Laceration Repair: A Practical Approach

Transcription

1 Laceration Repair: A Practica Approach RANDALL T. FORSCH, MD, MPH; SAHOKO H. LITTLE, MD, PhD; and CHRISTA WILLIAMS, MD University ofmichigan Medica Schoo, Ann Arbor, Michigan The goas of aceration repair are to achieve hemostasis and optima cosmetic resuts without increasing the risk of infection. Many aspects of aceration repair have not changed over the years, but there is evidence to support some updates to standard management. Studies have been unabe to de nea goden period for which a wound can safey be repaired without increasing risk of infection. Depending on the type of wound, it may be reasonabe to cose even 18 or more hours after injury. The use of nonsterie goves during aceration repair does not increase the risk of wound infection compared with sterie goves. Irrigation with potabe tap water rather than sterie saine aso does not increase the risk ofwound infection. Good evidence suggests that oca anesthetic with epinephrine in a concentration of up to :100,000 is safe for use on digits. Loca anesthetic with epinephrine in a concentration of 1:200,000 is safe for use on the nose and ears. Tissue adhesives and wound adhesive strips can be used effectivey in ow-tension skin areas. Wounds hea faster in a moist environment and therefore occusive and semioccusive dressings shoud be considered when avaiabe. Tetanus prophyaxis shoud be provided if indicated. Timing of suture remova depends on ocation and is based on expert opinion and experience. (Am Fam Physician. 2017; 95 ( 10) : Copyright 2017 American Academy of Famiy Physicians.) -. More onine at aafp.orgiafp. This cinica content conforms to AAFP criteria for continuing medica education (CME). See CME Quiz Questions on page 622. Author discosure: No reevant financia affiiation. P Patient information: A handout on this topic is avaiabe at aafp.org/afp/2008/1015/ p952.htm. 1% pproximatey 6 miion patients present to emergency departments for 15 " aceration treatment every year.... Athough many patients seek care at emergency departments or urgent care centers, primary care physicians are an important resource for urgent aceration treatment. Many aspects of aceration repair have not changed, but there is evidence to support some updates to standard management. Approach to the Wound The goas of aceration repair are to achieve hemostasis and optima cosmetic resuts without increasing the risk of infection. Important considerations incude timing of the repair, wound irrigation techniques, providing a cean edfor repair to minimize contamination, and appropriate use of anesthesia. An artice on wound care was previousy pubished in American Famiy Physiciari? EVALUATING THE WOUND When a patient presents with a aceration, the physician shoud obtain a history, incuding tetanus vaccination status, aergies, and time and mechanism ofinjury, and then assess wound size, shape, and ocation. If active beeding persists after appication of direct pressure, hemostasis shoud be obtained using hemostat, igation, or sutures before further evauation. Hemostasis contros beeding, prevents hematoma formation, and aows for deeper inspection of the wound. The next step is to determine whether vesses, tendons, nerves, joints, musces, or bones are damaged. Anesthesia may be necessary to achieve hemostasis and to expore the wound. Devitaized and necrotic tissue in a traumatic wound shoud be identi edand removed to reduce risk of infection. Ifa foreign body (e.g., dirt partices, wood, gass) is suspected but cannot be identi ed visuay, then radiography, utrasonography, or computed tomography may be needed. About one-third of foreign bodies may be missed on initia inspection. Injuries that require subspeciaist consutation incude open fractures, tendon or musce acerations of the hand, nerve injuries that impair function, acerations of the saivary duct or canaicuus, acerations of the eyes or eyeids that are deeper than the subcutaneous ayer, injuries requiring sedation for repair, or other injuries requiring treatment beyond the knowedge or ski of the physician. TIMING OF WOUND CLOSURE No randomized controed trias (RCTS) have compared primary and deayed cosure 528 American Famiy Physician Voume 95, Number 10 ' May 15, 2017

