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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Nov 27, 2017

In this episode

  • When is showering OK after stitches?
  • What type of ointment should be placed on a laceration to promote healing?
  • Is there an advantage to using antibiotic ointment over petroleum jelly on a non infected laceration?
  • How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon?
  • What type suture to use for extensor tendon repair.

 

How long does one have to wait to take a shower after getting stitches?

  • There is limited data addressing this question, but based on the data we do have, showering after 48 hours is probably OK.
  • Even the NHS thinks so.
  • It may be perfectly fine to shower even sooner, but there's no evidence that gives a time cutoff for optional showering.
  • Note- showering does not mean submersion and it certainly doesn't mean getting in a hot tub. Second note-  the intent of this podcast it for medical providers to understand the medical literature and differing opinions on this question, not direct medical advice to patients.

 

What should you use to dress a wound?

  • Keep it moist. Don't let the wound dry. Lungs do the breathing, the wound needs to be smothered.
  • Petroleum jelly is fine. Antibiotic ointment on a non infected wound does not confer extra benefit and may actually lead to worse outcomes (hypersensitivity)
  • A 1995 study found that using antibiotic ointment on acutely sutured traumatic lacerations decreased the incidence of 'stitch abscess' but otherwise did not improve outcome for more severe infectious, such as cellulitis
  • Non adherent dressing, absorptive dressing, then overwrap. Many dressings incorporate all three of these in one product

 

How much of an extensor tendon needs to be cut for you to either repair it yourself or refer to a hand surgeon?

  • Our interviewed expert says he repairs anything 25% or greater
  • In Roberts and Hedges it says repair is optional if the laceration is less than 50% of the cross-sectional area of the tendon.
  • A study that surveyed hand surgeons on flexor tendons found that some surgeons repair all of tendon lacerations, some only if they were more than 50% PMID: 7606610
  • If you’re wondering if that injured tendon needs repair, if it’s a little divot, probably not. When you get into the 25-50% range, possibly. If in doubt, splint and refer. 

What type suture to use for extensor tendon repair

  • Many options
  • Avoid Vicryl. It will break down too fast (2-3 weeks, not long enough for the tendon to heal)
  • Nylon commonly used
  • Our consultant prefers 4-0 Monocryl or PDS II. They will both dissolve but maintain tensile strength for a long enough the for the tendon to heal

 

References

Showering after laceration repair 

  1. Hsieh, Pei-Yin, et al. "Postoperative showering for clean and clean-contaminated wounds: a prospective, randomized controlled trial." Annals of surgery 263.5 (2016): 931-936. PMID:26655923
  2. Toon, Clare D., et al. "Early versus delayed post‐operative bathing or showering to prevent wound complications." The Cochrane Library (2015). Full text link
  3. Harrison, Conrad, Cian Wade, and Sinclair Gore. "Postoperative washing of sutured wounds." Annals of Medicine and Surgery 11 (2016): 36-38. Full text link

Keeping the wound moist to promote healing

  1. Dyson, Mary, et al. "Comparison of the effects of moist and dry conditions on dermal repair." Journal of investigative dermatology 91.5 (1988): 434-439. Full text link
  2. Dire, Daniel J., et al. "Prospective Evaluation of Topical Antibiotics for Preventing Infections in Uncomplicated Soft‐tissue Wounds Repaired in the ED." Academic Emergency Medicine 2.1 (1995): 4-10. PMID: 7606610

Contact Dermatitis Offenders

  1. Fransway, Anthony F., et al. "North American contact dermatitis group patch test results for 2007–2008." Dermatitis24.1 (2013): 10-21 PMID: 23340394
  2. Common contact allergens explained The Dermatologist 2014