All lacerations need to be examined thoroughly

EDITOR—Quinn et al show that conservative treatment is faster and less painful for small uncomplicated lacerations of the hand.1 However, we think that lacerations to the hand, no matter how small, must be examined thoroughly to exclude injuries to tendons, nerves, or joints. The authors make no comment on the mechanism of injury, which is extremely important. A knife stab laceration or glass injury to the hand would make exploration of the wound mandatory. An unimpressive skin wound may hide a remarkable amount of damage to deep structures.2 Similarly, injuries caused by thin slivers of glass produce unimpressive skin wounds but commonly divide flexor tendons and nerves in the forearm.3

To suture or not to suture?

(Credit: SPL)

In emergency settings we think that it is crucial to take a good history from the patient about the mechanism of injury and to examine the patient thoroughly before deciding on further management of hand lacerations, albeit suturing or conservative management. In our plastic surgery unit the nurse practitioners who refer cases of hand trauma to us have all been on a hand trauma study day organised by our department. If the mechanism of injury raises any suspicion of a tendon or nerve injury, patients are referred to us and their wounds formally explored in an operating theatre.

Hand lacerations should be explored before conservative treatment

EDITOR—We are surprised by the publication of the article by Quinn et al on conservative treatment of small hand lacerations.1 Their conclusions will come as no surprise to surgeons who treat hand injuries often, who recognise that wounds on the palmar aspect of the hand heal well if left open.2 Skin defects in the palm are often left to heal by secondary intention after surgery for Dupuytren's disease, with excellent results.3

Our concern is that this paper trivialises small hand lacerations, ignoring the fact that lacerations such as that shown in the front cover photograph may injure any of the underlying soft tissue and bony structures in the finger. In their method, they do not state who made the judgment that there was no associated neurovascular, tendon, or bone injury. This cannot be excluded in this type of wound unless a careful history of the mechanism of injury is taken, a radiograph is obtained, and the wound is explored under local anaesthesia by someone experienced enough to make this judgment.

If neglected, injuries to these structures will usually result in permanent functional disability. Wounds that have penetrated and contaminated the flexor tendon sheath can lead to devastating infection with massive soft tissue loss and all of its sequelae. Similarly, those which have penetrated the joint capsule may lead to septic arthritis.

Small hand lacerations, along with many other conditions in emergency departments, are seen and treated by (through no fault of their own) junior and inexperienced doctors and, increasingly, nurse practitioners. This paper sends out a message that is likely to result in more patients having treatable hand injuries neglected, with regrettable and entirely avoidable consequences. Encouraging such wounds to be treated conservatively is unlikely to benefit the patients or the medical staff treating them, but should keep the lawyers busy.

Incisions are not lacerations

EDITOR—Quinn et al in their paper on the management of lacerations are guilty of a failure to use the correct nomenclature in describing wounds accurately.1 For, although they refer to lacerations of the hand, it is clear from the photographs used to illustrate the paper, both on the front and inside the journal, that these are incised wounds. Indeed, one of them has all the appearances of being a penetrating incised wound or stab wound from a single edged weapon.

Without going into detailed definitions in respect of the differences between lacerations and incisions, in my experience, full thickness wounds to the hands are more commonly incised wounds, which are the result of contact with a sharp bladed object or implement. They are much less likely to be lacerations, which are the result of splitting or tearing of the skin as a result of some form of blunt force trauma. Unfortunately this paper seems to be a further example of doctors, and not always junior doctors, using the incorrect nomenclature in describing wounds accurately.

This is an issue that has been raised in the past by Milroy and Rutty and Norfolk and Stark. 2 3 Both sets of authors made it clear that the accurate description of wounds and the use of correct nomenclature are of considerable importance, particularly in assessing the causation of wounds, which is clearly of considerable relevance in medicolegal issues.

In many respects this is a sad indictment of present day undergraduate medical training, which is devoid of any input in forensic medicine. This use of incorrect nomenclature is on the increase and causes considerable problems and arguments in court. Without the reintroduction of formal training in forensic medicine for medical students these are problems that are going to continue increasing.

Authors' reply

EDITOR—Most hand lacerations are incised wounds from sharp objects, and we apologise to those who were offended that we did not differentiate between incised wounds and blunt lacerations. Most hand wounds in emergency departments are incised, small, superficial, and uncomplicated wounds. Trained practitioners can provide excellent wound care and routinely assess these wounds to determine whether an underlying injury or foreign body exists.

Our trial excluded patients with wounds suspicious for underlying injury, and no underlying injuries were missed on the patients enrolled in the study. De Souza's recommendations to have trained people assess all hand wounds and refer suspicious cases were precisely the methods followed in our study. These are the standards of care in any emergency department in North America and hopefully in the United Kingdom as well.

Contrary to Dunn and Watson's comments, our study does not trivialise small hand lacerations, and we are concerned that anyone would conclude this. All wounds in our study received the same initial care regardless of wound closure (sutures or a simple dressing). This care included history taking and examination by a trained practitioner followed by appropriate general wound care. The only difference in the two groups was the method of closing the wound. We think that underlying injuries may be missed regardless of the closure method used. In addition, small lacerations closed without thought or proper examination are at risk of becoming occult injuries and are also likely subject to a higher risk of infection.1

We admit that we could have better described the wound care techniques used in this study. We assumed that most readers were knowledgeable about this or had access to the numerous articles and texts on the topic, 2 but our assumption in no way condones ignoring small hand lacerations.

Finally, the BMJ unfortunately selected photographs to accompany our article that were neither from our study nor reviewed by us before publication. It is hard to comment on the eligibility of such lacerations from photographs, but the location and apparent depth of the wound make it likely that such a wound would have been ineligible. The pictured wound is misleading and may have caused some of the concerns generated by hand surgeons.