Summary: Most laceration wounds do not need emergency care. Closing small open cuts (lacerations) is mainly done to minimize the scar that results from the wound. There are many ways to close an open wound: wound closure tape, wound tissue glue, staples and stitches. The differences between these wound closure methods and whether a plastic surgeon may be beneficial are discussed in this chapter.

A common reason for coming to an emergency room is a bleeding wound that might need to be closed. Lacerations are wounds that have split the skin open to expose the tissue under the skin (usually muscle, bone, fat and blood vessels). There are two aspects to this situation: 1) Does the wound need to be closed at all? 2) If it is better to close the wound, what is the best way to close it?

Large wounds need immediate medical attention, so this chapter will not discuss these much. Unless your physician's office is exceptionally well equipped (perhaps it is part of a hospital), such large wounds should be brought to an ER. Large wounds need attention because they are more likely to damage internal structures, cause excessive bleeding and result in ugly scarring.

Small wounds are generally those less than 2.5 cm (about 1.5 inches). Most small bleeding wounds actually do not need to be closed. There are three "reasons" to close a small wound: a) to stop bleeding, b) to make the scar smaller, c) to speed healing, and d) to prevent infection. Oops, the last two reasons are not as true as you might think. Surprised? Closing a small wound does not speed the wound healing time by much.

Closing wounds does NOT usually help to prevent infection. Actually, the exact opposite is usually true. I'm mentioning this because this is a common misconception by patients. Many parents bring their children in because they want the wound closed to prevent it from becoming infected. While it is understandable to believe that an open wound would be prone to infection, closing this wound might actually increase the possibility of infection.

The wound needs to be cleaned well. If the entire wound can be cleaned well to remove most of the dirt, grass, other debris and bacteria, the wound is not likely to become infected. Clean the surface with an antiseptic (do not use alcohol) or a good soap. Rinse the wound thoroughly with water. If the wound is deep, the inside of the wound must be rinsed also. Lots of water removes dirt and debris particles and it rinses out bacteria. For most small wounds, the body will expel small degrees of contamination. But if the wound is closed, the body can't expel this. Instead, infection develops around the debris similar to what happens to a splinter in the body. Closing the wound seals in infections so the body cannot remove it through its natural means. Most wound infections develop from within the wound (contamination during the injury) rather than from contamination entering the wound from the outside (contamination during healing).

Unless the wound is large, the risk of a wound infection is higher for wounds closed with stitches (sutures) because the sutures act as foreign material which the body reacts against (just like a splinter). Sutures made from multifilament material such as silk thread are more likely to harbor infection and cause an inflammatory reaction by the body than smooth monofilament sutures such as nylon (similar to fishing line). So suturing a wound closed increases the infection risk in two ways: 1) sealing in infection, preventing the expulsion of infected debris, and, 2) placing foreign material into the wound. Small wounds on the bottom (sole) of the feet are best not sutured since they are highly infection prone.

Another reason to close a wound is to stop bleeding. Most wounds in healthy children bleed a lot because the vessels supplying blood flow to the area are very healthy. This initially seems worrisome because the bleeding can start off very vigorous. But for most small wounds, the bleeding has stopped by the time the child has arrived in the ER. Because of lots of bleeding, it may be difficult to see how large the wound is. When the blood clots and covers the wound, it may not be possible to easily see the wound. If the clot is removed or cleaned off to see how big the wound is, bleeding will start again. Thus, many parents are reluctant to clean the wound well to see what it looks like. Wounds need to be cleaned. It is better to clean them early. I have seen many children in the ER who come in for a bleeding wound. After cleaning off all the blood clots, we find a wound that is 2 mm (less than 1/8th of an inch) long. Such a small wound would not benefit from wound closure much. Parents will then say that if they had known the wound was this small, they would not have come to the ER. They thought the wound was large because it bled a lot. As noted earlier, most wounds in children, especially on the face and scalp, bleed a lot. Even wounds as small as 2 mm on the scalp can nearly cover a shirt with blood.

When a wound is bleeding, direct pressure should be applied to it. The wound can be cleaned and rinsed while it is bleeding. When cleaning and rinsing is done, use something absorbent to apply pressure over the wound. Using a tourniquet is potentially harmful and it can increase the bleeding if it is not applied correctly.

