Suturing versus conservative management of lacerations of the hand: randomised controlled trial
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7359.299 (Published 10 August 2002) Cite this as: BMJ 2002;325:299All rapid responses
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Dear Sir,
We would like to commend the authors Quinn et al 1 on an elegant
study showing conservative treatment is faster and less painful for small
uncomplicated lacerations of the hand. However, we think it is imperative
that lacerations in the hand no matter how small be examined thoroughly to
exclude tendon, nerve or joint injuries. The authors make no comment on
the mechanism of injury which is extremely important. A knife stab
laceration or glass injury to the hand would make exploration of the wound
mandatory. An unimpressive skin wound may hide a remarkable amount of
damage to deep structures 2. Similarly, injuries caused by thin slivers of
glass produces unimpressive skin wounds but commonly divide flexor tendons
and nerves in the forearm 3.
In the emergency setting we suggest that it is vital to take a good
history from the patient with regard to the mechanism of injury and to
examine the patient thoroughly before deciding on further management of
hand lacerations albeit suturing or conservative management. In our
Plastic Surgery Unit, the Nurse Practitioners who refer us hand trauma
cases have all been on a hand trauma study day organised by our
department. If the mechanism of injury raises any suspicion of a tendon or
nerve injury the cases are referred to us and formally explored in
theatre.
Beryl A. De Souza, Plastic Surgery Registrar
bds@dr.com
Mohammed Shibu, Consultant Plastic Surgeon
Graham Moir, Consultant Plastic Surgeon
Nigel Carver, Consultant Plastic Surgeon
Department of Plastic Surgery, Bart's & The Royal London Trust,
The Royal London Hospital, Whitechapel, London E1 1BB.
References
1. Quinn J., Cummings S., Callaham M. & Sellers K. Suturing
versus conservative management of lacerations of the hand: randomised
controlled trial. BMJ 2002;325:299-300.
2. Schwager R.G., Smith J.W. & Goulian D. Small deep forearm
lacerations. Plast & Recons Surg. 1975;55:190-194.
3. Joseph K.N., Kalus A.M. & Sutherland A. B. Glass injuries of
the hand in children. Hand 1981;13:113-119.
Competing interests: No competing interests
Dear Sir,
We read with great interest the article by Quinn et al “Suturing
versus conservative management of lacerations of the hand”. It is nice to
see that not all hand injuries need to sutured. However, the article does
raise some queries. The authors state that wounds that are not sutured
will heal normally. This depends on the definition of normal. Of course,
it will heal, but the cosmetic appearance is also important. The best
cosmetic result will be achieved with suturing. Also, secondary problems
may arise due to scarring below the wound leading to a functional defect.
Furthermore, the authors have very strict exclusion criteria for the
trial. In our experience of hand surgery, these criteria exclude over 95%
of patients that are treated by hand surgeons in the UK. Therefore, the
non suturing of hand wounds would be of little use to any hand injury that
is seen.
There is also a risk that a wound may be less than 2cm, but hide
serious damage beneath, for example, a stab injury may not show any
underlying defect even after thorough clinical examination, but may hide a
50% laceration of the underlying tendon. This may present days later with
a tendon rupture, resulting in further surgery. This then highlights the
case for exploration of all suspected serious hand injuries.
The final point is that the diagnosis of eligible hand injuries for
conservative management has to be made by an experienced hand surgeon.
Anyone who has not had considerable experience with hand injuries would
not be in a position to diagnose an uncomplicated hand injury, in case a
wrong diagnosis is made.
Therefore, although it a good idea to treat some wounds
conservatively, for hand injuries there is too much at risk to do this,
and the majority of hand surgeons would still advocate exploration of any
suspicious hand injury.
Competing interests: No competing interests
There appears to be some confusion. Professor Quinn now states "these
references support the claim made in the BMJ that sutures carry an
increased risk of infection compared with other closures". This I can
accept, but this is not what the BMJ printed, and this was not the subject
of Quinn's article. Quinn's article did not compare suturing with other
methods of closure, while the BMJ simply stated of sutures that their
"placement is not without associated increased risk of infection". But
increased compared with what? They do not clarify.
Both Quinn and the BMJ editors are being misleading. It is accepted
that the use of sutures carries a slightly higher risk of infection
compared with other methods of closure, but it is not accepted that
sutures carry a higher risk of infection compared with no closure at all -
the subject of Quinn's article. This is one of the principle reasons that
we close wounds, to prevent infection. An open wound will invariably
become contaminated, the risk rising over the first few days, and closure
clearly prevents this. If sutures were felt to be more risky than non-
closure, then we would not bother to close elective wounds at all.
