Management of Lacerations
- Apply basic ATLS principles to the polytrauma patient.
- Evaluate the wound and consider anatomical structures that might be involved.
- Screen for nerve injury: median/radial/ulnar nerve involvement and digital nerve at finger level.
- Screen for tendon injury.
- Screen for vascular injury.
- Irrigate the wound with normal saline and remove all macroscopic debris.
- If no structures are involved, suture the wound with a sterile technique.
- Use lignocaine with a nylon 4.0 or 5.0 interrupted sutures. Use light dressing that would not restrict movement. (See dressing section).
- If there is any concern regarding involvement of nerve, tendon, vascular structures or penetration of joint, refer the patient and dress the wound (see below).
- If uncertain about structural involvement and the subcutaneous fat is exposed, refer the patient and dress the wound appropriately.
Management of the patient that will be admitted for surgery.
- Irrigate the wound with saline and remove all macroscopic debris
- Cover the wound with Jelonet (Vaseline gauze) type dressing. Cover the jelonet dressing with absorbing dressing (gauze/telfa/webril) soaked in Povidone Iodine to sterilise the wound until it is opened in theatre.
- Wrap this with any form of bandage.
- If it is a tendon or nerve injury, it is best to splint the forearm and hand in a POSI Z-splint.
- Prescribe IV antibiotics (Augmentin 1.2 g IVI tds), keep the patient fasted and prescribe elevation of the limb in the ward.
- All lacerations with exposure of subcutaneous fat, should ideally be explored surgically.
- Suspected nerve injuries should be explored surgically.
- Suspected tendon injuries should be explored surgically.
- Suspected joint penetration should be explored surgically.
All injuries with structural involvement (nerve or tendon) will require intensive therapy that will entail the following time frames
- Fulltime splinting for 4 - 6 weeks
- Followed by 2 weeks protective splinting (at night and when vulnerable)
- Followed by another 4-6 weeks of therapy to regain movement and strength
- Patients should expect a 12 week rehabilitation period
The patient will need to engage actively in a therapy programme to achieve the best outcome, including graded active range of movement exercises, stretching, graded strengthening exercises, oedema and scar management.