Management of Potentially Contaminated

Superficial Hand Lacerations and Incisions :

Primary Closure vs Secondary Closure

Benjamin C. Deveza, M.D.

Janix M. De Guzman, M.D.

Edgardo P. Penserga, M.D., FPCS,FPSGS

Reynaldo Joson, M.D., MHA, MHPEd, MS Surg

____________________________

Reprint requests : Benjamin C. Deveza, Department of Surgery, Ospital ng Maynila Medical Center, Quirino Ave. Malate, Manila Philippines

E-mail : ommcsurgery@yahoo.com

Abstract

Objective  To assess the difference in clinical outcome between primary closure and secondary closure in the management of potentially contaminated superficial hand lacerations and incisions, in terms of infection rate and function  Methods  The study  was a randomized controlled trial. Setting were at the  Emergency Room and Out-Patient Department, Department of Surgery, Ospital ng Maynila Medical Center  Subjects include consecutive patients at least 10 years of age with superficial, potentially contaminated lacerations and/or incisions of the hand, at least 1cm in size, regardless of location within the confines of hand, and less than 24 hours duration at the time of injury (without tendon, joint, fracture, or nerve complications).Participants were grouped according to the size of laceration/incision then randomized to suturing or conservative treatment  Results  A total of 120 patients were included in the study. Under  Group I, there were 65 patients, 30 for the primary closure and 35 for the secondary closure. On the other hand,under Group II, there were 55 patients, 30 for the primary closure and 25 for the secondary closure. Patients treated in both groups had similar clinical and demographic characteristtics.  Conclusion There was no significant difference with regards to infection rate and function in patients with hand laceration or incision treated with primary closure or conservatively

Introduction

Hand Lacerations are common simple problems. Every doctor is asked, "Will this cut needs stitches?" with the expectation that the answer is determined using some scientific knowledge. In truth, we give an opinion based on experience. The value of closure and whether it is even needed have never been objectively studied. This study aims to give support to doctors' answers.

Suturing is the most popular method of securely closing wounds, although it has many disadvantages: sutures require the use of needles to inject painful anaesthetics, are time consuming, have the greatest tissue reactivity of any wound closure device, are costly, and are inconvenient for patients.

Normally, wounds repair themselves, regardless of whether wound edges are approximated. Most doctors have seen lacerations that were not sutured and healed normally: when infection is a worry wounds and incisions are left to heal by delayed secondary healing, and most heal with functional scars.

The goal of wound healing is to have a functional and cosmetically appealing scar, and to inflict minimal pain and inconvenience on patients. This study aims to determine whether the conservative management of hand lacerations or incisions, that is, managing the wound through secondary closure produces similar clinical outcomes to wounds that are sutured.

Method:

DESIGN: Randomized controlled trial.

SETTING: Emergency Room, OPD, Department of Surgery, Ospital ng Maynila Medical 

                   Center

TIME OF STUDY : January to August 2006

SUBJECTS/PARTICIPANTS: Consecutive patients at least 10 years of age with superficial, potentially contaminated lacerations and/or incisions of the hand, at least 1cm in size, regardless of location within the confines of hand, and less than 24 hours duration at the time of injury (without tendon, joint, fracture, or nerve complications).Free and informed consent were secured.

INTERVENTION: Participants were grouped according to the size of laceration/incision then randomized to suturing or conservative treatment.

                        1 – 2 cm                                   >2 – 4 cm                               

                             R                                               R                                         

                        1^o         2^o                                 1^o         2^o                                

Closure will be simple interrupted using non-absorbable 4-0 sutures after cleaning with antiseptic betadine solution.

MAIN OUTCOME MEASURES: Outcomes will be evaluated in terms of infection rate and function.. .Patient will be followed-up on out-patient basis after a week up to 3 months.

 Definition of Terms:

                             Potentially Contaminated Wound – any open, fresh traumatic wounds

                        Clean –nontraumatic, uninfected wound

                        Dirty – traumatic wound with retained devitalized tissue, foreign bodies,fecal contamination, or delayed treatment, or from dirty source.

