In the emergency and urgent care settings, clinicians often make wound repair and treatment decisions based on a combination of well-developed studies, insufficient studies, anecdotal evidence, erroneously extrapolated data (for example, elective surgical wound repair techniques transferred to the acute traumatic setting), or habit (“this is how we've always done it.”). This article examines some common traumatic wound management topics and applies evidence-based practice to the clinician's decision matrix.
COMMON RISK FACTORS FOR WOUND HEALING
Children with acute traumatic wounds are at significantly lower risk for infection compared with adults.1-3 However, in both populations, certain factors can affect the quality of wound healing:
- Location. Wounds in well-vascularized areas (such as the face, neck, and scalp) tend to heal faster and have a lower risk of infection than those on the extremities, especially the lower extremities, which carry the highest overall risk.4,5
- Infection risk. Wounds that are more likely to be infected include bite wounds, jagged wound margins that may potentially become devitalized, stellate-shaped wounds often caused by a blunt force crushing mechanism leading to devitalized margins and perfusion issues, visibly contaminated wounds, injuries deeper than the subcutaneous tissue that make wound irrigation more difficult and that may involve relatively avascular structures, the presence of a foreign body, and lacerations greater than 5 cm.3,5
- Patient characteristics. Diabetes, obesity, malnutrition, chronic renal failure, immunosuppressants, and extremes of age are among patient characteristics associated with impaired wound healing and increased infection risk.6,7 Certain medications also may impede wound healing. Anticoagulation therapy can lead to hematoma, creating a nidus for infection and increasing wound tension; common nonsteroidal anti-inflammatory drugs (NSAIDs) may impede the proliferation phase of wound healing (Figure 1).8
FOREIGN BODY COMPLICATIONS
Retained foreign bodies can lead to a host of problems, including increased risk of infection, poor cosmesis, decreased functionality, hypersensitivity, and chronic pain.
Organic foreign bodies such as wood, spines, and dirt can elicit significant inflammatory reactions. Many infections involving foreign bodies do not respond to antibiotics. Surgical removal or removal by thorough wound cleansing and irrigation is the definitive treatment for infections involving foreign bodies. Evaluating for a foreign body in a wound requires a methodical exploration of the wound with sufficient hemostasis to allow direct visualization. Imaging is indicated if a foreign body is suspected but not identified on examination.
Radiography is an appropriate imaging modality for radiopaque foreign bodies (gravel, metal, glass), but is significantly less sensitive in detecting radiolucent foreign bodies such as plastic, wood, or cactus spines.9 CT can be effective in identifying glass, metal, and wood particles such as splinters, however, wood that has been in a wound for more than 48 hours absorbs fluid, thus changing its density and making it look similar to soft tissue. Therefore, CT is less sensitive in identifying wood foreign bodies in patients who delay presentation.10,11 For radiolucent foreign bodies in superficial tissue, ultrasound has been found to visualize radiolucent foreign bodies better than plain radiography and CT.12,13 Specificities and sensitivities depend on sonographer experience as well as the size of the foreign body.
THE GOLDEN PERIOD OF WOUND CLOSURE
The concept of the golden period of wound closure, the optimal acceptable time frame between injury and wound closure to minimize risk of infection, has been perpetuated in textbooks for decades without supporting evidence. More recently, investigators have challenged the overall concept of a golden period.