2 L{C2u( ;Mg [:o0,ocl : "_2 o(oo( "7, Laceration Repair Evidence Physicians shoud wear protective gear, such as a mask with shied, during irrigation. CLEAN vs. STERILE GLOVES Cinica recommendation rating References _ Use of cean nonsterie examination goves, Noninfected wounds caused by cean objects B 2, 7-9 rather than sterie goves, during wound repair has itte to no impact on rate of sub- t d. f t. A RCT f 493 may Lmdergo primary Cosure up to 18 hours after injury. Head wounds may be repaired up to 24 hours after injury. Seqen Woun in ec 1_on' _O _ Using potabe tap water instead of sterie saine A 2, patients undergomg Skm excson Wth pm for wound irrigation does not increase the risk mary C05u1'e reveaed that cean goves were of infection. not inferior to sterie goves regarding infec- Use of cean nonsterie examination goves A 11, tion risk. A arger RCT with 816 patients rather than sterie goves during wound repair and good f0how_up reveaed no Statisti_ does not significanty increase risk of infection. Cay Signi cant difference in the incidence if there is no concern for vascuar compromise B 29, 30 of infection between cean and sterie gove to an appendage, oca anesthetic containing epinephrine in a concentration of up to use. Smaer observationa studies support 1:O0,000 is safe for use in aceration repair these ndings." 2 of the digits, incuding for digita bockade. Lacerations are considered contaminated A = consistent, good-qua/ity patient-oriented evidence, B = inconsistent or imitedquaiity patient-oriented evidence; C = consensus, disease-oriented evidence, usua practice, expert opinion, or case series. For information about the SORT evidence rating system, go to p.org/afpsort. of nonbite traumatic wounds? One systematic review and a prospective cohort study of 2,343 patients found that acerations repaired after 12 hours have no signi cantincrease in infection risk compared with those repaired earier. A case series of 204 patients found no increased risk of infection in wounds repaired at ess than 19 hours.3 Noninfected wounds caused by cean objects may undergo primary cosure up to 18 hours after injury. Head wounds may be repaired up to 24 hours after injury. Factors that may increase the ikeihood ofinfection incude wound contamination, aceration ength greater than 5 cm, aceration ocated on the ower extremities, and diabetes meitus? WOUND IRRIGATION Irrigation ceanses the wound of debris and diutes bacteria oad before cosure. However, there is no strong evidence that ceansing a wound increases heaing or reduces infection. A Cochrane review and severa RCTs support the use of potabe tap water, as opposed to sterie saine, for wound irrigation.3" " To diute the wound s bacteria oad beow the recommended 105 organisms per ml, 50 to 100 ml ofirrigation soution per 1 cm of wound ength is needed. Optima pressure for irrigation is around 5 to 8 psi. This can be achieved by using a 19-gauge neede with a 35 ml syringe or by pacing the wound under a running faucet. ' at presentation, and physicians shoud make every effort to avoid introducing additiona bacteria to the wound. However, strict sterie techniques appear to be unnecessary. Sutures, needes, and other instruments that touch the wound shoud be sterie, but everything ese ony needs to be cean. ANESTHETIZING THE WOUND Topica and injectabe oca anesthetics reduce pain during treatment ofacerations and may be used aone or in combination. Topica anesthetics (etabe A) are particuary usefu when treating chidren. Topica agents commony used in the United States incude idocaine/ epinephrine/tetracaine and idocaine/priocaine. Lidocaine/priocaine is not approved by the U.S. Food and Drug Administration for use on nonintact skin, athough it has been used this way in numerous studies. When using an injectabe oca anesthetic, the pain associated with injection can be reduced by using a high gauge neede, buffering the anesthetic, warming the anesthetic to body temperature, and injecting the anesthetic sowy. '2 Lidocaine may be buffered by adding ] ml of sodium bicarbonate to 9 ml ofidocaine 1% (with or without epinephrine)? If there is no concern for vascuar compromise to an appendage, then oca anesthetic containing epinephrine in a concentration of up to :100,000 is safe for use in aceration repair of the digits, incuding for digita bockade_. " Loca anesthetic containing epinephrine in a concentration of 1:200,000 is safe for aceration repair of the nose and ears. A systematic review documents the safe use of idocaine with epinephrine (in a May 15, 2017 Voume 95, Number 10 www,aafp.org/afp American Famiy Physician 629

3 Laceration Repair concentration up to 1:80,000) in more than 10,000 procedures invoving digits without any reported incidence of necrosis. Ony two studies examined the safety of epinephrine-containing anesthetics in patients with periphera vascuar disease. Athough no patients had ischemic compications, the studies were sma. Concern for periphera vascuar compromise shoud be considered a contraindication to the use of an epinephrinecontaining anesthetic. Tabe 1. Laceration Cosure Techniques Technique Simpe interrupted sutures Simpe running SUIUFES Horizonta mattress sutures (Figure 1) Vertica mattress sutures (Figure 2) Haf-buried mattress sutures (Figure 3) Running subcuticuar sutures Comments Genera tissue approximation Can be used for most wounds Fast and effective for ong acerations A sutures are ost if one suture is cut by mistake or removed for drainage Effective for everting wound edges Can cause skin necrosis and excessive scars Most effective for everting wound edges Can cause skin necrosis and excessive scars Most effective in everting trianguar wound edges in fap repair Fast and effective in accurate skin edge apposition Does not aow for drainage Suited for cosing cean wounds, such as surgica wounds in the operating room Wound Repair Laceration cosure techniques are summarized in Tabe I. For a video of suturing techniques, see youtube.com/watch?v= ZWUgKiBxf<. There are no signi cantstudies to guide technique choice. Compared with mutiayer repair, singe ayer repair has simiar cosmetic resuts for facia acerations and is faster and more cost-effective for scap acerations. Running sutures reportedy have ess dehiscence than interrupted sutures in surgica wounds. Mattress sutures (Figures 135 and 235) are effective for everting wound edges.~ 37 Haf buried mattress sutures are usefu for everting trianguar edges in aprepair (Figure 3). Cosmetic outcomes of facia wounds repaired without deep derma sutures are simiar to ayered cosure. The approach to repair varies by wound ocation. Nonbite and bite wounds are treated differenty because of differences in infection risk. Figure 4 is an agorithm for the management of acerations. FACIAL LACERATIONS Debridement of facia wounds shoud be conservative because of increased bood suppy to the face. Removing subcutaneous fat may ead to depression of the scar. Singe ayer 5-0 or 6-0 nyon sutures are suf cient. LIP LACERATION THROUGH VERMILION BORDER Interrupted derma sutures Stapes Wounds adhesive strips Tissue adhesive Effective in accurate skin edge apposition and wound everson Aows for minima drainage Suited for cosing cean wounds Fast, creates oose cosure Aows for drainage Suited for uncean wounds Shoud be avoided if cosmetic outcome is important Fast, no anesthesia required Used to approximate cean, simpe, sma acerations with itte tension and without beeding Fast, no anesthesia required Used to approximate cean, simpe, sma acerations with itte tension and without beeding NOTE: For a video of suture techniques, see htrps:// v= -ZWUgKiBxfk. An optima cosmetic resut depends on