To stitch or not to stitch? And other laceration tidbits.

One of the most frequent questions I am asked by friends and family is about lacerations. “I cut my finger, do I need to go to the ER?” or “My kid fell and has a cut, what should I do?” These cuts, or lacerations, may rarely be life-threatening. But knowing whether stitches are necessary can be difficult for those not trained in emergency care.

This article will discuss the answers to a number of questions that you may have when you run into the unfortunate scenario of a laceration.

1. Do I need stitches?
2. How soon after I cut myself can the laceration still be closed?
3. If I need to seek care, where should I go?
4. What should I do right away after I get cut?
5. What’s the best way to prevent infection?
6. What lacerations are at highest risk for infection?
7. Do I need antibiotics?
8. Do I need to update my tetanus shot?
9. What can the provider do to prevent pain while placing my stitches?
10. Can the laceration be glued shut?
11. What’s better, absorbable or non-absorbable sutures?
12. When are staples used?
13. What do I need to worry about if the cut is REALLY deep?
14. What is the best post-suture care?
15. When do I need to get the stitches removed?
16. Can I take the stitches out myself?
17. Other considerations

Do I need stitches?

This is probably the most common question I am asked by friends and family after they’ve cut themselves. This is also a common reason people visit the ER or urgent care. There are 2 different scenarios. The first is a large laceration – stitches are obviously needed to close the wound. But the other scenario that is not rare is a cut that is fairly superficial, perhaps continuing to bleed, or doesn’t seem to be spread apart too much. This leaves a gray area in regards to whether stitches will help or not.

What do stitches do?

Before answering the question of whether stitches are necessary, it’s important to understand what stitches do. The most obvious is that they close the wound. This can prevent scarring, improve time to healing, and in the case of larger wounds, can prevent infection (assuming the wound was cleaned well before closure).

But let’s be clear, many wounds will generally heal on their own without any stitches. We call this healing by secondary intention where the body will create a scab over the wound and eventually regrow the skin that was previously there. This will usually cause a significant scar and take longer to heal. The point is, stitches are not always necessary for actual healing, but can provide other benefits as pointed out.

The main reason to get stitches, in my opinion, is when a wound is gaping. This means that the edges of the cut are separated from each other and it takes some effort to pull them back together. If you’ve ever had a paper cut, especially a bigger one, you’ll notice that even though it is painful and can bleed, the edges of the wound are generally together without exposing the tissue underneath. This is a situation where a Band-Aid or a little tape over the cut can suffice without the need for stitches. In the ER we use Steri-Strips, which are glorified tape that keep a wound closed. But for some wounds, they are spread apart enough that tape alone will not work to hold the wound together, and this is when stitches are necessary.

Other potential reasons to get stitches would be difficulty controlling bleeding, a jagged cut, or a very deep cut. As you’ll see in this article, stitches are not the only way to close a laceration. There are many factors that we take into account before jumping right to stitches.

How soon after I cut myself can the laceration still be closed?

The American College of Emergency Physicians recommends that lacerations be closed within 8-12 hours. The reason for this is the theory that bacteria can make its into the wound, and once it is closed, that bacteria can cause a significant infection.  The longer you wait, the more potential bacteria that can get into the wound.  However, there is some evidence that would contradict this rule. 

Some studies suggest that whether the laceration is closed up early or late, the chances for infection are the same.  Ultimately, most physicians will follow the 8-12 hour rule. However, this golden period of wound closure is probably unfounded and should not be the most significant factor regarding whether or not to close the laceration.  Furthermore, certain areas of the body, including the face, should certainly be closed, even if someone presents after 12 hours. This could otherwise leave scarring that would be aesthetically displeasing. Thus, most facial wounds are closed without regard to timing.

Either way, if you think you might need stitches, it’s better to go in early than wait until the next day.

If I need to seek care, where should I go?

For most lacerations, going to an urgent care will be the most cost effective strategy.  Most urgent cares have the ability to suture and have the proper medications to numb the area prior to suturing.  Physicians and other providers in the urgent care should be skilled enough to handle most lacerations.  For much larger lacerations, concern for tendon injury or deep tissue injury, it may be warranted to go to an emergency department where there are emergency specialists and other specialists who are trained to deal with these more severe injuries. 

Another common concern from parents is when the laceration is on a child’s face or through the lip.  Many people request plastic surgery to sew up the wound.  My personal opinion is that there might be certain circumstances when plastic surgery can provide benefit, but that most of the time, emergency physicians and urgent care providers are able to suture just as well as plastic surgeons for common lacerations, even facial.  Situations when plastic surgery might be necessary would be a large lip laceration that is jagged, or certain misshapen facial lacerations that might require specific plastic surgery techniques.  Most emergency physicians will understand when this is needed and who to call. So in these situations, an emergency department would be the best place to go.