I have no objection to studies like Quinn's but I object to the BMJ
"throwing" assumptions at us this way, which Quinn has clearly seized upon
and amplified. The presentation of the "what is already known on this
topic" section was simplistic and misleading, and served only to confuse
the debate surrounding this paper, which did not really consider wound
infection in the first place. The BMJ should not have commented on
infection risk in this section, especially when it was not the primary
focus of the article.
Competing interests: No competing interests
Editor
James Quinn et al in their paper on the management of lacerations are
guilty of a failure to use the correct nomenclature in describing wounds
accurately. For although they refer to lacerations of the hand, it is
clear from the photographs used to illustrate the paper, both on the front
and inside of the journal, that these are incised wounds and one of them
has all the appearances of being a penetrating incised wound or stab wound
from a single edged weapon.
Without going into detailed definitions in respect of the differences
between lacerations and incisions, it is certainly my experience that full
thickness wounds to the hands are more commonly incised wounds, which are
the result of contact with a sharp bladed object or implement, and are
much less likely to be lacerations which are the result of splitting or
tearing of the skin as a result of some form of blunt force trauma.
Unfortunately this paper would appear to be a further example of
doctors, and not always junior doctors, using the incorrect nomenclature
in describing wounds accurately.
This is an issue that has been raised in the past by others, namely
Milroy and Rutty and Norfolk and Stark. Both sets of authors made it
clear that the accurate description of wounds and the use of correct
nomenclature are of considerable importance, particularly in assessing the
causation of wounds, which is clearly of considerable relevance in respect
of the medico-legal issues.
In many respects this is a sad indictment of present day
undergraduate medical training which is devoid of any input in forensic
medicine. This use of incorrect nomenclature is on the increase and
causes considerable problems and arguments in court. I fear that without
the reintroduction of formal training in forensic medicine for medical
students, these are problems that are going to continue increasing.
References
Milroy C. M., Rutty G. N. "If A Wound Is "Neatly Incised", It Is Not
A Laceration" BMJ 1997;315:1312
Norfolk G. A., Stark M. M. "The Future Of Clinical Forensic Medicine"
BMJ 1999;319:1316-1317
Competing interests: No competing interests
Dr. Fogarty,
Please take the opportunity to actually read the literature before
making further comments.
Edlich's papers are time honored, not outdated and use monofilament
sutures. My references were in response to your initial comments ".. BMJ
are guilty of assuming that sutured wounds have an "increased risk of
infection" in their section "what is already known about this topic".
From where do they derive this assumption...". These references support
the claim made in the BMJ that sutures do carry an increase risk of
infection compared to other closures.
Wounds in our study were not left open to further contamination and
increased infection as you suggest (note the only infection in our study
occurred in a sutured
wound). You obviously miss the point that it is the dressing not the
suturing that prevents contamination and infection, and there is
overwhelming evidence that sutures
potentiate infection. More of Edlich's work. "Studies in the management of
the contaminated wound. VII. Susceptibility of wounds to postoperative
surface contamination". Am J Surg 1971.
Competing interests: No competing interests
Editor-
The recent paper by Quinn and colleagues regarding the management of
hand 'lacerations' (1) is imprecise in its terminology and has the
potential to mislead, with potentially significant forensic implications.
The paper refers predominantly to 'lacerations', but elsewhere
mentions 'cuts'. No definitions of these terms are provided. Furthermore,
photographs on the front page of the week's BMJ and also in a leader
article - both referring to the paper - depict wounds that are clearly
incised in nature and not lacerations.
Lacerations are produced by tearing of the tissues due to the
appliance of force beyond the limits of elasticity. Incised wounds, on the
other hand, occur when the tissues are sliced by a sharp object. The
former are ususally jagged in outline whereas incised wounds are often
neatly divided. There may be bruising, abrasion and crushing of the
margins of a laceration. Hair overlying a laceration
may also remain intact and on closer examination residual tissue strands
may be seen traversing the wound. Any underlying bony injuries may also
provide a clue as to the nature of the wound (2).
The distinction is important as it implies a method of causation.
This may have profound implications in later legal actions. For example,
an accused charged with inflicting injuries with a knife would be greatly
assisted in his defence by a doctor's report describing the victim's
injuries as 'lacerations'.
Whilst the distinction may not always be clear, an attempt should
always be made to differentiate between the two and to document the
findings clearly.
1. Quinn J, Cummings S, Callaham M, Sellers K. Suturing versus
conservative
management of lacerations of the hand: randomised control trial. BMJ
2002;325:299-300.
2. See for example: Knight B. Forensic Pathology, 2nd Ed. London,
Arnold, 1996.
Matthew M Orde, DMJ (Path), Barrister.
(I have no competing interests.)
