Injury, Int. J. Care Injured 32 (2001) 373–376

A new approach to the management of pretibial lacerations

John Silk *Accident and Emergency Department, Whipps Cross Hospital, London, E11 1NR, UK

Accepted 20 December 2000

Abstract

This paper describes a technique for the management of pretibial lacerations by deep reinforced suturing through steristrips,which are applied parallel to the wound edges. This is carried out under local anaesthesia and followed by application of gentlelocalised compression dressing. Typical victims of pretibial lacerations are the elderly and patients on long-term systemic steroidtherapy. This suturing technique, which was used on both flap and linear lacerations, obliterates the dead space in the wound andprevents tearing of the thin, fragile skin of these patients. The dressing technique used, has a great advantage over the toes to kneepressure dressing currently used for such lacerations, because it frees the foot of bandaging and allows the patients (especially theelderly with decreased mobility) to wear their normal footwear immediately post-operatively and to maintain their normalmobility.

In the total sample of 147 patients treated by this method, the average healing time was 26 days for 112 patients with flaplacerations, and 16 days for the remaining 35 patients with linear lacerations. This is significantly shorter than that reported inthe medical literature using both non-operative methods and simple suturing. Moreover, none of these patients required skingrafting or hospitalisation (except for social reasons). © 2001 Elsevier Science Ltd. All rights reserved.

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1. Introduction

Pretibial lacerations are commonly encountered inaccident and emergency departments. Various methodsare currently used for treating flap lacerations. Theconservative method, that involves debridement andapplication of steristrips across the wound edges, hasan average healing time of 65 days [1]. Alternatively,primary excision and grafting under general anaesthesiahas an average healing time of 27 days, and an averagestay in hospital of 35 days [2], although this may beshortened by early mobilisation [3]. Primary excisionand delayed primary grafting under regional anaesthe-sia [4], and primary meshed grafting under local anaes-thesia [5], both performed as out-patient procedures,have achieved good results. Debridement, defatting theskin flap and conventional application of steristripsunder local anaesthesia requires an average healingtime of 40 days and an average stay in hospital of 16days, but almost one third of patients treated in thisway required secondary grafting [6]. Simple suturinghas been shown to require an average healing time of

53 days, and carries a 31.8% rate of wound infection, a72.7% rate of wound necrosis and a 13.5% requirementfor skin grafting [7].

Primary closure of pretibial linear lacerations witheither simple sutures or steristrips requires an averagehealing time of 25 and 23 days respectively, with a 13%rate of wound infection for both methods and a 20%rate of wound necrosis for those treated by simplesuturing [7]. This paper describes an effective methodfor both deep reinforced suturing and gentle localisedcompression dressing, which have been shown to over-come some of the problems associated with currenttreatment of pretibial lacerations (both flap and linear).

2. Patients and methods

This is a prospective study of 147 patients whoattended the Accident and Emergency Department ofWhipps Cross Hospital, London with pretibial lacera-tions. The author has been using the technique de-scribed below over a 5-year period, during which timeall new patients seen by him with pretibial lacerationswere considered for treatment using this technique. Out* Tel.: +44-20-85395522; fax: +44-20-85356594.

0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved.PII: S0020-1383(01)00006-7

J. Silk / Injury, Int. J. Care Injured 32 (2001) 373–376374

Fig. 1. A severe pretibial laceration.

of a total of 156 seen by the author, nine were excludedfrom the study. Of these, one had an open fracture of thetibia and fibula and eight had true skin necrosis or lossof the flap. The decision to exclude them was taken atthe initial assessment.

Within the remaining 147, 112 patients were in the flaplaceration group (103 women and nine men) and had anaverage age of 78.1 years (range 44–99 years). A further35 patients (24 women and 11 men) had linear lacerations

and the average age of this group was 57.3 years (range27–80).

2.1. Surgical technique

Surgery was carried out under local anaesthesia using1% plain Lignocaine which was infiltrated into thewound.

Fig. 3. Pretibial flap 19 days after repair.Fig. 2. Post-operative result, after the technique described.

J. Silk / Injury, Int. J. Care Injured 32 (2001) 373–376 375

2.2. Primary deep reinforced suturing

Primary deep reinforced suturing was carried outfor 132 pretibial lacerations, which were not associ-ated with tense compartments, where the fingers(wearing sterile gloves) could not approximate theedges of the linear wounds and those with woundinflammation. For such cases (total of 15), delayedprimary deep reinforced suturing was carried out.

2.3. Flap laceration

The skin flap was held gently in a piece of gauze,then turned over, assessed and prepared. Only non-vi-able subcutaneous fat or that of doubtful viability,blood clots, thrombosed blood vessels and any trulynecrotic skin edges were excised (Figs. 1–3). This wasfollowed by debriding the flap bed leaving a healthy,lightly bleeding uniform surface. The prepared flapwas then applied to its bed. The laceration and thesurrounding skin were dried well and the latter wassprayed with OpSite (Smith & Nephew Medical Ltd,Hull), to improve adhesion. Sterile Steristrips (6 mmwide) were cut to appropriate size and applied to theskin parallel to and about 1 cm away from thewound edges for reinforcing the skin. The woundedges were then opposed by the index and thumb andsutured using 2/0 silk on a curved needle. Interruptedsutures were placed about 1 cm apart, by insertingthe needle through steristrip, skin, subcutaneous tis-sue, deep fascia, and muscle or periosteum (followingthe curve of the needle), then exiting in the samemanner through the steristrip on the opposite side. Inaddition, if the flap was large, steristrips were thenapplied onto the flap itself, for suturing it onto itsbed. Again, this was carried out by inserting theneedle through the steristrip, skin, fat, deep facia andmuscle, then exiting in the same manner on the sameside near the point of insertion through the steristrip.This procedure has the effect of immobilising the flapand closing the gap between the flap and its bed tohelp revascularisation (immobilising suture; Figs. 4and 5).

2.3.1. Linear lacerationAfter debridement or excision, the subcutaneous tis-

sue was slightly undermined from the deep fascia ifnecessary, and suturing carried out using the sametechnique as for the margins of flap lacerations, de-scribed above.

2.4. Delayed primary deep reinforced suturing

Initially, antibiotics were given if the wound wasinflamed, then after debridement or excision, gentlelocalised compression dressing was applied and

Fig. 4. Skin flap laceration. Types of deep reinforced sutures (throughsteristrips).

changed as necessary. When the local conditions per-mitted, the wound edges were refreshed and suturingwas performed as described above.

2.5. Postoperati�e management

The wound was dressed using gentle, localised com-pression dressing. This involved applying non-adher-ent dressing on the wound, over which a dressing padwas placed and secured with a few strips of adhesivetape. This in turn was covered by gently applying awool and crepe bandage around the local area only.

Walking and weight bearing were allowed immedi-ately post-operatively and the patient was sent home(if the occupational therapy assessment was satisfac-tory), with instructions to keep the leg elevated aslong as possible for three days.

The wound was cleaned and reviewed weekly, tocheck for any inflammation or necrosis, and the samedressing technique was used. Removal of the suturesand steristrips took place usually in 2 weeks, and thepatient was discharged when the wound had com-pletely healed. The need to protect the wound wasstressed, and older women in particular were advisedto wear long socks and trousers for this purpose.

Fig. 5. Technique for deep reinforced suturing skin flap laceration,(see text for full explanation).

J. Silk / Injury, Int. J. Care Injured 32 (2001) 373–376376

3. Results

In the group with flap lacerations, the flap sizeranged from 25×20 to 4×5 cm. Seventy-two flapswere proximally based, 14 were distal, 15 were medialand 11 were lateral. Out of 112 patients in this group,16 were on steroids, and the average healing time —defined as dry stable wound and no dressing required— was 26 days (range 14–66). Eight patients whoseflaps became inflamed were treated with antibiotics (sixof these were on steroids). Two flaps developed smallpartial areas of necrosis, which required excision of thenecrotic tissue and secondary suturing. Eight patientswere admitted to hospital for social reasons and theiraverage stay was 48 h (range 24–72). No patients inthis group required skin grafting.

In the linear laceration group, the average length ofthe laceration was 6.2 cm (range 3–10) and the averagehealing time was 16 days (range 14–21). No patientswere admitted to hospital and there were nocomplications.

4. Discussion

The results show that patients treated by this methodof suturing had a much shorter healing time than thosereported in the literature using conservative methods[1,7] and simple suturing [7] and that they did notrequire skin grafting or hospital admission (except forsocial reasons). This technique should not be tried incases when there is total loss or true skin necrosis of theflap and if the experience of the doctor in dealing withthis kind of wound is in doubt.

There are a number of difficulties associated with theconventional use of steristrips in conservative treatmentof pretibial lacerations. These include difficulties inassessing the wound if too many steristrips are applied,gaps between the wound edges, oozing of plasma if thepatient has oedema, accumulation of haematoma, andnecrosis of the skin flap. Most of these problems re-quire debridement, antibiotics (if associated withwound infection) and skin grafting.

Excision of the skin flap and skin grafting usuallyrequires referral to plastic surgeons, admission to hospi-tal and operation under general anaesthesia with all theassociated hazards. In addition, the donor site is associ-ated with pain and may be complicated by woundinfection and delayed healing.

Simple suturing of pretibial lacerations is usuallydoomed to failure [8]. Studies have shown that it tearsthe thin skin [9], spreads necrosis [10], and is associated

with slower healing and increased necrosis [7]. More-over the skin flap seldom survives [2], and may requiregrafting [1].

The conservative methods [1,7], simple suturing [7],and skin grafting [2–6], require pressure dressing fromtoes to the knee, which can hinder the mobility of thetypical patients with such lacerations, especially theelderly.

5. Conclusion

The technique described can be used to manage mostpretibial lacerations effectively. It is simple, convenient,easy to learn, cost effective and patients treated withthis technique had a short healing time, rarely neededhospital admission and none required skin grafting. Itis therefore recommended for managing such lacera-tions.

Acknowledgements

The author would like to thank Dr A. Sadana, MrM. Hunt, Dr C.O’Donnell, consultants in charge of theA&E Department and Dr C.M. Roberts, clinical tutorat Whipps Cross Hospital, for their support and en-couragements.

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