Suturing Dog bites
Date First Published:
February 16, 2015
Last Updated:
January 10, 2015
Report by:
Dr Jennifer Scott, ST6 Emeregency Medicine (Royal Bolton Hospital)
Three-Part Question:
In [dog bite wounds] does [primary closure with sutures] have any impact on [wound outcome].
Clinical Scenario:
A patient who works as a model, presents to the A&E with dog bite lacerations to the hand and arms. You check tetanus status and clean and irrigate the wounds. Having recently read the Cochrane review on not providing prophylactic antibiotics in dog bites, you wonder whether this also means you can primarily close the wounds.
Search Strategy:
1.tMedline via Ovid interface (1946 to date)
2.tEmbase (1980 to date)
3.tCochrane Library Database
4.tGoogle Scholar (keywords; suturing , closure dog bites)
5.tBibliography review of identified papers
2.tEmbase (1980 to date)
3.tCochrane Library Database
4.tGoogle Scholar (keywords; suturing , closure dog bites)
5.tBibliography review of identified papers
Search Details:
([dog] OR [canine] OR [mama*] AND [bite] OR [wound] OR [injury]) OR [“dog bite”] AND ([sutur*] OR [Stich*] OR [manag*] OR [Clos*]) NOT [rabies]
NB: Some minor differences in Medline with terms exploded.]
NB: Some minor differences in Medline with terms exploded.]
Outcome:
571 paper identified
475 excluded from title
76 Excluded from abstract
6 additional papers identified from reference searching.
17 Excluded as not answering clinical question
3 Excluded as retrospective review
3 Papers included in the review as RCT's
475 excluded from title
76 Excluded from abstract
6 additional papers identified from reference searching.
17 Excluded as not answering clinical question
3 Excluded as retrospective review
3 Papers included in the review as RCT's
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Emergency treatment on facial laceration of dog bite wounds with immediate primary closure:a prospective randomized trial study. Rui-feng C, Li-song H, Ji-bo Z, Li-qiu W. 2013 China | 600 pts. 1-64 years. 300 sutured, 300 non-sutured. No antibiotics |
Randomised controlled trial | Infection rate | Sutured group 6.3% Non-sutured group was 8.3% (P>0.05) | No power calculation Single centre - applicability |
| Recovery time | Recovery time less in sutured group (<0.05) | ||||
| Primary closure versus non-closure of dog bite wounds. A randomised controlled trial. Injury. Paschos NK, Makris EA, Gantos A, Georgoulis AD. 2014 Greece | 168 adult patients, 82 sutured 86 non-sutured. All received antibiotics |
Randomised controlled trial | Infection rate | Sutured 9.7%, non-sutured 6.9% p=0.51 | Per protocol analysis Limited to adults Powered for cosmetic difference, not infection. |
| Cosmesis (Vancouver scar scale) | Sutured: 1.74, Non-sutured: 3.05 p=0.0001 | ||||
| Dog-bite lacerations: a controlled trial of primary wound closure. Maimaris C, Quinton DN UK 1988 | 96 ED patients 2-83yrs with 169 lacerations. 92 sutured 77 non-sutured No antibiotics |
Randomised controlled trial | Infection rate | Overall infection rate was 7.7%, the sutured rate 6.6% (nil sig) Hand wound infection was higher(p<0.01) | No randomisation method stated No power calculation Lack of statistics No validated cosmesis scale used |
| Cosmesis | Scar width 1-5mm in closed group, 2-6 in open. |
Author Commentary:
The literature is in support of primary closure of dog bites and although only Paschos et al. addressed cosmesis of wounds adequately, in the absence of increasing infection leading to complications, it can be assumed that primary closure of dog bites will only serve to improve cosmetic appearance. To achieve these results in our current practice we must apply the principles used in all these studies, copious irrigation, would cleaning and debridement. Hand wounds will always have higher infection rates regardless and the decision to close them should be based on individual clinical acumen, depending on the extent of devitalised tissue and nature of the wound (puncture/laceration). Most of the studies excluded immune-compromised patients and this should be kept in mind when dealing with these patients.
Bottom Line:
Primary closure of dog bites can be recommended in the ED providing they are adequately debrided and irrigated.
References:
- Rui-feng C, Li-song H, Ji-bo Z, Li-qiu W.. Emergency treatment on facial laceration of dog bite wounds with immediate primary closure:a prospective randomized trial study.
- Paschos NK, Makris EA, Gantos A, Georgoulis AD. . Primary closure versus non-closure of dog bite wounds. A randomised controlled trial. Injury.
- Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure.