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Laceration

A laceration is defined as the injury to the skin and the soft tissue underneath it, which results in an irregular break in the skin appearing as a torn and ragged wound.


Presentation

A laceration appears as a mild to serious breaking of the epidermis of varying size, in which the first layer of the skin is torn from small slices to deep gashes. The breaking might look like a cut, tear, or gash with edges close together or wide apart, and the laceration might hurt, bleed, bruise, or swell. The bleeding varies according to the depth and severity of the damage, going from mild cases, with a brief bleeding and minimal pain, to more severe cases, with profuse bleeding and intense pain. Bleeding might depend on the site of the laceration, as some parts of the body, like the scalp, are more prone to lose blood. Numbness and decreased movement around the area concerned can occur.

Pleural Effusion
  • We describe a case of a 19-year-old woman with persistent fever and pleural effusion, in which thoracentesis resulted in tension hemothorax due to intercostal artery laceration.[ncbi.nlm.nih.gov]
Splenectomy
  • The patient underwent a distal pancreatectomy and total splenectomy. Pancreatic injuries, particularly those severe enough to warrant surgical intervention, are extremely rare in athletes.[ncbi.nlm.nih.gov]
Subcutaneous Emphysema of the Neck
  • emphysema along her neck and mediastinum in addition to her peritoneum and mesentery.[ncbi.nlm.nih.gov]

Workup

The diagnosis of a laceration is firstly performed through a complete physical examination, to evaluate the wound and understand its extent and severity. This is usually integrated with cultures of samples taken from the site of the wound and from the blood, to detect the presence of infections. If the laceration is severe, a fracture is suspected and in the presence of a foreign body, like pieces of metal, gravel and glass, is suspected, an X-ray examination should be performed. 

Pericardial Effusion
  • Chest X-ray and computed tomography (CT) revealed right haemothorax and little pericardial effusion. She was taken to the operating theatre for emergent operation because of hypotension and massive bleeding from the right-sided chest tube.[ncbi.nlm.nih.gov]
Pleural Effusion
  • We describe a case of a 19-year-old woman with persistent fever and pleural effusion, in which thoracentesis resulted in tension hemothorax due to intercostal artery laceration.[ncbi.nlm.nih.gov]

Treatment

The treatment of a laceration depends on the type, cause, and depth as well as the presence and involvement of other structures over the surface of the damaged skin. In any case, the first step is always cleaning, accomplished using different solutions like tap water and sterile saline solutions [10], whose main goal is to avoid and prevent infections. Follows closure, which should be done immediately with the use of clean and sterile gloves [11] [12] [13]. There are several techniques to carry out closure, which include bandages, cyanoacrylate glue, staples, and sutures, each one of them having their own advantages and disadvantages. Dressing, instead, is the last step of the treatment of laceration, as that of the other types on wound, which consists in the application of a sterile pad, whose goal is to keep the wound clean and avoid further damage. However, the effectiveness of dressing in preventing infection and improve healing itself is at the moment not supported by evidence [14].

The risk of getting tetanus cannot always be ruled out, especially when there are doubts about previous vaccinations or the patient received the last tetanus shot more than 5 years earlier. Tetanus infection is particularly possible when dirt or saliva are present in the laceration or for puncture wounds. In these cases, tetanus vaccination is strongly advised.

Prognosis

Prognosis depends on the severity of the laceration. Minimal superficial lacerations should heal completely within 2 weeks. Healing is a little bit longer with deeper lacerations or for those which occur in areas undergoing regular movements, such as knees and elbows. The situation is more difficult with the lacerations which also involve tendons, that have impaired the use of local muscles, or profuse bleeding from internal organs and blood vessels which might result in severe blood loss and possibly death. In these cases, emergency care is advised.

Bacterial infection is the most common complication of lacerations, which can impede healing and lead to life-threatening conditions. Therefore, it is important to make sure no infection has begun after the damage. Unfortunately, current laboratory-based detection of infections might be very long, taking from several hours to even several days to be completed.

Etiology

A laceration occurs when an object strike the skin and opens a wound. The severity of the laceration depends on many factors, like the angle of the hit, the force with which the skin has been stricken, the depth of the wound and the nature of the object which has provoked it. Thus, some lacerations might be more serious than others, reaching deeper tissues and provoking more profuse bleeding.

Epidemiology

No precise epidemiological data exist on the prevalence and incidence of laceration. However, it is particularly frequent among people who work with sharp instruments and objects, such as machineries equipped with saws or knifes and cutters in the kitchen used by the those working in the food industry. Furthermore, laceration is also the most common nonfatal injury among those aged between 10 to 17 [1].

Sex distribution
Age distribution

Pathophysiology

Healing of the laceration, as well as any type of wound, begins when white blood cells arrive at the site of the damage, to clear the wound and remove debris. Then, an orchestrated cascade of biochemical pathways is set in motion to repair the damaged tissue [2] [3], in a process divided in four main stages:

  • Blood clotting (homeostasis) [4] [5]: The wound is essentially plugged thanks to the action of platelets and the gluing mesh of fibrin in which they are bound together. 
  • Inflammation: Damaged and dead cells, bacteria and other pathogens are cleared out through phagocytosis.
  • Proliferation (new tissue growth): Performed through the important stages of angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction, which serve to reconstruct the damaged blood vessels [6] and tissues [7].
  • Maturation (tissue remodeling) [8]: Collagen is realigned along the skin tension lines, while unneeded cells are eliminated through apoptosis.

It is important to notice that although wound healing is a complex process, it is also very fragile and very susceptible to interruption and failure, which might result in the formation of non-healing chronic wounds. There are several factors that foster non-healing chronic wound formation and these include diabetes mellitus, cardiovascular diseases, infections, and metabolic deficiencies [9]. Therefore, measures to speed up wound healing are highly recommended.

