Letters

Rapid Responses from bmj.com

Setting precedents for the treatment of hand lacerations

Stitch marksI can tell the difference

Patient knowledge as a confounding factor

Why am I not convinced?

Editor's summary

From BMJ USA 2002;October:558

As of September 19, 2002, this article had generated 32 Rapid Responses (http://bmj.com/cgi/eletters/325/7359/299) from which the following edited excerpts are taken.Editor

Setting precedents for the treatment of hand lacerations

EDITORIt is not stated who assessed the wounds, but I assume it was the authors. I am sure that they have great experience in hand assessment, but it has been reported that up to 49% of hand and forearm lacerations result in subclinical deep injuries. Even hand surgeons miss 16% of tendon injuries. My major concern is that this study might set a precedent for junior staff to treat all such injuries with minimal deference.

Although the study quantified the patients' subjective assessment of the pain of treatment, there was no mention of the occasionally disabling symptom of scar tenderness. Theoretically, an unsutured laceration will have a greater tendency to granulation tissue formation, with the possibility of a greater degree of disorganized reinnervation. I note that return to normal activities was similar in both groups, but people often return to activities such as work out of necessity and in spite of symptoms such as hyperesthesia.

Jonathon M Pleat, Duke of Kent Research Fellow in plastic and reconstructive surgery. 
Stoke Mandeville Hospital, Aylesbury, UK jonathon.pleat{at}talk21.com

Stitch marksI can tell the difference

EDITORI doubt that the doctors who independently evaluated cosmetic appearance at 3 months were truly unaware of the method of treatment. Sutures can create impression markings, and careful wound inspection could detect those with previous stitching. Furthermore, without the quality of the photographs having been specified (eg, professional versus amateur photography) or validated, the assessment of the doctors was no more than guess work. No wonder there was no difference between the two groups.

I wonder how wounds could be assured of neurovascular and tendon integrity without being first properly explored under local anesthesia. If all wounds were explored, then the time advantage (duration of treatment) and reduction in pain may not turn out to be genuine. It is highly likely that the pain of the suture procedure was due to the injection of local anesthetic; suturing itself is pain-free. With proper exploration, all the advantages of the conservative approach would become null.

Ludwig Tsoi, senior medical officer. 
HKG tsoich{at}ha.org.hk

Patient knowledge as a confounding factor

EDITORThe patients who refused to enter the study could perhaps have felt that their wounds were too serious to be treated conservatively, and so using their own judgment removed themselves from consideration. The results for these types of wounds might not have been so good.

Colin D Fraser, general practice registrar. 
Crieff Health Centre, Crieff, UK cfraser{at}crieffhc.finix.org.uk

Why am I not convinced?

EDITORThe 6-point score may appear comprehensive, but it only compared those patients who achieved optimal results by 8-10 days. How have all the others done? How many achieved an optimal result within 2-3 days, rather than 8-10 days, and how many from each group still had problems at 12-14 days? My own experience with non-sutured wounds is that they require dressings for much longer than sutured wounds, with resultant inconvenience and disability. A sutured wound can allow near normal function, including bathing within days, while a non-sutured wound languishes behind with dressings for weeks.

Furthermore the BMJ is guilty of assuming, in their section "What Is Already Known on This Topic," that sutured wounds have an "increased risk of infection." From where do they derive this assumption? It has long been accepted that primary closure of wounds prevents infection. That is one of the principal aims of closure. Conversely, healing by second intention is invariably associated with at least superficial infection, which often precludes delayed closure. I accept that sutured wounds have higher infection rates than topical or suture-less closure, but they are less prone to infection than are wounds that are left open. If sutures were felt to be more risky than non-closure, then we would not bother to close elective wounds at all.This subject is important, but should we let one flawed paper overturn centuries of surgical common sense?

Adrian Fogarty, consultant in accident and emergency medicine. 
Royal Free Hospital, London, UK afogarty{at}btinternet.com

Editor's summary

EDITORThe Rapid Responses include replies from the lead author addressing a variety of these criticisms, including a protracted exchange with Professor Fogarty in which he defended the evidence that sutures potentiate infection and disputed the contention that wounds treated conservatively in the study were left open to contamination ("it is the dressing and not the suturing that prevents infection"). In response to the many readers who emphasized the need for wound exploration before closure, he stated that "wounds with suspected neurovascular, tendon, bone, or joint injury should be explored under anesthesia and usually referred to a hand surgeon. The experience of hand surgeons is, however, subject to referral bias. Most hand lacerations (80% in our study and in other research) presenting to emergency departments can be evaluated with a good history, physical examination, and gentle exploration without anesthesia. If a practitioner does not feel that they can fully evaluate a wound with this approach they should use local anesthesia and do a proper exploration. These wounds by our criteria would no longer be simple or uncomplicated and thus would have been excluded."