Scarring, in my view, is the most important reason to close a small wound. Scars resulting from wounds are usually about the same size as the shape of the wound. The thickness of the scar relates to the depth of the wound. Deep wounds tend to form thick scars. Most lacerations form a football shaped opening. If left alone, the resulting scar will be football shaped. Closing the wound brings the skin edges together so that the resulting scar looks like a line instead of a football. It is not possible to eliminate a scar, but it can be minimized. Closing the wound properly results in a smaller scar. This is the most important benefit of closing small wounds.

Depending on the size of the wound and its location, the importance of minimizing a scar is variable. For example, a 0.5 cm (1/4th inch) wound on the scalp is not as important as a 1.0 cm (1/2 inch) wound on the cheek. The cheek wound is in a cosmetically sensitive location so it is much more important to close it. The cosmetic importance of closing a wound is not necessarily a medical decision. It is mostly a parent and child decision. Many parents are surprised to find that they have a choice in these matters. For a doctor in the ER, the choice is simple. The physician could let it heal on its own and charge a patient $25 or he/she could suture the wound and charge a patient $120. Notice that there is a money incentive for physicians to suture the wound. Small wounds that clearly do not need to be sutured, are often sutured because the physician can make more money by suturing. Because of this, many doctors will recommend that wounds be sutured. Ask your doctor about the options of wound closure using different methods.

Does it matter if your child is a girl or a boy? Most parents would want a better cosmetic result for a girl. For example, consider a 1 cm (1/2 inch) laceration wound on the forehead. Most parents would want such a wound sutured for their daughter, but not necessarily for their son. The direction of the wound also matters. If the wound is horizontal on the forehead, the natural lines of tension tend to close the wound. But a vertical forehead laceration tends to open wider and is more likely to scar poorly, so a vertical laceration is more likely to need suturing than a horizontal laceration.

Another common example is a 3 mm (1/8th inch) laceration to the outside corner of the eye. This wound is small and it is in a sensitive area. Suturing this wound would result in anxiety for the child because the physician would need to work close to his eye where the child can see these metal instruments being brought close to his eye. The physician estimates that the scar will be about 1 mm wide if the wound is not sutured and only 0.5 mm wide if the wound is sutured closed. Which choice is best? As you can probably tell, this is not a medical decision since the importance of the difference between 1.0 mm and 0.5 mm scars can only be judged subjectively. Obviously, a thinner scar is better than a wider scar, but to accomplish this, the child would have to undergo a stressful procedure. Whether this stress on the child is worth it, is best determined by parents and not by physicians, in my opinion. It would be selfish and incomplete to impose the physician's choice upon the patient rather than the better option of discussing the options with the family to make the best decision for the child. Ultimately, the consent of parents is required for a physician to proceed. This "informed consent" can only be truly informed, if physicians discuss all the treatment options during this process so that parents can make an informed decision. If the child's parents are planning a career as an actress or model for the child, then minimizing the scar might be a very high priority. But another family may have different priorities and may not feel that the scar minimization in this case is worth the effort.

The section at the end of this chapter attempts to summarize the locations of wounds and when they should be sutured. This is a rough guide only. For your child's wound, the wound care options should be discussed with your physician or the emergency physician assigned to you.

In summary, to determine if the wound needs to be sutured, clean the wound well so that you can see what the wound looks like. Determine the size of the wound and how wide and deep it is. If the wound is large, it would probably be best to repair the wound in an ER. If the wound is small, call your child's physician to discuss recommendations over the phone. For small wounds in areas that are not cosmetically important, you might be advised to take care of the wound at home.

All wounds must be cleaned well. Once it has been determined that the wound should be closed, there are four options: 1) wound closure tapes, 2) wound closure glue, 3) suturing (or staples) by the emergency physician or your primary care physician, or 4) suturing by a specialist such as a plastic surgeon.

Suturing wounds requires that the wound be numb. This is called local anesthesia. Local anesthesia can be accomplished by using a gel or liquid placed in the wound for 30 minutes (topical local anesthesia) or it can be injected into the wound edges with a needle (infiltration) which results in instant anesthesia. While infiltrated local anesthesia sounds painful, most adults will tell you that this pain is minor. It's the same as most dental anesthetic injections. However, just the idea of a needle will frighten children to varying degrees. Parents who are in a rush will usually prefer infiltrated local anesthesia, while parents of children who have an excessive fear of needles may choose to opt for topical local anesthesia.

