Preparation Is Key

Mark Bouchard, MD

Sports Dermatology Series Editor:
William Dexter, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 2 - FEBRUARY 2005

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In Brief: Abrasions and lacerations commonly occur during athletic activities. Physicians providing sideline coverage who make adequate preparations, including a well-stocked medical bag, can easily manage these injuries. Abrasions are typically irrigated and then covered with a topical antibiotic and adhesive dressing. Lacerations are treated with local anesthesia, irrigation, and appropriate wound closure using sterile technique. Follow-up for both conditions is necessary to monitor for signs of infection and to ensure a good cosmetic result.

Physicians and athletic trainers see many abrasions and lacerations during sporting events. In 1996, an estimated 11 million lacerations were treated in emergency departments in the United States.¹ That figure may be low when one considers that physicians and other providers treat many skin injuries that go unreported while performing sideline medical coverage.

Most wounds are located on the head and neck (approximately 50%) or the upper extremities (roughly 35%).² The location of wounds is sport-specific and determined by the use—or lack—of protective equipment. The most common mechanism of injury is blunt trauma. Lacerations caused by sharp equipment (eg, skates, sticks, shoe spikes) are also common.

Physicians who carry the necessary equipment in a medical bag (table 1) will be able to treat abrasions and lacerations soon after they occur. Prompt treatment on the sideline will help minimize infections and enable the athlete to return to play immediately.

TABLE 1. Recommended Materials for Sideline Abrasion and Laceration Management Sterile saline and sterile bowl (0.5-1 L) 60-mL syringe for irrigation Large-bore needles: 18 gauge or angiocatheter    (for irrigation and drawing up anesthetic) 4-in. X 4-in. sterile gauze Antibacterial cleansing agent 1% lidocaine with and without epinephrine Lidocaine jelly (2%) or LET gel for abrasions Sterile scrub brush Povidone-iodine 5-mL syringes 25-gauge needles (1-1/2-in. long) Needle driver Tweezers Skin stapler Aftercare instructions for patients Scissors Sterile drapes or towels Nylon sutures: 3-0, 4-0, 5-0, 6-0 Polyglactin sutures: 3-0, 4-0, 5-0 Liquid cyanoacrylate adhesive Compound benzoin tincture Adhesive strips: 1/4-, 1/2-, and 1-in. wide Bacitracin or triple antibiotic ointment Nonadherent pads Sterile adhesive dressings in various sizes Hydrocolloid dressings Protective skin covering Aluminum chloride solution Athletic tape LET = lidocaine 4%, epinephrine 0.1225%, and tetracaine 0.5%

Another general consideration in wound care management is tetanus prophylaxis. Tetanus-diphtheria toxoid (Td) and tetanus immune globulin (TIG) may be required, depending on the athlete's immunization status and the type of wound (eg, contaminated, crush injury) (table 2).

TABLE 2. Guidelines for Tetanus Prophylaxis in Routine Wound Management Tetanus Clean, Minor Wounds All Other Wounds* Vaccination History Td† TIG Td† TIG < 3 doses or unknown status Yes No Yes Yes 3 or more doses:   Last dose within 5 yr   Last dose within 5-10 yr   Last dose >10 yr No‡ No‡ Yes No No No No Yes Yes No§ No§ No§ *Wounds such as, but not limited to, those contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, or frostbite. †For children younger than 7 years, DTaP (DT, if pertussis vaccine is contraindicated) is preferred to tetanus toxoid alone. For patients 7 years or older, Td is preferred to tetanus toxoid alone. ‡If only 3 doses of fluid toxoid have been received, then a fourth dose of toxoid, preferably an adsorbed toxoid, should be given. §Yes, if HIV-infected, regardless of immunization history. Td = tetanus-diptheria toxoids (adult type); TIG = tetanus immune globulin; DTaP = diptheria and tetanus toxoids with acellular pertussis vaccine; DT = diptheria and tetanus toxoids, adsorbed, pediatric strength Data from: Epidemiology & Prevention of Vaccine-Preventable Diseases: The Pink Book, ed 8, chapter 6: Tetanus. Centers for Disease Control and Prevention, January 2004.

Abrasions

Skin can be divided into two layers: the upper, protective epidermis and the lower, supportive dermis. The spectrum of abrasion severity depends on the size and depth of involvement into the dermis. The initial goals for treating abrasions on the sideline are to cleanse the wound and provide a protective covering to allow the athlete to return to action.

Most athletic organizations require that any bleeding skin injury be covered before the athlete can return to play, because of concerns about the risk of infection caused by bloodborne pathogens such as hepatitis B and the human immunodeficiency virus (HIV). For example, the National Collegiate Athletic Association guidelines for bloodborne pathogens state that any bleeding "must be stopped and the open wound covered with a dressing sturdy enough to withstand the demands of activity."³

Cleansing. An important consideration is the amount of debris in the abrasion. Debris not removed during initial cleaning can become embedded during the healing process and result in "tattooing" of the healed abrasion.

Initially, the area should be cleansed with a mild antimicrobial soap and tap water. Agents such as Shur-Clens (ConvaTec, Skillman, NJ) or Hibiclens (Zeneca, Wilmington, DE) may be used, but these have not been proven superior to antimicrobial soap and water in preventing infections, and they are more costly. Agents such as hydrogen peroxide and povidone-iodine are not recommended because they may injure tissue and possibly delay healing. Debris may be flushed from the wound with a 30- to 50-mL syringe of sterile water or saline. If the involved area is quite large and the wound is very contaminated, applying a topical anesthetic such as LET (lidocaine 4%, epinephrine 0.1225%, and tetracaine 0.5%) gel or EMLA (eutectic mixture of local anesthetics [lidocaine and prilocaine in an emulsion base]) cream before wound cleansing is appropriate. A sterile surgical scrub brush can then be used to remove any remaining superficial debris after irrigation. Scrubbing should be minimized, because it can cause more trauma and inflammation.

After cleansing, hemostasis should be attained by applying direct pressure for several minutes. If this is ineffective, aluminum chloride (eg, Drysol [Person & Covey, Glendale, CA]) can be applied to the bleeding area to obtain hemostasis. The advantage of aluminum chloride over other agents, such as silver nitrate and Monsel's solution, is that it does not leave any colored residue that may result in a poor cosmetic outcome after treatment.

Dressings. Newer materials, such as semipermeable film or hydrocolloid dressings, are now the preferred agents to cover abrasions. These materials do not require the use of antibiotic ointments or overlying gauze. Both semipermeable film and hydrocolloid dressings improve healing rates when compared with traditional sterile gauze dressings. By fostering a moist wound environment that promotes epidermal migration, these dressings permit healing from the bottom and sides of the wound rather than allowing an overlying crust to develop. A moist wound environment also promotes angiogenesis and connective-tissue synthesis.⁴

The semipermeable film dressings (eg, Bioclusive [Johnson & Johnson, New Brunswick, NJ] and Tegaderm [3M, St Paul]) are impermeable to water and bacteria and allow wound exudate to evaporate. Hydrocolloid dressings, such as DuoDerm (ConvaTec, Skillman, NJ) or Cutinova Hydro (Beiersdorf, Inc, Norwalk, CT) actually absorb any excess exudate. Both types of dressings can remain in place for up to 7 days.⁵ Smaller abrasions may be covered with a layer of liquid cyanoacrylate adhesive to provide an occlusive, protective layer and promote faster healing.

The traditional method for dressing an abrasion requires application of a topical antibiotic followed by a nonadherent material such as Telfa (Kendall Healthcare Products, Mansfield, MA) or Adaptic (Johnson & Johnson Medical, Arlington, TX). The dressing is then covered with gauze and taped in place. Daily dressing changes are required with this method.

Lacerations

Because of the depth of soft-tissue involvement and possible injuries to nerve and tendon tissues at the base of the wound, laceration management is much more complicated than abrasion management.

Evaluation. After hemostasis is obtained, local peripheral nerve and tendon function should be assessed. Injury to these tissues requires an immediate referral to a surgical specialist before the primary wound closure is performed.

If nerve function is normal, as assessed by distal two-point discrimination testing, then a local anesthetic block should be performed before the wound is irrigated. Lidocaine with epinephrine is typically used. Epinephrine causes local vasoconstriction, which temporarily decreases bleeding at the wound site. Epinephrine should not be used on extremities such as the digits, nose, or penis because the blood supply in these areas is limited, and tissue necrosis may develop. After anesthesia is obtained, tendon function can be assessed.

Table 3 lists the commonly used local anesthetics in wound repair. The onset of action for all anesthetics, when used for local blocks (eg, infiltrative injection), typically takes 2 to 4 minutes. One advantage of bupivacaine hydrochloride is its long duration of action, but it is typically underused, because the incorrect assumption is that its onset of action is also longer. The concomitant use of epinephrine with these agents increases their duration of action.

