Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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missed injuries- missed opportunities
- Umraz Khan (9 August 2002)
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All hand lacerations need careful evaluation
- Shehan Hettiaratchy (9 August 2002)
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Stitich marks - I can tell the difference
- Ludwig TSOI (10 August 2002)
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Re: missed injuries- missed opportunities
- James V. Quinn (10 August 2002)
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Not Suturing Wounds
- ANDREW D LAWSON (10 August 2002)
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Re: Re: missed injuries- missed opportunities
- John R Perry (11 August 2002)
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Re: Stitich marks - I can tell the difference
- James V. Quinn (11 August 2002)
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What about lower cost?
- Ron Law (11 August 2002)
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Why an I not surprised?
- Peter R Bradley (11 August 2002)
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Stitch in Time?
- Dilip Menon (12 August 2002)
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Patient Knowledge as a confounding factor
- Colin D Fraser (12 August 2002)
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Setting precedents for the treatment of hand lacerations
- Jonathon M. Pleat (12 August 2002)
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Re: Setting precedents for the treatment of hand lacerations
- James Quinn (13 August 2002)
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Re: Patient Knowledge as a confounding factor
- James Quinn (13 August 2002)
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Additional reasoning to support secondary intention healing
- Sody A Naimer (13 August 2002)
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Why am I not convinced?
- Adrian Fogarty (14 August 2002)
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Were any of these wounds really "actively managed"?
- Heather A Ellison (14 August 2002)
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Hand Wounds
- Dr David F Cochran (14 August 2002)
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Re: Why am I not convinced?
- James Quinn (15 August 2002)
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Polymyxin B in wound treatment
- Dr JK Anand (15 August 2002)
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Treating simple small superficial hand wounds: What does the excellent RCT prove?
- Dr Ahmed N. Ghanem, MD, FRCS Ed. (15 August 2002)
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Photograph does the article a great disservice
- Martin J Heaton, Mark Henley, Consultant Plastic Surgeon and Ian Starley, Consultant Hand Surgeon (15 August 2002)
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Wounds heal better from gradual regeneration
- Stewart F Mitchell (16 August 2002)
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not all hand lacerations are the same
- Tim N Board (16 August 2002)
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Re: Re: Why am I not convinced?
- Adrian Fogarty (16 August 2002)
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The distinction between lacerations and incised wounds
- Matthew M Orde (16 August 2002)
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Re: Re: Re: Why am I not convinced?
- James Quinn (17 August 2002)
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Incisions are not Lacerations
- Alistair J Irvine, Stockton on Tees, Cleveland TS21 3HE (21 August 2002)
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Re: Re: Re: Re: Why am I not convinced?
- Adrian Fogarty (21 August 2002)
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The Danger of Not Suturing Hand Injuries
- MANSOOR S KHAN, Simon D Bann (22 August 2002)
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Suturing versus conservative management of lacerations of the hand
- Beryl A. De Souza, Mohammed Shibu,Graham Moir,Nigel Carver (28 August 2002)
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Hand lacerations should be explored before conservative treatment
- Roderick Dunn, Stuart Watson (2 September 2002)
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Umraz Khan, Consultant Plastic Surgeon Charing Cross Hospital, London W6 8RF
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Sir, It has been stated that a third of A/E (ER) attendees have a hand injury. I, therefore, read this article hoping that it would give guidelines on the management of these common injuries. Whilst the methodology is to be admired their conclusion may be mis-interpreted by the unwary. The main issue I have with this article is that of the potential trap of missing an injury to the underlying structures. Glass laceration are notoriuos for producing small puncture wounds in the skin but mutliple lacerations of the deeper structures. Clinical examination may fail to throw light on the state of the underlying nerve and tendon especially in children. There is of course the potential to have partial injuries to the tendons and nerves which only transpire some time after the event. Since the return of hand function is the ultimate goal of treatment (as it will determine the return to work in the majority of cases), the aim of management is to secure this as swiftly as possible. Missing an injury to an important structure will lengthen this time. Whether a hand laceration should be sutured or not is irrelevant, since the question is be whether it should be explored. The state of the underlying structures can only turly be acertained by surgical exploration with loupe magnification, tourniquete control and good lighting. This article should not support the routine of allowing small hand lacerations to heal by secondary intention for the sake of the patient as well as to prevent a trip to the law courts. |
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Shehan Hettiaratchy, Fellow Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston,USA
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Quinn et al's well designed study clearly shows that small lacerations in the hand do not require suturing. However it must be emphasised that even small hand lacerations can be associated with nerve or tendon injury. Signs of such injuries can be subtle and failure to detect them can lead to significant morbidity. A detailed history of the mechanism of injury and a careful clinical examination are vital. Unless a high level of suspicion is maintained when evaluating hand lacerations, concomitant injuries will be missed. If there is any concern about potential damage to underlying structures, then an immediate referral to a hand surgeon should be made. |