Wound closure tapes are commonly known as "Butterflies", but this brand of wound closure tapes are not sticky enough to stay on long enough. Most hospitals use lighter stickier wound closure strips (the brand name is not essential here). The wound is cleaned, then dried, then a sticky liquid is applied to the skin. The edges of the wound are brought together by hand. Then the tapes are applied crossing over the wound (perpendicularly) to hold the wound closed. The advantages of this method are that it doesn't require local anesthesia, sutures do not need to be removed and it is easy enough to perform in an office. The disadvantages of this method are, it can only be used for small wounds that are not under tension, excessive perspiration or moisture will cause them to loosen prematurely, and wounds that are still bleeding cannot be closed with this method. Wound closure tapes are not as accurate as sutures in bringing the wound edges together well, but since these are only used for small wounds, the difference would be hard to notice.

Wound tissue glue is a relatively new option in this country. The first tissue glue was approved for use in the U.S. in late 1998, but similar tissue glues have been used in other countries for many years before this with good results. The advantages and disadvantages are similar to wound closure tape. Studies on wound tissue glue indicate that the resulting scars are similar to wounds closed with sutures. Probably because wound tissue glue is new, it is very expensive. Currently, a single wound treated with glue costs $21 compared to $3 for a suture, which means that hospitals charge as much as $75 and $10, respectively, for these supplies after mark-up. This comparison is not exactly fair since a suture requires local anesthesia ($10 to $100 charge) and a tray of instruments ($15 to $125 charge).

Suturing a wound closed is considered to be the standard method of wound closure. The many types of sutures and suturing strategies permit the closure of many different types of wounds from small to large over most parts of the body. Since the wound is brought together in small increments at a time, similar to a zipper, the edges can be brought together more accurately. Suturing requires local anesthesia and thorough wound cleansing. Sutures are foreign material embedded in the skin and thus, they have the potential to become infected. Suturing can be done in an office, but most of these wounds are referred to emergency rooms for suturing because of the need to keep an inventory of different sutures, sterile suturing instruments, the occasional need for an X-ray and the additional personnel required to restrain an uncooperative child. Larger offices which carry supplies might choose to suture a wound in the office in an older cooperative child. When I was a child, I had a large chin wound sutured in the office of the neighborhood physician. I have seen this work well sometimes, but sometimes a single struggling child can overwhelm the resources of an office. It is certainly much cheaper to have a wound closed in an office rather than an ER.

Metal staples can also be used to close a wound. While this might sound painful, they are the same as sutures, but they can be placed faster using a special hand staple gun. The staples don't penetrate the skin as deeply and they are less likely to become infected. Staples must be removed with a staple remover which bends the staples back to reverse it out of the skin. This sounds painful, but it's no different than sutures. Most patients don't like staples, but since they are very fast to place, physicians prefer these for large wounds that would take a long time to suture.

In many large emergency rooms, you might be surprised to find that non-physician suture technicians do most of the wound suturing after the wound has been evaluated by a physician. Although this seems like a difficult job that only physicians should do, this task is performed well by non-physicians who are specifically trained to suture.

In some instances where the wound is complicated or prone to ugly scarring, the physician might decide to have a specialist consulted to close the wound. This might be a hand specialist for a complicated hand wound, an oral surgeon or ENT (ear, nose, throat) surgeon for a complicated mouth wound, an ophthalmologist for an eye wound, but for most complex wounds, plastic surgeons are consulted. A specialist could also be an emergency physician with special training. Wounds that are generally considered complex are very large wounds, wounds involving tendons or nerves, facial wounds involving the eyebrow, eyelids or the vermilion border (the edge of the lips), etc.