TABLE 3. Commonly Used Local Anesthetic Agents Anesthetic Typical Concentration Duration (hr) Maximum Dose (mg/kg) Cautions or Contraindications Lidocaine 1%-2% 10-20 mg/mL 0.5-3 3-5 Liver or renal disease, allergy to amides Mepivacaine   hydrochloride 0.5%-1% 5-10 mg/mL 1.5-3 4 Pregnancy Bupivacaine   hydrochloride   0.25%-0.5% 2.5-5 mg/mL 4-24 1-2 Pregnancy

Several techniques may be used to minimize the discomfort associated with anesthetic injections, such as using smaller needles (27 or 30 gauge), a slower injection rate, using subcutaneous instead of intradermal injection sites, and warming the anesthetic to body temperature. Buffering lidocaine to increase its pH may reduce injection discomfort. Typically, one part of 1 mEq/mL of sodium bicarbonate is added to 9 or 10 parts of 1% lidocaine. However, lidocaine's shelf life decreases with the addition of sodium bicarbonate, from 3 to 4 years to 1 to 3 months at room temperature.

Irrigation. The wound should be inspected carefully for any foreign material. Wound irrigation can be performed with sterile saline and a 30- to 50-mL syringe with an attached angiocatheter or 18-gauge needle.

One study⁶ compared tap water irrigation with sterile saline irrigation in patients who were 1 to 17 years old. The authors enrolled 271 patients in the saline group and 259 in the tap-water group. Wounds that required antibiotic prophylaxis or were deemed complicated were excluded. The infection rate was 2.8% in the saline group and 2.9% in the tap-water group, similar to findings in most studies of wound infection rates. The study found no increase in complications from wound infections.

Wound closure. Most lacerations need to be closed within 8 hours. However, clean facial lacerations may be closed up to 24 hours after the injury without much increased risk for developing an infection.⁷ Any devitalized tissue should be removed prior to wound closure. A decision must be made at this time whether the wound should be treated in an open or closed fashion.

Conspicuously dirty, contaminated wounds have a higher risk of developing infection, regardless of the timing of closure. They are best closed using delayed primary closure techniques. Debrided tissue should be cultured initially. Wounds are classified as contaminated if quantitative bacterial cultures exceed 10⁵ organisms per gram of debrided tissue.

Wounds to be treated with delayed primary closure techniques are debrided and irrigated in the same way as for primary closure, and then a topical antibiotic is applied.⁸ The wound is packed with dry or petrolatum-impregnated gauze dressing to prevent premature closure and dressed. Most experts recommend broad-spectrum prophylactic oral antibiotics as well. The choice of antibiotic is updated when the initial wound culture sensitivities are obtained.

The patient should return in 24 hours for a wound check and packing change. Any necrotic tissue should again be debrided and sent for quantitative bacterial culture. Follow-up for closure should be made in another 72 hours. An interim dressing change can be made if the wound still appears contaminated. The wound should not be closed if follow-up quantitative bacterial cultures exhibit more than 10⁵ organisms per gram of debrided tissue.⁸

If underlying fascial layers are involved, these deeper layers need not be closed. Deep sutures may potentiate infection, and no evidence indicates that closing deep layers improves cosmesis. Deep sutures may be needed with gaping facial lacerations for improved cosmesis and with deep myotendinous structures that require repair. For facial wounds, the combination of deep stitches and closure of the wound with tissue adhesive achieves excellent cosmetic results. Pressure dressings or mattress sutures may be employed if dead-space reduction of deep soft tissues in nonfacial regions is a concern.

Closing Lacerated Skin

Several different methods may be used to close the skin, including sutures, staples, and tissue adhesives.

Sutures. Nonabsorbable synthetic suture materials, such as nylon or polypropylene, are typically used for skin closure, because they have higher tensile strengths and lower rates of infection as compared with natural materials, such as silk and catgut. The appropriate size of the suture material differs according to the skin tension at the wound site and for various body regions (table 4). Four basic suturing techniques are commonly used (figure 1). The running stitch is quick to perform (ie, only two knots, one at the beginning and end) and is effective when used on the extremities. Its main disadvantage is that if one knot releases, wound dehiscence is much more likely.

