Does My Child Need Stitches?

By Steven Rothrock, MD, FACEP, FAAP on November 28, 2011

As children grow, learn to walk, and begin to take risks, they frequently fall with resulting cuts or lacerations.  In fact, 1/3 of all children who go to an emergency room for an injury have a wound that may need repair.1,2 Cuts and wounds are most common around age 2 with nearly half of all wounds needing repair found in those who are 5 years old or younger.1,2 There are a variety of factors to consider when deciding to close a wound.

First Some Definitions

Many different words are used to describe wounds that might need to be repaired.  A lot of people, including medical professionals, use the word laceration to describe any type of a cut or open wound.  Strictly speaking, an incision is a cut that is made by a sharp edged object like a knife, glass other hard material that slices or incises the skin.  Lacerations are tears to skin from blunt force (e.g. a child that falls and hits their head, face, or chin) with a resulting wound that is open.  The edges of lacerations are more likely to be irregular although they can be straight or linear and look just like incisions.  Avulsions occur when a layer of skin is removed and a patch of exposed tissue is seen under the removed skin. Avulsions generally cannot be sutured or stitched closed. Punctures occur when something stabs through the skin like cat or dog bites or when someone is stabbed. Suture is the medical term for a stitch.

Why Do Wounds Need to Be Closed?

The main reason many wounds are closed, especially those on the face, is to minimize scar formation and to improve the appearance of the healed wound. Other reasons to consider closing a wound include restoring tissue function, increasing wound strength, speeding up healing of the wound, preserving living tissue while removing dead tissue and preventing pain. Not all of these goals are attained by closing wounds and there are a variety of reasons to consider leaving a wound open.

Contamination, Injury and Foreign Bodies

When deciding to repair a wound, the location of the wound and the potential for underlying injury, foreign bodies, contamination and infection needs to be considered.  Any wound with a potential foreign body or contamination is going to need to be explored and cleaned thoroughly.  X-rays may be needed to look for underlying fractures, glass or other contaminants. All glass larger than 1-2 millimeters shows up on plain X-rays.3 Wood and organic material usually do not show up on plain X-rays and exploration or an ultrasound, CT scan or MRI may be needed to detect these materials.3 Wounds that involve injury to bones, joints, tendons, nerves, and arteries will require expert management, exploration, and cleansing.

Contrary to popular belief, closing or suturing a wound does not decrease the potential for infection.  In fact, leaving a wound open usually decreases the chance an infection will develop. Human and animal bites have a high potential for causing infections especially if these injuries cause punctures.  These wounds are often left open although smaller, less traumatized bites on the face are occasionally closed with the realization that 6% of these carefully selected and cleansed bites will still develop an infection.4  Wounds that are contaminated with dirt, unclean water (lakes, streams, ponds) or other materials may need to be left open. Wounds and lacerations with dead tissue or that are extremely contaminated may need to be debrided or have dead tissue cut away.

Cleaning Wounds

Independent of whether or not they are closed, open wounds often need to be cleansed. Initially, the intact skin (not the wound itself) around a wound can be cleansed with anti-septic solutions like povidone-iodine (Betadine).  Soaking open wounds in saline, water, or povidone-iodine does little to alter the chance an infection will develop.5 In fact, many solutions like Betadine unless diluted to 1% solution, hydrogen peroxide, alcohol and chlorhexidine are toxic to open wounds and their use is not recommended for cleaning, scrubbing, or irrigating open wounds.5 Cleaning intact skin around the wound with these solutions is fine. Directly scrubbing wounds with sterile brushes can remove bacteria and particles. Scrubbing causes tissue damage and decreases the wound’s ability to fight infection.6 For this reason, scrubbing is usually reserved for wounds with a high degree of contamination with visible particles.