What if the wound is small and simple; should a plastic surgeon be called to perform the suturing? Most emergency physicians are very capable of doing a good job in closing small wounds. Such small wounds do not require plastic surgeons, but you don't always know the wound suturing capabilities of the physician assigned to you. You might be particularly concerned about the outcome of the scar. If so, you can request a plastic surgeon. You should be prepared to pay the higher cost. Your medical insurance company might decide to refuse payment since the plastic surgeon is optional (not medically required). If you feel that this is important enough, then you should be willing to pay for it. Plastic surgeons may charge $100 to $1000 more than the usual and customary fees. Your insurance company might pay for part of this, none of this or all of this, depending on how generous they are. Don't count on such generosity since insurance companies are more profitable if they don't pay. They have all kinds of excuses to refuse payment. "We don't pay for plastic surgery", would be a typical reason for non-payment. My feeling is that if plastic surgeons would charge a reasonable fee, parents should have the right to pay the additional amount for a specialist if that's what they prefer.

There are many physicians who believe that all medical decisions should rest solely in the hands of physicians, without much input from parents. Such physicians are not practicing truly informed consent which states that all alternative treatments should be discussed in addition to the choice preferred by the physician. Accordingly, a fully informed consent should include at least the mention of all medically reasonable alternative treatments such as, no wound closure, wound closure tapes, wound tissue glue, sutures and a plastic surgeon. Emergency physicians have a financial conflict of interest since they can charge about $100 or more if they suture the wound, but they can only charge about $50 if a plastic surgeon is called in to suture the wound.

Some emergency departments do not have routine plastic surgeon availability. In this case, it would be unreasonable to expect the ER staff to scramble around for a plastic surgeon only to perform a minor elective procedure. Some ER's have a plastic surgeon on call, but this plastic surgeon may not be willing to come in at an inconvenient time for only a small wound. In general, if more plastic surgeons are available in town, the likelihood of finding a willing and available plastic surgeon increases. Young plastic surgeons are more willing to come in since they are looking for new patients. If a parent requests a plastic surgeon for a small wound that does not require a plastic surgeon, should the ER be obligated to get one? No, but if a parent requests one, this request should somehow be addressed by an explanation of why a plastic surgeon is not needed, or why a plastic surgeon is not available for such a case. If a plastic surgeon is available and parents prefer one, the ER staff should at least try to see if one could come in.

A friend of mine had a 2 inch facial laceration and she requested a plastic surgeon to repair her wound. The ER refused. Not only was this rude, but it might be considered unethical because of the financial conflict of interest. While the actual resulting scar may be indistinguishable (general physician compared to a plastic surgeon), it is the comfort of having greater confidence that a highly skilled physician will be fixing one's face, rather than a poorly skilled one. Most emergency physicians and suture techs are very good at suturing wounds, but how can a patient know this? I actually know a few emergency physicians who are not very good at suturing wounds. Emergency physicians are also responsible for the other patients in the ER, so they may be rushed or they may not be able to devote 100% of their attention to closing your wound.

Are antibiotics beneficial to prevent wound infections? Although antibiotics are highly effective in treating infections, they do not work as well in preventing wound infections. Studies have demonstrated that antibiotics play only a minor role in preventing wound infections. The major means to prevent wound infections is to wash all debris and bacteria out of the wound. This is not always possible since some debris (such as splinters and tiny particles) may be stuck in the wound. Because these particles are small and they hide between the many crevices and folds inside a wound, a physician cannot find all of them for removal. Thoroughly rinsing and irrigating the wound dilutes the bacterial count and the number of remaining debris particles. Antibiotics usually cannot prevent wound infections because debris particles contain infection that the antibiotics cannot penetrate.

For example, it is well known that a splinter in the skin will cause infection. Antibiotics may temporarily suppress the infection, but once the antibiotics are stopped, the infection will spread from the splinter until it is removed. Similarly, a tiny piece of gravel is filled with microscopic crevices that harbor infection. If such a particle remains in the wound when it is closed, infection will result. Once the infection is identified, the wound will need to be opened and examined to locate the cause of the infection. If this patient was put on antibiotics when the wound was closed, it would temporarily suppress the infection and delay its identification. Once the antibiotics are stopped, the infection would become more obvious and the final identification and treatment of the wound infection would be delayed. This is why most wounds are not treated with antibiotics. There are indications to treat these wounds initially with antibiotics, but it would be best to let the physician determine this.

Table - Wound sizes, locations and repair recommendations

Wound size: There is no standard definition, but as a rough guide, tiny wounds are less than 0.5 cm (< 1/4 inch), small wounds are 1-2 cm (1/2 to 1 inch), medium wounds are 3-5 cm (1-2 inches) and large wounds are bigger than this.

