Lacerations and wound closure
Check nerves and tendons before anaesthetic, wash it out well, close with the right method, and sort tetanus.
A 35-year-old cut his forearm on broken glass 3 hours ago. The wound is 4 cm long and gaping. He can move all his fingers but says the tip of his thumb feels numb.
A 6-year-old has a 1.5 cm cut on the forehead from a table corner.
What do you check before closing, what closes each wound best, and when do the stitches come out?
- Stop bleedingDirect pressure and elevation.
- Check below the woundPulses, capillary refill, sensation, power, every tendon. Before anaesthetic.
- X-rayGlass, metal, or bone involvement.
- Clean and exploreLocal anaesthetic, irrigate generously, look for foreign bodies and tendon damage.
- Choose closureSutures, glue, strips or leave open.
- TetanusCheck status, give booster or immunoglobulin.
- AdviceKeep dry 48 hours, signs of infection, when to remove stitches.
- Tendon, nerve or vessel damage
- Open fracture or joint involvement
- Facial wounds crossing the lip margin or eyelid
- Heavily contaminated wounds
- Suspected non-accidental injury
- Retained foreign body near structures
- Nerve injury (test before anaesthetic)
- Partial tendon cut
- Retained glass
- Joint involvement
- Tetanus
- Non-accidental injury in children
| Lidocaine 1% | Up to 3 mg/kg |
| Lidocaine 1% with adrenaline | Up to 7 mg/kg |
| Irrigation | Generous volume with saline or clean tap water |
| Primary closure | Usually within 6–12 hours (up to 24 hours on the face) |
| Removal: face | 3–5 days |
| Removal: scalp | 7–10 days |
| Removal: arms and trunk | 7–10 days |
| Removal: legs, hands, over joints | 10–14 days |
Check every dose against a current drug reference and your hospital protocol.
On this page
Assess before you anaesthetise
- Circulation: pulses, capillary refill, colour.
- Sensation: both sides of each finger (digital nerves), median, ulnar and radial areas.
- Movement: each tendon separately, against resistance (a partly cut tendon may still work, but hurt).
- Bone and joint: tenderness, deformity, wounds over joints.
Choosing the closure
Tissue glue or adhesive strips
Sutures
Staples or sutures, or hair apposition
Leave open or delayed primary closure
Suture choice
| Site | Suture |
|---|---|
| Face | 5-0 or 6-0 non-absorbable |
| Scalp | 3-0 or 4-0 non-absorbable, or staples |
| Arms, trunk | 4-0 non-absorbable |
| Hands | 4-0 or 5-0 non-absorbable |
| Legs | 3-0 or 4-0 non-absorbable |
| Deep layers, lips inside the mouth | Absorbable |
Technique
- AnaestheticLidocaine infiltrated through the wound edges (less painful). Adrenaline is safe in fingers in healthy people, but plain lidocaine is standard.
- IrrigateGenerously with saline or clean water.
- ExploreIn a bloodless field, look for glass, tendons, joint capsule.
- DebrideDead tissue, ragged edges.
- CloseSimple interrupted sutures, evert the edges, don't tie too tightly.
- DressNon-adherent dressing.
Special areas
- Lip: align the vermilion border first.
- Eyelid: involving the margin or tear duct: ophthalmology.
- Ear: cartilage involvement or haematoma: specialist.
- Hand: low threshold for hand surgeon review.
- Pretibial lacerations (elderly): thin skin, use strips not sutures; elevate.
Tetanus
Nothing extra
Booster
Booster plus tetanus immunoglobulin
Treatment
Aftercare
- Keep dry for 48 hours, then gentle washing.
- Signs of infection: increasing pain, redness, pus, fever.
- Sun protection for facial scars.
- Remove stitches on time.
Common mistakes
- Testing sensation after the anaesthetic.
- Not X-raying glass wounds.
- Suturing a contaminated wound.
- Missing a partial tendon cut.
- Tying sutures too tight (necrosis, scarring).
- Forgetting tetanus.
Frequently asked questions
When should facial sutures be removed?
After 3–5 days.
Can a laceration be closed after 12 hours?
Many clean wounds can be closed within 12–24 hours, longer on the face. Older or contaminated wounds are usually left open or closed later.
Which wounds can be closed with tissue glue?
Small, clean, straight wounds under low tension and not over joints.
When is tetanus immunoglobulin needed?
For a tetanus-prone wound in someone not immunised or with unknown status.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. What is the maximum dose of plain lidocaine?