A 2013 Cochrane review found no evidence to guide clinical decision-making on the timing for closing traumatic wounds. The review deferred to the standard of care, which lacked general consensus.14
A 2014 study by Quinn and colleagues defined delayed presentation as wounds more than 12 hours old.15 Quinn and colleagues concluded, after finding no significant increase in infection in wounds closed more than 12 hours after injury, that the “concept of a golden period no longer exists.”15 However, the study had several weaknesses. Only 72 (3.2%) of 2,257 wounds were closed primarily after 12 hours, with a median time from injury of 16 hours and a maximum of 24 hours. The anatomic locations of the lacerations closed within this time span were not provided. The study also did not state whether clinicians attempted to mitigate the increased risk of infection in delayed-closure wounds, for example, by using a closure technique with greater spacing between closure material.15
Lammers and colleagues conducted a retrospective cohort study to identify risk factors for wound infection.16 They concluded that hand lacerations have an increased risk of infection if primary closure occurs 8 or more hours after injury.16 This study found that all nonhand lacerations more than 10 hours old exhibited a similar increased risk of infection (14% became infected when treatment was delayed for 10 to 24 hours).16
In a 2012 meta-analysis by Zehtabchi and colleagues, none of the studies that met criteria for inclusion were randomized clinical trials.17 Cut-off times for delayed presentation (4 to 12 hours) were varied and not based on wound physiology. Overall, there was a high risk of bias in the included studies and the quality of the evidence was low. Therefore, no determination could be made on the role of wound age on infection rate.17
In our practice, we use a more general decision matrix based on anatomic region to determine appropriate time to primary closure. This approach is based on our standards of practice and the understanding that in acute wounds, bacterial counts increase significantly after 8 hours and that certain host and wound characteristics interfere with normal defenses against increased bacteria loads. We offer these suggested timeframes for closing wounds:
- Neck, face, or scalp: Within 24 hours
- Upper extremity or torso: Within 12 hours
- Lower extremity: Within 8 hours.
In some cases, this primary closure timeline may need to be adjusted depending on the mechanism of injury, relative degree of contamination, patient's past medical history, previous treatment, and the patient's ability to properly care for the wound. Clinicians should understand that many factors influence wound healing and risk of infection and that these factors play a critical role in how the guidelines should be applied.
When the risk of infection is considered very high—bite wounds to extremities, significantly delayed presentation (more than 8 hours in extremities and 24 hours for face), puncture wounds, highly contaminated wounds—consider letting the wound heal by secondary intention or performing a delayed primary intention closure (tertiary closure).
PREPARATION FOR WOUND CLOSURE
Shaving at and around the wound site has been found to increase infection risk.18 A meta-analysis of 19 randomized controlled trials found that shaving before surgery did not prevent surgical site infections, and in fact increased infection risk.18 Because shaving certain areas may disrupt anatomic landmarks, it also can increase microorganisms present in the wound.
The terms skin prep and wound prep are often used synonymously. However, they actually refer to two distinct processes:
- Skin prep refers only to cleaning the skin around the wound. Many different brands of skin antisepsis agents are on the market but all belong to two general groups: iodophor or chlorhexidine. The latter has been shown to be slightly more effective than the former.19 Both are bactericidal as well as cytotoxic. These agents were meant to clean intact skin only. Cleaning the skin outward from the wound edges with a sponge or gauze is the preferable method.
- Wound prep refers to the antisepsis of the wound and surrounding tissue. This is one of the most important elements in the wound management process. Appropriately cleaning the wound before primary closure will reduce infection risk, reduce scarring, and preserve function.
Multiple studies have demonstrated the cytotoxic effects of topical antiseptic agents such as povidone-iodine and hydrogen peroxide on fibroblasts, keratinocytes, and other important cellular components of wound healing.19-22 Applying these agents is associated with delayed wound healing and increased inflammatory responses, even at subcytotoxic levels.20 Dilutional studies suggest that hydrogen peroxide and povidone-iodine actually lose their bactericidal activity before they lose their tissue toxicity.23
Wound irrigation mechanically debrides loose and devitalized tissue, foreign matter, and bacteria.24 Irrigant volume should range between 50 to 100 mL per centimeter of wound length in uncomplicated wounds.16 The higher the contamination of the wound, either visible contamination or bacterial, the higher the volume of irrigant used.25
For open avascular structures including cartilage, tendon lacerations, or distal phalanx tuft fractures, 1 to 2 L of irrigant is appropriate. Open joints and other open fractures typically require irrigation in the OR before closure.
Fluid choice for wound irrigation is controversial. Sterile 0.9% sodium chloride solution has been the standard of care, but the added costs may not translate to better outcomes.
Most wounds become infected when they contain more than 100,000 bacteria cells per gram of tissue, although this number may be lower in wounds with compromised vascularity or in patients with compromised host defenses such as immune deficiency.26,27 Potable tap water in the United States typically does not contain a sufficient number of bacteria to cause infection in a wound. Additionally, bacterial isolates from tap water are unlikely to be skin pathogens.28 Other qualities of tap water to consider are the hypotonicity, which may interfere with the osmotic potential of bacterial cells, resulting in cell death, as well as the bactericidal effects of chlorine in tap water.
