Family Medicine · Year 3 · from Family Medicine

Case 2: Laceration Repair

Patient Demographics

  • Age: 28 years old
  • Sex: Female
  • Occupation: Chef

Chief Complaint

"I cut my hand while slicing onions at work about an hour ago."

History of Present Illness

Ms. Sarah Kim is a 28-year-old chef who sustained a laceration to her left index finger while cutting vegetables at work approximately 1 hour ago. She was using a sharp chef's knife which slipped and cut the palmar surface of her finger. There was moderate bleeding which she controlled with direct pressure. She denies loss of consciousness, other injuries, or contamination of the wound with foreign material. She removed her glove immediately and rinsed the wound with water before wrapping it.

Past Medical History

  • No chronic medical conditions
  • No prior surgeries
  • No known allergies
  • Tetanus: Tdap 3 years ago

Social History

  • Non-smoker
  • Occasional alcohol
  • Right-hand dominant

Physical Examination

Vital Signs: Normal

Wound Examination (after cleaning):

  • Location: Palmar surface, left index finger, over middle phalanx
  • Length: 2.5 cm, linear
  • Depth: Through dermis, does not appear to involve tendon sheath
  • Wound edges: Clean, sharp, well-approximated when pressed together
  • Contamination: Clean wound, no visible foreign body
  • Bleeding: Minimal with pressure applied

Neurovascular Assessment:

  • Capillary refill: <2 seconds in fingertip
  • Radial and ulnar digital pulses: Present
  • Two-point discrimination: Intact at 5 mm on both sides of finger
  • Sensation to light touch: Intact throughout
  • Motor: Full active flexion and extension of DIP and PIP joints against resistance

Tendon Assessment:

  • Flexor digitorum superficialis: Intact (tests by flexing PIP while holding other fingers extended)
  • Flexor digitorum profundus: Intact (tests by flexing DIP while holding PIP extended)
  • No tendon visible in wound base

Clinical Image

Image: Illustration showing proper wound assessment technique including evaluation of wound depth, neurovascular status, and tendon function before repair.

Image Source: Wikimedia Commons Attribution: Medical illustration, Educational Use URL: https://commons.wikimedia.org/wiki/File:Wound_assessment.png

Assessment

  1. Simple laceration, left index finger - clean, sharp wound appropriate for primary closure
  2. No tendon, nerve, or vascular injury identified
  3. Low infection risk: clean wound, early presentation, no contamination

Procedure: Wound Repair

Informed Consent:

  • Risks: Infection, bleeding, scarring, wound dehiscence, nerve damage, need for reoperation
  • Benefits: Wound healing, reduced scarring, reduced infection risk
  • Alternatives: Wound left to heal by secondary intention (not recommended for this location)
  • Patient consented

Anesthesia - Digital Block:

  • 1% lidocaine WITHOUT epinephrine (traditional teaching, though evidence supports epinephrine safety in digits)
  • Digital block at base of finger: 2 mL injected on each side of the finger base to block digital nerves
  • Waited 5 minutes for full anesthesia
  • Confirmed anesthesia with pinprick testing

Wound Preparation:

  • High-pressure irrigation with 150 mL normal saline via 35 mL syringe with 18-gauge angiocatheter
  • Wound edges examined - minimal debridement needed
  • Wound base examined under anesthesia - no tendon involvement confirmed

Closure:

  • 5-0 nylon simple interrupted sutures
  • 4 sutures placed with 3-4 mm spacing
  • Sutures placed 2-3 mm from wound edge, equal depth on both sides
  • Wound edges everted
  • Sutures tied with appropriate tension - approximating without strangulating

Dressing:

  • Wound covered with non-adherent dressing (Adaptic)
  • Gauze wrap applied
  • Finger splinted in position of function for protection

Tetanus Prophylaxis:

  • Tdap given 3 years ago
  • Clean wound
  • No tetanus booster needed (booster needed if >10 years for clean wound)

Post-Procedure Instructions

Wound Care:

  • Keep dressing clean and dry for 24-48 hours
  • After 48 hours: May get wet briefly in shower, pat dry, apply thin layer of petrolatum ointment, cover with bandage
  • Do not soak in water
  • Elevate hand above heart level when possible for first 24-48 hours

Activity:

  • Avoid heavy use of the hand for 7-10 days
  • May return to non-cutting duties at work
  • No handling raw meat or potentially contaminated materials until wound healed

Warning Signs - Return Immediately If:

  • Increasing redness spreading beyond wound edges
  • Increasing pain after first 24 hours
  • Fever
  • Purulent drainage
  • Numbness or tingling in fingertip
  • Color changes in fingertip (pale, blue)

Follow-Up:

  • Suture removal in 10-14 days
  • Sooner if any concerning symptoms

Teaching Points

  1. Systematic wound assessment before repair:
  • Mechanism, time since injury, contamination
  • Wound depth and structures involved
  • Neurovascular status (pulses, capillary refill, sensation)
  • Tendon function (active range of motion against resistance)
  1. Digital blocks provide excellent anesthesia for finger procedures
  • Block both digital nerves at base of finger
  • Traditional teaching avoided epinephrine, but modern evidence supports its safety
  1. High-pressure irrigation is the most important step to reduce wound infection risk
  1. Suture selection:
  • Face: 6-0 non-absorbable, remove 3-5 days
  • Hand: 5-0 non-absorbable, remove 10-14 days
  • Trunk/extremities: 4-0 non-absorbable, remove 7-14 days
  1. Tetanus prophylaxis:
  • Clean wounds: Booster if >10 years since last dose
  • Contaminated wounds: Booster if >5 years since last dose
  • Add tetanus immune globulin if <3 prior doses and dirty wound
  1. Wounds appropriate for primary closure:
  • Clean wounds presenting within 6-12 hours (body)
  • Face: Up to 24 hours (excellent blood supply)
  • Exception: Bite wounds generally left open (except face)

All cases for this lecture as Markdown