What is the optimal management for a patient with a wrist laceration, potentially with a history of bleeding disorders or anticoagulant use, requiring operative repair?

Operative Report for Wrist Laceration Repair

Preoperative Assessment and Hemostasis

For wrist lacerations requiring operative repair, achieve hemostasis through direct digital pressure, temporary tourniquet application, and compressive dressings rather than rushing to immediate surgical exploration. 1

• Document hand perfusion status by assessing capillary refill, radial and ulnar pulses, and Allen test to confirm palmar arch patency 1
• Examine for associated injuries including nerve function (median, ulnar, radial nerve distribution), tendon integrity (flexor and extensor groups), and vascular compromise 1
• Neither arterial, nerve, nor tendon injuries require immediate surgical repair unless critical ischemia is present 1
• One intact forearm artery (radial or ulnar) is adequate to sustain hand viability if palmar arch circulation is intact 1

Timing of Repair

Primary closure can be performed safely beyond the traditional "golden period" - evidence supports repair up to 18-24 hours post-injury for most wrist lacerations. 2

• The concept of a strict golden period (3-12 hours) is not supported by current evidence 2
• Three of four studies showed no significant difference in infection rates between early and delayed wound closure 2
• Wound age alone should not determine closure eligibility; assess contamination level, tissue viability, and patient factors instead 2

Infection Risk Stratification

Assess these specific risk factors that increase infection likelihood:

• Patient factors: Age (1% increased risk per year), diabetes mellitus (6.7-fold increased risk) 3
• Wound characteristics: Laceration width (5% increased risk per millimeter), presence of foreign body (2.6-fold increased risk) 3
• Protective factor: Wrist location has lower infection risk than trunk or lower extremity (adjusted OR 0.28) 3
• Overall infection rate for traumatic lacerations is 3.5% 3

Operative Technique

Anesthesia

• Local anesthetic with epinephrine 1:100,000 concentration is safe for digital use 4
• Epinephrine 1:200,000 concentration is safe for nose and ears 4

Wound Preparation

• Irrigate with potable tap water rather than sterile saline - no increased infection risk 4
• Nonsterile gloves are equivalent to sterile gloves for infection prevention 4

Repair Strategy for Complex "Spaghetti Wrist" Injuries

Perform immediate primary repair of all injured structures (tendons, nerves, arteries) for optimal functional outcomes. 5

• Use microscopic repair for significant arterial injuries 5
• Perform microscopic grouped fascicular repair for nerve injuries 5
• Repair all tendon lacerations primarily 5
• This aggressive primary repair approach yields good tendon and nerve function recovery 5

Closure Materials

• Tissue adhesives and wound adhesive strips are effective for low-tension areas 4
• Traditional sutures remain standard for wrist lacerations under tension 4
• Use subcutaneous absorbable sutures with external adhesive strips to minimize scar thickness 6

Postoperative Management

Dressing

• Apply occlusive or semiocclusive dressings - wounds heal faster in moist environments 4

Mobilization

• Initiate early mobilization with dynamic splinting 5
• Arrange intensive occupational therapy 5

Tetanus Prophylaxis

• Provide tetanus prophylaxis if indicated based on immunization history 4

Suture Removal Timing

• Wrist location: 10-14 days (based on expert opinion) 4

Critical Pitfalls to Avoid

• Do not perform emergent operative exploration for isolated forearm arterial laceration - conservative hemostasis methods are equally effective and more cost-beneficial 1
• Do not assume immediate repair is mandatory - delayed primary repair by hand specialist yields equivalent or superior outcomes for complex injuries 1
• Do not ligate popliteal artery if injury extends proximally - this carries 33-97% risk of ischemia and 5-33% amputation risk due to poor collateral circulation 6, 7
• Do not leave foreign bodies - they increase infection risk 2.6-fold 3

Consultation and Follow-up

• Obtain early hand surgery consultation for complex injuries involving multiple structures 1
• Arrange follow-up within 48-72 hours for wound check 1
• Complex injuries can undergo delayed primary repair after initial hemostasis and wound assessment 1