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Three Part Question

In [small, uncomplicated hand wounds] does [conservative management or suturing] result in [less pain, shorter duration of treatment, more rapid return to normal activities, less infection, better cosmetic appearance]?

Clinical Scenario

A patient attends the Emergency Department with a small and uncomplicated hand wound (no fracture, foreign body, tendon injury, bone injury, joint injury, or neurovascular injury). You wonder whether there is any evidence to support suturing the wound over conservative management.

Search Strategy

Medline 1950- January 2007 using the OVID interface
Cochrane Database of Systematic Reviews January 2007
[(exp Hand Injuries/ or hand laceration$.mp.) OR (hand wound$.mp.)] AND [(exp Sutures/ or suture$.mp.) OR (exp Suture Techniques/ or wound closure.mp.)], limit to humans and english language.

Search Outcome

This produced 413 citations.
By limiting the search to include only clinical trials the number of citations was reduced to 27. Only one addressed the question. Searching Cochrane did not add to this.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Quinn J 10 August 2002 USA	91 patients with 95 lacerations enrolled. Criteria for inclusion: full thickness hand laceration, <2cm, uncomplicated (ie no tendon, vascular, joint, nail bed, nerve involvement or fractures), presentation within 8 hours of injury, haemostasis achieved within 15 minutes of presentation and no complications from diabetes, anticoagulants or steroids.	RCT.	Cosmetic appearance after 3 months.	No significant difference in cosmetic appearance 95% C.I.	Small study. No differentiation between location of the wounds on the hand made; in particular palm versus finger and dorsal versus volar. Concerns over correct use of wound nomenclature. Were these "lacerations" actually incisions?
			Duration of treatment.	Conservative management led to shorter duration of treatment (NOT statistically significant).
			Pain during treatment.	Conservative management led to less pain (NOT statistically significant).
			Time to resume normal activities.	Mean time to resume normal activities the same in both groups.
			Bleed Arrest	Bleeding ceased without surgical intervention

Comment(s)

This is the only study that addresses the issue of conservative management versus suturing for small (<2cm), uncomplicated hand lacerations. It showed that there was no difference in cosmetic appearance or time to return to normal activities between the two groups. It also suggested that conservative management was less painful and had a shorter treatment time than suturing. However, it is important to be sure that the wound is uncomplicated and to realise that it has been reported that up to 49% of forearm and hand locerations result in deep subclinical injury (1) that junior emergency department staff miss up to 36% of tendon injuries on clinical grounds and that even hand surgeons miss 16% (2). Therefore if there is any doubt one should have a low threshold for making a referral to the local hand surgeon for consideration of exploration under anaesthesia.

Editor Comment

The paper by Quinn et al attracted a flurry of correspondence. Much of it focused on the need for a proper evaluation of these wounds by a competent person.

Clinical Bottom Line

Uncomplicated hand lacerations less than 2cm should be treated conservatively.

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(7539);299.
2. McNicholl BP. Martin J. McAleese P. Subclinical injuries in lacerations to the forearm and hand. British Journal of Surgery 1992 Aug;79(8):765-7.
3. Patel J, Coull R, Harris P.A, Percival N.J. Hand lacerations: An audit of clinical examination The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand Volume 23, Issue 4 , August 1998, Pages 482-484