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Ludwig TSOI, Senior Medical Officer HKG
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One of the main outcome measures was cosmetic appearance after 3 months. "...the research assistant took a digital photograph of patients' healed wounds. Two independent doctors, who were unaware of the method of treatment, rated the photographs for cosmetic appearance..." I doubt very much the independent doctors are truly unaware of the method of treatment. Because stitiches could create impression markings on the sutured wounds. Careful inspection could of course detect the ones with previous stitching and those without. Those with excessive pressure would even give rise to zipper sign. Furthermore, the quality of the photographs is not ascertained. Professional photographer using state-of-the art camera could produce better quality photos than an amateur photographer using a digital camera. Without the quality of the photos being validated, the assessment of the two independent doctors was no more than guess work. No wonder there is no difference between the 2 groups. For hand wounds, proper exploration to exclude "associated or suspected neurovascular, tendon, or bone injury" for full thickness wounds is of paramount importance, and this is usually done under local anesthetic. I wonder wounds like the one depicted in this issue's BMJ cover could be assured of neurovascular and tendon integrity without being first properly explored under local anesthesia. Furthermore, if all wounds were explored, then the time advantage (duration of treatment) may not turn out to be genuine. The same rationale also applies to the pain score. It is highly likely that the pain during the suture procedure was due to the injection of local anesthetic, the suturing was painfree. So with proper exploration, all the advantages of the conservative approach would become null. |
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James V. Quinn, Associate Clinical Professor University of California, San Francisco
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Dr. Kahn, Thank you for your interest in our article, your strongly worded letter requires a reply. I think you failed to realize that all patients were examined prior to inclusion into the study and the high risk wounds you are correctly concerned about were excluded. This study only involves uncomplicated hand lacerations which are clearly defined in the study. Most wounds seen in emergency departments are uncomplicated and easily treated without specialist referral. It is the emergency physician's job to identify complicated wounds or those at risk for complications requiring referral to a specialist such as yourself. The study purpose is not to ignore treating hand lacerations and it does not advocate that the initial history and physical exam be ignored. In fact a good history and physical were imperative to determine which patients were eligible for the study. Physicians who utilize our conservative treatment strategy should be well aware of this. While practice in England may be different than that in the USA, I doubt a specialist would see any of the uncomplicated lacerations treated in this study. It is unfortunate that you have misunderstood the exclusion criteria and the purpose of the study. |
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ANDREW D LAWSON, Consultant Anaesthetist Chelsea & Westminster Hospital
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Editor- I read with interest the paper on conservative management of lacerations of the hand. Last summer on holiday in France I sustained a 2.5cm full thickness laceration to my forehead. After driving back to our house with my right hand, the left hand compressing the wound, we had to decide what to do. We had forgotten our usual minor injury pack . Training told my wife and I that we should head off to the nearest hospital, however we cleaned the wound and opposed it with some strips of plaster. The strips were changed at three days and I am left with a near invisible scar which a plastics consultant said is a s good as any surgical result. The lesson, not everything we are taught is true and we should constructively criticise established techniques. Dr Andrew Lawson FFARCSI FRCA FANZCA
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John R Perry, General Practitioner Cambridge CB4 1GL
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I read Quinn et als paper with interest. I think the BMJ cover photograph of a complicated finger injury with evident risk of vascular and nerve damage is a misleading link to this paper on uncomplicated hand injury. It may make an eyecatching cover but it subverts the message of the study. A more appropriate photograph might be less dramatic but would reduce the risk of sending the wrong message. |
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James V. Quinn, Associate Clinical Professor University of California, San Francisco, 94143-0208
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Dr. Tsoi, You raise so interesting and valid points that I should clarify. When I started my career in research involving wound care and wound closure, I was frustrated to find that most research involved case studies and few if any made attempts to critically evaluate clinical outcomes. Tremendous amount of work has been done developing and validating the clinical wound evaluation scales and techniques used in this study. They involve using standardized techniques for medical photography, allow the blinded evaluation of wounds and lacerations and are referenced in the manuscript. Given your interest I invite you and others to review them. Like the others you are correct that wounds with suspected neurovascular, tendon, bone or joint injury should be explored under anesthesia and usually referred to a hand surgeon. Unfortunately I think your experience like other hand surgeons is subject to referral bias. In fact most hand lacerations (80% in our study and reported by other researchers as well) presenting to emergency departments can be evaluated with a good history, physical exam and gentle exploration without anesthesia (note conservative treatment is not completely painless due to this