Irrigating with a stream of liquid under pressure is the best way to decrease the amount of bacteria, remove contaminants and prevent wound infections.6  Some degree of pressure (7 to 40 pounds per square inch/psi) during irrigation is recommended to clean out wounds.6,7  This can be accomplished with a 35 ml syringe and 18 to 19 gauge needle or other device for squirting the wound NOT injecting liquid.6,7 Pressures higher than 50 to 70 psi can damage tissues and are avoided.7  Experts generally recommend using 50 to 100 ml for every centimeter (½ inch) of wound length.8 Sterile saline, salt solution, has been the most common solution recommended for irrigating wounds.7 Tap water has shown to be an effective alternative with no increased risk of infection.9 Non-contaminated, non-bite wounds to the face and scalp are an exception to the rule that wounds need to be irrigated. Irrigation does not decrease the already low infection rate in these types of injuries when cared for within 6 hours of the injury.10

Other risk factors for infection may play a role in whether or not a wound needs to be sutured.  Wound healing is delayed and infections are more common in those with diabetes, malnutrition, chronic kidney failure or a weak immune system including those who use medicines that can suppress the immune system.11 Since infection are more common, wounds are less likely to be closed if these risks are present.

Wound Location

The scalp and face have a rich blood supply.  Because of this, infections are much less common in these locations. Since we all want the smallest scarring and residual damage on the face, most face lacerations are closed. Both the face and scalp bleed quite a bit when they are injured. Closing these wounds can help to stop bleeding.

The feet are relatively dirty, there are multiple overlapping tissue planes and closed spaces where bacteria can become trapped and cause serious infection so lacerations on the feet often are often not closed.  Hands also have a higher risk of infection with punctures and deeper cuts.  There are multiple overlapping tissue planes, and important structures in small enclosed spaces (e.g. artery, tendon, joint, nerves) and swelling from infection can be devastating in the hand.  Studies have shown that small, uncomplicated hand wounds 2 centimeters (one inch) or smaller that are NOT closed, heal faster, with less pain and have the same look and function compared to those that are sutured.12  For these reasons, many hand lacerations do not need to be closed.

Skin directly overlies cartilage in the ear.  Because cartilage has a poor blood supply, exposed cartilage needs to be covered by skin during repair.

Lacerations through the eyelid, the philtrum (area between nose and lip), and where lips and dry skin connect (vermillion border) all require meticulous alignment for the best cosmetic appearance.

The mouth and tongue are colonized with high amounts of bacteria that predispose to infections.  For this reason, most lacerations on the inner lip (area not seen with mouth closed), inside the mouth, and along the tongue are best left open. Extremely large, gaping areas where food might get stuck or very large areas through the tongue occasionally require closure.

Timing Issues

Wounds should be closed early to prevent the wound from becoming colonized with bacteria that live on the skin. In as few as 3 to 6 hours after injury, bacteria migrate and multiply in open wounds to the point that infection becomes a risk especially if wounds are not cleansed.13 For highly vascular areas like the face and scalp, clean wounds can be closed within 24 hours with low infection rates.13 On the trunk and extremities, infections begin to increase by 6 to 12 hours so most wounds should be closed within this time period.13 Infections may occur even earlier if foot and leg wounds are closed. Even less time is allowed for crushed or contaminated wounds.

Antibiotics

Antibiotics do not prevent infection in simple, uncomplicated lacerations.14 Antibiotics are generally reserved for animal bites and wounds that are old, with poor blood flow, contaminated, or involve areas with highest risk of infection.14

A Little on Wound Closure Methods

Early descriptions of the first sutures come from East Africa where wounds were closed with acacia thorns used as needles and strips of leaves used as sutures. Large black ants were also used to bite wound edges together. After biting, their bodies were twisted off with the heads and jaws left in place to hold the wound together.15, 16 Today’s choices are a little cleaner, less painful, and stronger.   Most wound now are treated with tapes, sutures or repaired using staples or tissue adhesives (glue or cyanoacrylate). 

Tape can only be used on areas that are small and have very little separation of wound edges with little tension pulling the wound apart.  

Traditionally, sutures have been used to close most wounds.  Non-absorbed material  like nylon and polypropylene are often used to close skin while absorbable sutures including polyglactin, polyglycolic acid and chromic are used for deeper structures.6 Non-absorbable sutures need to be removed within a 5 to 14 day period depending on their location. Absorbable sutures have been found to work as well as rapidly dissolving non-absorbable sutures like chromic-catgut for some childhood facial lacerations negating the need to remove or pull out sutures.17, 18

Staples can be applied rapidly, removed easily, and have lower infection rates, and tissue irritation than sutures.6 They are usually used in scalp, trunk, arm and leg wounds. They cannot be used to meticulously close wounds.

