Should a laceration be closed immediately?

Laceration Closure Timing

Most lacerations should be closed immediately after thorough cleaning and debridement to achieve optimal cosmetic results and reduce infection risk. 1, 2

General Principles of Laceration Closure

• Primary wound closure is recommended for most lacerations, especially facial wounds, which should be managed with copious irrigation, cautious debridement, and preemptive antibiotics 1
• The traditional concept of a "golden period" for wound closure has been challenged, with evidence suggesting that some wounds may be safely closed even 18 or more hours after injury without increasing infection risk 2
• The goals of laceration repair are to achieve hemostasis and optimal cosmetic results while minimizing infection risk 2

Factors Affecting Closure Decision

• Location of the wound:

  • Facial lacerations should be closed immediately after thorough cleaning due to better cosmetic outcomes and low infection risk 1, 3
  • Hand wounds may have higher infection rates with primary closure compared to other locations 1
  • Wounds in high-tension areas require suturing for optimal healing 2

• Type of wound:

  • Clean, sharp-edged wounds are ideal for immediate closure 2
  • Puncture wounds should not be closed primarily 1
  • Animal bite wounds (except facial) should generally not be closed primarily 1

• Contamination level:

  • Heavily contaminated wounds may benefit from delayed closure after thorough cleaning 2
  • Wounds with foreign bodies or devitalized tissue require debridement before closure 4

Closure Methods

• Suturing remains the standard method for most lacerations, particularly those under tension 2, 4
• Tissue adhesives and wound adhesive strips can be effectively used in low-tension skin areas 2
  • Topical skin adhesives (TSA) are used in approximately 25% of ED wound closures and are associated with shorter ED length of stay compared to sutures/staples 5
• Sterile adhesive strips can be used for simple, linear lacerations with minimal tension 6

Wound Preparation Before Closure

• Complete wound cleansing with irrigation under pressure is essential 4
• Examination for foreign bodies and radiographic assessment if necessary 4
• Debridement of devitalized tissue 4
• The use of nonsterile gloves during laceration repair does not increase infection risk compared to sterile gloves 2
• Irrigation with potable tap water rather than sterile saline also does not increase wound infection risk 2

Special Considerations

• Tetanus prophylaxis should be provided if indicated:

  • For patients without toxoid vaccination within 10 years 1
  • Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given 1

• For obstetrical perineal lacerations:

  • A systematic evaluation including visual inspection, thorough perineal exam, and digital rectal examination should be performed after all vaginal deliveries 7
  • Rectal examination after repair is crucial to check for any sutures penetrating the rectal mucosa 7

Post-Closure Care

• Wounds heal faster in a moist environment; occlusive and semiocclusive dressings should be considered 2
• The wound should be kept clean and dry for the first 24-48 hours 8
• Follow-up should occur within 24 hours to ensure proper healing 8
• Monitor for signs of infection such as increasing pain, redness, swelling, or discharge 8

Common Pitfalls to Avoid

• Failing to thoroughly clean and debride the wound before closure, which increases infection risk 4
• Closing heavily contaminated wounds or puncture wounds primarily 1
• Not providing appropriate tetanus prophylaxis when indicated 1
• Neglecting to perform a rectal examination after obstetrical perineal laceration repair 7
• Using catgut sutures, which are associated with more pain and higher risk of requiring resuturing 8