Suturing versus conservative management of lacerations of the hand: randomised controlled trial

Introduction

Lacerations are common simple problems; their treatment requires tremendous resources. Every doctor is asked, “Will this cut needs stitches?” with the expectation that the answer is determined using some scientific knowledge. In truth, we give an opinion based on experience. The value of closure and whether it is even needed have never been objectively studied. This study aims to give scientific support to doctors' answers.

Suturing is the most popular method of securely closing wounds, although it has many disadvantages: sutures require the use of needles to inject painful anaesthetics, are time consuming, have the greatest tissue reactivity of any wound closure device, are costly, and are inconvenient for patients.1

Normally, wounds repair themselves, regardless of whether wound edges are approximated. 2 3 Most doctors have seen lacerations that were not sutured and healed normally: when infection is a worry wounds and incisions are left to heal by delayed secondary healing, and most heal with functional scars. Case series on the non-closure of hand incisions show that wounds left open heal similarly to those sutured.4

The goal of wound healing is to have a functional and cosmetically appealing scar, and to inflict minimal pain and inconvenience on patients. This randomised controlled trial aims to determine whether the conservative management of hand lacerations produces similar clinical outcomes to wounds that are sutured.

Patients and methods

Patients with lacerations of the hand—that is, lacerations distal to the volar wrist crease—that would normally be treated with sutures were eligible for the study. Patients were excluded if their lacerations were longer than 2 cm; they presented more than eight hours after the injury; haemostasis could not be attained after 15 minutes of pressure; their lacerations had associated or suspected neurovascular, tendon, or bone injury; their lacerations were of the nail bed, were puncture wounds, or were secondary to a bite from any source. Patients with complications from diabetes, receiving anticoagulants or prolonged chronic steroid use (defined as continuous use for more than 14 days, three times a year) were also excluded, as were patients unable to participate in the follow up.

The study took place in the Emergency Department of the University of California, San Francisco Medical Center during the hours of operation of the clinical research unit (11 am to 11 pm) to provide a consecutive patient sample. The committee on human research at the University of California in San Francisco approved the study protocol.

We sought informed consent from eligible patients; if it was given, they were prospectively enrolled and randomised to be treated conservatively or with sutures. After lacerations were irrigated under tap water for 1-2 minutes the patient applied direct pressure.

Patients were randomised by a computer, in blocks of 10. We opened sequentially numbered sealed opaque envelopes, with the treatment marked inside, at the time of randomisation. The department of biostatistics randomised and prepared these envelopes; we had no access to the randomisation codes.

Patients randomised to receive sutures had the area of laceration anaesthetised and cleansed, at the healthcare providers' discretion. We closed the skin with monofilament suture (United States pharmacopoeia sizes 4-0 or 5-0), using standard sterile techniques, and applied polymyxin B antibiotic ointment containing bacitracin with a gauze dressing to last 24-48 hours.

Patients randomised to receive conservative treatment received tap water irrigation and had the same ointment and dressing applied to last 48 hours.

In both groups, use of ointments after 48 hours was discouraged, and patients were given written instructions to keep their wounds clean and dry.

Results

During the study period, 16 February to 30 November 2000, 58 (38%) patients refused enrolment, 5 (3%) patients were missed, and 91 (59%) patients with 95 lacerations were enrolled. More than 80% (154/192) of all lacerations seen during the study period were eligible (154 consecutive patients). At the end of the trial we evaluated photographs of 41 lacerations treated with sutures and 40 treated conservatively (figure).

Selection of patients and allocation of treatment

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Patients treated with sutures and those treated conservatively had similar baseline demographic and clinical characteristics (table 1). The mean scores for cosmetic appearance assigned by doctors blinded to whether treatment had been with suturing or not were not significantly different (83 (range 54-96) mm v 80 (49-98) mm; difference 3 mm (95% confidence interval −1 to 8) mm) (table 2). Patients' ratings of their wound at three months were similar (83 mm v 82 mm).

At 8-10 days follow up, optimal wound scores in the sutured and non-sutured groups were similar (92% v 89%, P=0.71), and patients in both groups stated similar mean times to return to normal activities (3.4 days; difference 0 (−1.4 to 1.3) days). One sutured wound was treated with antibiotics for an infection. No infections were treated in any of the conservatively treated wounds.

Patients' mean rating on the visible analogue pain scale was lower for lacerations treated conservatively (difference 18 (12 to 24) mm). The mean time to treat with sutures was greater than for conservative treatment (19 min v 5 min) (difference 14 (10 to 18) min).

Discussion

The goal of wound care and closure is to have a resultant functional and cosmetically acceptable scar, with low morbidity and high patient satisfaction and comfort. These goals can be achieved by treating simple lacerations of the hand conservatively instead of with sutures. The time saving has implications for health policy.

Uncomplicated lacerations of the hand, shorter than 2 cm, are currently being sutured unnecessarily and would heal with similar results without sutures. In this study, all lacerations needed sutures before randomisation. The inclusion criteria were broad, as eligible lacerations represented over 80% of all lacerations of the hand presented during the study period.

Large gaping wounds should be closed, after meticulous wound care, and our results cannot be generalised to cosmetically sensitive areas such as the face. The suturing of simple lacerations of the hand, however, provides no clinical benefit, as our study shows: the 95% confidence interval contains zero and is less than 10 mm (a difference of 12-15 mm on the scale is clinically important).

Until recently, few objective randomised trials looking at the clinical outcomes of wound closure techniques have been performed. Previously most guidelines for wound closure were anecdotal or based on animal work. This study builds on the work we started several years ago: to look objectively at the clinical outcomes of wound closure.10

This is the first randomised controlled trial to determine whether the conservative management of hand lacerations produces similar clinical outcomes to wounds that are sutured. We expected to obtain these results because, in our experience, wounds that are dehisced or those treated with delayed primary closure usually heal without complication: the three phases of wound healing—inflammation, epithelisation, and maturation—occur whether or not wounds are securely closed. We were impressed with how inconspicuous most scars were after three months and at the high level of patients' satisfaction with the appearance of their wound.