Tissues adhesives (cyanoacrylates) are a type of glue that can be placed over wounds that are held closed by pressing the adjacent skin together. They can be applied more quickly than sutures with the same look or cosmetic outcome with infection and dehiscence rates (wound pulling apart) as sutures.19 Tissue adhesives can be used on the face, trunk, and extremities. Wound need to be relatively straight and clean with little tension on the wound edges and where there is no repetitive movement like over joints.  Wounds larger than 4 to 5 centimeters are usually too large to close with tissue adhesives. After the adhesive is applied, it should remain dry for 48 hours. No ointment or creams should be applied during that time.  After 5 to 10 days, the glue falls off like a scab. Glue also can be applied to wounds that have already been sutured to provide extra support and decrease bacteria getting into a wound.19

The takeaway message

The decision to close, stitch, suture, glue, or staple a wound involves a lot of factors, including timing, type of injury, degree of contamination, wound location, injury type and a child’s underling health and immune status.  Clean wounds on the face that are less than 24 hours old can usually be closed.  Leaving a wound open is an acceptable option for many wounds that are dirty or on places where we do not care about the look like the hands, feet and trunk. The decision to close a wound is complex and many simple, non-face wounds heal fine or even better if they are left open.



References

  1. Berk WA, Osbourne DD, Taylor DD. Evaluation of the golden period for wound repair: 204 cases in a third world emergency department. Ann Emerg Med 1988; 17: 496-500.
  2. Krauss BS, Herakal T, Fleisher GR. General trauma in a pediatric emergency department: spectrum and consultation patterns. Pediatr Emerg Care 1993; 9: 134-138
  3. Blankenship RB, Baker T. Imaging modalities in wounds and superficial skin infections. Emerg Med Clin North Am 2007; 25: 223-234.
  4. Chen E, Hornig S, Shepherd SM, Hollander JE. Primary closure of mammalian bites. Acad Emerg Med 2000; 7: 157-161
  5. Lammers RL, Fourre M, Callaham ML, Boone T. Effect of povidone-iodine and saline soaking on bacterial counts in acute, traumatic, contaminated wounds. Ann Emerg Med 1990; 19: 709-714.
  6. Hollander JE, Singer AJ. Laceration Management. Ann Emerg Med 1999; 34: 356.
  7. Luedtke-Hoffman KA, Schafer DS. Pulsed lavage in wound cleansing. J Am Phys Ther 2000; 80: 292-300.
  8. Nicks BA, Ayello EA, Woo K, et al. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med 2010; 3: 399-407.
  9. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2008; 23: CD003861.
  10. Hollander JE, Richman PB, Werblud M, et al. Irrigation in facial and scalp lacerations: does it alter outcome? Ann Emerg Med 1998; 31: 73-77.
  11. Hollander JE, Singer AJ, Valentine SM, et al. Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med 2001; 8: 716-720.
  12. Quinn J, Cummings S, Callaham M, Sellers K. Suturing versus conservative management of lacerations of the hand: randomized controlled trial. Br Med J 2002; 325:
  13. Moreira ME, Markovchick VJ. Wound management. Emerg Med Clin North Am 2007; 25: 873-899.
  14. Nakamur Y, Daya M. Use of appropriate antimicrobials in wound management. Emerg Med Clin North Am 2007; 25: 159-176.
  15. Forrest RD. Early history of wound treatment. J R Soc Med 1982; 75: 198-205.
  16. MacKenzie D. The history of sutures. Med His 1973; 17: 158-168.
  17. Karounis H, Gouin S, Eisman H, et al. A randomized, controlled trial comparing long term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med 2004; 11: 730-735.
  18. Luck RP, Flood R, Eyal D, et al. Cosmetic outcomes of absorbable versus non-absorbable sutures in pediatric facial lacerations. Pediatr Emerg Care 2008; 24: 137-142.
  19. Hockberg J, Meyer KM, Marion MD. Suture choice and other methods of skin closure. Surg Clin North Am 2009; 89: 629-641.