Evidence Update 2022–2024: The traditional "6-hour golden period" is based on Paul Friedrich's 1898 guinea pig study and is not supported by modern clinical evidence. Multiple large studies (including a 2024 review of 6,408 lacerations) show wound age alone is not a significant predictor of infection. The key predictors are: contamination level, lower extremity location, wound length >5cm, and diabetes — not time. Clean wounds on the trunk and extremities can be safely closed up to 18 hours after injury. Use clinical judgment, not a clock.
Wound Configurator
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Clean (minimal)
Mildly contaminated
Heavily contaminated
Foreign body present
Healthy adult
Elderly / fragile skin
Diabetes
Immunocompromised
Chronic steroids
Vascular disease / PVD
Pediatric patient
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Primary Closure Appropriate
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Location Quick Reference
Closure Window by Location
| Location | Primary Closure Window | Skin Suture | Size | Removal | Infection Risk |
|---|
Selection Principle: Match material to location, depth, and contamination level. For skin: non-absorbable for most sites (remove at appropriate time), or fast-absorbing Vicryl Rapide for face/pediatric (dissolves, no removal needed). For deep closure: buried Vicryl (dermis, fat, fascia) or Monocryl (subcuticular). Always choose the least reactive material appropriate for the purpose.
Non-Absorbable (Permanent / Skin)
Absorbable (Deep Layers / Dissolving)
Alternatives (Adhesive / Strips)
Selection Guide by Layer
Core Principle: All skin sutures should EVERT the wound edges (edges pointing slightly upward). Flat or inverted edges heal with a depressed, visible scar. Achieve eversion by entering and exiting at 90° to the skin surface, biting as wide as deep.
Most Important Intervention: Adequate wound irrigation is the single most effective intervention to reduce infection risk — more important than antibiotic prophylaxis. High-pressure pulsatile lavage (5–8 PSI) removes 90% of bacteria and debris when performed correctly.
Volume Calculator
Irrigation Volume
Device: 35–60mL syringe + 18–19G angiocath or splash guard
Pressure: 5–8 PSI (express firmly and continuously)
Solution: Normal saline or tap water (equivalent — Fernandez 2012)
Pressure: 5–8 PSI (express firmly and continuously)
Solution: Normal saline or tap water (equivalent — Fernandez 2012)
- 1Fill 35–60mL syringe, attach 18–19G angiocath or splash guard
- 2Position perpendicular to wound opening, 1–2cm above surface
- 3Express with firm continuous pressure — fills entire wound depth
- 4Irrigate entire wound length systematically, side to side
- 5Remove visible debris with forceps after irrigation — do not scrub wound interior
- 6Debride devitalized tissue with iris scissors or #15 blade
Recommended Volume
—
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Solutions
✓ USE
Normal saline (NS)
Tap water (potable)
Lactated Ringer's
Commercial wound wash
Tap water (potable)
Lactated Ringer's
Commercial wound wash
✗ AVOID
Full-strength povidone-iodine
Hydrogen peroxide
Dakin's (undiluted)
Chlorhexidine (in wound)
Hydrogen peroxide
Dakin's (undiluted)
Chlorhexidine (in wound)
Puncture Wounds: High-pressure irrigation of puncture wounds tracks contamination deeper along tissue planes. Use low-pressure irrigation or avoid in pure puncture wounds. Instead: explore for foreign body, soak if appropriate.
Bite Wounds: Copious high-pressure irrigation is the most important intervention — minimum 200mL per cm regardless of contamination appearance. Bite wounds appear deceptively clean.
Risk Stratification
Wound Infection Risk
Low Risk
<5%
- Clean wound, minimal contamination
- Presenting promptly (any time, clean wound)
- Face, scalp, neck location
- Sharp mechanism (knife, glass)
- Healthy, immunocompetent adult
- Simple linear laceration
Moderate Risk
5–15%
- 6–12 hours old
- Mildly contaminated (dirt, debris removed)
- Extremity location
- Stellate or crush mechanism
- Diabetes mellitus
- Mild immunosuppression
- Ear cartilage involvement
High Risk
>15%
- Greater than 12 hours old
- Heavily contaminated wound
- Animal or human bite
- Lower extremity / foot
- Severe immunosuppression
- Retained foreign body
- Devascularized/devitalized tissue
- Intraoral lacerating through cheek
Antibiotic Prophylaxis
When to Give Antibiotics
Antibiotics NOT routinely indicated for: Clean laceration, face/scalp wounds, simple contamination after thorough irrigation, standard extremity lacerations in healthy patients. Irrigation > antibiotics for infection prevention.