reapproximation of the Vermiion border. Therefore, the rst skin suture shoud be paced at this border. The border shoud be marked before anesthetic injection because the anesthetic may bur the border. The musce ayer and ora mucosa shoud be repaired with 3-0 or 4-0 absorbabe sutures, and skin shoud be repaired with 6-0 or 7-0 nyon sutures. EYELID The patient shoud be referred to ophthamoogy if the aceration invoves the eye itsef, the tarsa pate, or the eyeid margin, or penetrates deeper than the subcutaneous ayer. Laceration through the portion of the upper or ower id media to the punctum often damages the acrima duct or the 630 American Famiy Physician Voume 95, Number 10 May 15, 2017

4 Laceration Repair media cantha igament and requires referra to an ophthamoogist or pastic surgeon. Laceration of upper or ower eyeid skin can be repaired with 6-0 nyon sutures. ILLUSTRATION BY RENEE CANNON EYEBROW The edges of the eyebrow serve as andmarks, so the eyebrow shoud not be shaved. Pacing a singe suture at eachrmargin rstensures good aignment. EAR Figure 1. Horizonta mattress sutures. Reprinted with permission from Forsch RI Essentias of skin aceration repair. Am Fam Physician. 2008,'78(8):948. Cartiage has poor circuation and is prone to infection and necrosis. It needs to be covered with skin to hea. A singe bite with reverse cutting neede or tapered neede (6-0 poypropyene sutures) shoud be used to approximate skin and perichondrium simutaneousy. Ear trauma often causes a hematoma, and appying a pressure dressing can be dif cut.fuffed gauze under a circumferentia head wrap can achieve adequate pressure to prevent a hematoma. ILLUSTRAYION BV RENEE CANNON SCALP Figure 2. Vertica mattress sutures. Reprinted with permission from Forsch RT. Essentias of skin aceration repair. Am Fam Physician. 2008;78(8):948. A rich bood suppy to the scap causes acerations to beed signi canty. After ruing out intracrania injury, beeding shoud be controed with direct pressure for adequate exporation of the wound. Shaving the area is rarey necessary. If the gaea is acerated more than 0.5 cm it shoud be repaired with 2-0 or 3-0 absorbabe sutures. Skin can be repaired using stapes; interrupted, mattress, or running sutures, such as 3-0 or 4-0 nyon sutures; or the hair apposition technique (Figure 535). Stapes are faster and more cost-effective than sutures with no difference in compications. The hair apposition technique using tissue adhesive has the owest cost and highest patient satisfaction for scap repair. A video of the hair opposition technique is avaiabe at aceration repair.com/aternative-wound-cosure/ hair apposition-technique/. ILLUSTRATION BY RENEE (ANNON HANDS AND FOREARM Figure 3. Haf-buried mattress sutures. May 15, 2017 Voume 95, Number 10 Lacerations of the ngers, hands, and forearms can be repaired by a famiy physician if deep tissue injury is not suspected. These acerations are repaired with 4-0 or 5-0 nyon sutures. Any suspicion of injury invoving tendon, nerve, musce, vesses, bone, or the nai bed warrants immediate referra to a hand surgeon. Traditionay, a arge subungua hematoma invoving more than 25% of the visibe nai indicated nai remova for nai bed inspection and repair, but a recent review concuded that a subungua hematoma without signi cant ngertip injury can be treated with trephining (drainage through a hoe) aone. American Famiy Physician 531

5 Management of Acute Lacerations Beeding? Y L» Hemostasis (igation or sutures) 1 i~ _Contaminated with debris or dirt, bite L» Irrigation, debridement, remova of foreign body wound, or concern for infection? 