What is the immediate management for a healthy patient with a hand laceration and no significant past medical history?

Immediate Management of Hand Lacerations

For a healthy patient with a hand laceration, immediately irrigate the wound with sterile saline under pressure, examine for tendon and neurovascular injuries, ensure tetanus prophylaxis is current, and repair the laceration with layered closure focusing on dermal approximation—then provide wound care instructions emphasizing keeping the dressing clean and dry. 1, 2, 3

Initial Wound Assessment and Preparation

Critical evaluation steps:

• Examine specifically for tendon, nerve, and vascular injuries by testing active range of motion of all digits, two-point discrimination, and capillary refill—any laceration over the hand requires this systematic evaluation as these structures cannot heal without surgical repair 2
• Assess wound depth, contamination level, and location to determine closure method 1
• Obtain radiographs if there is concern for foreign body or underlying fracture 1

Immediate wound preparation:

• Irrigate thoroughly with 100-1000 mL of sterile saline or tap water under pressure to remove debris and reduce infection risk—this is the single most important step in preventing infection 1, 3
• Remove only superficial debris during cleansing; avoid iodine or antibiotic-containing solutions 4
• Verify tetanus immunization status and administer 0.5 mL intramuscularly if outdated or unknown 4

Anesthesia

• Apply adequate local anesthesia before wound manipulation using lidocaine injection 1
• Consider buffering lidocaine with bicarbonate and use slow injection technique to minimize pain 1
• For extensive lacerations, regional nerve blocks may be more appropriate than local infiltration 3

Wound Closure Technique

Layered closure principles:

• The dermis provides the skin's greatest tensile strength—accurate approximation of the entire dermal depth to the opposite dermal side is essential for wound strength 3
• Use absorbable sutures (such as 5-0 Vicryl) for dermal layer closure, which provides equivalent outcomes to non-absorbable sutures and eliminates need for suture removal 5
• Epidermal approximation provides cosmetic appearance but does not contribute to wound strength 3
• Avoid suturing fat or muscle as these tissues do not support sutures 3

Special considerations for hand lacerations:

• Full-thickness sutures may only be safely used on palmar and plantar surfaces 3
• For lacerations near joints or extensive wounds, immobilize with a splint or sling 3

Infection Prevention

The evidence on prophylactic antibiotics is mixed:

• Povidone-iodine treatment before suture reduces infection rates when data from multiple trials are combined, though individual trial significance varies 6
• Currently, no clear evidence supports routine prophylactic antibiotics for simple hand lacerations (those not involving bone, tendon, nerve, or vessels) 7
• The degree of contamination is the most important factor in deciding whether to prescribe antibiotics 7
• If antibiotics are prescribed, cephalexin is most commonly used 7

Critical infection prevention measures:

• Instruct patients to keep dressing clean and dry—this is significantly associated with reduced infection and improved healing 6
• The overall infection rate for hand lacerations is approximately 5% with proper technique 6

Post-Repair Care and Follow-Up

Immediate post-procedure instructions:

• Elevate the injured hand using a sling to reduce swelling, which accelerates healing 4
• Prescribe oral NSAIDs (such as ibuprofen) at the lowest effective dose for pain relief, considering gastrointestinal and cardiovascular risk factors 4
• Acetaminophen is an alternative for patients with NSAID contraindications 4

Follow-up timing:

• Examine the wound 2-3 days after repair to assess for early signs of infection (increased pain, redness, swelling, purulent discharge) 1, 3
• Monitor for signs of infection including pain disproportionate to injury 4

Common Pitfalls to Avoid

• Do not miss tendon or neurovascular injuries—these require urgent surgical referral as they cannot heal without surgical approximation 2
• Do not inadequately irrigate the wound—insufficient irrigation is a primary cause of infection 3
• Do not rely solely on epidermal closure—dermal approximation provides wound strength 3
• Do not prescribe NSAIDs without assessing risk factors, particularly in elderly patients 4