             Superficial wound –  injury involving  breaks in the epidermis and/or dermis layers of the skin

        Hand – anything distal to the wrist crease extending circumferentially will be the area of the hand,

Guidelines

Superficial Hand Injuries

(Incision/Laceration)

All patients coming at the Emergency Room of Out-Patient department with Potentially contaminated Superficial Hand Lacerations and/or Incisions, age 10 years old and above are  in the study.

Superficial – involving only epidermis and dermis, with no fracture, no tendon injuries, no major vessel injuries

Potentially contaminated – all open, fresh traumatic injuries, less than 24 hours post-injury, with no retained devitalized tissue, no foreign bodies, not from dirty source.

Wound size should be determined using a ruler measured in centimeter in order to group patient accordingly.

o       In case of stellate lacerations – get total length by adding all lacerations

o       In case of multiple lacerations and or incisions of various lengths in one hand, get the largest size and use as a guide to group the patient.

o       In Case of injury to both hands classify patient whichever largest size in either hand.

 Grouping: Group 1 (1 – 2cm); Group 2 (>2 – 4cm)

For primary closure:

                        Clean wound with betadine antiseptic

                        Use non-absorbable 4-0 interrupted suture.

                        Dry sterile dressing.

For Secondary closure:

                        Clean wound with betadine antiseptic

                        Dry sterile dressing.

Wound flushing must be done if necessary. Anti-tetanus must be given during the initial consult. Upon discharge, patient is given prescription for antibiotics. Daily wound care with water and soap must be advised to the patient. Follow-up after the 1^st week until the 3^rd month is also advised.

Results

            A total of 120 patients were included in the study. Under  Group I, there were 65 patients, 30 for the primary closure and 35 for the secondary closure. On the other hand,under Group II, there were 55 patients, 30 for the primary closure and 25 for the secondary closure. Patients treated in both groups had similar clinical and demographic characteristtics.

            With regards to clinical outcomes, there were no significant difference as to the  infection rate and presence of contracture. There was one patient under Group I  who underwent primary closure and developed infection after the first week. This was attributed to poor wound care. Appropriate treatment was given and patient improved. With regards to follow up, there were 3 patients under group 2 that did not come back.There was none under Group I.

Discussion

The goal of wound care and closure is to have a resultant functional and cosmetically acceptable scar, with low morbidity and high patient satisfaction and comfort. These goals can be achieved by treating simple lacerations of the hand conservatively instead of with sutures.

Uncomplicated lacerations of the hand are currently being sutured unnecessarily and would heal with similar results without sutures. Large gaping wounds should be closed, after meticulous wound care. This study  was aimed to determine whether the conservative management of hand lacerations produces similar clinical outcomes to wounds that are sutured. Wounds that are dehisced or those treated with delayed primary closure usually heal without complication: the three phases of wound healinginflammation, epithelisation, and maturationoccur whether or not wounds are securely closed. Most scars appeared inconspicous after three months and patients had high level of satisfaction with the appearance of their wound.

Table 1           

Group 1   Lacerations / Incisions 1-2 cm

Table 2

            Group 1       Demographic Data

Table 3

            Group I     Clinical Outcome

Table 4

            Group I     Follow-up of Patients

Table 5

            Group II   Lacerations / Incisions  > 2- 4 cm

 Table 6

            Group 1I       Demographic Data

Table 7

            Group II     Clinical Outcome

 Table 8

            Group II    Follow-up of Patients

References:

1. Maano, LR, Hand Injuries, PCS-POA Joint Midyear Convention Lecture, 1992, May 29-30
2.  Quinn J. etal. Suturing versus conservative management of lacerations of the hand randomized control trial, BMJ, 2002 Aug 10; 325
3. Via, RM. Suturing unnecessary for hand lacerations under 2 cm. Journal of Family Practice. 2003, Jan 01; 524

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