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Medico-legal 101 | Lacerations

Greg Henry, MD and Mike Weinstock, MD
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Mike and Greg discuss management and approach to high risk lacerations. High risk lacerations should be recognized and potential complications discussed with the patient.

 

Pearls:

  • Lacerations with retained foreign bodies and in cosmetically-critical areas are high-risk from a medico-legal standpoint.

  • Aftercare instructions are really important to both decrease the risk of infection and decrease your medicolegal risk should the wound become infected.

 

  • High Risk Lacerations

    • Vermillion border of the lip

      • The first stitch is key. Any injected anesthetic is going to distort the anatomy.  Consider a nerve block or use a topical anesthetic only for the first stitch.  Then if you need more anesthetic, you can inject.

      • The face and scalp almost never get infected because they are so well vascularized.

    • Cuts caused by glass are at high risk for retained foreign body.

      • On the scalp or the face, an infection is indicative of a retained foreign body because they are otherwise so rare.

      • If there are large pieces of glass in a wound, remove them. If there are a lot of little slivers of glass in the wound, it is often not possible to remove them all.  In this case, tell the patient that there is glass in the wound and that over the next week or so they will likely work their way to the surface and come out.  

      • Do we need to XR all  lacerations with potential foreign bodies?

        • Yes, particularly if the wound is such that you cannot explore it completely.

        • Most glass has enough lead in it that it shows up on XR.

        • Lacerations with an unknown mechanism need to be imaged and explored.

  • Timing:

    • The classic teaching is that wounds > 12 hrs old cannot be repaired primarily and wounds to the face > 24 hrs old cannot be repaired primarily.

    • Mike and Greg both agree that they have pushed these limits to about 24 hours with fine results.

  • Quinn JV, et al. Traumatic lacerations: what are the risks for infection and has the `golden period’ of laceration care disappeared? Emergency medicine journal : EMJ. 2014;31(2):96-100. [PMID: PMC3797169].

    • Looked at 2,663 patients who presented with lacerations and found that 2.6% developed an infection.

    • Identified 4 main groups with higher likelihood of infection.

      • Diabetics

      • Lower extremity lacerations

      • Contaminated lacerations

      • Lacerations > 5cm

  • Hollander JE, et al. Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med. 2001 Jul;8(7):716-20.  [PMID: 11435186].

    • Looked at 5,521 patients with lacerations and found 3.5% developed infections.

    • Infections were associated with

      • Age

      • Diabetes

      • Laceration with a retained foreign body

  • These studies give us good insight about patients we need to be more cautious about.

  • Aftercare instructions are really important to both decrease the risk of infection and decrease your medicolegal risk should the wound become infected.

  • Not everyone needs to come back for a wound check. Tell the patient and their family members signs of infection that should prompt a return visit.  

  • When the stitches need to come out:

    • 5 days in the face

    • 14 days over a joint that moves

    • 7-10 days for everything else

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