Specialist Registrar in Histopathology,
Royal Sussex County Hospital,
Brighton,
BN2 5BE.
Competing interests: No competing interests
Professor Quinn misses my point. He states that sutured wounds will
have higher infection rates than topical or suture-less closure. I accept
this, but my point was that sutured wounds are less prone to infection
than wounds which are left open. And Quinn's paper studied the treatment
of wounds by "non-closure", i.e. his paper did not consider other methods
of closure.
When asked for evidence, I was not impressed that Quinn quoted a
rapid response posted the day before! Later Quinn does quote some
published work but these papers are hopelessly outdated, before
monofilament materials were developed! One paper considers dead space
closure, and here the "nidus of infection" argument is accepted unlike
with skin sutures. Another paper compares suturing with closure using
tissue adhesive - again this was not the subject of Quinn's paper or of my
argument. I accept that atraumatic methods of closure are valuable in
wound management, but I don't accept that non-closure provides a superior
result to sutured closure in most cases.
Competing interests: No competing interests
I read with interest the article by Quinn et al suggesting that small
hand lacerations could be treated conservatively with no detriment to the
patient. I would be interested to know if they found any difference in
outcome based on the site of the laceration, in particular palm versus
finger and volar versus dorsal lacerations. On may expect that volar
lacerations on the fingers and palm would be more troublesome than dorsal
ones due to the skin excursion.
The authors state that return to normal activities took a mere 3.4
days in both groups. Was it that they had no manual workers in their
treatment groups as I find it difficult to beleive that any such person
could return to normal activity, ie work after this time.
I also find their choice of photograph for the article very
concerning as it seems to show a laceration that should niether be left
alone or sutured in an emergency department but explore fully in theatre
as lacerations like the one shown are frequently accompanied by digital
nerve and flexor tendon damage.
Competing interests: No competing interests
Naturopathic treatment of wounds involves simple cleansing
followed by a firm, cool moist dressing which does not aim
to inite the wound. This has been shown to be spectacularly
effective for burns, ingrained injury, laceration and birth
tear to second degree.
Patients are often initially apprehensive because of
'stitching consciousness' but quickly adopt the treatment
because the cool dressing instantly eases pain. While wounds
sometimes need to be dressed for longer periods than
conventional dressings a clear advantage is that as a result
even aged tissues remain supple, and scarring is minimal
Competing interests: No competing interests
Hand lacerations should be explored before conservative treatment
Editor,
We are surprised by the BMJ’s publication of Quinn et al’s article on
conservative treatment of small hand lacerations. 1 Their conclusions will
come as no surprise to surgeons who treat hand injuries frequently, who
recognise that wounds on the palmar aspect of the hand heal well if left
open. 2 Skin defects in the palm are often left to heal by secondary
intention following surgery for Dupuytren’s disease with excellent
results. 3
Our concern is that this paper trivialises small hand lacerations,
ignoring the fact that lacerations such as that shown in the front cover
photograph may injure any of the underlying soft tissue and bony
structures in the finger. In their method, they do not state who made the
judgement that there was no associated “…neurovascular, tendon or bone
injury”. This cannot be excluded in this type of wound unless a careful
history of the mechanism of injury is taken, a radiograph is obtained, and
it is explored under local anaesthetic by someone experienced enough to
make this judgement. If neglected, injuries to these structures will
usually result in permanent functional disability. Wounds which have
penetrated and contaminated the flexor tendon sheath can lead to
devastating infection with massive soft tissue loss and all of its
sequelae. Similarly, those which have penetrated the joint
capsule may lead to septic arthritis.
Small hand lacerations, along with many other conditions in Accident
and Emergency departments, are seen and treated by (through no fault of
their own) junior and inexperienced doctors and increasingly, nurse
practitioners. This paper sends out a message which is likely to result
in more patients having treatable hand injuries neglected, with
regrettable, and entirely avoidable consequences. Encouraging such wounds
to be treated conservatively is unlikely to benefit the patients or the
medical staff treating them, but should keep the lawyers busy.
Yours sincerely,
Roderick Dunn
Specialist Registrar
Stuart Watson
Consultant
1. Quinn J, Cummings S, Callaham M, Sellers K. Suturing versus
conservative management of lacerations of the hand: randomised controlled
trial. BMJ 2002;325:299-300.
2. Brown PW. Open injuries of the hand. In: Green DP, Hotchkiss RN,
Pederson WC, eds. Green's Operative Hand Surgery, Philadelphia: Churchill
Livingstone, 1999:1612-4.
3. McCash CR. The open palm technique in Dupuytren’s contracture.
Br J Plast Surg 1964;17:271-80.
Competing interests: No competing interests