications 1
- Perform hand hygiene with antimicrobial soap and water or alcohol-based hand rub before treating the wound 1
- For macerated wounds, special attention must be paid to the softened, waterlogged tissue which can complicate healing 4
Wound Cleansing and Irrigation
- Irrigate the wound thoroughly with sterile saline or tap water under pressure (100-1000 mL) to remove debris and reduce bacterial load 1, 5
- Higher irrigation pressures are more effective than lower pressures for reducing infection rates 1
- Tap water is as effective as sterile saline for wound irrigation 1, 5
- Avoid using hot water as repeated exposure may increase the risk of dermatitis 1
- For contaminated wounds, soap and water may be more effective than irrigation with saline alone 1
Wound Debridement
- Remove all devitalized tissue, foreign bodies, and debris 3
- For macerated wounds, carefully trim the white, soggy edges of skin to create clean wound margins 4
- Examine the wound thoroughly for foreign bodies; radiographic examination may be necessary if deep foreign bodies are suspected 3
Wound Closure
- For simple hand lacerations without involvement of deeper structures, primary closure is appropriate if the wound is clean 3, 5
- The skin's greatest strength is in the dermal layer; ensure accurate approximation of the entire depth of dermis on both sides 3
- Consider tissue adhesives or wound adhesive strips for low-tension areas 5
- For extensive lacerations or those near joints, consider splinting to reduce tension and movement 3
Dressing Selection
- Apply a clean occlusive dressing that keeps the wound moist and prevents drying 1
- For macerated wounds, use dressings that can manage excess moisture while maintaining a moist wound environment 4
- Avoid multiple-use cloth towels of the hanging or roll type 1
Antibiotic Prophylaxis
- Routine antibiotic prophylaxis is not necessary for simple hand lacerations, as studies show approximately 5% infection rate regardless of antibiotic use 6
- Consider antibiotic prophylaxis for high-risk wounds including 2:
- Immunocompromised patients
- Wounds with significant contamination
- Moderate to severe injuries to the hand
- Injuries that may have penetrated periosteum or joint capsule
- When antibiotics are indicated, amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days is recommended as first-line therapy 2
Follow-up Care
- Examine the wound 2-3 days after repair for signs of infection 3
- Timing of suture removal depends on location, typically 10-14 days for hand wounds 5
- Provide tetanus prophylaxis if indicated based on immunization status 5
Special Considerations for Macerated Wounds
- Maceration complicates wound healing, particularly in chronic wounds 4
- Pay special attention to drying the surrounding skin while maintaining appropriate moisture in the wound bed 4
- Consider more frequent dressing changes to manage excess moisture 4
Pitfalls and Caveats
- Avoid using iodine or antibiotic-containing solutions for irrigation as they may impair wound healing 2
- Do not delay wound irrigation and debridement, as these are the most important steps in preventing infection 1, 3
- Be cautious with antibiotic use to prevent development of resistant organisms; only prescribe when clearly indicated 1
- Never close grossly contaminated wounds primarily; consider delayed primary closure 1
- Do not miss underlying tendon, nerve, or vascular injuries; perform a thorough examination of hand function 3