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Three Part Question

In [children with facial lacerations requiring closure] is [wound glue better than sutures] at [improving cosmetic outcome and reducing the distress of the procedure]?

Clinical Scenario

A 3 year old girl presents to the emergency department after catching her face on the edge of a table. She has a 2.5 cm laceration to the cheek which requires closure. The wound is not suitable for steristrips. The parents are very worried abbout her having stitches and also about scarring. You wonder whether glue is the best option for this child.

Search Strategy

Medline 1966-07/99 using the OVID interface.
({exp fibrin tissue adhesive OR exp tissue adhesives OR exp enbucrilate OR exp cyanoacrylates OR wound glue$.mp OR histoacryl.mp OR octylcyanoacrylate$ OR butylcyanoacrylate$} AND {exp wounds and injuries OR wound$.mp OR lacerate$.mp OR laceration$.mp} AND maximally sensitive RCT filter) LIMIT to human AND english.

Search Outcome

138 papers found of which 130 irrelevant or of insufficient quality for inclusion. The remaining 8 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Quinn JV, et al. 1993. Canada.	81 children with facial lacerations less than 4 cm in length and 0.5 cm wide. Sutures vs histocaryl blue.	PRCT	Cosmesis at 3 months	No significant difference
			Parent view of procedural pain	Less with glue (43.7 vs 24.7mm)
			Time taken for procedure	Shorter with glue (15.6 min vs 7 min)
Bruns TB, et al. 1996. USA.	61 children aged 1 - 17 years with lacerations less than 5 cm. Sutures vs histoacryl blue.	PRCT	Cosmesis at 2 months	No significant difference	Preliminary report of reference 4. Local anaesthetic technique was not controlled.
			Parent view of procedural pain	Less with glue (29mm vs 8mm)
			Time taken for procedure	Shorter with glue (17 min vs 7 min)
Quinn J, et al. 1997. USA.	130 adults with facial and selected extremity lacerations (not hands and feet). Sutures vs octylcyanoacrylate glue.	PRCT	Cosmesis at 3 months	No significant difference	Preliminary report of reference 5. Adults.
			Time taken for procedure	Shorter with glue (12.4 min vs 3.6 min)
			Time to healing	No significant difference
Simon HK, et al. 1997. USA.	61 children aged 1 - 17 years with lacerations less than 5 cm. Sutures vs histoacryl blue.	PRCT	Cosmesis at 1 year	No significant difference	Only 32 of 61 children were followed up.
Quinn J, et al. 1998. USA.	130 adults with facial and selected extremity lacerations (not hands and feet). Sutures vs octylcyanoacrylate glue.	PRCT	Cosmesis at 1 year	No significant difference	Only 77 of 130 patients were followed up. Adults.
Singer AJ, et al. 1998. USA.	124 patients over 1 year of age with recent non-bite, non-crush lacerations. Standard wound closure (sutures or steristrips) vs octylcyanoacrylate glue.	PRCT	Cosmesis at 3 months	No significant difference	Wound assessments were not blinded.
			Patients wound rating	No significant difference
			Use of irrigation or scrub	No significant difference
			Need for local anaesthesia	Less with glue (89% vs 21%)
			Wound complications	1 infection and 2 dehisences in the glue group
Barnett P, et al. 1998. Australia.	163 children over 4 years old with recent lacerations less than 5 cm in length. Sutures vs histoacryl blue.	PRCT	Cosmesis at 3 months	No significant difference	Poor follow up wound assessments were not blinded.
			Cosmesis at 12 months	No significant difference
			Time taken for wound repair	Less with glue (0-2 min vs 6-10 min)
			Carer view of procedural pain	Less with glue
			Childs view of procedural pain	No difference
			Wound complications	No difference
Bruns TB, et al. 1998. USA.	83 children with lacerations. Sutures or staples vs octylcyanoacrylate.	PRCT	Cosmesis	No significant difference	20% of patients not followed up.
			Time taken for wound repair	Less with glue (5.8 min vs 2.9 min)
			Parents view of procedural pain	Less with glue

Comment(s)

There are a number of well designed PRCTs that directly address the 3 part question posed, and a number that are relevant. Cosmesis is a difficult outcome since true blinding is impossible because of suture marks. Glue is quicker to apply, causes less procedural pain and gives equivalent cosmetic results to sutures. One trial shows a higher wound complication rate; this emphasises the point that glued wound require the same diligent as wounds that are to be sutured.

Clinical Bottom Line

Glue is the wound closure method of choice in recent lacerations to the face in children.

References

1. Quinn JV, Drzewiecki A, Li MM, et al. A randomised, controlled trial comparing a tissue adhesive with suturing in the repair of pediatric facial lacerations. Ann Emerg Med 1993;22(7):1130-35.
2. Bruns TB, Simon HK, McLario DJ, Sullivan KM, Wood RJ, Anand KJ. Laceration repair using a tissue adhesive in a children's emergency department. Pediatrics 1996;98(4 Pt 1):673-75.
3. Quinn J, Wells G, Sutcliffe T, et al. A randomised trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA 1997;277(19):1559-60.
4. Simon HK, McLario DJ, Bruns TB, Zempsky WT, Wood RJ, Sullivan KM. Long term appearance of lacerations repaired using a tissue adhesive. Pediatrics 1997;99(2):193-95.
5. Quinn J, Wells G, Sutcliffe T, et al. Tissue adhesive versus suture wound repair at 1 year: randomized clinical trial correlating early, 3-month and 1-year cosmetic outcome. Ann Emerg Med 1998;32(6):645-49.
6. Singer AJ, Hollander JE, Valentine SM, Turque TW, McCuskey CF, Quinn JV. Prospective, randomised, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs standard wound closure techniques for laceration repair. Stony Brook Octylcyanoacrylate Study Group. Acad Emerg Med 1998;5(2):94-99.
7. Barnett P, Jarman FC, Goodge J, Silk G, Aickin R. Randomised trial of histoacryl blue tissue adhesive glue versus suturing in the repair of paediatric lacerations. J Paediatrics Child Health 1998;34(6):548-50.
8. Bruns TB, Robinson BS, Smith RJ, et al. A new tissue adhesive for laceration repair in children. J Pediatrics 1998;132(6):1067-70.