Consider prophylaxis for: Bite wounds to hands/extremities, contaminated wounds in immunocompromised, open fractures, wounds with devitalized tissue, intraoral lacerations penetrating through cheek, wounds with suspected retained FB.
Antibiotic Selection Guide
By wound type and patient factors
| Wound Type | First-Line Agent | Dose | Duration | PCN Allergy Alternative |
|---|---|---|---|---|
| Animal bite (cat/dog) | Amoxicillin-clavulanate | 875/125mg BID | 5–7 days | Doxycycline 100mg BID + Metronidazole 500mg TID |
| Human bite / fight bite | Amoxicillin-clavulanate | 875/125mg BID | 5–7 days | TMP-SMX DS BID + Metronidazole 500mg TID |
| Contaminated extremity wound | Cephalexin OR Amoxicillin-clavulanate | 500mg QID (ceph) or 875/125 BID (augmentin) | 5 days | Clindamycin 300mg TID or TMP-SMX DS BID |
| Open fracture (outpatient) | Cephalexin | 500mg QID | 3–5 days | Clindamycin 300mg TID |
| Ear cartilage laceration | Ciprofloxacin | 500mg BID | 7 days | TMP-SMX DS BID (less Pseudomonas coverage) |
| Immunocompromised patient | Amoxicillin-clavulanate | 875/125mg BID | 5–7 days | Consult ID if high risk |
| Oral/intraoral through-and-through | Amoxicillin-clavulanate or Penicillin VK | 500mg TID (PCN) or 875/125mg BID | 5 days | Metronidazole 500mg TID |
Tetanus Prophylaxis
Tetanus Decision Guide
Clean minor wound: Td/Tdap only if >10 years since last booster. All other wounds (dirty, contaminated, bite, deep puncture, crush, devitalized tissue, burns): Td/Tdap if >5 years since last booster. TIG (Tetanus Immune Globulin): only if incomplete vaccination series or uncertain history.
Clean Minor Wound
Up to date (<10 years)Nothing needed
>10 years since boosterTd or Tdap ×1
Unknown / <3 dosesTd or Tdap ×1
TIGNOT needed (clean wound)
Dirty / High-Risk Wound
Up to date (<5 years)Nothing needed
5–10 years since boosterTd or Tdap ×1
>10 years since boosterTd or Tdap ×1
Unknown / <3 dosesTd/Tdap + TIG 250 units IM
Use Tdap (not just Td) preferentially if the patient has never received Tdap — this adds pertussis coverage. Give in separate site from TIG if both needed. Avoid Td in pregnancy — use Tdap (ACIP recommendation, safe and protects neonate).
Remove Sutures on Time: Sutures left too long cause permanent stitch marks (epithelial tunneling along the suture tract, "railroad tracks"). Early removal on face is critical — replace with Steri-strips if wound still needs support. In high-risk patients (diabetes, immunocompromised, lower extremity), err toward longer removal times.