Wound size and shape: Wound depth and width (the distance between the skin edges) are also important since these determine how noticeable the scar will be. The shape of the wound (straight or zigzag) also affects the appearance of the scar and how difficult it will be to close the wound.

Wound location is an important factor. Rough guidelines for each location follow. Discuss the specifics of your child's wound with your physician for more a more accurate prognosis and recommendation. For the purpose of the discussion below, a non-specialist refers to your child's pediatrician, family physician or the emergency physician on duty in an ER. A specialist refers to a surgeon with special expertise in this type of wound such as a plastic surgeon, ENT (ear, nose, throat) surgeon, oral surgeon, eye surgeon, etc.

Eyelid: These wounds are difficult to repair. A cut near the corner of the eye could damage the eye's regulation of tears. Dry or watery eyes could result if the wound is not repaired properly. Lacerations involving the edge of the eyelid (near where the eyelashes grow) could result in an ugly distortion of the eyelid. For these reasons, wounds involving the eyelids should be repaired by a specialist such as an ophthalmologist (eye surgeon). Some small wounds involving only the skin portion of the eyelid can usually be managed by a non-specialist.

Eyebrow: These wounds are often closed by non-specialists, but scars from these wounds can be more noticeable later because the scar that results, does not grow any hair, leaving a noticeable gap in the eyebrow. Depending on the size of the wound, its location within the eyebrow and the patient's desire for nice eyebrows, the repair can be done by a non-specialist or a specialist.

Face: These wounds are usually small and easy to close, but since they involve the face, minimizing the scar is the major goal here. Plastic surgeons can do a better job, but one might not be easily available for a small wound. Plastic surgeons should ideally be called in for larger facial wounds since there may be associated injury to the nerves or glands and they are more likely to result in ugly scarring.

Chin: Open wounds commonly occur over the chin during a fall against something hard (like the sidewalk or a road) during play. The chin is particularly prone to injury because there is only a thin layer of fat between the skin and bone. While these wounds can heal without sutures, these wounds are often contaminated with debris from the ground and they are often open wide because the skin normally stretches and pulls the wound open over the "hump" of the chin. These wounds usually benefit from some type of wound closure. Small wounds can be closed with glue or wound closure tape if the wound is dry. Larger wounds usually are sutured. Lacerations over the chin are usually easy to suture and the resulting scar is hidden so a plastic surgeon is usually not necessary. However, some chin lacerations may be very large, ugly, and more visible, thus, repair by a plastic surgeon may be beneficial in such a case.

Ear: Lacerations involving the ear itself may heal poorly because the cartilage which forms the flexible portion of the ear, does not heal well when it is cut. Some of the ear folds may not heal back in their normal position, which might give the ear a deformed appearance. In complex wounds of the ear, such as those wounds involving the ear folds or cartilage, a specialist such as a plastic surgeon or ENT surgeon, may be able to minimize the risk of a noticeable deformity.

Nostril: The nostrils and the septum (the tissue between the two nostrils) also contain cartilage making it difficult for these areas to heal well. The nostrils have a lot of bacteria which may infect stitches placed to close wounds here. A deformity of the nose may be very noticeable and undesirable. Complex wounds involving the nostrils or septum should be repaired by a plastic or ENT surgeon.

Lips: Small cuts inside the mouth (the wet portion of the lips in the mouth) will bleed a lot, but they generally do not need to be sutured. These wounds are the equivalent of biting your lip which takes a painful 1 to 2 weeks to heal up, but it does so without sutures. Larger wounds inside the mouth may need to be sutured, but many may be best left alone. When there is a cut outside the mouth (on the skin) opposite the cut inside the mouth, this suggests that the wound goes all the way through the skin. This is a bit more serious, but since most of these holes are small, it will usually close on its own. If saliva leaks from this wound (usually only larger wounds), this indicates that the "tunnel" needs to be closed to prevent this tunnel from becoming a permanent leak in the lip.

Since the mouth contains large amounts of bacteria, parents are often concerned about the risk of infection developing in the wounds in the mouth. The body's immune system does an excellent job at preventing infection in these mouth wounds. Although biting your lip is common, infected mouth wounds are very uncommon. When sutures are used to close wounds inside the mouth, the bacteria cling to the sutures (just like a splinter) which often results in an infection.