TABLE 4. Guidelines for Appropriate Suture Size Body Region Monofilament (for Superficial Lacerations) Absorbable (for Deep Lacerations) Scalp 5-0 or 4-0 4-0 Face 6-0 5-0 Eyelid 7-0 or 6-0 Not recommended Eyebrow 6-0 or 5-0 5-0 Trunk 5-0 or 4-0 3-0 Extremities 5-0 or 4-0 4-0 Joint surface 4-0 Not recommended Hand 5-0 5-0 Foot, including sole   4-0 or 3-0 4-0 Reprinted with permission from: Siberry GK, Iannone R (ed): The Harriet Lane Handbook: A Manual for Pediatric House Officers, the Harriet Lane Service, Children's Medical and Surgical Center of the Johns Hopkins Hospital, ed 16. St Louis, Mosby, 2001, p 75.

Staples. Using staples for skin closure is much quicker than suturing. Staples are typically used in emergent settings where time is limited. They are also a good choice for scalp lacerations where obtaining excellent cosmesis is not required. Accurate approximation of tissue is more difficult to achieve with staples; therefore, good cosmesis may be difficult to attain. Wounds closed with staples have similar infection rates and less foreign-body reaction than wounds closed with sutures.⁹

Tissue adhesives. Tissue adhesives (eg, Dermabond, [Ethicon, Inc, Somerville, NJ]) have been approved for use by the US Food and Drug Administration since 1998. Two available forms are 2-octyl cyanoacrylates and butyl cyanoacrylates. The former have been shown to be more stable, more flexible, degrade more slowly, and have a greater breaking strength. Multiple studies^10-13 have shown similar cosmetic outcomes and infection rates when compared with wound closure with sutures.

Tissue adhesives are appropriate for wounds under low tension, typically in areas where 5-0 or 6-0 nonabsorbable sutures are used. These locations are primarily found on the face, torso, and extremities. Adhesives are an excellent choice to use with children because of speed of application, less associated pain, and avoidance of needles. Adhesives should not be used in wounds at a mucocutaneous junction, heavily contaminated wounds, puncture wounds, or wounds over joints that undergo high tension.

Tissue adhesive use is becoming more popular in athletic environments. Dermabond was approved for treatment of selected facial wounds at the 2002 International Ice Hockey Federation World Championships.¹⁴ Lacerations have been identified as the third most common type of injury in hockey, behind contusions and sprain or strain injuries. During the 15 games of the world hockey championships, the four facial lacerations treated with tissue adhesive had excellent outcomes.¹⁴

Another study¹⁵ on professional hockey players followed the results of 32 lacerations sustained during games and closed with Dermabond. The players were allowed to return to the game immediately. The lacerations were checked after the game and again at 7 days. At the 1-week follow-up, 31 of 32 lacerations achieved good or excellent cosmetic outcomes. One laceration sustained minor dehiscence and was rated as acceptable by the authors.

Using tissue adhesives still requires good initial wound irrigation to prevent infection. The field should be relatively dry and bloodless for adhesion of the glue to the skin surface. The wound edges must be approximated, and then three to four coats of adhesive should be applied. The wound edges should be held for at least 30 seconds after applying the adhesive. In at least one reported case,¹⁶ a foreign body reaction to tissue adhesives occurred in a wound when the skin edges were not approximated. Tissue adhesives also have the advantage of not requiring removal or sterile dressings. Agents helpful in removing tissue adhesives in unwanted areas include petrolatum, acetone, and water (immersion).

Follow-Up Wound Care

Most wounds require follow-up care to ensure proper healing and eventual suture removal. No evidence supports the use of antibiotic ointments to reduce infections in appropriately cleansed, simple wounds. Ointments may help in providing a moist wound environment to promote cell migration and epithelialization. Prolonged use after 48 hours, however, may lead to macerated skin. To avoid the increased risk of wound dehiscence, wounds closed with tissue adhesive should not be treated with topical antibiotic ointments.

Initially, most wounds are covered with a sterile dressing to protect against infection and reinjury while epithelialization occurs. For athletes, padding is typically used to provide additional protection during sporting activities. Sutured and stapled lacerations should be kept dry for at least 24 hours to allow epithelialization to begin to protect the wound. At that point, patients can gently cleanse the area and pat it dry. Patients whose wounds were closed with tissue adhesives may shower immediately but should not bathe or swim for 2 to 3 days. Excessive exposure to moisture can weaken the adhesive bond and cause wound dehiscence.

Prophylactic systemic antibiotics are reserved for patients whose wounds were caused by human or cat bites. About one third of all bite wounds contain anaerobic bacteria that may cause relatively serious infections or abscesses.¹⁷ Cat bites have up to a 50% infection rate.¹⁸ Most healthcare providers use oral amoxicillin with clavulanate potassium as their first antibiotic of choice. Clindamycin may also be used for patients who are allergic to penicillin.

