The guidelines presented by the New York State Workers Compensation Board provide fundamental principles for managing lacerations. These directives are designed to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in laceration management can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.
It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The ultimate decision regarding laceration management should involve collaboration between the patient and their healthcare provider.
Wound and Laceration Management
The primary objective of wound and laceration management is to prevent infection, identify potential nerve injuries, handle tendon lacerations, and attain a cosmetically acceptable outcome with optimal function and patient satisfaction.
Diagnostic Studies
X-Rays
- Recommended: In cases of traumatic injury resulting in skin lacerations, for ruling out fractures or when a radiopaque foreign body is suspected.
- Evidence: Supporting the use of X-rays to evaluate lacerations with suspected fracture or foreign body.
Ultrasound
- Recommended: For evaluating suspected radiolucent materials or as an alternative when a radiopaque foreign body is suspected but not detected on X-ray images.
- Evidence: Supporting the use of ultrasound for assessing suspected superficial foreign bodies.
CT
- Not Recommended: For suspected superficial foreign bodies.
- Recommended: When evaluating suspected radiolucent materials or as an alternative when a radiopaque foreign body is suspected but not detected on X-ray images or ultrasound.
- Evidence: Supporting the use of CT for evaluating suspected superficial foreign bodies.
Medications
Antibiotic Prophylaxis
- Not Recommended: For uncomplicated hand and forearm lacerations.
- Evidence: Lack of recommendation for antibiotic prophylaxis.
Non-Steroidal Anti-Inflammatory Drugs/Acetaminophen
For most patients, ibuprofen, naproxen, or other older-generation NSAIDs are recommended as first-line medications. Acetaminophen may be an alternative for patients not suitable for NSAIDs, though evidence suggests it is slightly less effective. NSAIDs are considered effective for pain relief and are less impairing than opioids.
NSAIDs for Treatment of Acute, Subacute, or Chronic Upper Extremity Post-Laceration Repair Pain
- Recommended: For treating pain associated with upper extremity post-laceration repair.
- Indications: Applicable for acute, subacute, or chronic post-laceration repair pain, with OTC agents as the first-line option.
- Frequency/Duration: As needed, with discontinuation upon symptom resolution or due to adverse effects.
- Indications for Discontinuation: Resolution of symptoms, lack of efficacy, or adverse effects necessitating discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
- Recommended: For concomitant use with cytoprotective drugs in patients at high risk of gastrointestinal bleeding.
- Indications: Consider for patients with a high-risk profile and indications for NSAIDs, especially for longer-term treatments.
- Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended, with doses per manufacturer instructions. No substantial differences are believed in efficacy for preventing gastrointestinal bleeding.
- Indications for Discontinuation: Intolerance, adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
- Recommended: Discuss risks and benefits of NSAID therapy for pain with patients having known cardiovascular disease or multiple risk factors.
- Preferred: Acetaminophen or aspirin as first-line therapy for cardiovascular safety.
- Preferred NSAIDs: Non-selective over COX-2 specific drugs. For patients on low-dose aspirin, NSAIDs should be taken 30 minutes after or 8 hours before daily aspirin.
Acetaminophen for Treatment of Upper Extremity Post-Laceration Repair Pain
- Recommended: For treating upper extremity post-laceration repair pain, especially in patients with NSAID contraindications.
- Indications: Suitable for all patients with such pain, irrespective of it being acute, subacute, chronic, or post-operative.
- Dose/Frequency: Per manufacturer’s recommendations, used on an as-needed basis.
- Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
- Limited Use: Recommended for a brief duration (less than seven days) for acute and post-laceration repair pain management as adjunctive therapy alongside more effective treatments.
- Indications: For acute injury and post-operative pain management, opioids may be prescribed briefly as adjuncts to more efficacious treatments, particularly for nocturnal use.
- Frequency/Duration: Prescribed as needed throughout the day, later only at night, and eventually weaned off.
- Rationale for Recommendation: Judicious use of opioids may be helpful for patients with insufficient pain relief from NSAIDs, especially for nocturnal use. Opioids are advised for brief, selective use in post-laceration repair patients, primarily at night to facilitate sleep post-laceration repair.
Rehabilitation
Rehabilitation necessitated by a work-related injury should primarily concentrate on reinstating the functional capacity required for the patient to meet their daily and occupational responsibilities, with the ultimate goal of returning to work and striving to restore the injured worker to their pre-injury state as much as feasible.
Active and Passive Therapy
Active therapy involves internal efforts by the patient to complete specific exercises or tasks, while passive therapy encompasses interventions not demanding exertion from the patient, relying instead on modalities delivered by a therapist.
Generally, passive interventions are considered supportive measures to aid progress in an active therapy program, simultaneously achieving objective functional gains. Emphasis should be placed on active interventions over passive ones.
Home-Based Therapy
Patients should be guided to continue both active and passive therapies at home as an extension of the treatment process to sustain the achieved levels of improvement. Additionally, assistive devices may be integrated into the rehabilitation plan as adjunctive measures to enhance functional gains.
Active Therapy: Therapeutic Exercise
Recommended:Utilize therapeutic exercises to address functional deficits resulting from lacerations.
Frequency/Dose/Duration: The total number of visits may range from two to three for patients with mild functional deficits to 12 to 15 for those with more severe deficits, provided there is documented ongoing objective functional improvement.
If persistent functional deficits exist, exceeding 12 to 15 visits may be warranted with documented improvement toward specific objective functional goals (e.g., enhanced grip strength, key pinch strength, range of motion, advancement in work-related activities). As part of the rehabilitation plan, a home exercise program should be devised and executed in conjunction with therapy.
