Treatment of Reopened Hand Laceration
For a reopened hand laceration, perform thorough wound irrigation with sterile saline or tap water under pressure, debride any necrotic tissue, and consider delayed primary closure rather than immediate resuturing, with antibiotic prophylaxis (amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days) reserved only for deep wounds, contaminated wounds, or high-risk patients. 1, 2
Immediate Wound Management
Preparation and Hygiene
- Perform hand hygiene with antimicrobial soap and water for 2-6 minutes before treating the wound 1, 2
- Remove any rings, watches, or bracelets to allow proper assessment 1
Wound Cleansing
- Irrigate copiously with 100-1000 mL of sterile saline or tap water under pressure to remove debris and reduce bacterial load 1
- Tap water is as effective as sterile saile for irrigation 1
- Avoid excessive irrigation pressure that could spread bacteria into deeper tissue layers 2, 3
- For contaminated wounds, soap and water may be more effective than saline alone 1
- Avoid using iodine or antibiotic-containing solutions for irrigation as they may impair wound healing 1
Debridement
- Remove all necrotic tissue and mechanically reduce the bacterial burden 2, 3
- This is more important than antibiotic administration for preventing infection 2
Wound Closure Decision
Critical Pitfall
Do not close grossly contaminated or reopened wounds primarily - consider delayed primary closure instead 1
Reopened wounds have already failed initial healing and carry higher infection risk. The wound has been exposed to additional contamination and may have underlying issues that caused dehiscence.
If Closure is Appropriate
- Closure can be completed up to 24 hours after trauma for clean wounds 4
- Hand lacerations have higher infection risk when closed compared to other locations 3
Antibiotic Prophylaxis
When to Prescribe
Antibiotics are indicated for: 1, 2
- Deep wounds penetrating to periosteum or joint capsule
- Wounds in critical areas (hands, feet, near joints, face, genitals)
- Significant contamination
- Immunocompromised patients
- Wounds presenting with signs of inflammation
When NOT to Prescribe
- Do not give antibiotics if presenting ≥24 hours after injury without signs of infection 2, 5
- Simple, clean, superficial lacerations in immunocompetent patients do not require prophylaxis 5, 6
- Research shows only ~5% of simple hand lacerations become infected, with no significant benefit from routine prophylaxis 6
Antibiotic Selection
Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days is first-line when antibiotics are indicated 1, 5, 2
- Provides coverage against Staphylococcus aureus, Streptococcus species, and Pseudomonas aeruginosa 5
Dressing and Follow-up
- Apply a clean occlusive dressing that keeps the wound moist 1
- Patients should keep dressings clean and dry, as wet or changed dressings are associated with imperfect healing 7, 8
- The wound can get wet within 24-48 hours without increasing infection risk 4
Tetanus Prophylaxis
- Administer tetanus toxoid if >10 years since last dose for clean wounds 3, 4
- Administer if >5 years since last dose for contaminated wounds 3, 5
- Prefer Tdap over Td if patient has not previously received Tdap 3
Key Clinical Pearls
The most important factors associated with wound infection and imperfect healing are: 7, 8
- Wound contamination
- Condition of the dressing (wet or changed)
- Location on hand
- Presence of pain
Proper wound irrigation and debridement are far more important than antibiotic administration for preventing infection - do not rely on antibiotics to compensate for inadequate mechanical cleaning 2, 1