gentle exploration and irrigation without anesthesia). If a practitioner does not feel at they can fully evaluate a particular 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 from the study. In reality most hand lacerations are caused by household accidents. They are small, simple and uncomplicated not requiring referral to a hand surgeon. Even those of us in emergency medicine are also subject to bias since many people with simple lacerations, that normally would be sutured if they showed up in an emergency department, treat themselves conservatively at home. No research has been done on the ability of patients to assess their own hand wounds and I am not advocating that patients avoid seeking care for their small simple hand lacerations. All wounds need proper evaluation and wound care including irrigation and ascertainment of tetanus status. However once it is clear that their is no underlying injury we have merely shown what many lay people have known for years, these simple hand lacerations heal just fine without sutures. We should not feel obligated to suture patients with small, simple hand lacerations just because they they show up in the emergency department. However we should not ignore or down play these injuries either. They still need proper wound evaluation and wound care. Finally the laceration pictured in the BMJ was not from our study. Without knowing more about the wound I can not comment on its eligibility for the study. |
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Ron Law, Consultant Beyond Alternative Solutions, Waitakere City, New Zealand
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Quinn et al conclude their excellent article with the words, "What this study adds: Non-suturing of hand lacerations of <2 cm produced similar cosmetic and functional outcomes to suturing and was faster and less painful." They should also have included the words, "and considerably less cost -- especially if the cost of removing sutures and treating infected sutures is taken into account." An excellent treatment for rapid wound healing is to keep them moist -- honey provides a cheap option for safe and effective wound treatment... |
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Peter R Bradley, GP 4127 Qld Australia
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Sometimes intuitive logic obviates need for controlled studies. I've long been an advocate of the above from as soon as steristrips and similar became available. Probably because I remembered the beaut cuts on the fingers and palms I often gave myself 'whittlin' down on the farm as a kid, when I knew I'd be for it if Mum found out - (not about the cut, but using her best kitchen peeling knife for the purpose) - so I'd just whack on a bandaide - pulling the edges together as I did so, went about my business, and they all healed perfectly. I have always felt Suturing these is just adding further insult to injury - or probably better put - further injury to the original assault. And the patients love you for it. Unfortunately, I feel some may elect to suture these because of the perverse incentive of the fee being higher in many jurisdictions. |
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Dilip Menon, Specialist Registrar Emergency Unit University Hospital of Wales
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Quinn and Cummings paper suggests recent,non-bleeding,full thickness distal to the volar skin crease hand lacerations less than 2 cm with no neurovascular,tendon or bony injuries can be managed conservatively with similar cosmetic and functional outcomes to suturing and less pain. As an emergency physician,I would like to share my experience and concern with this practise.The exact site of these wounds is important and could have been clarified in the paper.I tend to suture such full thickness wounds as it encourages my patients to move their fingers with the reassuarance the edges won't gape and the wound won't rebleed which are two major concerns expressed by them.Another point is keeping the area clean and washed if change of dressing is required which is easier with primary closure.Often bleeding at presentation or rebleeding requiring compression during cleaning of the wound shifts the focus to suture hemostasis sparing the physician or his assistant the additional time required to wait for the bleeding to stop.I find the use of local wound anaesthetic an excellent aid to good wound assessment,cleaning and assessment of distal neurovascular and tendon function which the conservative route may compromise mainly due to pain at the site.The irony is that the incised wound(glass.knife)that seems most amenable to conservative care is the wound that is at greatest risk of neurovascular damage compared to the blunt injury induced jagged laceration that is often only skin deep and sparing deeper structure injury.I find the value of the findings in this paper is probably most relevant in the paediatric patient population where sparing children(and the physician!) the trauma of painful injections,suture and later suture removal by conservative treatment without compromising their wound care,cosmesis and functional outcome an excellent alternative. Dilip MENON
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Colin D Fraser, GP registrar Crieff Health Centre, Crieff, Scotland. PH1 5NP
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I read with great interest your study and was of course impressed. I would gladly forego suturing these sometimes difficult wounds, and I'm sure that the patients will be pleased not to have to be put through the torture of a ring block. However I was unsure as to whether all wounds were actually included in the study. The patients that refused to enter the study, could they perhaps have felt that their wounds were too serious to be possibly treated conservatively, and so using their own judgement removed themselves from consideration. If this was so, it may be that the results of conservative treatment of these types of wounds, not included in the study but actually meeting your criteria, may not have been so good. I may have missed it in your study, and if I did I do apologize, but I would like to see the initial wound characteristics of those patients that did not allow themselves to be entered into the trial. Thank you for a potentially very useful study, well done. Colin Fraser |
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Jonathon M. Pleat, Duke of Kent Research Fellow Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Aylesbury, UK.