Answer: 3 mg/kg. 1% lidocaine is 10 mg/mL; a 70 kg adult can have about 20 mL plain.
- 7 mg/kg: With adrenaline.
- 1 mg/kg: Too low.
- 20 mL for all: Weight-based.
- 10 mg/kg: Toxic.
2. A wound is contaminated with soil in a man who has never been vaccinated. What tetanus prophylaxis?
Answer: Toxoid and immunoglobulin. Unimmunised with a high-risk wound needs both.
- Immunoglobulin alone: Vaccine also needed.
- Toxoid alone: Immunoglobulin also needed for dirty wounds.
- Nothing: No.
- Antibiotics only: Not enough.
3. When are sutures usually removed from the face?
Answer: About 5 days. Face 5 days; scalp and arms 7–10; legs 10–14.
- They dissolve always: Not all.
- 14 days: Too long; scarring.
- 1 day: Too early.
- 21 days: Too long.
4. A 25-year-old has a clean 3 cm laceration on the forearm sustained 2 hours ago from glass. After irrigation and exploration (no foreign body, no tendon injury), what is appropriate?
Answer: Primary closure with sutures. Clean wounds presenting early (< 6–12 h; face up to 24 h) can be closed primarily after irrigation, debridement and exploration (glass: X-ray for fragments; check tendons, nerves). Contaminated wounds, bites (except face) and late presentations → delayed primary closure or healing by secondary intention. Suture removal: face 5 days, scalp 7, trunk/arms 7–10, legs/back 10–14.
- Leave open to heal by secondary intention: A clean fresh wound can be closed primarily.
- Delayed primary closure at 5 days: Delayed primary closure is for contaminated wounds.
- Skin graft: A skin graft is not needed for a simple laceration.
5. A farmer with an unimmunised history has trismus, risus sardonicus and painful spasms 8 days after a dirty foot wound. Which combination is the core treatment?
Answer: TIG, metronidazole, debridement. Tetanus management: human tetanus immunoglobulin (neutralises unbound toxin), wound debridement, metronidazole (or penicillin), benzodiazepines and magnesium sulfate for spasms, a quiet dark room, and airway protection/ventilation in severe cases. Autonomic instability causes late deaths. Tetanus infection does not confer immunity, so start the toxoid course too. Neonatal tetanus follows unhygienic cord care in unimmunised mothers — prevented by TT/Td in pregnancy.
- Benzylpenicillin alone: The toxin is already bound, so penicillin alone is not enough.
- Tetanus toxoid alone: Toxoid alone is too slow, and the disease does not give immunity.
- Physostigmine infusion, toxoid: Physostigmine is not a treatment for tetanus.
6. What is the main biochemical role of vitamin C in collagen synthesis?
Answer: Hydroxylation of proline and lysine. Vitamin C is a cofactor for prolyl and lysyl hydroxylase, which hydroxylate proline and lysine in the rough endoplasmic reticulum. Hydroxyproline stabilises the triple helix. Without it, collagen is weak, causing scurvy: bleeding gums, perifollicular haemorrhages, poor wound healing and corkscrew hairs.
- Glycosylation of hydroxylysine: A later step, not vitamin C dependent.
- Cleavage of procollagen peptides: Done by procollagen peptidases outside the cell (defective in some Ehlers–Danlos).
- Cross-linking by lysyl oxidase: Lysyl oxidase needs copper (Menkes disease).
- Assembly of the triple helix: Follows hydroxylation; not directly vitamin C dependent.
7. Which type of collagen forms basement membranes and is targeted in Goodpasture syndrome?
Answer: Type IV. Type I: bone, skin, tendon (osteogenesis imperfecta). Type II: cartilage, vitreous. Type III: reticular fibres, blood vessels, granulation tissue (vascular Ehlers–Danlos). Type IV: basement membranes (Goodpasture's antibodies, Alport syndrome).
- Type I: Bone, skin, tendon.
- Type II: Cartilage.
- Type III: Reticular fibres, vessels.
- Type V: Minor; classic Ehlers–Danlos.
References and dose sources
- UKHSA — Tetanus: the Green Book, chapter 30
- Lidocaine (lignocaine) dosing: Drugs.com: Lidocaine dosage (see also our lidocaine (lignocaine) dose page)
- Tetanus toxoid and immunoglobulin dosing: Drugs.com: Tetanus toxoid dosage (see also our tetanus toxoid and immunoglobulin dose page)
- Flucloxacillin dosing: Drugs.com: Flucloxacillin (international) (see also our flucloxacillin dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.