1 NO V Deep tissue injuries? I NO YES Repair of musce/tendon Referra for deep injury of the hands, eyeids, and nose; acrima duct injury; nerve injury; or open fracture Management of skin aceration Face I Trunk Upper extremities Lower extremities Simpe interrupted, simpe running, horizonta mattress, vertica mattress sutures If the wound is cean with itte tension, running subcuticuar sutures, tissue adhesives Simpe interrupted, simpe running, horizonta mattress, basic attice sutures; tissue adhesive; surgica strips Simpe interrupted, simpe running, horizonta mattress sutures Scap Skin repair: Simpe interrupted, simpe running, horizonta Simpe interrupted or simpe mattress, vertica mattress running sutures, surgica strips, sutures; stapes; hair tissue adhesives apposition technique If the wound is cean, doubeayer with running subcuticuar or interrupted derma sutures Mucosa surface (ips, ora, genitaia) repair: Simpe interrupted or simpe running sutures; absorbabe Leave skin open; patient shoud be seen within 24 hours of injury Figure 4. Agorithm for the management of acute acerations. Up to 19% of bite wounds become infected. Cat bites are much more ikey to become infected compared with dog or human bites (47% to 58% of cat bites, 8 /o to 14% of dog bites, and 7% to 9% of human bites)." The risk of infection increases as time from injury to repair increases, regardess of suture materia. Evidence on optima timing of primary cosure and antibiotic treatment is acking." Cosmesis was improved with suturing compared with no suturing in RCTs of patients with dog bites, athough the infection rate was the same. * 5 Therefore, dog bite wounds shoud be repaired, especiay facia wounds because they are ess prone to infection." Cat bites, with higher infection rates, have better outcomes without primary cosure, especiay when not ocated on the face or scap. Bite wounds with a high risk of infection, such as cat bites, deep puncture wounds, or wounds onger than 3 cm," shoud be treated with prophyactic amoxiciin cavuanate (Augmentin). 7" Cindamycin may be used in patients with a peniciin aergy. 632 American Famiy Physician ILLUSTRATION EV RENEE CANNON BITE WOUNDS Figure 5. Hair apposition technique for aceration cosure. Opposing strands of hair are brought together with a simpe twist and are secured with a drop of tissue adhesive. Reprinted with permission from Forsch R7. Essentias of skin aceration repair. Am Fam Physician. 2008;78(8):949. Voume 95, Number 10 May 15, 2017

6 Tabe 2. Commony Used Suture Materias Common neede Time to ose Materia type* 50% strength Configuration Typica use Absorbabe Chromic Reverse cutting 10 to 14 days Monofiament Mucosa, eye wounds Gycoide/actide poymer Conventiona or 2 to 3 weeks Braided Deep derma, musce, fascia, ora mucosa, (poygactin 910 [Vicry ]) reverse cutting genitaia wounds Poigecaprone (Monocry) Conventiona and 7 to 10 days Monofiament Derma, subcuticuar wounds reverse cutting Poydioxanone (PDS ) Reverse cutting 4 weeks Monofiament Musce, fascia, derma wounds Nonabsorbabe Nyon (Ethion) Cutting edge > 10 years Monofiament Skin Poypropyene (Proene) Tapered point, indefinite Monofiament Mosty used in vascuar surgeries; can be bunt tip used for skin, tendon, and igaments, depending on the needes Sik Does not come 1 year Braided Used for hemostasis in igation of vesses with neede or for tying over bosters * A variety of needes are avaiabe to order, but the most typica needes ikey to be stocked are isted. information from references 50 and 5. -«:-:.-. '-.»::.* :-;r:.-.<-.. v..~.:-it CHOOSING THE APPROPRIATE SUTURE MATERIAL Physicians shoud use the smaest suture that wi give suf cient strength to reapproximate and support the heaing wound. -5' Commony used sutures are incuded in Tabe 2 3 ; however, good evidence is acking regarding the appropriate suture size for aceration repair. The 5-0 or 6-0 sutures shoud be used for the face, and 4-0 sutures shoud be used for most other areas. The 3-0 sutures work we for the thicker skin on the back, scap, pams, and soes.5 '5 A meta-anaysis of 19 studies of skin cosure for surgica wounds and traumatic acerations found no signi - cant difference in cosmetic outcome, wound infection, or wound dehiscence between absorbabe and nonab; sorbabe sutures.52'53 A systematic review did not show any advantage of mono ament sutures over braided sutures with regard to