Suture Removal Timeline
| Location | Removal Timing | Closure Window | Recommended Material | Notes |
|---|---|---|---|---|
| Face | 5–7 days | Up to 24h | 5-0/6-0 Prolene or Vicryl Rapide | Remove EARLY — replace with Steri-strips if needed. Stitch marks permanent after 7d. |
| Eyebrow | 5–7 days | Up to 24h | 5-0/6-0 Prolene | Do NOT shave — use for alignment landmarks |
| Eyelid | 5–7 days | Up to 24h | 6-0 Prolene or Vicryl Rapide | Ophthalmology for tarsal plate / complex injuries |
| Lip / Vermilion | 5–7 days (skin) | Up to 24h | 6-0 Prolene (skin), 4-0 Vicryl (deep) | Align vermilion border FIRST. 3-layer closure. |
| Oral Mucosa | Self-absorbs | Up to 24h | 3-0 Chromic gut or Vicryl | No removal needed; rinse with chlorhexidine |
| Scalp | 7–10 days | Up to 24h | 3-0 Nylon or Staples | Repair galea separately if gaping. Staples OK. |
| Ear | 5–7 days | Up to 24h | 4-0 Nylon | Cover cartilage with perichondrium. Fluoroquinolone if cartilage exposed. |
| Neck | 5–7 days | Up to 18h | 4-0 Prolene | Zone-based management for penetrating injuries |
| Trunk / Chest / Abdomen | 10–14 days | Up to 18h (clean) | 3-0 Nylon or Staples | Check for pneumothorax (anterior chest). Peritoneal entry (abdomen). |
| Upper Extremity / Arm | 10–14 days | Up to 18h (clean) | 4-0 Nylon | Document neuro/vascular exam pre-repair |
| Hand / Fingers | 10–14 days | Up to 12h | 4-0 to 5-0 Nylon | Digital block with PLAIN lidocaine (no epi). Test tendon function first. |
| Over a Joint | 14 days | Up to 12h | 4-0 Nylon (horiz. mattress) | Check for joint capsule penetration. Evaluate ROM. |
| Lower Extremity / Leg | 14–21 days | Up to 12h (clean) | 3-0 to 4-0 Nylon | High infection risk. Pretibial in elderly: consider alternatives. Restrict weight-bearing. |
| Foot / Plantar | 14–21 days | Up to 12h (clean) | 3-0 Nylon (horiz. mattress plantar) | Check for FB (XR or US). Restrict weight-bearing. |
Secondary Intention & Delayed Closure
When NOT to Close Primarily
Do NOT primarily close:
• Animal/human bites to hands/extremities
• Heavily contaminated wounds
• Wounds >18–24h with moderate/heavy contamination
• Infected wounds
• Crush injuries with devitalized tissue
• Puncture wounds
• Animal/human bites to hands/extremities
• Heavily contaminated wounds
• Wounds >18–24h with moderate/heavy contamination
• Infected wounds
• Crush injuries with devitalized tissue
• Puncture wounds
Delayed Primary Closure (3–5 days):
• Contaminated wounds requiring monitoring
• Bite wounds with low infection risk (can reconsider at 3–5 days)
• Wounds with inadequate debridement
Pack open with moist gauze, reassess at 3–5 days, close if no signs of infection.
• Contaminated wounds requiring monitoring
• Bite wounds with low infection risk (can reconsider at 3–5 days)
• Wounds with inadequate debridement
Pack open with moist gauze, reassess at 3–5 days, close if no signs of infection.
Secondary Intention (heal open):
• Small wounds (<1cm) in most locations
• Heavily infected wounds
• Wounds where closure would create tension
• Perineal lacerations (most)
• Treat with wound care instructions — keep moist, clean daily, watch for infection.
• Small wounds (<1cm) in most locations
• Heavily infected wounds
• Wounds where closure would create tension
• Perineal lacerations (most)
• Treat with wound care instructions — keep moist, clean daily, watch for infection.
The traditional "6-8 hour rule" for extremity closure is not supported by modern evidence. Clean wounds on the trunk and extremities can be safely closed up to 18 hours after injury (AAFP guidelines; supported by a systematic review of 2,343 patients). The primary determinants of infection risk are contamination level, lower extremity location, wound length >5cm, and patient comorbidities — not time since injury. Use clinical judgment: a clean cut from a kitchen knife at 14 hours is lower risk than a heavily contaminated wound at 2 hours.
Discharge Instructions
Standard Wound Care Instructions
First 24 Hours
- •Keep wound dry and covered
- •Elevate extremity if applicable
- •Apply ice wrapped in cloth (20 min on/off) for swelling
- •Pain control as prescribed
Daily Wound Care (Day 1 onward)
- •Gently clean with mild soap and water once daily
- •Apply thin layer petroleum jelly (Vaseline) or antibiotic ointment
- •Cover with non-stick dressing
- •Keep moist — dry wounds scar more
Return to ED Immediately If:
- •Increasing redness, warmth, swelling after 48h
- •Pus or foul-smelling discharge
- •Red streaking from wound (lymphangitis)
- •Fever >38.5°C
- •Wound opens (dehiscence)
- •Numbness or weakness beyond wound
Scar Optimization
- •Keep wound out of direct sun for 6–12 months (SPF 30+)
- •Silicone gel strips after suture removal (evidence-based)
- •Massage scar 3× daily with gentle friction (6–12 weeks post-closure)
- •Plastic surgery follow-up for cosmetically sensitive areas
Critical Safety: Epinephrine is safe for use in the face, scalp, and most areas EXCEPT: digital blocks (fingers/toes), penile blocks, and select end-artery areas. Do NOT use epinephrine in digital ring blocks — use plain lidocaine only.