Two other special lip situations are described below. The vermilion border is the lip stick line where the red part of the outer lip meets the skin. The moustache area is between the upper lip and nose. Lacerations crossing the vermilion border or occurring in the moustache region are scar prone and more noticeable so these should preferably be repaired by a plastic surgeon.

Tongue: Most tongue lacerations do not need suture wound closure. These are similar to cuts inside the mouth, but they differ in that movement of the tongue will change the appearance of the wound. Most of the time when the tongue is resting inside the mouth, a tongue laceration will be together with its edges close together. To see the laceration, we have to ask children to stick out their tongue. This stretches the muscle fibers in the tongue so that the wound edges are separated. In other words, it opens the wound making it appear like the wound is gaping open and in need of suture repair. However, this is usually not necessary since most of the time when the tongue is in the mouth (98% of the time), the edges of the tongue laceration are together to promote healing. Look at the wound with the tongue in the floor of the mouth where it usually is. If you can see that the wound is small and it closes well, then there will be little benefit from suturing the wound.

Gums: Small lacerations of the gums are usually not serious. However, gum wounds may affect the support of teeth. Additionally, gum wounds may signify that the teeth are cracked. These are dental conditions for which an oral surgeon or a dentist should be contacted. Dental x-rays may be necessary.

Roof of the mouth (palate): The front section which is hard is called the hard palate, while the back section deeper in the mouth which is soft, is called the soft palate. Wounds of the palate usually occur when children fall with a straw in their mouth. The straw frequently pokes a hole in the palate. These holes have a good chance of closing on their own. Since it is particularly difficult to suture inside an uncooperative child's mouth, my feeling is that these are best left alone to close on their own. Some of these will not close on their own and these can be closed electively at a scheduled date. Occasionally, palate wounds can be complicated by a fracture of the bone in the hard palate or a puncture wound to the back of the throat. Puncture into the brain by stiffer rods (stiffer than a straw) entering the mouth and poking upward through the floor of the brain cavity above have been described, but such an injury is very rare.

Neck: Open wounds in the neck are very unusual. These usually occur with sharp objects such as sharp corners, wires, knives, glass, or gunshot wounds. Since many important structures travel through the neck (blood vessels, nerves, glands, esophagus and airway), any sharp penetrating wound in the neck raises the possibility that one of these structures may be injured. Neck wounds should be managed by surgical specialists since these wounds need to be checked for deeper injury.

Chest & Abdomen: Just like neck wounds, these are also usually caused by sharp penetrating objects. The cosmetic outcome of these is less important than the possibility of injury to an internal organ such as the heart, lungs, kidneys, intestines, etc. Unless this possibility can be confidently ruled out, penetrating wounds in the chest or abdomen should be managed by a surgeon.

Hands: The hands are skilled at fine movements. Playing the piano or violin, writing, cutting diamonds, surgery, typing, cooking, sewing, etc., all require intricate fine movement that only human hands can perform. The hands have many tiny muscles, nerves, blood vessels and tendons that work together. Tendons connect muscles to bones. In the hands, the tendons function like puppet strings to carefully move the fingers. The tendons are close to the skin. You can see these on the underside of the wrist and on the back sides of the fingers. Tendons allow the fingers to curl or straighten with fine control and great force since the actual large muscle doing the pulling, is way down in the forearm (towards the elbow), but the thin tendon connects this muscle all the way to the finger tip.

Tendons and nerves can be easily cut by sharp objects such as glass and metal. Even if the fingers seem to move around well, the tendon may not be cut, but it may have a large nick that will weaken the tendon (or it can break at a later time) unless it is repaired. Wounds over tendons must be opened to visually examine the tendon. Complex hand wounds may be associated with hidden nerve or tendon injuries. Specialists, such as hand surgeons or plastic surgeons, may be better able to properly manage these wounds. In reality, certain professions that rely on their hands are given preferential medical referrals to hand specialists. These include concert musicians, surgeons, artists, jewelers, etc. While this might not seem fair, it is reality since these professionals rely on their hands more than others.