cosmetic outcome, wound infection, or wound dehiscence. USE OF TISSUE ADHESIVE OR WOUND ADHESIVE STRIPS The two types of tissue adhesive avaiabe in the United States are n buty 2 cyanoacryiate (Histoacry Bue, PeriAcry) and 2-octy cyanoacryate (Dermabond, Surgisea). Tabe 3 shows the criteria for tissue adhesive use. A Cochrane review found these adhesives to be comparabe in cosmesis, procedure time, discomfort, and compications. They work we in cean, inear wounds that are not under tension. They are not generay used in hair-bearing areas (except in the hair apposition technique). There is a sighty higher ikeihood of wound dehiscence with tissue adhesives than with sutures, with a number needed to harm of 25 for tissue adhesives.53'5 Tissue adhesive shoud not be appied to misaigned wound edges. Care shoud be taken to avoid getting tissue adhesive into the wound or accidentay adhering gauze or instruments to the wound. Iftissue adhesive is misappied, it shoud be wiped off quicky with dry gauze. To remove dry adhesive, petroeum based ointment shoud be appied and wiped away after 30 minutes. Wound adhesive strips can aso be used. One anaysis suggests that wound adhesive strips are the most cost-effective method of cosure for appropriate owtension wounds. The strips are appied perpendicuar to the vector of the wound to approximate and secure the edges. One study found the same cosmetic outcomes. L.,.»:-E6- F228.»..\...V :4... Tabe 3. Criteria for Use of Tissue Adhesives Wound ess than 12 hours od Linear (not steate) Hemostatic Not crossing a joint Not crossing a mucocutaneous junction Not in a hair-bearing area (uness hair apposition technique is being used) Not under significant tension (or tension reieved with deep absorbabe sutures) Not grossy contaminated Not infected Not devitaized Not a resut of mammaian bite No chronic condition that might impair wound heaing if a!.i.-.4 trap -S»'1.' '::?-2" <:-.-/ ~4":LV»' 31$: May 15, 2017 Voume 95, Number 10 American Famiy Physician 633

7 Laceration Repair with adhesive strips vs. tissue adhesive when used to repair facia acerations. Tabe 4. Tetanus Wound Management Laceration Aftercare Once a wound has been adequatey repaired, consideration shoud be given to the eements of aftercare. Athough patients have traditionay been instructed to keep wounds covered and dry for 24 hours, one study found that uncovering wounds for routine bathing within the rst12 hours after cosure did not increase the risk ofinfection. A sma prospective study showed that traumatic acerations repaired with sutures had ower rates of infection when antibiotic ointment was appied rather than petroeum jey. The owest rate of infection occurred with the use of an ointment containing bacitracin and neomycin. Therefore, topica antibiotic ointment shoud be appied to traumatic acerations repaired with sutures uness the patient has a speci c antibiotic aergy. A meta-anaysis did not show ben- e t with the use of prophyactic systemic and Prevention, antibiotics for reducing wound infections in simpe, nonbite wounds. Wounds hea most quicky in a moist environment. Occusive and semioccusive dressings ead to faster wound heaing, decreased wound contamination, decreased infection rates, and increased comfort compared with dry gauze dressings. Choice of moisture retentive dressing shoud be based on the amount of exudate expected. Transparent m(e.g., Tegaderm) and hydrocooid dressings are readiy avaiabe and suited for repaired wounds without drainage. Fim dressings aow for visuaization of the wound to monitor for signs of infection. Gauze dressings with petroeum ge with or without an antibiotic are commony used for wounds with some drainage. Foam dressings are more absorptive but mosty used for chronicay draining wounds. When using interactive dressings such as mdressings, hydrocooid dressings, or foam dressings, they shoud be changed according to package recommendations, which is anywhere from three to seven days or when uidaccumuation