Local Anesthetics
Lidocaine 1% (Without Epi)
Concentration
1% = 10 mg/mL
Max Volume (70kg)
~21 mL (1%)
Use When
Digital blocks, penile, end-arteries
pH Buffering
NaHCO₃ 1 mEq/10mL reduces pain
Always buffer lidocaine for painful injections: add 1mL of 8.4% sodium bicarbonate to 9mL lidocaine. Use smallest needle (27–30G), inject slowly, inject while advancing, use topical (EMLA, LET gel) first in children. Warm the solution.
Lidocaine 1% + Epinephrine 1:100,000
Max Volume (70kg)
~49 mL (1%)
Epinephrine Effect
Reduces bleeding, extends duration 2–3×
Safe Locations
Face, scalp, trunk, extremities
Avoid
Digital ring blocks, penis, pinna ring block
Epinephrine is safe on the face (including nose and ears in small amounts). The myth that epi causes nasal tip or ear necrosis has been debunked in the literature — catastrophic outcomes described were from cocaine + epi combinations or infected tissue. Use epi with confidence on face — reduces bleeding dramatically.
Bupivacaine 0.25% (Marcaine)
0.25% Concentration
2.5 mg/mL
Max Volume (70kg)
~70 mL (0.25%)
Best Use
Long procedures, nerve blocks, post-procedure analgesia
Cardiac Toxicity
High — never IV; use with care
Preferred for nerve blocks when prolonged analgesia needed post-repair (3–8h coverage). Can mix 50:50 with lidocaine for rapid onset (lido) plus prolonged duration (bupivacaine). NEVER inject IV — cardiotoxic (VF refractory to defibrillation).
Topical Agents (LET / EMLA)
LET Composition
Lidocaine 4% + Epinephrine + Tetracaine
EMLA Composition
Lidocaine 2.5% + Prilocaine 2.5%
LET Best For
Pediatric face/scalp lacerations
EMLA Best For
IV insertion, skin punctures (pretreatment)
LET gel is the pediatric ED standard — apply to wound, cover with occlusive dressing, wait 20–30 min. Provides excellent anesthesia for face/scalp wounds in children, often eliminating need for injection. Blanching of wound edges indicates effective anesthesia. Do NOT use on mucous membranes.
Regional Nerve Blocks for ED Wound Repair
Digital Block
Fingers and toes. Inject at base of digit, both sides of flexor tendon sheath at MCP level.
2–3mL plain lidocaine each side
PLAIN LIDOCAINE ONLY — No epi. End artery supply.
Infraorbital Nerve Block
Upper lip, cheek, lower eyelid, side of nose. Inject at infraorbital foramen (1cm below mid-orbit).
2–3mL lido with epi. Intraoral or extraoral approach.
Avoids tissue distortion — preferred for lip repair.
Mental Nerve Block
Lower lip and chin. Inject at mental foramen, below and between lower premolars.
2mL lido with epi. Intraoral approach preferred.
Best approach for lower lip lacerations — no distortion.
Supraorbital / Supratrochlear Block
Forehead, anterior scalp. Inject at supraorbital notch, both sides of midline.
3–5mL lido with epi each side.
Excellent for forehead lacerations — minimal injection pain.
Posterior Auricular / Ring Block
Ear. Ring of anesthetic around base of ear. Plain lidocaine at pinna (end artery).
5–8mL total; plain lido at pinna, epi OK at base.
Do NOT inject into pinna cartilage — pericondrial injection only.
Posterior Tibial Nerve Block
Plantar surface of foot. Inject posterior to medial malleolus between achilles tendon and tibia.
5–10mL lido ± epi (not sole).
Excellent for plantar lacerations where injection into sole is extremely painful.
Hematoma Block (Wrist/Ankle)
Fracture site. Inject 5–10mL lido directly into fracture hematoma under sterile technique.
10–15mL lido without epi into hematoma.
Useful for distal radius fractures requiring reduction — analgesia equal to procedural sedation in some studies.
Scalp Ring Block
Entire scalp. Inject field of anesthetic in a ring around scalp base (temporal/occipital line).
20–40mL lido with epi total.
