In this Part 2 of our 3-part podcast series on management of lacerations Dr. Haley Cochrane, Dr. Justin Morgenstern and Dr. Anton Helman explore the evidence around the various methods to repair skin lacerations in the Emergency Department. In it they discover 4 themes making concrete conclusions on this topic challenging: the lack of blinding in all the studies, the subjective outcomes measured in the studies, the interplay between the multiple steps of suture repair and the effect of the skill of the provider that may impact outcomes…

Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Anton Helman January, 2023

Cite this podcast as: Helman, A. Cochrane, H. Morgenstern, J. Journal Jam 22 Laceration Repair – Glue vs Strips vs Staples vs Sutures. Emergency Medicine Cases. January, 2023. https://emergencymedicinecases.com/laceration-repair-glue-strips-staples-sutures. Accessed June 2, 2023

Surgical skin glue for skin lacerations

2002 Cochrane review comparing skin glue to sutures

  • 11 RCTs
  • no differences in cosmesis
  • advantages of skin glue: pain scores and time of laceration repair lower with glue; overall less expensive
  • disadvantages of skin glue: skin glue more likely to have short term localized erythema and rate of dehiscence is 2% higher

Adding adhesive strips (“steri-strips”) to skin glue doubles the tensile strength as compared to using either alone.

Hair apposition technique for scalp lacerations

1 RCT – the HAT trial comparing hair apposition technique to sutures

  • 189  patients with scalp lacerations 3-10 cms
  • excluded patients requiring resuscitation, with arterial bleeds and with significant contamination
  • hair apposition 5 mins vs sutures 15 mins
  • hair apposition 2 vs 4 out of 10 pain score
  • At 7 days 100% of the hair apposition group had adequate wound healing compared to 96% of the suture group. 
  • At 4 weeks all wounds were healed, but scars were bigger in the suture group
  • When asked if they would want the same procedure in the future, 84% of the hair apposition group said “yes” compared to 10% of the suture group

It is unknown whether hair apposition technique has any advantage over simply applying skin glue to a scalp laceration.


Wound closure strips for skin lacerations

2021 systematic review comparing wound closure strips (“steri-strips”) to sutures and to skin glue

  • included traumatic wounds in ED and patients in the operating room
  • all studies were small, at high risk of bias
  • infection and dehiscence equivalent in all three groups
  • wound closure strips associated with better cosmesis in 1 small unblinded RCT
  • wound closure strips generally faster and less painful compared to sutures

Surgical skin staples for skin lacerations

2020 meta-analysis of 42 low quality RCTs of operating room studies

  • staples are generally faster than sutures
  • cost is about equivalent
  • no differences in cosmesis
  • the overall adverse event rate is about double with staples

Absorbable vs non-absorbable sutures for skin lacerations

2007 meta-analysis of 7 small unblinded underpowered ED or operating room RCTs comparing absorbable to absorbable sutures for skin lacerations

  • no overall statistical difference in cosmesis
  • Odds Ratio (OR) for dehiscence 0.16 favouring absorbable sutures
  • Odds Ratio (OR) for infections 0.42 favouring absorbable sutures 

Sutures vs simple dressing

2002 RCT hand lacerations ≤2cm comparing sutures to simple dressing

  • 3 months cosmesis, no difference

Take home points on laceration repair glue vs strips vs staples vs sutures

There is no convincing evidence that one method of laceration repair is much better than another. Factors to consider in deciding which material to use/method for laceration repair:

  • location, depth and length of wound
  • need for tensile strength (eg laceration over large joint)
  • patient’s work/recreational activities, age
  • patient pain associated with using a particular material
  • convenience of aftercare
  • efficiency, flow of ED
  • cost
  • exclusion criteria used in the studies
  • patient preference
  • physician experience

Next episode in this series…Journal Jam 23 Laceration Aftercare

References

Morgenstern, J. Lacerations: Does closure technique matter?, First10EM, November 28, 2022. Available at:
https://doi.org/10.51684/FIRS.128664

Morgenstern, J. Laceration evidence: absorbable sutures or not?, First10EM, December 5, 2022. Available at:
https://doi.org/10.51684/FIRS.128625

Bresnahan KA, Howell JM, Wizorek J. Comparison of tensile strength of cyanoacrylate tissue adhesive closure of lacerations versus suture closure. Ann Emerg Med. 1995 Nov;26(5):575-8.

Brown JL, Jehle D, Mayrose J, Schwartz L, Pugh J, O’Brien C. Skin tapes and tissue adhesive vs. either method alone for laceration repair in a porcine model. Am J Emerg Med. 2021 Jul;45:317-323.

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Smith TO, Sexton D, Mann C, Donell S. Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis. BMJ. 2010 Mar 16;340:c1199.

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