The cosmetic consequences of hand wounds can be important. Hand models (those who model jewelry and nail cosmetics) depend highly on the appearance of their hands. Others who have beautiful hands may want to preserve the cosmetic appearance of their hands as much as possible. A request for a plastic surgeon can always be made. An emergency physician may not always appreciate the cosmetic concern of a patient. Since the emergency physician may not always ask about your preference or concerns, it would be best to inform the physician of your request for the best possible cosmetic outcome.

Nails: Crush injuries to the finger tips can result in permanent nail deformities. These cannot always be predicted accurately. Underneath the nail, a type of hard skin called the nailbed firmly holds the nail onto the finger tip. In some crush injuries, the nailbed splits resulting in a laceration of the nailbed. If this laceration heals in an irregular fashion such that the scar leaves a bump or cleft, the nail that grows over this nailbed will show the same lump or dent forever. Unfortunately, it is not possible to easily see most nailbed lacerations because in most cases, the overlying nail is still present, hiding the laceration. When a nailbed laceration is suspected in a patient with a finger tip crush injury, the nail should be removed to expose the nailbed to determine if a laceration is present. If a laceration is present, it should be sutured. If no laceration is present, the nail was removed for nothing. The nail is rather hard to remove and it is obviously painful. Several injections of numbing medicine into the base of the finger (nerve blocks) can numb the finger for the nail removal. This procedure can be very difficult on a small finger such as that of an infant. When advised of this procedure, most parents decline it because it sounds too difficult and painful. This is understandable since the only consequence of not repairing a nailbed laceration is a dented or lumpy nail. Parents who perceive this as important will accept the difficulties of the procedure, while others who do not feel that this deformity is important will decline this procedure.

Another type of nail injury is a nail that has been loosened or partially pulled out. Whenever the end of the nail closest to the wrist (where nail growth originates) is crushed, there is a risk that the nail will grow back poorly. I have seen nails that grow back split (two nails on a finger instead of one). These can be hard to prevent if the crush injury is severe. Nails that have been partially pulled out should be replaced back in their original position as much as possible to improve the chance of normal nail regrowth.

Nail injuries are commonly seen in emergency departments, but many office physicians may not be very experienced in properly managing these wounds. You may want to consult a hand specialist or plastic surgeon.

Arms and Legs: Sharp penetrating wounds may injure nerves, tendons or blood vessels. These wounds should be evaluated. Otherwise, most small wounds of the arms and legs can be closed without much difficulty. In the lower leg over the shins, the skin is very thin and tight. This area does not heal well. Even if a wound is closed well, the tension on the healing scar continues even months after wound repair. This stretches the scar and widens it so that a small scar eventually turns into a wide scar. There is not much that can be done to prevent this.

Top of the feet: Like the hand, many tendons pass over the top of the foot. These tendons can be injured by sharp objects. Tendon function should be tested and a specialist should be consulted if a tendon injury has occurred. Otherwise, most small wounds on the top of the foot can be closed without much difficulty. Cosmetic appearance may be an important factor for some, but most people do not consider foot cosmetics to be a high priority.

Under the feet (sole): Unless the wound is very large, these wounds should be cleaned well and allowed to heal without sutures. Suturing these wounds might speed healing and reduce pain to a modest degree, but these wounds are highly infection prone and suturing this type of wound may increase the risk of infection. If these wounds are sutured, there is a lot of pressure on the wound and tension on the sutures because patients are walking on the wounds. Perhaps crutches could reduce the pressure on the wound and meticulous foot care to prevent infection could minimize the risk of suturing. This is a lot of work and it may be easier to not suture it. There are no cosmetic concerns for wounds under the foot.

Genitalia: In females, lacerations to the labia and sometimes lacerations inside the vagina can result from falling on something between their legs such as a seesaw, bicycle or playground bars. These tend to bleed a lot even if the wound is small. Most small lacerations that have stopped bleeding will heal without sutures. Larger lacerations may require suturing. Since small children may understandably be uncooperative, this repair may have to be done under general anesthesia.

Male genitalia have many tiny tubes in and around the testes. Many of these tubes are microscopic and are not repairable. If the larger tubes are injured, a urologist should be consulted. Most testicular injuries involve only the skin and these can be easily closed. Injuries to the penis may require the expertise of a urologist.