separates the dressing from the surrounding skin. Patients with contaminated or high risk (e.g., deep puncture) wounds who have not had a tetanus booster for more than veyears shoud receive a tetanus vaccine. Patients who have not had at east three doses of a tetanus vaccine or who have an unknown tetanus Cean, minor wounds Contaminated or high-risk wounds* Tetanus Tetanus Tetanus immune immune vaccination history Tdap or Tdr gobuin Tdap or Tdt g/obu/in Unknown or fewer Yes No Yes Yes than 3 doses 3 or more doses No: No No No Td tetanus and diphtheria toxoids; Tdap = tetanus toxoid, reduced diphtheria toxoid, and aceuar pertussis. ' Exampes are wounds contaminated with dirt, feces, soi, or saiva, deep puncture wounds; avusions; and wounds resuting from missies, crushing injury, burns, or frostbite. t -Tdap is preferred over Td for aduts who have never received Tdap. Singe-antigen tetanus toxoid is no onger avaiabe in the United States. t Yes, if it has been more than 70 years since the ast dose of a tetanus toxoid containing vaccine. Yes, if it has been more than 5 years since the ast dose of a tetanus toxoid containing vaccine. Adapted from Tetanus. In: Hamborsky J, Kroger A, Wofe C, eds. Epidemioogy and Prevention of Vaccine-Preventabe Diseases. Atanta, Ga: Centers for Disease Contro vaccine history shoud aso receive a tetanus immune gobuin. Patients with a cean and minor wound shoud receive the tetanus vaccine ony if they have not had a tetanus vaccine for more than 10 years. Tetanus immune gobuin is not indicated for cean, minor wounds (Tabe 4). Sutures shoud be removed after an appropriate interva depending on ocation (Tabe 535). This is based on expert opinion and experience. Tabe 5. Timing of Suture or Stape Remova Wound ocation Face 3 to 5 Scap 7 to 10 Arms 7 to 10 Trunk 10 to 14 Legs 10 to 14 Hands or feet 10 to 14 Pams or soes 14 to 21 r Timing of remova (days) Adapted with permission from Forsch RT Essentias of skin aceration repair. Am Fam Physician. 2008;78(8): American Famiy Physician Voume 95, Number 10 May 15, 2017

8 Laceration Repair This artice updates previous artices on this topic by Forsch" and by Zuber."" Data Sources: The authors used an Essentia Evidence summary based on the key words facia aceration, aceration, and tissue adhesives. The search incuded reevant POEMs, Cochrane reviews, diagnostic test data, and a custom PubMed search. Key words were skin aceration, skin repair, oca anesthesia, sterie technique, sterie goves, and wound irrigation. Search dates: Apri 2015 and January 5, The Authors RANDALL T. FORSCH, MD, MPH, is an assistant professor in the Department of Famiy Medicine at the University of Michigan Medica Schoo in Ann Arbor. SAHOKO H. LITTLE, MD, PhD, is an assistant professor in the Department of Famiy Medicine at the University of Michigan Medica Schoo. She is aso an attending physician at the Comprehensive Wound Care Cinic, University of Michigan. CH RISTA WILLIAMS, MD, is a cinica ecturer in the Department of Famiy Medicine at the University of Michigan Medica Schoo. Address correspondence to Randa T. Forsch, MD, MPH, University of Michigan Medica Schoo, 1301 Catherine, Ann Arbor, MI (e-mai: rforsch@umich.edu). Reprints are not avaiabe from the authors. REFERENCES 1. Zehtabchi S, Tan A, Yadav K, Badawy A, Lucchesi M. The impact of wound age on the infection rate of simpe acerations repaired in the emergency department. Injury. 202;43(11): Worster B, Zawora MO, Hsieh C. Common questions about wound care. Am Fam Physician. 201S;91(2): American Coege of Emergency Physicians. Cinica poicy for the initia approach to patients presenting with penetrating extremity trauma. Ann Emerg Med. 1994;23(5): Edich RF, ThackerJG, Buchanan L, Rodeheaver GT. Modern concepts of treatment of traumatic wounds. Adv Surg. 1979;13: Haury B, Rodeheaver G, Vensko J, Edgerton MT, Edich RF. Debridement: an essentia component of traumatic wound care. 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