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Editor - I welcome the paper by Quinn et al. (BMJ 2002; 325:299) on suturing versus conservative management of hand lacerations. There have been many papers showing the great burden this type of injury places upon accident and emergency/emergency room resources. Indeed, for all hand injuries it has been suggested before that, "Over half the patients needed only reassurance or a simple dressing..." (J Hand Surgery (B) 1985; 10: 298), and that, "The vast majority of the presenting patients could have been treated in a modern, well equipped GP surgery" (J Roy Coll Surg Ed 1996; 41: 401). There is undoubtedly a need to more effectively sift the wheat from the chaff. However, I must concur with the responses of Khan and Hettiaratchy and also add one additional consideration. Who assessed the wounds to ensure that there was no, "...associated or suspected neurovascular, tendon or bone injury"? It is not stated, but I assume that it was the authors. I am sure that they have great experience in hand assessment, and it appears that there were no major complications within their study, but it has been reported that up to 49% of hand and forearm lacerations result in deep injuries that are subclinical (Br J Surg 1992; 79: 765). Even hand surgeons miss 16% of tendon injuries on clinical grounds (J Hand Surg (B) 1998; 23: 482). The corresponding figure for junior accident and emergency staff was 36% of such injuries. The latter group's knowledge of hand anatomy may be far from ideal (Arch Emerg Med 1992; 9: 14). My major concern is that in the light of Quinn and colleagues' study, there may be a precedent for junior staff to treat all such injuries with minimal deference. There is no substitute for experience and I would reiterate a point that Quinn makes in one of his responses, "All wounds need proper evaluation". As detailed by previous correspondence, this should include a thorough exploration for deeper injury when there is any uncertainty on clinical assessment. The article may have circumvented some of this criticism with a more detailed description of the exact means of testing for deeper injury, for example two-point discrimination for touch sensation. Additionally, this would have reinforced the rigorousness of assessment to the more junior reader. Finally, although the study seemed to quantify the patient's 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 hyperaesthesia. Was this considered by the authors? |
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James Quinn, Associate Clinical Professor University of California San Francisco
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Dr. Pleat, Like all the other correspondence I appreciate the interest our article has generated. I agree that most of the criticism of the article revolves around my assumption that it is already "precedent" that a competent person will evaluate these wounds. This article was on a wound closure technique and its purpose was not to be a review article on proper wound evaluation and management. If space and time allowed I would have gladly written a review article on the subject to accompany our article. However there are many articles and book chapters on the topic including several co-authored by myself (see. "Evaluation and Management of Traumatic Lacerations, NEJM 1997;337:1142- 1148"). I must emphasize that no one in our study came back with a missed injury, including hyperesthesia. I say that because many have voiced concerns that somehow our study insinuates that these wounds can be ignored resulting in missed injuries. To the contrary all wounds in our study were carefully examined by competent practitioners. If they had any suspicion of an underlying injury they excluded these wounds ( note 20% of wounds were excluded and not all because they were greater than 2 cm, some were excluded because of this suspicion). While this does involve judgment, which may vary with comfort level and experience among practitioners, I expect that anyone employing our conservative treatment protocol would ensure that the wounds are examined carefully and deemed to be "simple and uncomplicated" by a competent practitioner. If practitioners are going to be responsible for the care they provide they need to have some competency. I do not think it is too much to expect that all practitioners who care for wounds have some competency in wound care. If wounds are evaluated properly the wound closure method should not be a risk factor for a missed injury. I apologize if some felt my assumptions that a competent person would care for wounds was erroneous. As a physician, teacher and researcher dedicated to the proper care of wounds I want to make sure my position is clear on this matter. |
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James Quinn, Associate Clinical Professor University of California, San Francisco
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Dr. Fraser, Thanks for your thoughtful comments. In response to your question, length was not any different (not surprising since it was a criteria for consideration) nor were the patient demographics for those who refused to participate, but were eligible for the study. As well many patients in the refusal group actually chose conservative treatment instead of suturing. |
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Sody A Naimer, Lecturer Department of Family Medicine , Faculty of Health Sciences, Ben Gurion University, Israel
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Dear Editor, This study adds a substantial basis of data to lean back on clinically and medicolegally in the era of evidence based medicine. Cost and comfort are major issues but an additional consideration paramount in technique choice is the complication rate. This study was too small to bring out statistical significance, but the established decrease of infection rate with secondary intention healing adds further support to choose secondary intention healing. I am surprised time and time again to learn of the ignorance of physicians nurses, students and patients of the simple fact that suturing a wound increases the probability of it becoming infected. I would not be surprised if one of the main concerns of the large group of patients refusing to participate in the study was erroneous fear of a wound infection if the presented laceration is not sutured! |
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Adrian Fogarty, Consultant in Accident & Emergency Medicine Royal Free Hospital, London