Highly effective, reduces total anesthetic needed. Excellent hemostasis with epi component.
Dental Nerve Block (Inferior Alveolar)
Lower teeth, gum, lower lip. Inject at mandibular foramen on lingual side of ramus.
1.5–2mL 2% lido with epi (dental cartridge).
Standard dental technique — highly effective for intraoral lacerations, tooth avulsions.
Animal Bite Wounds
Pasteurella multocida (cat — 80%)Capnocytophaga (dog)Eikenella (human)
Cat bites: Infection rate 30–80%. Small puncture wounds penetrate deep — never underestimate. MCP bites → admit for IV antibiotics and hand surgery.Dog bites: Infection rate 5–15%. More crush injury. Copious irrigation. Face: primary closure acceptable (excellent blood supply). Extremities: delayed closure or secondary intention if >6h or contaminated.
When NOT to close: Cat/dog bites >6h old on hand/extremity. Always leave bite wounds to hands and feet open.
Antibiotics: Amoxicillin-clavulanate 875/125mg BID × 5–7 days for all hand/extremity bites. Face bites in healthy adults: prophylaxis controversial for low-risk wounds.
Rabies: Assess risk (wild animal, unprovoked attack, bat). Contact public health. Post-exposure prophylaxis (RIG + vaccine ×4) if indicated. Bats found in room with sleeping person = exposure.
Always document neurovascular status before anesthesia. Cat bites to the hand over an MCP joint: assume joint capsule penetration — admit, IV antibiotics, hand surgery consultation.
Human Bite / Fight Bite
Eikenella corrodensStreptococcusAnaerobes
Fight bite (clenched fist MCP wound): Most dangerous hand wound in EM. Small wound over MCP joint made with fist — wound entry point is displaced when fist opens. Always examine with hand in clenched-fist position to identify full depth.NEVER close fight bite wounds. Must assume joint capsule penetration until proven otherwise. All require OR exploration and IV antibiotics.
Organisms: Eikenella corrodens is resistant to penicillinase-resistant PCN (dicloxacillin) and first-generation cephalosporins. Use amoxicillin-clavulanate.
Occlusional bites (incisor mark): Lower infection risk. Copious irrigation. Primary closure acceptable on face; secondary intention or delayed closure elsewhere.
A fight bite patient who presents late (24–48h) with any sign of infection of the hand = admission, IV antibiotics, hand surgery. Missed fight bite infections are among the most litigation-prone injuries in emergency medicine.
Pretibial Lacerations (Elderly)
Among the most challenging ED wound closures. Thin, friable skin + poor blood supply + dependent edema = high complication rate regardless of technique.
Suture techniques often fail — sutures tear through fragile skin. Preferred approaches:
• Steri-strips: Often best primary option for small flap wounds
• Tissue adhesive: For small clean lacerations
• Horizontal mattress sutures: If closure required (large wounds)
• Wound closure strips + non-adherent dressing
Always elevate limb, consider compression bandaging, close follow-up in 48–72h. Warn patients of high dehiscence/infection risk. Consider referral to wound care clinic.
Suture techniques often fail — sutures tear through fragile skin. Preferred approaches:
• Steri-strips: Often best primary option for small flap wounds
• Tissue adhesive: For small clean lacerations
• Horizontal mattress sutures: If closure required (large wounds)
• Wound closure strips + non-adherent dressing
Always elevate limb, consider compression bandaging, close follow-up in 48–72h. Warn patients of high dehiscence/infection risk. Consider referral to wound care clinic.
The "flap" pattern is common — a triangular skin flap with the apex pointing distally (poorest blood supply at apex). Use corner stitch / half-buried mattress to preserve apical blood supply. Do not suture through the flap tip.
Pediatric Wounds
Maximize comfort: LET gel (lidocaine/epinephrine/tetracaine) applied 20–30 min before → greatly reduces or eliminates need for injection in face/scalp. EMLA for skin prep. Child life specialist if available.
Suture choice: Vicryl Rapide 5-0 for face — dissolves in 10–14 days, no removal visit. Dermabond for low-tension clean facial wounds <3cm. Both eliminate the stressful "coming back to get stitches out" visit.
Restraint: Papoose/immobilizer board is appropriate for young children — prevents accidental injury during repair. Parental presence often helps (offer choice).
