Tag Archives: repair

Wounds: When Are They Too Old To Close?

At some point in their training, every trauma professional is taught that there is a certain period time during which a wound can be safely closed. The exact number varies, but is usually somewhere between 6 and 24 hours. After that, we are told, “bad things happen.”

Always question dogma, I say. Is this true, or is it another one of those “facts” that have been propagated through the ages? Two emergency medicine groups recently performed a meta-analysis to try to answer my question. As usual, they found that much of the published literature is not very good. Out of 418 papers in their original search, only 4 fully met their criteria (laceration repaired primarily, in the ED, with clear early vs delayed criteria.

With the exception of one study with a very limited focus, there was no correlation between wound age and infection or dehiscence after primary closure. None of the studies could reliably provide a specific time beyond which closure was destined to fail. And the use of antibiotics in some of the studies also confounded the results.

Bottom line: It is more likely that infection-prone wounds get infected, not old ones. Although leaving a wound open to heal by secondary intention usually avoids the problem, it’s a big patient dissatisfier, especially with large wounds. Since many patients don’t present to the ED until their wound is “old”, it may be reasonable to try primary closure in all but infection-prone wounds. (The meaning of that phrase is not exactly clear, but most of us know it when we see it.) 

Reference: The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury 43(11):1793-1798, 2012.

Wounds: When Are They Too Old To Close?

At some point in their training, every trauma professional is taught that there is a certain period time during which a wound can be safely closed. The exact number varies, but is usually somewhere between 6 and 24 hours. After that, we are told, “bad things happen.”

Always question dogma, I say. Is this true, or is it another one of those “facts” that have been propagated through the ages? Two emergency medicine groups recently performed a meta-analysis to try to answer my question. As usual, they found that much of the published literature is not very good. Out of 418 papers in their original search, only 4 fully met their criteria (laceration repaired primarily, in the ED, with clear early vs delayed criteria.

With the exception of one study with a very limited focus, there was no correlation between wound age and infection or dehiscence after primary closure. None of the studies could reliably provide a specific time beyond which closure was destined to fail. And the use of antibiotics in some of the studies also confounded the results.

Bottom line: It is more likely that infection-prone wounds get infected, not old ones. Although leaving a wound open to heal by secondary intention usually avoids the problem, it’s a big patient dissatisfier, especially with large wounds. Since many patients don’t present to the ED until their wound is “old”, it may be reasonable to try primary closure in all but infection-prone wounds. (The meaning of that phrase is not exactly clear, but most of us know it when we see it.) 

Reference: The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury 43(11):1793-1798, 2012.

Which Lacerations Can I Close?

There is always debate about which lacerations can be closed, but not a lot of literature to back it up. Here are some good rules to follow:

  • In general, close all face and scalp lacerations. They almost never get infected. Complicated ones may need extra care, debridement, or involvement of a plastic surgeon. 
  • Closing lacerations that are more than 24 hours old is risky (except for the face). They tend to be colonized with skin flora and become infected much more frequently.
  • Most other lacerations can be closed primarily within 24 hours. For the most part, it doesn’t matter what the cutting instrument was. One exception is an object that is heavily contaminated (e.g. freshly used pitchfork). Most knives don’t fall into this category. They are clean, but not sterile and the risk of infection is low.

All wounds should be inspected for foreign bodies. On occasion, this may require an xray. But remember that many foreign objects (wood, glass) are not radiopaque and will be invisible. Next, the wound should be copiously irrigated with sterile saline to flush out any small particles and reduce bacterial counts. Finally, if the edges are ragged the wound should be sharply debrided.

Antibiotics are not usually needed, since the few bacteria left will be rapidly taken care of by the patient’s immune system. If there are worries about contamination or the patient is immunocompromised, a very brief course of antibiotic is recommended. Tetanus toxoid should be given if indicated.

The most important issue is patient education. The signs and symptoms of early wound infection should be explained, and a phone number or location for followup should be clearly listed.

Bottom line: All lacerations can be safely closed within 24 hours, with a few exceptions.