Textbook of Urgent Care Medicine, Chapter 37, Laceration Repair and Wound Management

Original author: Jasmeet Singh Bhogal

Originally published in 2014. Substantially updated and clinically reviewed in 2026.

INTRODUCTION

Lacerations and bite wounds, punctures, skin tears, and skin abrasions are among the most common problems seen at urgent care centers and range from clean cuts to heavily contaminated wounds. The goal of wound care in an urgent care center should be to assist the body with the natural healing process while providing adequate hemostasis, pain control, wound closure (if appropriate), infection prevention, and follow-up care.

Expectations regarding scar formation, wound-closure options, and the rationale behind their use should be discussed with patients.

Before repair, determine whether the wound is suitable for urgent care closure or whether deeper structural injury, uncontrolled bleeding, severe contamination, or a high-risk location requires emergency or specialty care.

PRESENTATION

• Lacerations are usually straightforward but may be associated with serious or multiple injuries.
• Most patients with lacerations present immediately after the injury.
• The wound may be bleeding profusely.
• Given the amount of blood loss, the patient may be hemodynamically unstable at presentation.
• Any injured digits may be swollen and painful because of metal rings or bands acting as tourniquets. Immediate removal of these is imperative.
• Delayed presentation is not, by itself, a reason to avoid wound closure. Assess contamination, tissue viability, infection, location, comorbid conditions, and the ability to achieve cleansing and follow-up rather than applying a rigid “golden period.”

TRIAGE PEARLS

• Always use universal precautions.
• Consider this an evaluation of a traumatized patient. Initial assessment should include the ABCs (airways, breathing, and circulation) and arrangement for appropriate transfer if the patient is in unstable condition.
• Establishment of initial hemostasis: Apply pressure to the bleeding wound; avoid blind clamping of blood vessels.
• Removal of jewelry from the affected limb using the appropriate technique or tools.
• Assess distal perfusion, sensation, movement, and potential tendon injury before local anesthesia or digital blockade; document baseline findings.
• Bleeding unresponsive to direct pressure, expanding hematoma, compromised perfusion, suspected vascular injury, or signs of shock warrant EMS transfer.
• When a delay in wound care is expected, cover the wound with a clean, moist dressing; maintain patient comfort and avoid unnecessary manipulation.

HISTORY AND PHYSICAL EXAM PEARLS

Wound History

Determine the following:

• The mechanism of injury
• The age of the wound
• Associated symptoms
• Whether there is a risk of glass, metal, wood, dirt, or other retained foreign material
• Exposure to animal or human saliva, freshwater or saltwater, soil, or contaminated equipment

Medical History and Social History

Ascertain the following:

• Whether the patient has any allergies
• Whether the patient has diabetes mellitus, advanced liver disease, or renal failure
• The patient’s tetanus status
• The medications that the patient takes on a long-term basis: steroids, nonsteroidal anti-inflammatory drugs, anticoagulants
• The patient’s handedness (for hand injuries)
• Smoking, immunosuppression, antiplatelet use, and healing limitations that may alter management or follow-up

Physical Exam

Document the following:

• Vital signs
• General health
• Wound: location, length, depth, condition, and degree of contamination
• The relationship of the wound to tendons, joints, nerves, vessels, bone, and retained foreign material; assess function through the relevant range of motion.
• A focused sensory, motor, and vascular assessment before anesthesia, particularly for wounds of the hand, foot, and face.
• Signs of infection or devitalized tissue, including erythema, warmth, purulence, necrosis, and loss of tissue viability.

Indications for Immediate Referral

• Avulsion or scalping lacerations of the scalp
• Intramarginal eyelid lacerations
• Lacerations involving the lacrimal duct apparatus
• Lacerations crossing the vermilion border, if you are not comfortable suturing them
• Cheek lacerations with parotid gland or facial nerve involvement
• Complex ear injuries involving the cartilage
• Flap laceration with the base of the flap away from the heart
• Suspected tendon or nerve transection, open joint, open fracture, vascular injury, high-pressure injection injury, compartment syndrome, or penetrating wound near a vital structure.
• Highly contaminated or complex wounds that cannot be adequately evaluated, debrided, or safely closed in urgent care.

TREATMENT AND DISPOSITION PEARLS

Anesthesia and Pain Control

• Choice of anesthetic and technique is individualized (Table 1).
• When using lidocaine, remember that as a local anesthetic, its onset is immediate; as a block, its onset is within 5 to 10 minutes.
• Toxicity: Hypotension, bradycardia, seizures. Always aspirate before injecting the anesthetic into a body part.
• Lidocaine with epinephrine can be used for digital anesthesia when perfusion is intact and appropriate concentrations and doses are used; avoid it when digital ischemia or substantial vascular compromise is suspected.
• Buffered or warmed local anesthetic, a smaller-gauge needle, and slow injection can reduce procedural discomfort. Use weight-based dose limits, particularly in children.
• Use topical lidocaine-epinephrine-tetracaine (LET) on appropriately selected wounds, commonly on the face or scalp. Follow formulation-specific age, dose, location, and contact-time precautions.