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Professor Quinn's article raises important points about a standard surgical topic that is normally taken for granted. However the study is far from comprehensive enough to satisfy those of us who have experienced the vagaries of wound management on many occasions. Quinn's six-point wound assessment score may appear comprehensive, but he only compares those patients who achieve optimal results by 8-10 days. How have all the others done? How many from each group have fared averagely and how many have poor results? 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 of 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. We do not need a blinded trial to tell us this, our patients will let us know if we open our eyes! Furthermore the BMJ are guilty of assuming that sutured wounds have an "increased risk of infection" in their section "what is already known about this topic". From where do they derive this assumption, which is not substantiated by references? It has long been accepted that primary closure of wounds prevents infection, indeed that is one of the principle aims of wound closure. Conversely healing by second intention is invariably associated with at least superficial infection, which often precludes delayed closure. Finally Quinn's arguments become blurred in the final paragraph; he speaks of dehisced wounds healing without complication (surely their healing is by definition now delayed?), and he compares with delayed primary closure (aren't these wounds surgically closed?). Yes, there are recognised phases to wound healing, but they are accelerated by primary closure, when exuberant granulation is minimised and when epithelialisation is allowed to progress unhindered. Maturation, including wound contraction, is then of lesser importance. This subject is important, but should we let one flawed paper overturn centuries of surgical common sense? |
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Heather A Ellison, Visiting Medical Officer Wesley Emergency Centre, Wesley Hospital, Brisbane Australia 4064
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Quinn et al study unfortunately does not enlighten me as to the best way to treat hand wounds. The authors report that patients in the sutured group were instructed to "keep the wounds clean and dry" Could the authors provide evidence to support this advice? My understanding of surgical wounds and washing is that there is no excess infection in wounds washed and bathed as usual. My own personal experience in the emergency department setting in that wounds kept "clean and dry" are anything but that at the time of suture removal. Often caked with blood and serum, suture removal becomes taxing and difficult, particularly with children. Conversely, wounds washed abd dried as usual, cause no such difficulties. Both groups of patients in Quinn et al's study appear to have had to keep their wounds covered and dry for up to 10 days. Equal satisfaction with the treatment modes could equally well be reported as equal dissastisfaction: no patient could return to normal activities for quite some time. My patient population is a well educated, employed group. Few of them would tolerate this enforced inactivity of one hand for up to 10 days without a very good reason. I recommend to them the treatment I would want for myself: infiltration of the wound with buffered lignocaine, cleaning, exploration and suture. A simple dressing, some simple analgesia and I will be back at work immediately. I await evidence that this true active management of simple wounds is in any way detrimental |
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Dr David F Cochran, Medical Director, Forensic Medical Examiner Service Lothian Primary Care NHS Trust, 3 Morningside Terrace, Edinburgh, EH10 5HG
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Editor, As a Forensic Medical Examiner often asked for an opinion regarding causation of hand wounds I was disappointed and concerned that the prominent illustrations on the front cover and within the Journal (BMJ 2002; 10 August 2002) are clearly incised wounds and most definitely not lacerations. Similarly Quinn et al use the term laceration inappropriately. Lacerations are caused by blunt force trauma with tearing and mangling of the tissues with resultant tissue damage and often delayed healing. Incised wounds "cuts" are caused by sharp force trauma and clearly form the bulk of the data contained within the study. The distinction between hand lacerations and hand incised wounds is of huge medico-legal and clinical significance and the Authors should be given the opportunity of clarifying this important matter. Dr David F M Cochran
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James Quinn, Associate Clinical Professor University of California, San Francisco
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Dr. Fogarty, You should care for your patients based on your experience, judgment and comfort level. Suturing wounds is a good option for your patients. Your approach will rarely be questioned, but for the sake of the needle phobic and frightened person you should consider suture less options where appropriate. I do not expect to change your mind, but please review the paper again. We knew it was important to assess early functional status. In our study return to normal activity (full use of their injured hand) regardless of treatment was the same in both groups and not effected by conservative management. That and the primary outcome of 3-month cosmesis are the main outcomes. None of the other measures were different between the two groups. More frequent and daily wound assessment would be a waste of resources if not impossible in any clinical trial. I respect your opinion and while I may disagree with your interpretation of our study your letter makes some factual comments about sutures that are inaccurate and need correction. "… the BMJ are guilty of assuming that sutured wounds have an "increased risk of infection" in their section "what is already known about this topic". From where do they derive this assumption, which is not substantiated by references? It has long been accepted that primary closure of wounds prevents infection, indeed that is one of the principle aims of wound closure. Conversely healing by second intention is invariably associated with at least superficial infection, which often precludes delayed closure." The BMJ and I are correct in our statement; this is not an assumption and is backed by strong evidence. I also encourage you to read the letter of Dr. Naimer on this subject. There is no doubt that sutures are associated with higher infection rates compared to topical or suture less closure. They are a foreign body and act as a nidus for infection in contaminated wounds (note all wounds are contaminated to some degree). This infection rate is probably clinically important in wounds contaminated with greater 105 colony forming units and varies among different types of sutures. Another reason why proper wound care (irrigation) is important. The literature on this is extensive but I have included a few key references for your review. 1-3 1. Edlich RF, Panek PH, Rodeheaver GT. Physical and chemical configuration of sutures in the development of surgical infection. Ann Surg 1973; 177:679-687. 2. De Holl D, Rodeheaver G, Edgerton MT, Edlich RF. Potentiation of infection by suture closure of dead space. Am J Surg 1974; 127:716-720. 3. Quinn JV, Maw JL, Ramotar K, Wenckenbach G, Wells GA. Octylcyanoacrylate tissue adhesive wound repair versus suture wound repair in a contaminated wound model. Surgery 1997; 122; 69-72. |