In 2012, a Cochrane review assessed three studies comparing tap water with 0.9% sodium chloride solution for cleaning lacerations and for acute and chronic wound cleaning.29 Of the three studies in the review, one reported a higher infection rate with 0.9% sodium chloride solution, which may be attributed to differences in irrigant temperatures. The other two studies showed no difference in infection rates between 0.9% sodium chloride solution or tap water irrigation. Of note, those two studies were conducted with children, who have an overall reduced risk of infection. The authors concluded that noninferiority was not established and more research is needed.29 This finding supported Sasson and colleagues' review that found insufficient evidence to support or refute tap water as being at least equivalent to 0.9% sodium chloride solution.30
In 2013, Weiss and colleagues published a large single-center controlled clinical trial comparing tap water with sterile 0.9% sodium chloride solution for irrigation before wound closure.31 This study included immunocompetent patients with wounds less than 9 hours old, no punctures or bites, and no tendon or bone involved. The study also addressed multiple deficiencies seen in the studies identified in the Cochrane review, including control for technique and volumes used in irrigation, blinding providers as well as subjects, and relatively few patients lost to follow-up. The authors concluded that tap water was not inferior to 0.9% sodium chloride solution.31 In this study, determination of wound infection was based on subjective indicators of infection.31
Clean, drinking-quality tap water may be appropriate for irrigating low-risk wounds. These wounds are defined as those with minimal tissue injury, in a vascular area, with a low risk of infection, in a healthy patient, when irrigation is performed close to the time of injury. At this juncture, however, the evidence supporting a change in standard of care is still considered insufficient.
As stated previously, foreign matter and devitalized tissue or tissue of uncertain viability increases the likelihood of an inflammatory response and infection.32 Even wounds with intact margins at the time of primary closure but exhibiting poor perfusion may result in compromised tissue.
Debridement of clearly devitalized tissue has a twofold benefit:
- The potential for infection, similar to the threat of an organic foreign body, is significantly reduced
- Greater cosmesis and increased functionality secondary to decreased scarring can occur unimpeded.33,34
However, any aggressive sharp debridement has a potential downside because tension on the wound edges increases with tissue removal. This increase in tension may be offset by debriding wound edges using as close to a perpendicular angle as possible and undermining the tissue. Debridement should only be performed within the clinician's comfort and skill set, and clinicians should not create a defect in order to repair one. Areas that should not be debrided include those that are difficult to reconstruct (for example, the philtrum), those with significant superficial innervation (such as the dorsal wrist), extensor surfaces, and eyelids.
Aseptic technique is another highly debated topic in wound closure. Although the standard of care has been to close a wound under completely aseptic conditions, some evidence supports the use of clean gloves instead of sterile gloves. However, open boxes of gloves are more likely to have increased numbers of bacteria, and open nonsterile gloves are potential vehicles for transmission of pathogens, particularly if wet.24,35
In 2012, Creamer and colleagues looked at bacterial load on sterile versus nonsterile gloves (from an open box in the examination room) in an outpatient minor surgical clinic.36 The volunteers in the study consisted of PA students, general surgery residents, and surgical specialty staff. A statistically significant difference was found in the mean bacterial growth between clean gloves and sterile self-donned gloves. However, in all of these scenarios, the bacteria count was less than 100,000 colony-forming units.36 Creamer did not address other factors, including host immune defense, local wound conditions, devitalized tissue, organism virulence, and foreign bodies that may reduce the number of bacteria necessary to produce infection. The study was conducted in a minor surgery setting and, therefore, the glove exposure to environmental bacteria may differ from other settings. Additionally, the study provided some indication that level of training may also be a risk factor (higher bacteria counts were found on students' gloves).36
A frequently cited 2016 meta-analysis by Brewer and colleagues concluded that no difference existed in rates of soft-tissue infections between patients whose procedures were performed by clinicians wearing sterile versus nonsterile gloves.37 For patients with more complex wounds, the infection rate was 14.7% if the clinician wore nonsterile gloves compared with 3.4% for sterile gloves.37 Most of the studies cited were dermatologic and dental procedures. The most notable trial involving lacerations found no statistically significant difference in the incidence of infection between wounds closed with clean gloves and those with sterile gloves. This study excluded patients with immune compromise, contaminated wounds, bites, complex wounds, suspected foreign bodies, or wounds older than 12 hours. The study did not state whether the clean gloves were taken from a newly opened box or a box that had been sitting out open to the environment.38 Given the paucity of data specifically addressing traumatic lacerations, extrapolating the results of this meta-analysis to acute traumatic wounds may not be appropriate.