Table 1. Anesthetic Choices and Techniques

Wound Cleaning

• Gross contaminants should be loosened and removed before wound closure.
• Irrigation is a critical part of wound care, and the wound should be adequately visualized before closure.
• Use normal saline or potable running tap water for routine irrigation. A practical starting point is approximately 50 to 100 mL per centimeter of wound length, adjusted for contamination and depth.
• Avoid routine soaking or irrigation of clean open wounds with concentrated povidone-iodine, chlorhexidine, or hydrogen peroxide because these agents may damage healing tissue. Antiseptics may be used to prepare surrounding intact skin.
• Do not shave hair, especially the eyebrows. Use a lubricant or antibiotic ointment to flatten hair away from the wound.
• Debridement: Use surgical scissors or a no. 15 scalpel to remove visible contaminants after taking the preceding steps.
• Debride only devitalized tissue required for adequate cleaning and closure; preserve viable tissue and refer complex wounds requiring extensive debridement.

Foreign Bodies in Wounds

• Palpate before anesthetizing the area.
• Obtain radiographs when there is a suspicion of radiopaque retained foreign material such as metal or glass, and assess for associated fracture.
• Ultrasound can help localize radiolucent materials such as wood or thorns when available and used by a trained clinician. A normal radiograph does not exclude all retained foreign bodies.
• Inert or nonreactive objects may be left in place if inaccessible and removal is riskier than retention, after counseling and appropriate follow-up.
• Reactive objects such as wood, thorns, and soil may cause infection or inflammatory reactions and should generally be removed if this can be done safely.
• Attempt removal only when the foreign body is superficial, clearly localized, and accessible without risk to adjacent nerves, vessels, tendons, or joints.
• Deep, multiple, or poorly localized foreign bodies, especially in the hand or face, warrant referral. Avoid prolonged blind exploration.

Wound Closure

Wound closure options include sutures, glue, staples, and wound taping (Table 2). Table 3 outlines suture techniques and indications, and Table 4 shows which suture materials and sizes are appropriate for various body parts.

Selection depends on wound tension, edge alignment, contamination, tissue loss, and anatomic site. Primary closure may be appropriate beyond older fixed time windows when an otherwise low-risk wound is well cleaned and not infected; delayed primary closure is often preferable for highly contaminated wounds.

Table 2. Wound Closure Options, Indications, and Cautions

Table 3. Suture Techniques and Indications

Table 4. Choosing Appropriate Suture Materials and Sizes

Special Anatomic Sites

Scalp

• Extensive bleeding can occur in this location, so it is imperative to control bleeding.
• Avoid tissue debridement as much as possible.
• Staples are usually preferred for laceration repair on the scalp because they allow rapid closure of wound edges.
• Assess for galeal disruption, skull fracture, and associated head injury; repair of deep galeal defects requires appropriate expertise.

Eyelid

• Do not shave the eyelashes.
• Check integrity of the lacrimal duct, medial palpebral ligament, lateral palpebral raphe, and levator palpebrae superioris muscle.
• Check for hyphema, foreign bodies, corneal abrasions, and blowout fractures.
• Lacerations through the eyelid margin, medial canthus, canalicular system, or tarsal plate require urgent ophthalmic assessment; evaluate vision and possible globe injury first.

Eyebrows

• Do not shave the eyebrows.
• Apply an initial alignment suture to avoid cosmetic deformity.
• Debridement should be done parallel to the brow hair shafts.

Cheek

• Check for injury to the parotid gland and the facial nerve.
• Through-and-through lacerations require careful assessment of the oral mucosa, teeth, salivary duct, and wound contamination.

Ear

• Simple lacerations can be closed under direct local anesthesia and with nonabsorbable 6-0 monofilament sutures.
• A perichondrial hematoma should be drained promptly to decrease the risk of cauliflower ear.
• Exposed cartilage, tissue loss, and complex ear injury require prompt specialist referral and adequate skin coverage; consider antibiotics according to wound contamination and cartilage exposure.

Lips

• Check for broken teeth and retained tooth fragments.
• Misalignment of 1 mm of the vermilion border can be seen by the casual observer. Therefore, always start with the alignment suture.
• Through-and-through lacerations: Perform an alignment suture, suture the orbicularis oris muscle, and then close the external and oral cavity parts as described in the preceding step.
• Through-and-through lip lacerations communicating with the oral cavity commonly warrant prophylactic antibiotics and careful follow-up; consider specialty referral for complex tissue loss.

Tongue

• Non-gaping lacerations of less than 1.5 cm will often heal without intervention.
• Lacerations needing repair include widely gaping lacerations, those with active bleeding, those that are flap-shaped, and those with muscle involvement.
• Assess airway, bleeding control, and cooperation; refer deep posterior, complex, or uncontrolled bleeding injuries.