What should I do right away after I get cut?

The best thing to do right after getting a laceration would be to run the cut under water. Tap water is perfectly fine and has been proven not to cause any infection risk.  Washing it out significantly can decrease the risk of infection, especially if the wound was contaminated by the cutting item or mechanism. After washing it out, pressure will be necessary to stop the bleeding.  Hold pressure for 15 minutes without letting go, as this is the best way to stop the bleeding. If the wound appears deep, is gaping, or the bleeding will not stop, then seeking care at that time will be appropriate for evaluation.

What’s the best way to prevent infection?

The absolute best way to prevent infection is to wash out the wound immediately.  This has been proven time and time again. This can be done right under the faucet with regular tap water.  Wash for an extended period of time to make sure you’ve removed all of the contaminant from the wound.

In an ER or urgent care, we will once again wash out the wound, and usually with a significant amount of fluid. We have a saying that goes “the solution to pollution is dilution.” The more fluid we use to wash out a wound, the better chance of preventing infection. So wash, wash, and wash again. There are really no other methods that have been shown to significantly decrease infection risk.

What lacerations are at highest risk for poor outcomes?

Studies have shown that the major risk factors for poor outcomes after a laceration include diabetes, bite wounds, jagged or misshaped wounds, visible contamination (dirt or other debris), deep lacerations, presence of a foreign body (glass, splinters, pebbles, etc.), and lacerations greater than 5cm in length. On top of washing out the wound well, my general practice is to treat any of these lacerations with oral antibiotics even though there is no specific evidence that this will prevent infection. This is certainly on a case by case basis. This brings us to the next question.

Do I need antibiotics?

Based on studies, it is unclear whether antibiotics are helpful to prevent infection.  However, common lacerations in people without major risk factors heal very well and are unlikely to need antibiotics for prophylaxis.  I tend to use prophylactic antibiotics on patients who have immune deficiencies including medications that decrease immune system function. I also use antibiotics on wounds that are contaminated and the other risk factors mentioned above, as these tend to be higher risk for poor outcomes.  Hopefully in the future we will have more information to help us determine when antibiotics are useful for prophylactic therapy.

Do I need to update my tetanus shot?

It is generally considered appropriate to update a tetanus vaccine if you have not had one within 5 years of getting a laceration. Normally we update tetanus every 10 years, but in the setting of laceration, it is recommended that the tetanus vaccine be given earlier.  It is also recommended that a pertussis vaccine be added to the tetanus (available in one shot) for all patients over 10 years of age due to increased incidence of pertussis.  If you’re unsure of your last tetanus shot, it is worth getting as there are no problems associated with getting the vaccination even if you end up finding out you’ve had it within the past 5 years. Though tetanus is rare and many think we give out too many tetanus vaccines, the actual disease is very serious and can lead to death, so it’s worth updating your shot.

What can the provider do to prevent pain while placing my stitches?

For adults, it is most common to use lidocaine injected into the wound edges to create a numbing effect. For kids, LET, which is a combination of lidocaine, epinephrine, and tetracaine, can be placed over the wound as a gel and can work great to numb the area where sutures are necessary.  This prevents an injection which can be painful and traumatic to a child. EMLA cream is another alternative that is similar. When using these creams, it is not uncommon for the child to cry or scream throughout the procedure. However, this is usually related to the emotional trauma if the procedure, and not pain. Rest assured, these creams work exceptionally well.

There are a couple of other things to think about. If the lidocaine is warmed prior to injection, this can reduce the pain.  Smaller needles lessen the pain.  And finally, you can ask the provider to mix the lidocaine with sodium bicarbonate.  This can decrease the burning sensation upon injection.

Can the laceration be glued shut?

There are many wounds on which glue works very well.  These wounds are generally not gaping or have minimal gaping but could be deep enough to require closure.  The best wounds on which to use glue are those that have low tension and can easily be placed back together without much pressure.  These tend to be facial wounds, such as wounds around the eyebrow.  Some other wounds on the extremities, specifically the hands or feet, may be amenable to glue. It is certainly a nice alternative to sutures because numbing medication is generally not necessary when glue is applied.

When do I use staples instead of sutures?

Staples can be placed faster and can be less painful than traditional sutures. However, staples can have more risk for scarring and thus are not as aesthetically pleasing. For this reason, staples should be placed in areas that are not generally visible on the body. I almost exclusively place staples on adult scalp lacerations that are hidden by hair. They do incredibly well to keep a wound together, are quick and easy to place, and are also easy to remove. Amazingly, I have also heard of absorbable staples, but I have yet to see any in clinical practice.

What’s better, absorbable or non-absorbable sutures?