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Dr JK Anand, Retired public health physician
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I note that the patients in this trial invariably received topical Polymyxin B. Local antibiotics are not exactly smiled upon in such situations in the United Kingdom. May be the authors have a point in using it in patients with contused wound margins or dirty wounds, as opposed to clean incised wounds? The views of the UK A&E consultants would be most helpful. Dr JK Anand |
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Dr Ahmed N. Ghanem, MD, FRCS Ed., Consultant Urological Surgeon, King Khalid Hospital, Najran, Saudi Arabia
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Dear Authors and Editors I am writing truly to express my admiration for this excellent RCT [1] that is well constructed, conducted, reported and of the type "BMJ loves" as the Editor himself described it [2]. The methodology and analysis are of great educational value to readers and authors of future RCT studies. I have also read all the correspondence on the study with the many valid criticisms made and the competent replies by authors. I wonder if both the editors and authors would light heartedly entertain most concerned criticisms of RCT in general taking this excellent model as example: What do such studies actually add to our knowledge, and is the final conclusion actually convincing to the learned readers? Carefully assessing the conclusion of the article and the rapid responses, one finds that the most convincing criteria of the concluded point depended on factors not studied at all or was presumed by the authors, namely: Competent assessment of the injury by an experienced doctor who employs common sense on how best to treat a specific hand wound that fit the defined criteria possibly summarized as 3Ss (Simple, Superficial and Small) hand wounds. One may safely assume that such wound must had also involved a hand crease, as those perpendicular to the crease may gap widely and lead to an ugly scar if not approximated by sutures or taps. The authors themselves state that they had anticipated the results of their study. No doubt that their medical, and possibly childhood experience with own cut wounds too, would lead to the same conclusion when again competent assessment, experience and common sense culminate in a wise decision on the best method of therapy of either suturing or conservative. Many readers may even favour their own conclusions of treating such wounds of similar criteria using adhesive taps! Or, for EBM sake, should this be proved by another RCT? My questions now, and please forgive me if I overlooked the point, does the powerful and sound statistical results used in this study support the conclusion? If this is so, why are there so many arguments and criticisms that require further qualifications and explanations? The authors also state that the conclusion should not apply to other areas such as the face. So, must all the work, effort and expense be repeated to studies of other body areas in order to reach a common sense answer? Yours faithfully, Dr Ahmed N. Ghanem, MD, FRCS Ed.
References 1. Quinn J, Cummings S, Callaham M, Seller. Suturing versus conservative management of lacerations of the hand: randomised controlled trial BMJ 2002;325: 299 2. EDITOR'S CHOICE. Surgery: the worthy produce of heaven. BMJ 2002 325: 0. |
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Martin J Heaton, SpR Plastic Surgery Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, Mark Henley, Consultant Plastic Surgeon and Ian Starley, Consultant Hand Surgeon
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Sir, We were somewhat concerned following the article by Quinn et al particularly in view of the prominence of the accompanying photograph on the front cover. In our opinion the relevant question for this wound is "how urgently should it be explored" not whether it should be sutured or not in an emergency department without adequate light and magnification. In our experience wounds such as the one illustrated are frequently associated with partial flexor tendon damage and partial or complete division of the neurovascular bundle requiring repair and yet may be accompanied by few symptoms. We would be interested in knowing who selected the photograph, since, if it was not one of the authors, it does their article a great disservice and will only encourage incorrect management. |
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Stewart F Mitchell, Consultant Naturopath Exeter Devon
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Naturopathic treatment of wounds involves simple cleansing followed by a firm, cool moist dressing which does not aim to inite the wound. This has been shown to be spectacularly effective for burns, ingrained injury, laceration and birth tear to second degree. Patients are often initially apprehensive because of 'stitching consciousness' but quickly adopt the treatment because the cool dressing instantly eases pain. While wounds sometimes need to be dressed for longer periods than conventional dressings a clear advantage is that as a result even aged tissues remain supple, and scarring is minimal |
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Tim N Board, SpR Orthopaedics, North West Rotation Blackpool. FY3 8NR
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I read with interest the article by Quinn et al suggesting that small hand lacerations could be treated conservatively with no detriment to the patient. I would be interested to know if they found any difference in outcome based on the site of the laceration, in particular palm versus finger and volar versus dorsal lacerations. On may expect that volar lacerations on the fingers and palm would be more troublesome than dorsal ones due to the skin excursion. The authors state that return to normal activities took a mere 3.4 days in both groups. Was it that they had no manual workers in their treatment groups as I find it difficult to beleive that any such person could return to normal activity, ie work after this time. I also find their choice of photograph for the article very concerning as it seems to show a laceration that should niether be left alone or sutured in an emergency department but explore fully in theatre as lacerations like the one shown are frequently accompanied by digital nerve and flexor tendon damage. |