Buccal Mucosa

• Minor superficial buccal mucosal wounds often heal without repair; large, gaping, deeply contaminated, or persistently bleeding wounds require assessment for closure.
• Instruct the patient to eat a soft diet and rinse their mouth gently after each meal for 3 to 4 days.

Penis and Scrotum

• Penis: Use local anesthesia with direct infiltration for uncomplicated wounds.
• Scrotum: Use appropriate absorbable sutures when a superficial wound needs repair.
• Any suspected urethral, testicular, deep genital, or extensive crush injury warrants immediate ED or urologic evaluation.

Hand

• Perform motor and sensory function testing.
• Perform tendon function testing.
• Explore the wound for partial tendon lacerations and violation of joint capsules.
• If the nail is still attached to the nail bed, treat subungual hematoma with trephination when indicated.
• Do not assume preserved movement excludes a partial tendon laceration; document examination of each tendon and distal neurovascular status before anesthetic.

Wounds Under Tension

The following techniques reduce tension:

• Deep sutures
• Wound undermining
• Close placement of sutures (but be aware of increased risk of infection)
• Use buried absorbable sutures selectively to offload skin tension. Excessive tension, impaired perfusion, or inability to approximate viable edges should prompt reconsideration of primary closure or referral.

Indications for Prophylactic Use of Antibiotics

• Crush wounds
• Contaminated wounds, especially in patients with orthopedic implants
• Mammalian bites
• Wounds involving cartilage, tendon, joints, or exposed bone
• Circulatory impairment and conditions that raise infection risk
• Do not use wound age alone as an indication for systemic antibiotics. Routine prophylaxis is not indicated for simple, well-cleaned nonbite lacerations in otherwise healthy patients.
• Consider prophylaxis for selected deep puncture wounds, high-risk hand wounds, through-and-through oral cavity wounds, significant tissue destruction, substantial contamination, or immunocompromised patients.
• Bites require bite-specific assessment of bacterial risk, rabies exposure, and tetanus status. Amoxicillin-clavulanate is commonly first-line when prophylaxis is indicated; verify allergies and individualized dosing.

Tetanus Prevention

Wound care and tetanus prevention are separate decisions. Review the vaccine record and classify the wound as clean/minor or dirty/major; do not prescribe antibiotics solely to prevent tetanus.

Table 5. CDC Tetanus Prophylaxis After Wound Injury (2026)

Wound Dressing

• No dressing may be needed for small, selected wounds when protection is unnecessary.
• Avoid circumferential tape on the digits.
• Use a nonadherent, moisture-retentive dressing when indicated; avoid unnecessarily tight wraps that impair circulation.
• Give written instructions for gentle cleansing, dressing changes, infection signs, avoidance of prolonged immersion, and return precautions.

Suture Removal

• For the face and the neck, remove sutures after 3 to 5 days.
• For the extremities, remove sutures after 7 to 12 days.
• Individualize timing by site and wound tension: scalp commonly 7 to 10 days, arms 7 to 10 days, trunk 10 to 14 days, and hands/feet 10 to 14 days; delay removal if wound integrity remains inadequate.

Urgent Care Disposition

Table 6. Initial Disposition of Traumatic Wounds

MEDICOLEGAL PEARLS

• Missed foreign bodies and missed tendon lacerations are two of the more common reasons for medical misadventures. Document your evaluation of both.
• Document wound irrigation because it helps prevent infection.
• Consider delayed primary closure for contaminated wounds.
• Use antibiotics for contaminated or potentially high-risk wounds.
• Aspirate before injecting local anesthetic. Numerous cases of seizure and death have been described secondary to inadvertent intravascular injection of anesthetic.
• Document the patient’s neurovascular and tendon examination before local anesthetic, the nature and extent of exploration, imaging results, irrigation, tetanus assessment, repair method, and specific follow-up/return precautions.
• For a bite, document species or human source, exposure circumstances, wound assessment, antibiotic decision, tetanus status, rabies risk evaluation, and public health follow-up when indicated.

References

1. Forsch RT, Little SH, Williams C. Laceration repair: a practical approach. Am Fam Physician. 2017;95(10):628-636.
2. Rupert J, Honeycutt JD, Odom MR. Foreign bodies in the skin: evaluation and management. Am Fam Physician. 2020;101(12):740-747.
3. Appelbaum RD, Farrell MS, Gelbard RB, et al. Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open. 2024;9(1):e001304. doi:10.1136/tsaco-2023-001304.
4. Centers for Disease Control and Prevention. Clinical guidance for wound management to prevent tetanus. Updated September 8, 2026.
5. Centers for Disease Control and Prevention. Rabies post-exposure prophylaxis guidance. Updated September 17, 2026.
6. Centers for Disease Control and Prevention. Information for veterinarians: managing an animal that has bitten a person.