For dog bites, prophylactic antibiotic therapy remains controversial. One meta-analysis showed that 14 patients would need to be treated with prophylactic antibiotics to prevent 1 infection.¹⁸ Some experts recommend antibiotic prophylaxis for high-risk wounds, including deep puncture wounds, hand bites, wounds requiring surgical debridement, wounds in older or immunocompromised patients, and wounds near a prosthetic joint.

Open fractures and exposed tendon and joint injuries also typically require systemic antibiotics. One randomized clinical trial¹⁹ examined the risk of infection in intraoral lacerations. Penicillin VK 500 mg four times per day for 5 days significantly reduced the rate of intraoral infections. When patients who were poorly compliant with therapy were eliminated from analysis, none of the 28 patients treated with penicillin developed an infection, but 5 of 32 patients treated with placebo did.

In general, staples and sutures should be removed about 7 days after being placed (table 5). Typically, facial sutures should be removed in about 3 to 5 days to reduce the risk of patients' developing sinus tracts. Sutures for wounds under higher tension, such as those in active people and athletes, should be left in for 10 to 14 days, especially for wounds in areas prone to repeat trauma or high tensile forces when patients return to sports.

TABLE 5. Guidelines for Suture Removal Location Days After Injury Scalp 7 Face 3-5 Chest 8-10 Back 10-14 Forearm 10-14 Hand or fingers 8-10 Leg or thigh 8-12 Foot 10-12 Reprinted with permission from: Capellan O, Hollander JE: Management of lacerations in the emergency department. Emerg Med Clinic North Am 2003;21(1):214.

After suture removal, most experts recommend applying benzoin and then adhesive strips (eg, Steri-Strip, [3M, St Paul]) across the opening to provide initial support while the wound tensile strength is still quite low. At 3 weeks, the healing wound has only 15% to 20% of its ultimate strength and about 60% at 4 months. The adhesive strips begin to fall off within 1 to 2 weeks after application and are usually not replaced. Some regions under high tension may require reapplication of adhesive strips for up to 4 weeks.

Closing Remarks

Having the appropriate equipment on the sidelines will help clinicians get athletes who sustain abrasions or lacerations back in the game quickly and safely. Meticulous cleaning and appropriate wound management will reduce the risk of infection and poor cosmetic outcomes.

References

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3. NCAA Guideline 2H: Blood-borne pathogens and intercollegiate athletics, April 1988, revised August 2000. Available at http://www.ncaa.org/library/sports_sciences/sports_med_handbook/2003-04/2h.pdf. Accessed January 6, 2005
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10. Quinn JV, Drzewiecki A, Li MM, et al: A randomized, controlled trial comparing a tissue adhesive with suturing in the repair of pediatric facial lacerations. Ann Emerg Med 1993;22(7):1130-1135
11. Quinn J, Wells G, Sutcliffe T, et al: A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 1997;277(19):1527-1530
12. Quinn J, Wells G, Sutcliffe T, et al: Tissue adhesive versus suture wound repair at 1 year: randomized clinical trial correlating early, 3-month, and 1-year cosmetic outcome. Ann Emerg Med 1998;32(6):645-649
13. Goktas N, Karcioglu O, Coskun F, et al: Comparison of tissue adhesive and suturing in the repair of lacerations in the emergency department. Eur J Emerg Med 2002;9(2):155-158
14. Branfield AS: Use of tissue adhesives in sport? a new application in international ice hockey. Br J Sports Med 2004;38(1):95-96
15. Perron AD, Garcia JA, Parker Hays E, et al: The efficacy of cyanoacrylate-derived surgical adhesive for use in the repair of lacerations during competitive athletics. Am J Emerg Med 2000;18(3):261-263
16. Edmonson MB: Foreign body reactions to Dermabond. Am J Emerg Med 2001;19(3):240-241
17. Goldstein EJ: Bite wounds and infection. Clin Infect Dis 1992;14(3):633-638
18. Cummings P: Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med 1994;23(3):535-540
19. Steele MT, Sainsbury CR, Robinson WA, et al: Prophylactic penicillin for intraoral wounds. Ann Emerg Med 1989;18(8):847-852

Dr Bouchard is a family practice physician and the assistant director of the sports medicine fellowship at the Maine Medical Center in Portland, Maine. Address correspondence to Mark Bouchard, MD, Maine Medical Center, 272 Congress St, Portland, ME 04012; e-mail to bouchm@mmc.org.

Disclosure information: Dr Bouchard discloses no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.