Are Simple Lacerations older than 12 hours more prone to infection after primary repair compared to lacerations inflicted less than 12 hours?
Date First Published:
May 22, 2006
Last Updated:
August 1, 2011
Report by:
Amr Badawy, Academic Associate, Emergency Medicine (State Universtiy of New York Downstate Medical Center)
Search checked by:
Shahriar Zehtabchi, State Universtiy of New York Downstate Medical Center
Three-Part Question:
In [patients with simple traumatic lacerations] is [primary closure after 12 hours] associated with [a greater risk of infection] than [primary closure before 12 hours]?
Clinical Scenario:
A 32 year old male presents to the Emergency Department with a laceration on his right forearm. He accidentally cut his forearm with the sharp edge of a metal can 14 hours ago. The wound appears clean and there is no evidence of any foreign body. Neuro-vascular and tendon examination are normal. The wound is irrigated with saline and repaired with nylon sutures. You wonder whether this wound is at a higher risk for infection because of the time lapse from injury to repair.
Search Strategy:
OVID interface on the world-wide web. 1966-May 2011.
Search Details:
[exp laceration OR exp simple laceration OR laceration OR wounds] AND [exp primary closure OR exp wound repair OR treatment OR infection]
Outcome:
45 papers were found of which 43 were irrelevant or violated the pre-determined inclusion/exclusion criteria. The remaining 2 papers are shown in the table below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Evaluation of the ‘Golden Period’ for Wound Repair: 204 Cases From a Third World Emergency Department. Berk WA, Osbourne DD, Taylor DD. 1988 USA | 372 patients with simple traumatic lacerations. 204 completed a 7-days follow up. 72 wounds were sutured before 12 hours, and 132 wounds were sutured after 12 hours. Failed healing defined as wound dehiscence or evidence of infection. | Prospective observational study | Failed healing defined as wound dehiscence or evidence of infection. | 7/72 (10%, 95% CI, 5–19%) in wounds <12-hours old.<br><br>26/132 (20%, 95% CI, 14-27%) in wounds >12-hours old. | No randomization. Infection rate not reported separately. 45% lost to follow up (168/372). |
| Overall | Wounds sutured after 12 hours showed a more significant infection rate than those sutured before 12 hours. | ||||
| The delayed treatment of wounds of the hand and forearm under antibiotic cover. Morgan WJ, Hutchison D, Johnson HM. 1980 Scotland | 155 patients had superficial wounds (deep wounds requiring closure in the operating room were excluded from the total number). 136 wounds were sutured before 12 hours and 19 wounds were sutured after 12 hours. All patients received antibiotics (randomized to a single intramuscular penicillin injection or penicillin injection plus a 5-day course of Clindamycin). Follow up in 7 days. | Prospective study (randomization for type of antibiotics and not based on wound age) | Wound infection | 9/136 (6%, 95% CI, 3-12%) in wounds <12-hours old.<br><br>6/19 (32%, 95% CI, 15-54%) in wounds >12-hour old. | Non-randomized. 83 patients did not return for follow-up. Sample size was too small for wounds sutured after 12 hours to draw a meaningful conclusion. Patients received different antibiotics. |
| Overall | Wounds sutured after 12 hours showed a more significant infection rate than those sutured before 12 hours. |
Author Commentary:
The quality of the included studies is not optimal since none were randomized trials and the follow-ups were inadequate. More rigorous randomized prospective studies with a larger sample size are required to make definite recommendations.
Bottom Line:
There is not enough evidence to determine if simple lacerations repaired more than 12 hours after infliction are at a higher risk of infection.
References:
- Berk WA, Osbourne DD, Taylor DD.. Evaluation of the ‘Golden Period’ for Wound Repair: 204 Cases From a Third World Emergency Department.
- Morgan WJ, Hutchison D, Johnson HM.. The delayed treatment of wounds of the hand and forearm under antibiotic cover.