Lacerations
Exam Tips
- In OSCEs, always state and perform distal neurovascular assessment before and after wound closure.
- High-yield infection risk factors: contamination, diabetes, wound >5 cm, devitalized tissue/foreign body, lower-limb location.
- Do not close obviously infected/high-risk contaminated wounds at first visit; clean, dress, consider antibiotics, and review for delayed closure.
- Know referral triggers: arterial bleeding/pulse loss, motor-sensory deficit, tendon/joint/bone involvement, complex facial border wounds, suspected retained glass, or major tissue loss.
- Tetanus prophylaxis is exam-favourite: check vaccination history for every traumatic wound and add HTIG for selected high-risk tetanus-prone injuries.
Definition
A laceration is a traumatic disruption of skin, often with irregular wound edges, caused by blunt impact, sharp injury, or bites, and it may extend into subcutaneous tissue, muscle, tendon, vessels, or nerves. In clinical practice, the key issue is not only skin closure but also identifying contamination, deeper structural injury, and tetanus risk, because these factors drive complications and referral urgency.
Pathophysiology
Mechanical force causes tissue tearing and variable crush injury at wound margins, creating devitalized tissue and microvascular compromise that reduce oxygen delivery and impair host defence. Bacterial inoculation at injury (especially with soil, faeces, saliva, or retained foreign material) can progress from local colonization to cellulitis or deeper infection when bacterial burden exceeds local immune control. Healing then proceeds through haemostasis/inflammation, proliferative granulation-epithelialization, and remodelling; delayed cleansing, poor perfusion, diabetes, and wound tension increase infection and adverse scar formation. For revision, see standard wound-healing diagrams in core surgical texts (for example Newman, traumatic wound management chapter figure on healing phases).
Risk Factors
- Wound contamination (soil, faeces, body fluids, pus) or retained foreign body (especially glass)
- Diabetes mellitus (particularly if poorly controlled)
- Age over 65 years
- Long wound (>5 cm), jagged/stellate edges, or devitalized tissue
- Lower-limb location and impaired local perfusion
- Immunosuppression (e. g, chemotherapy, long-term steroids, HIV, cancer)
- Delayed presentation (time alone is less predictive than contamination/comorbidity, but still clinically relevant)
- Peripheral vascular disease, malnutrition, smoking
Clinical Features
Symptoms
- Pain at wound site
- Bleeding (sometimes pulsatile if arterial)
- Loss of function (e. g, reduced finger movement suggesting tendon injury)
- Numbness or altered sensation distal to wound
- Fever, malaise, rigors if infection develops
- Jaw stiffness/spasm symptoms if tetanus develops (rare)
Signs
- Visible skin/tissue tear with depth, gaping, or irregular margins
- Arterial bleeding, absent/reduced distal pulse, delayed capillary refill (vascular injury)
- Motor or sensory deficit distal to injury (nerve injury)
- Visible tendon, bone, joint involvement, or reduced active range of movement
- Erythema, warmth, swelling, purulent discharge, lymphangitis/lymphadenopathy (infection)
- Foreign material/devitalized tissue in wound bed
Investigations
Management
Lifestyle Modifications
- Irrigate thoroughly (potable water/normal saline), remove debris, and keep wound clean/dry initially
- Provide safety-net advice: return urgently for spreading redness, increasing pain, pus, fever, reduced movement/sensation, or bleeding
- Give written aftercare and planned timing for suture/staple removal by site
- Advise smoking reduction/cessation and optimize glycaemic control to improve healing
Pharmacological Treatment
Analgesia
- Paracetamol 1 g orally every 4-6 hours when required (max 4 g/day)
- Ibuprofen 400 mg orally three times daily with food when required (max 2.4 g/day prescribed)
Avoid/limit NSAIDs in peptic ulcer disease, CKD, heart failure, anticoagulant use, or late pregnancy; use lowest effective dose for shortest duration.
Empirical antibiotics for clinically infected laceration (adult)
- Flucloxacillin 500 mg orally four times daily for 5-7 days
- If penicillin allergy: Clarithromycin 500 mg orally twice daily for 5-7 days
- If severe infection/high polymicrobial risk: Co-amoxiclav 625 mg orally three times daily for 5-7 days
Take a wound swab before starting antibiotics when feasible. Adjust to culture results and local antimicrobial guidance. Key cautions: clarithromycin prolongs QT and interacts with statins/warfarin; co-amoxiclav contraindicated in previous co-amoxiclav-associated cholestatic jaundice/hepatic dysfunction; flucloxacillin can rarely cause cholestatic hepatitis.
Tetanus prophylaxis
- Tetanus-containing vaccine (Td/IPV) 0.5 mL IM booster if indicated by immunization history and wound risk
- Human tetanus immunoglobulin 250 IU IM for high-risk tetanus-prone wounds when indicated (use local protocol for higher-dose indications)
Give promptly in susceptible or uncertainly immunized patients with tetanus-prone wounds. HTIG can cause hypersensitivity reactions; ensure resuscitation facilities are available.
Local anaesthesia for wound exploration/closure
- Lidocaine (lignocaine) 1% infiltration; do not exceed BNF maximum dose limits (with/without adrenaline as appropriate)
Avoid adrenaline-containing solutions in end-arterial compromise and where tissue perfusion is poor; check allergy history and aspiration technique to reduce intravascular injection risk.
Surgical / Interventional
- Control haemorrhage and perform careful wound exploration under adequate anaesthesia
- Debride devitalized tissue and remove foreign bodies
- Primary closure for clean low-risk wounds after irrigation
- Delayed primary closure (after 2-5 day review) for initially high-risk/contaminated wounds once no infection is evident
- Dress appropriately and arrange follow-up
- Urgent referral to ED/specialists for vascular injury, nerve deficit, tendon/joint/bone involvement, complex facial wounds crossing cosmetic borders, palm laceration with infection, significant contamination/tissue loss, suspected retained foreign body, or inability to safely manage in primary care
Complications
- Wound infection (most common), including cellulitis/abscess
- Deep structure injury missed initially (nerve, tendon, vessel, bone, joint)
- Delayed healing, wound dehiscence, chronic pain
- Hypertrophic scar or poor cosmetic outcome
- Tetanus in under-immunized patients (rare in UK but high consequence)
- Functional impairment of affected limb/digit
Prognosis
Most uncomplicated lacerations heal well with timely irrigation, appropriate closure strategy, and follow-up. Prognosis worsens with contamination, diabetes, delayed recognition of deep injury, and poor perfusion; early identification of red flags and correct referral usually preserves function and cosmetic outcome.
Sources & References
🏥BMJ Best Practice(2)
✅NICE Guidelines(1)
- Lacerations[overview]
📖Textbook References(7)
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 186, 187)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 186, 187)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 363)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 363)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 360)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 360)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1090)[context]