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Do I need stitches?

This is one of the most common questions asked by patients either on the phone or when they come to the clinic. In the last four years, between 11 and 12 million wounds/lacerations per year have been treated in emergency rooms. The most common locations are the face, scalp, and hands. The main goals of managing lacerations are to avoid infection and to leave an acceptable scar. Although traditionally, infection prevention has been the primary focus, it's estimated that less than 5% of all lacerations develop infections. Most studies have shown that patients are more concerned with the appearance of the scar.

As far as whether a wound needs further attention besides cleaning and a band-aid, here are some suggestions. If only the top layer of skin, which is about 1 millimeter deep, has been cut, only cleaning with soap and water, a topical antibiotic, and a bandage are necessary. If bleeding does not stop despite elevating the wound above your heart while applying direct pressure for 10 minutes, there is likely tissue damage below the top layer of skin. In this case, the wound likely needs either stitches or, depending on the location, application of one of the new tissue adhesives ('glue'). Further treatment is also likely needed if you can see any deeper structures, such as fat tissue, which looks like groups of tiny yellow grapes; muscle, which looks like red raw meat; tendons, which are attached to the ends of muscles and appear white and shiny; or bone. Avoid cleaning a deeper wound with anything other than soap and water: agents such as hydrogen peroxide and detergents can further damage deeper tissues and slow healing. Also, avoid heavy scrubbing, which can also damage vital tissue; instead, use gentle irrigation and blot dry with clean gauze.

Although the majority of wounds do not develop infections, certain circumstances increase this risk. These include diabetes, obesity, chronic kidney failure, malnutrition, elderly age, the use of immune system suppressant medicines, such as steroids or chemotherapeutic agents, and any wounds caused by cat, dog, or human bites. In addition, wounds that are caused by a crushing force, such as a door slam, usually have more tissue damage and are more prone to infection. Finally, any injury in which the possibility of a foreign body being retained within the wound exists is much more likely to become infected.

So you have more than a superficial cut- does it really need to be closed at the clinic/emergency department and how long can you wait before coming in? Humans have managed wounds long before stitches were developed. The main difference in results between repairing a wound with stitches or 'glue,' known as primary closure, and letting the wound heal open (on its own) is the size and cosmetic appearance of the scar. Primary closure brings the two sides of the wound closer together, resulting in faster healing and decreased amount of scar tissue left behind. Leaving a wound open to heal will also cause significantly more pain. As far as how soon a deeper wound should be closed, most western health-care investigators have agreed on some general guidelines. For most wounds that are at low risk for infection, closure within 6-8 hours is acceptable. For low-risk wounds on the face or scalp, which have very extensive blood supply, closure within 24 hours is reasonable. For wounds in areas with less blood supply, such as fingers or toes, or for wounds at risk for infection, closure within 4-6 hours is warranted.

So you don't like the idea of stitches and have heard of this new miraculous 'glue.' 'Glue' refers to special tissue adhesives that have been used in Europe and Canada for many years but which have only recently (August 1998) been approved by the United States Food And Drug Administration (FDA). These adhesives are expected to eventually replace stitches in 25% to 30% of all laceration repairs. Studies done comparing stitches and 'glue' at 3 months after repair with regard to cosmetics, infection, and wound separation have shown no significant differences. However, 'glue' cannot be used in certain locations. It does not hold in areas of tension, such as the hands/fingers and over any joint.

How to manage any particular wound/laceration is not always a cut-and-dry issue. Although very few wounds become infected after proper cleaning, a deeper wound left to heal on its own will certainly leave a larger and more unappealing scar. How soon a wound needs to be closed in order to heal better depends on the location. Although the newly approved 'glue' requires no needles for repair, it is not helpful for wounds over areas of high tension.

1. Hollander: Ann Emerg Med, Volume 34(3). September 1999, 356-367. 2. Singer: NEJM, Volume 337(16). October 16, 1997, 1142-1148.