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Adrian Fogarty, Consultant in Accident & Emergency Medicine Royal Free Hospital, London
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Professor Quinn misses my point. He states that sutured wounds will have higher infection rates than topical or suture-less closure. I accept this, but my point was that sutured wounds are less prone to infection than wounds which are left open. And Quinn's paper studied the treatment of wounds by "non-closure", i.e. his paper did not consider other methods of closure. When asked for evidence, I was not impressed that Quinn quoted a rapid response posted the day before! Later Quinn does quote some published work but these papers are hopelessly outdated, before monofilament materials were developed! One paper considers dead space closure, and here the "nidus of infection" argument is accepted unlike with skin sutures. Another paper compares suturing with closure using tissue adhesive - again this was not the subject of Quinn's paper or of my argument. I accept that atraumatic methods of closure are valuable in wound management, but I don't accept that non-closure provides a superior result to sutured closure in most cases. |
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Matthew M Orde, Specialist Registrar in Histopathology Royal Sussex County Hospital, Brighton, BN2 5BE
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Editor- The recent paper by Quinn and colleagues regarding the management of hand 'lacerations' (1) is imprecise in its terminology and has the potential to mislead, with potentially significant forensic implications. The paper refers predominantly to 'lacerations', but elsewhere mentions 'cuts'. No definitions of these terms are provided. Furthermore, photographs on the front page of the week's BMJ and also in a leader article - both referring to the paper - depict wounds that are clearly incised in nature and not lacerations. Lacerations are produced by tearing of the tissues due to the appliance of force beyond the limits of elasticity. Incised wounds, on the other hand, occur when the tissues are sliced by a sharp object. The former are ususally jagged in outline whereas incised wounds are often neatly divided. There may be bruising, abrasion and crushing of the margins of a laceration. Hair overlying a laceration may also remain intact and on closer examination residual tissue strands may be seen traversing the wound. Any underlying bony injuries may also provide a clue as to the nature of the wound (2). The distinction is important as it implies a method of causation. This may have profound implications in later legal actions. For example, an accused charged with inflicting injuries with a knife would be greatly assisted in his defence by a doctor's report describing the victim's injuries as 'lacerations'. Whilst the distinction may not always be clear, an attempt should always be made to differentiate between the two and to document the findings clearly. 1. Quinn J, Cummings S, Callaham M, Sellers K. Suturing versus conservative management of lacerations of the hand: randomised control trial. BMJ 2002;325:299-300. 2. See for example: Knight B. Forensic Pathology, 2nd Ed. London, Arnold, 1996. Matthew M Orde, DMJ (Path), Barrister. (I have no competing interests.) Specialist Registrar in Histopathology,
Royal Sussex County Hospital,
Brighton,
BN2 5BE.
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James Quinn, Associate Clinical Professor University of California, San Francisco
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Dr. Fogarty, Please take the opportunity to actually read the literature before making further comments. Edlich's papers are time honored, not outdated and use monofilament sutures. My references were in response to your initial comments ".. BMJ are guilty of assuming that sutured wounds have an "increased risk of infection" in their section "what is already known about this topic". From where do they derive this assumption...". These references support the claim made in the BMJ that sutures do carry an increase risk of infection compared to other closures. Wounds in our study were not left open to further contamination and increased infection as you suggest (note the only infection in our study occurred in a sutured wound). You obviously miss the point that it is the dressing not the suturing that prevents contamination and infection, and there is overwhelming evidence that sutures potentiate infection. More of Edlich's work. "Studies in the management of the contaminated wound. VII. Susceptibility of wounds to postoperative surface contamination". Am J Surg 1971. |
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Alistair J Irvine, Forensic Medical Examiner Medico-Legal Services, Neasless Farm, Sedgefield,, Stockton on Tees, Cleveland TS21 3HE
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Editor James 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. 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 of the journal, that these are incised wounds and 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, it is certainly my experience that full thickness wounds to the hands are more commonly incised wounds, which are the result of contact with a sharp bladed object or implement, and 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 would appear 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 others, namely Milroy and Rutty and Norfolk and Stark. 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 respect of the medico-legal 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. I fear that without the reintroduction of formal training in forensic medicine for medical students, these are problems that are going to continue increasing. References Milroy C. M., Rutty G. N. "If A Wound Is "Neatly Incised", It Is Not A Laceration" BMJ 1997;315:1312 Norfolk G. A., Stark M. M. "The Future Of Clinical Forensic Medicine" BMJ 1999;319:1316-1317 |
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Adrian Fogarty, Consultant in Accident & Emergency Medicine Royal Free Hospital, London