Whether clinicians use nonsterile or sterile gloves, tap water, or sterile 0.9% sodium chloride solution, they should use aseptic technique otherwise to limit contamination of the wound and suture materials. This includes using sterile draping to ensure that suture material does not drag over clothing, hospital equipment, or unprepped skin and introduce additional contaminants into the wound field.
The standard of practice to use nonabsorbable sutures for percutaneous closures has been challenged in light of practices used in surgical settings. A meta-analysis of 19 randomized controlled trials examining absorbable versus nonabsorbable sutures for skin closure determined noninferiority for cosmesis, wound infection, scar formation, and patient or patient caregiver satisfaction.39 Fourteen of the studies included only surgical/dermatologic procedures; five studies involved traumatic wounds.39 A potential change in standards of practice warrants a closer look at those studies.
A 2008 study of pediatric facial lacerations demonstrated noninferiority of absorbable sutures compared with nylon.40 The study excluded lacerations less than 1 cm and greater than 5 cm, wounds with irregular borders, bite wounds, contamination deemed more than minimal, and wounds more than 8 hours old. Patients with coagulopathies, immune deficiency, diabetes, or renal disease were excluded. The study compared fast-absorbing gut sutures to nylon sutures (5-0 or 6-0). Surprisingly, fast-absorbing gut sutures were used for subcutaneous closure in all patients requiring subcutaneous closure. Typically, gut is not used for subcutaneous closures due to its tissue reactivity and rapid absorption (thus not contributing to the prolonged reduction in tension desired once percutaneous sutures are removed). In this study, patients returned at 4 to 7 days for suture removal (standard of practice is 3 to 5 days) and at that time nonabsorbable and remaining absorbable sutures were removed.40
Luck and colleagues conducted a follow-up study with the same patient population and exclusion criteria.41 The study found that for wounds requiring subcutaneous closure, the wounds sutured with fast-absorbing gut sutures were closed subcutaneously; the nylon-sutured wounds were closed subcutaneously with poliglecaprone 25 (Monocryl), which has 50% tensile strength at 7 days and remains in wounds for up to 119 days. Nonabsorbable sutures were removed at 7 days. Wounds closed with fast-absorbing gut sutures did not have sutures removed; 50% of absorbable sutures were still in place on day 9. In this study, cosmetic outcomes were notably poorer in the absorbable group and noninferiority could not be established. The authors point out multiple potential confounders that may explain this result.41,42 Polyglactin 910 (Vicryl) is the more appropriate choice for most intradermal (subcutaneous) acute wound closures because of its 50% tensile strength at 21 days and absorption by 70 days.42 Using polyglactin 910 for the subcutaneous closures in this study would have added an important control.
Holger and colleagues looked at fast-absorbing gut sutures versus nylon versus 2-octyl cyanoacrylate in patients age 5 years and up.43 The study excluded patients who were deemed immunocompromised or had formed keloids, and those who had stellate, bite, or crush wounds, or wounds more than 24 hours old. The study found no clinically important differences in cosmetic outcome between the three closure groups.43 Topical antibiotic ointment was only applied to sutured wounds for 48 hours, which may have reduced optimal outcomes for the nylon group but limited the degradation rate for fast-absorbing gut sutures.