Procedural sedation: Consider intranasal dexmedetomidine (1–2 mcg/kg), oral midazolam, or ketamine for highly anxious children or large wounds.
Suture choice: Vicryl Rapide 5-0 for face — dissolves in 10–14 days, no removal visit. Dermabond for low-tension clean facial wounds <3cm. Both eliminate the stressful "coming back to get stitches out" visit.
Restraint: Papoose/immobilizer board is appropriate for young children — prevents accidental injury during repair. Parental presence often helps (offer choice).
Procedural sedation: Consider intranasal dexmedetomidine (1–2 mcg/kg), oral midazolam, or ketamine for highly anxious children or large wounds.
For children, Dermabond or Vicryl Rapide are the gold standard for facial lacerations where applicable — cosmetic outcomes equivalent to sutures, and no removal visit = no second traumatic experience. Tissue adhesive should not be used near eyes or in high-mobility areas.
Foreign Body Assessment
Every wound with mechanism suggesting FB must be assessed before closure. Retained foreign bodies are a leading cause of ED litigation.
Imaging by material:
• Glass: Plain XR detects >2mm fragments in 85%+ (all glass is radio-opaque)
• Metal: Plain XR (highly sensitive)
• Wood/organic: Ultrasound or CT (wood is radiolucent on XR)
• Plastic: CT scan (not visible on XR or US)
• Gravel/stone: Usually radio-opaque — XR
Ultrasound: Highly sensitive for wood, glass >1mm. Use linear high-frequency probe (15 MHz). Foreign body appears as hyperechoic object with posterior shadowing.
Imaging by material:
• Glass: Plain XR detects >2mm fragments in 85%+ (all glass is radio-opaque)
• Metal: Plain XR (highly sensitive)
• Wood/organic: Ultrasound or CT (wood is radiolucent on XR)
• Plastic: CT scan (not visible on XR or US)
• Gravel/stone: Usually radio-opaque — XR
Ultrasound: Highly sensitive for wood, glass >1mm. Use linear high-frequency probe (15 MHz). Foreign body appears as hyperechoic object with posterior shadowing.
Document explicitly in the chart whether foreign body assessment was performed and what imaging was obtained. If you decide not to image, document clinical reasoning. Phrases like "foreign body excluded by imaging" vs "foreign body not suspected clinically" have significant medicolegal implications.
Wound Closure Alternatives
Staples vs Sutures: Equivalent infection rates. Staples: faster (scalp: 2–3 min vs 10–15 min), requires staple remover at follow-up, cannot use near MRI. Sutures: more precise, required for face/hand/cosmetic areas.
Tissue Adhesive vs Sutures: RCTs show equivalent cosmesis and infection rates for appropriate wounds (<3cm, clean, low tension, no mucosal surfaces). Preferred for pediatric face. Cannot use over joints.
Wound closure strips alone: Appropriate for superficial lacerations with minimal tension, elderly fragile skin, reinforcing subcuticular closure. Apply benzoin first. Fail in high-moisture areas.
Hair apposition technique (scalp): Twist adjacent hair strands across laceration and apply tissue adhesive. Excellent cosmetic result, no shaving required, effective for small scalp lacerations.
Tissue Adhesive vs Sutures: RCTs show equivalent cosmesis and infection rates for appropriate wounds (<3cm, clean, low tension, no mucosal surfaces). Preferred for pediatric face. Cannot use over joints.
Wound closure strips alone: Appropriate for superficial lacerations with minimal tension, elderly fragile skin, reinforcing subcuticular closure. Apply benzoin first. Fail in high-moisture areas.
Hair apposition technique (scalp): Twist adjacent hair strands across laceration and apply tissue adhesive. Excellent cosmetic result, no shaving required, effective for small scalp lacerations.
Hair apposition technique: requires wound edges that naturally oppose (not gaping). Twist 3–4 hairs from each side around each other across the wound, apply a drop of Dermabond to the twist. Holds for 7–10 days. Zero hair removal, zero suture removal appointment.
Medicolegal Documentation Checklist: Before closing: (1) Neurovascular exam documented — two-point discrimination, capillary refill, motor function. (2) Foreign body assessment documented — imaging obtained or clinical reasoning for not imaging. (3) Wound dimensions, depth, and contamination level. (4) Time of injury documented. (5) Tetanus status and prophylaxis given. (6) Informed consent for repair obtained. (7) Discharge instructions given with return precautions.