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There appears to be some confusion. Professor Quinn now states "these references support the claim made in the BMJ that sutures carry an increased risk of infection compared with other closures". This I can accept, but this is not what the BMJ printed, and this was not the subject of Quinn's article. Quinn's article did not compare suturing with other methods of closure, while the BMJ simply stated of sutures that their "placement is not without associated increased risk of infection". But increased compared with what? They do not clarify. Both Quinn and the BMJ editors are being misleading. It is accepted that the use of sutures carries a slightly higher risk of infection compared with other methods of closure, but it is not accepted that sutures carry a higher risk of infection compared with no closure at all - the subject of Quinn's article. This is one of the principle reasons that we close wounds, to prevent infection. An open wound will invariably become contaminated, the risk rising over the first few days, and closure clearly prevents this. If sutures were felt to be more risky than non- closure, then we would not bother to close elective wounds at all. I have no objection to studies like Quinn's but I object to the BMJ "throwing" assumptions at us this way, which Quinn has clearly seized upon and amplified. The presentation of the "what is already known on this topic" section was simplistic and misleading, and served only to confuse the debate surrounding this paper, which did not really consider wound infection in the first place. The BMJ should not have commented on infection risk in this section, especially when it was not the primary focus of the article. |
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MANSOOR S KHAN, Clinical Research Fellow Academic Surgical Unit, St Mary's Hospital, Paddington, London W21NY, Simon D Bann
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Dear Sir, We read with great interest the article by Quinn et al “Suturing versus conservative management of lacerations of the hand”. It is nice to see that not all hand injuries need to sutured. However, the article does raise some queries. The authors state that wounds that are not sutured will heal normally. This depends on the definition of normal. Of course, it will heal, but the cosmetic appearance is also important. The best cosmetic result will be achieved with suturing. Also, secondary problems may arise due to scarring below the wound leading to a functional defect. Furthermore, the authors have very strict exclusion criteria for the trial. In our experience of hand surgery, these criteria exclude over 95% of patients that are treated by hand surgeons in the UK. Therefore, the non suturing of hand wounds would be of little use to any hand injury that is seen. There is also a risk that a wound may be less than 2cm, but hide serious damage beneath, for example, a stab injury may not show any underlying defect even after thorough clinical examination, but may hide a 50% laceration of the underlying tendon. This may present days later with a tendon rupture, resulting in further surgery. This then highlights the case for exploration of all suspected serious hand injuries. The final point is that the diagnosis of eligible hand injuries for conservative management has to be made by an experienced hand surgeon. Anyone who has not had considerable experience with hand injuries would not be in a position to diagnose an uncomplicated hand injury, in case a wrong diagnosis is made. Therefore, although it a good idea to treat some wounds conservatively, for hand injuries there is too much at risk to do this, and the majority of hand surgeons would still advocate exploration of any suspicious hand injury. |
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Beryl A. De Souza, Plastic Surgery Registrar Bart's & The Royal London Hospital, Whitechapel, London E1 1BB, Mohammed Shibu,Graham Moir,Nigel Carver
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Dear Sir, We would like to commend the authors Quinn et al 1 on an elegant study showing conservative treatment is faster and less painful for small uncomplicated lacerations of the hand. However, we think it is imperative that lacerations in the hand no matter how small be examined thoroughly to exclude tendon, nerve or joint injuries. 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 produces unimpressive skin wounds but commonly divide flexor tendons and nerves in the forearm 3. In the emergency setting we suggest that it is vital to take a good history from the patient with regard to 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 us hand trauma cases 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 the cases are referred to us and formally explored in theatre. Beryl A. De Souza, Plastic Surgery Registrar
Mohammed Shibu, Consultant Plastic Surgeon Graham Moir, Consultant Plastic Surgeon Nigel Carver, Consultant Plastic Surgeon Department of Plastic Surgery, Bart's & The Royal London Trust, The Royal London Hospital, Whitechapel, London E1 1BB. References 1. Quinn J., Cummings S., Callaham M. & Sellers K. Suturing versus conservative management of lacerations of the hand: randomised controlled trial. BMJ 2002;325:299-300. 2. Schwager R.G., Smith J.W. & Goulian D. Small deep forearm lacerations. Plast & Recons Surg. 1975;55:190-194. 3. Joseph K.N., Kalus A.M. & Sutherland A. B. Glass injuries of the hand in children. Hand 1981;13:113-119. |
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Roderick Dunn, Specialist Registrar West of Scotland Regional Plastic Surgery and Burns Unit, Canniesburn Hospital, Glasgow, G61 1QL, Stuart Watson
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Editor, We are surprised by the BMJ’s publication of Quinn et al’s article on conservative treatment of small hand lacerations. 1 Their conclusions will come as no surprise to surgeons who treat hand injuries frequently, 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 following 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 judgement 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 it is explored under local anaesthetic by someone experienced enough to make this judgement. If neglected, injuries to these structures will usually result in permanent functional disability. Wounds which 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 Accident and 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 which 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. Yours sincerely, Roderick Dunn
Stuart Watson
1. Quinn J, Cummings S, Callaham M, Sellers K. Suturing versus conservative management of lacerations of the hand: randomised controlled trial. BMJ 2002;325:299-300. 2. Brown PW. Open injuries of the hand. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green's Operative Hand Surgery, Philadelphia: Churchill Livingstone, 1999:1612-4. 3. McCash CR. The open palm technique in Dupuytren’s contracture. Br J Plast Surg 1964;17:271-80. |
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