In a nutshell, absorbable sutures are stitches that do not need to be removed. The normal bodily process dissolves the sutures over time. These are nice because they do not require a visit to the doctor to have them removed. In many studies, absorbable sutures have been shown to be just as good as non-absorbable in all outcome measures. So why not use absorbable sutures all of the time?

The main answer to this question is twofold. First, absorbable sutures are not as strong as non-absorbable, so wounds that require more tension to bring them together require non-absorbable sutures. I find that extremity wounds usually are more gaping and require more suture strength so I tend to use non-absorbable sutures when repairing these wounds.

The other consideration is that absorbable sutures cause some localized inflammation in and around the wounds. This is because the body reacts to the sutures to dissolve them over 3-4 weeks. Theoretically this can predispose the body to increased risk of infection. This has never been proven in any articles. However, when I repair more contaminated wounds – those that may be dirtier than others such as dirt in the wound, or a cut caused by a dirty tool – I tend to err on the side of caution and use non-absorbable sutures. For other lacerations, absorbable sutures work great.

What do I need to worry about if the cut is REALLY deep?

This question really depends on the location of the laceration. There are a number of structures deep under the skin. These include tendons, ligaments, muscles, nerves, and blood vessels. Any deep wound should be explored meticulously to make sure that none of these major structures are damaged. If the laceration is near a tendon, such as in the arm or hand, the clinician should check tendon function by flexing and extending the fingers.

What is the best post-suture care?

Most closed lacerations will do fine with a normal Band-Aid or gauze to keep the wound covered and clean. However, there was a study in the 1990s that found that occlusive dressings, like waterproof Band-Aids, can prevent infection and be left in place for up to 7 days. In the urgent care or ER, there are clear films that can be placed over the wound (sometimes known as tegaderm), allowing you to see the wound and observe for any signs of infection, while keeping the wound covered and moist. These have also been shown to reduce pain and healing time.

In regards to antibiotic ointment, there is no data that putting antibiotic ointment on a wound after repair prevents infection. I tend to place antibiotic ointment on a wound for the first 24 hours. Following this, I recommend petrolatum jelly like Vasoline. This keeps the wound moist and may help prevent scarring.

When do I need to get the stitches removed?

There is no evidence on this subject. The general thought is that the higher the tension of the wound, the longer the sutures should be kept in. I tend to give the following advice. If the wound is on an extremity, I recommend sutures be removed in 10-14 days. When over a joint that puts tension on the wound when it moves, I err more towards 14 days. On the face, I recommend 5-7 days. The sooner the sutures come out of the face, the less chance of scarring and this allows the final healing to be more aesthetically pleasing.

Can I take the stitches out myself?

A very popular question – and the answer really could be yes. But there are a number of things to think about before grabbing the garden sheers and hacking away. First, we use sterile tweezers and scissors in the urgent care or ER when we remove stitches to prevent infection. You should make sure your scissors and tools are sterile if you decide to do this. This might mean using heat or rubbing alcohol to sterilize the tools.

You also want to make sure the entire suture is removed from the wound. An accidentally retained suture can be a risk for infection. I am a realist and understand that people remove sutures on their own all of the time. However, my recommendation would be to have a professional remove the stitches to prevent any potential complications. This is relatively cheap and may be free if you go back to the same clinic that placed the sutures in the first place.

Other considerations

Bite wounds including dogs, cats, other animals, and especially humans, can have a significant amount of bacteria transfer from mouth to wound. These cases require antibiotics and significant wash out to prevent infection. In fact, depending on the wound, many are not fully closed to prevent locking in bacteria, which could lead to infection. If I close the wound, such as on a face, I tend to approximate these wounds to keep them together but leave space for them to drain. Though there is no evidence to support this, it makes sense to me to prevent infection.

In addition to the techniques above regarding sutures, staples, glue, and steri-strips, there are two other techniques that can be beneficial for laceration closure. The first is called the hair opposition technique, which is great for closing scalp lacerations. Taking the hair on both sides of the wound, they are pulled over the wound for closure and then glue is applied over the hair to keep it in place. This works great and is a painless way to repair wounds, especially in kids. The second technique is called Zip-type closure. Tape is placed on both sides of the wound with a zipper or similar device in the middle and you basically zip closed the wound. I have seen this in theory but never in practice. Perhaps this will be the wave of the future.

Conclusion

Lacerations that are gaping, bleeding, or deep may need stitches. There are many other ways to close wounds including glue, tape, staples, and other modified techniques. The wounds should be closed within 8-12 hours and washed out profusely to prevent infection. Absorbable sutures are generally as good as non-absorbable and do not require removal. Urgent cares are the most cost-effective place to have the wound evaluated, while larger wounds may need emergency specialists.

And finally, though accidents happen all of the time, prevention is key. Always be as safe as possible with any tools and other higher risk work that could predispose you to injury.

Please tell any other thoughts or experiences you’ve had with lacerations below…