What is the treatment for a laceration presenting more than 24 hours after injury?

Treatment of Lacerations Presenting After 24 Hours

Lacerations presenting after 24 hours can still be safely closed with primary suturing if there are no signs of infection, the wound is properly prepared with thorough irrigation, and patient risk factors are considered. 1, 2

Timing Window for Delayed Closure

• Primary closure remains acceptable up to 24 hours after injury for most traumatic wounds with appropriate wound preparation 1, 2
• The traditional "golden period" of 6 hours is outdated and not evidence-based; studies confirm that delays in wound closure rarely cause infection when proper technique is used 3, 4
• Wounds can reasonably be closed even 18 or more hours after injury depending on wound characteristics 3
• For wounds presenting beyond 24 hours, delayed primary closure after 2-5 days once granulation tissue develops is the preferred alternative 1, 2

Critical Assessment Before Closure

Absolute contraindications to primary closure:

• Actively infected wounds (erythema, purulent discharge, warmth) 2
• Significant devitalized tissue that cannot be adequately debrided 2
• Heavy contamination that cannot be adequately cleaned 1, 2
• Visible foreign bodies that cannot be removed 2

High-risk features requiring special consideration:

• Hand wounds have elevated infection risk and benefit from prophylactic antibiotics 1
• Bite wounds (animal or human) require early antibiotic treatment for 3-5 days 5, 1
• Patient comorbidities: diabetes, immunosuppression, peripheral vascular disease necessitate more conservative management 1, 2

Essential Wound Preparation Protocol

Irrigation technique:

• Use sterile normal saline without additives for thorough irrigation 1, 2
• Potable tap water is acceptable and does not increase infection risk compared to sterile saline 3
• Avoid high-pressure irrigation as this drives bacteria into deeper tissue layers 1

Debridement:

• Remove superficial debris cautiously without enlarging the wound 1, 2
• Excise devitalized tissue as needed 2
• Examine for foreign bodies; obtain radiographs if indicated 6, 7

Closure Technique for Delayed Wounds

• Layered closure provides optimal strength by approximating the full depth of dermis to opposite dermis 6
• The dermal layer provides the skin's greatest tensile strength 6
• Accurate epidermal coaptation gives cosmetic benefit but does not contribute to wound strength 6
• Consider splinting or immobilization for extensive lacerations or those near joints 6

Antibiotic Prophylaxis Decision Algorithm

Give prophylactic antibiotics for:

• Bite wounds on any location (amoxicillin-clavulanate 875/125 mg BID orally) 5, 1
• Hand wounds, especially if heavily contaminated 1
• Immunocompromised patients, those with diabetes, or peripheral vascular disease 1, 2
• Heavily contaminated wounds even after irrigation 1, 2

Do NOT give prophylactic antibiotics for:

• Simple, clean lacerations on trunk or extremities (excluding hands) 5, 2
• Routine evidence shows no benefit for uncomplicated wounds 2

Duration when indicated:

• 2-day regimen is as effective as 5-day regimen for contaminated traumatic wounds (Cephalexin 500 mg QID) 8
• For bite wounds specifically, treat for 3-5 days 5, 1

Alternative Management for Wounds Beyond 24 Hours

If primary closure is not appropriate:

• Delayed primary closure after 2-5 days once granulation tissue develops 1, 2
• Negative pressure wound therapy (NPWT) can extend the closure window to 7-10 days or longer for complex wounds 1, 2
• Secondary intention healing for heavily contaminated or infected wounds 2
• Wound approximation with Steri-Strips as a temporizing measure 2

Post-Closure Management

• Keep surgical dressings undisturbed for minimum 48 hours unless leakage occurs 1, 2
• Elevate the injured area during the first few days to accelerate healing, especially if swelling is present 1, 2
• Follow-up within 24 hours (phone or office visit) is recommended for wounds closed near the time limit 2
• Examine wound 2 days after suture placement for signs of infection 6
• Moist environment promotes faster healing; use occlusive or semiocclusive dressings when available 3

Tetanus Prophylaxis

• Provide tetanus prophylaxis if indicated based on immunization history and wound characteristics 3, 7

Common Pitfalls to Avoid

• Do not refuse closure solely based on time elapsed if wound appears clean and patient is low-risk 3, 4
• Do not use high-pressure irrigation which embeds bacteria deeper 1
• Do not give routine antibiotics for simple clean wounds as this promotes resistance without benefit 2
• Do not close infected wounds primarily - always assess for signs of established infection first 2