Karounis and colleagues tested absorbable plain gut versus nonabsorbable nylon sutures in lacerations to the face, extremities, and torso in low-risk wounds less than 12 hours old in children.44 Sutures were placed 4 to 5 mm apart (not considered cosmetic in facial lacerations). This study also used plain gut to close deep layers. The authors concluded that plain gut absorbable sutures for pediatric lacerations is an acceptable alternative to nonabsorbable sutures; however, the study did not have enough statistical power and was inconclusive for the proposed minimum important difference.44
Al-Abdullah and colleagues performed a meta-analysis evaluating absorbable versus nonabsorbable sutures in percutaneous closure pediatric lacerations and surgical wounds.45 The authors concluded that the question could not be adequately answered because of the lack of methodically sound randomized controlled trials.45
Tejani and colleagues compared low molecular weight polyglactin 910 (Vicryl Rapide) with polypropylene (Prolene) suture for percutaneous closure of trunk and extremity lacerations and concluded that noninferiority of cosmetic outcomes was established.46 The authors noted that a higher percentage of wounds closed with Vicryl Rapide developed complications including infection (11% versus 3%) and scarring perpendicular to the wound edge (17% versus 8%); however, the sample size was too small to show statistical significance.46
Most studies looking at absorbable versus nonabsorbable sutures for percutaneous closures focus on children. The lower risk of scarring and wound infection in this population is important to consider when studying adult applications.1,11 To date, evidence is insufficient to support noninferiority of closing traumatic lacerations with absorbable sutures (Vicryl or plain gut). Although absorbable sutures are commonly used for percutaneous closures in surgical and dermatologic procedures, it is unclear if the data from these studies can be applied to acute traumatic wounds. Indications where absorbable percutaneous sutures may be appropriate include noncosmetic scalp wounds, sutures under extremity casts, noncosmetic wounds in children, and in patients who may have significant difficulty with suture removal or who are unlikely to follow up for suture removal. Understanding the qualities, risks, and benefits of the various absorbable sutures will help clinicians make appropriate choices for wound closure materials (Table 1). Sutures, as a foreign body, may reduce the threshold for infection, inducing bacterial load.47 Increased bacterial adherence to braided sutures also may be significant.48,49
Tetanus toxoid-containing vaccine (Td or Tdap) is indicated as a part of wound management if the patient has not received a tetanus vaccine in more than 5 years.50 If the patient is pregnant or is age 11 years or older and has not previously received Tdap, administer a Tdap vaccine. Patients who have not completed the three-dose primary vaccinations series, or whose tetanus vaccine history is unknown or uncertain, should receive tetanus toxoid.50 Advise patients to complete the vaccination series. Patients with severe immune deficiency or with HIV should receive tetanus immune globulin for contaminated wounds regardless of tetanus immunization history.50
Antibiotic ointment commonly is applied over a sutured wound, and moderate-quality evidence supports using topical antibiotics to reduce infection rates.51 Allergic contact dermatitis associated with antibiotic ointments reportedly ranges from 7.7% to 9.2% and up to 13% with neomycin.52 Multiple studies have found no difference in infection rates in wounds treated with topical antibiotic ointment compared with those treated with petrolatum.53 A moist wound bed facilitates wound reepithelialization, so the reduced infection rates may be the result of improved wound healing due to the emollient nature of ointments, regardless of their antibiotic content. We recommend the use of bacitracin in patients who previously have used it without complication. Patients who have never used bacitracin or have a known allergy should apply a thin film of white petrolatum over the wound twice a day after washing with soap and water.
Routine use of oral prophylactic antibiotics has not been found to significantly reduce infection rates in healthy patients with uncomplicated wounds.54,55 The exclusion criteria of most studies—including immune deficiency, diabetes, peripheral vascular disease, crush wounds, highly contaminated wounds, and wounds involving avascular structures—make it more difficult to determine when prophylactic antibiotics are indicated. Generally, wounds warranting prophylactic antibiotics include open fractures and joints, cartilage involvement, tendon laceration, grossly contaminated wounds, foot puncture wounds, bite wounds, foreign bodies, delayed presentation, through-and-through oral lacerations, and wounds in patients with diabetes.54,56 Given the high rate of infections in pretibial lacerations, we typically cover them if any risk factor, including dirt, is present. Prophylactic antibiotics should be administered for 3 to 5 days.54
When treating acute wounds, always consider multiple factors that may influence wound healing, how repair decisions are made, and the potential long-term outcome of each choice. Too often, these decisions are made through ill-defined algorithmic thinking rooted in habit and unsubstantiated data. Having a thorough, or even a basic, understanding of how both wound-creating mechanisms and the growing arsenal of wound-repair tools affect soft-tissue healing will yield greater positive outcomes.
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