Prevention

Since lacerations are provoked by accidental episodes, no particular prevention plan can be recommended, apart from following general safety measures like wearing protective gloves and clothes in environments at high risk of incidents, keep clear from sharp objects and stay away from dangerous equipment and machinery.

Summary

A laceration is a tear in tissue due to blunt trauma characterized by incomplete separation of stronger tissue elements. Five types of laceration occur:

  • Split laceration occurs when a part of the body is crushed between two external objects. The striking object makes a blunt impact and causes the skin with the tissues underneath to tear from compression. Mostly, this type of laceration occurs on the face, head, hands, and legs. 
  • Overstretching is generally caused by a single, angular force which strikes the skin causing it to stretch or break. A typical example of this type of laceration is represented by a gunshot, where the bullet pierces and penetrates the skin with a certain angle, then it lodges underneath the epidermis, compresses and expands causing the skin to tear beyond the initial point of impact.
  • Grinding compression occurs when an objects bluntly strikes the skin maintaining a certain angle or with a sweeping motion, provoking a grinding compression. This laceration causes the skin to peel away, while the tissue underneath is crushed.
  • Cut laceration consists in a cut provoked by a type of blade that has caused a break of the skin and the tissue underneath. This is the most common type of laceration.
  • Tearing occurs when the skin is broken by the hitting object and ripped as a consequence of the pressure pushing the wound in two different directions, as if it was a piece of paper ripped in two smaller ones.

Patient Information

A laceration is a particular type of wound, in which the skin and the soft tissue underneath are cut in an irregular, torn and ragged breaking. Experts distinguish five subtypes of lacerations:

  • Split laceration: The lacerations occurs when a part of the body is crushed between two external objects.
  • Over-stretching: The laceration is caused by an object with an angular force that causes the skin to stretch and break, like a gunshot. 
  • Grinding compression: The laceration is caused by an object with a sweeping motion.
  • Cut: The laceration is provoked by an object which causes a deep cut in the skin and the soft tissue underneath.
  • Tearing: The laceration is provoked by an object which rips the wound pushing it into two different directions.

In these cases, the wound appears as a breaking of the epidermis in the form of a cut, tear, or gush with edges close together or wide apart and size varying according to the case. The laceration might hurt, bruise, swell, and bleed, while the bleeding degree depends on the site of laceration as well as the severity of the damage.

The diagnosis is usually performed with a complete physical examination, to understand the size and severity of the damage, together with laboratory tests and imaging studies to detect the presence of infections, foreign bodies or hidden bone fractures. The treatment of a laceration, instead, as that of any other type of wound, consists in a first cleaning of the wound, to wash away dirt and debris and avoid infections, followed by closure and finally dressing, to keep the wound clean and prevent as much as possible future complications.

The prognosis of a laceration depends on the severity of the wound itself. If the damage is minimal, the laceration usually heals within a few weeks, otherwise the healing process might take much longer than that, creating the conditions for the occurrence of future possible complications. Since lacerations are provoked by accidental episodes, no particular prevention plan can be recommended, apart from following general safety measures like wearing protective gloves and clothes in environments at high risk of incidents, keep clear from sharp objects and stay away from dangerous equipment and machinery.

References

Article

  1. Rubin A. Managing Abrasions and Lacerations. Physician and Sports Medicine 26 5 (1998): 45-55. 
  2. Nguyen DT, Orgill DP, Murphy GF. Chapter 4: The Pathophysiologic Basis for Wound Healing and Cutaneous Regeneration. Biomaterials For Treating Skin Loss. Woodhead Publishing (UK/Europe) & CRC Press (US), Cambridge/Boca Raton, 2009, p. 25-57. 
  3. Rieger S, Zhao H, Martin P, Abe K, Lisse TS. The role of nuclear hormone receptors in cutaneous wound repair. Cell biochemistry and function 2014 33 (1): 1–13. 
  4. Rasche H. Haemostasis and thrombosis: an overview. European Heart Journal Supplements 2001 3 (Supplement Q): Q3–Q7. 
  5. Versteeg HH, Heemskerk JWM, Levi M, Reitsma PH. New Fundamentals in Hemostasis. Physiological Reviews 2013 93 (1): 327–358. 
  6. Chang HY, Sneddon JB, Alizadeh AA, Sood R, West RB, Montgomery K, Chi JT, Van De Rijn M et al. Gene expression signature of fibroblast serum response predicts human cancer progression: similarities between tumors and wounds. PLoS Biology 2004 2 (2): E7. 
  7. Garg HG. Scarless Wound Healing. New York Marcel Dekker, Inc. Electronic book. 2000
  8. Midwood KS, Williams LV, Schwarzbauer JE. Tissue repair and the dynamics of the extracellular matrix. The International Journal of Biochemistry & Cell Biology 2004 36 (6): 1031–1037. 
  9. Enoch S, Price P. Cellular, molecular and biochemical differences in the pathophysiology of healing between acute wounds, chronic wounds and wounds in the elderly. World Wide Wounds. 2004. Aug 13
  10. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane database of systematic reviews (Online) 2012 2: CD003861. 
  11. Eliya MC, Banda GW. Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury. Cochrane database of systematic reviews 2011 (Online) 9 (9): CD008574. 
  12. Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Annals of Emergency Medicine 2004 43 (3): 362–70. 
  13. van den Broek PJ. [Sterile gloves are necessary in minor surgery]. Nederlands tijdschrift voor geneeskunde 2011 155 (18): A3341. 
  14. D'Amico G, Pagliaro L, Pietrosi G, Tarantino I. Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients. Cochrane Database Syst Rev 3 2010 (3): CD002233.

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Last updated: 2017-08-09 17:48