Reducing the Impact of Pretibial Lacerations | SUTUREGARD

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Reducing the Impact of Pretibial Lacerations

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Maybe you have cared for or know of an elderly friend relative or patient who has experienced a relatively minor trauma to their thin fragile skin that led to a significant problem. This can occur in many areas of the body, but the arms and legs are the most frequently traumatized. Pretibial (shin) laceration is the best studied area. The issue of pretibial lacerations and the healing problems and complications they present is very significant. Thin fragile skin can occur with advanced age, severe sun damage or chronic steroid use (which thins the dermis). Often, they are on blood thinners, and the accompanying skin hematomas can rapidly cause skin necrosis. Those injured are high risk patients, and hospitalization or outpatient care for these injuries can be prolonged. Mortality for this group is doubled compared to matched populations without the pretibial laceration (1). The incidence of pretibial laceration progressively increases with patient age and overall prevalence becomes more common as our total population ages.

The UK has the best demographic data on the subject. There are 5.2 pretibial lacerations per 1000 emergency visits in the UK (2). In 2018-19, there were 67,000 emergency visits per day in the UK (3). This means the number of injuries per year is 348/day x 365=127,166 such injuries annually. There are 66 million people in the UK, for an annual incidence of 0.2%. If we translate this to the USA (population 325 million) we are considering about 800,000 such injuries annually.

These injuries happen most often with a minor collision or fall, but severe lacerations can result. There is a classification by Dunkin that grades these injuries I-IV, with over 50% falling in the more severe grades, with significant skin damage/loss (4). In this series 2/3 of patients required admission. Healing times are lengthy, on the order of 60 days for those managed with skin grafts, and 120 days for those managed with wound care alone (5).

IN the UK, admission cost is approximately $4500, but costs in the US are much higher (average cost of admission $10,700 per Healthcare Cost and Utilization Project (HCUP). If 2/3 are admitted as in Singh’s series, the cost in the USA might be 500,000 x $10K or $5B.

How can we help? This type of skin is damaged easily and is typically not able to be sutured due to suture tearing through the thin skin. Some skin is frankly necrotic if presenting late to care. But if the skin can be fully removed early on, cleaned and placed as an immediate skin graft, this method can be successful (6). If the skin is present and viable but just lacerated, HEMIGARD can facilitate suture repair as it prevents suture tearing through the skin. Repairs with adhesive tape only are limited as drainage typically lifts the adhesive tape off in days. HEMIGARD should be able to persist and adhere for 10-14 days during which time healing can be well underway. And the gentle adhesive allows atraumatic removal. We feel the HEMIGARDTM Retention Suture device can be a useful tool to assist in the management of this difficult problem.

thin fragile skin like paper
  1. Glass G et al Pretibial lacerations: experience from a lower limb trauma center and systematic review. J Plast Reconstr Aesthet Surg 2014;67(12) 1694-1702.
  2. Beldon P et al Classifying and managing pretibial lacerations in older people. Br J Nursing 2008:17(11):S4
  3. Baker, C. National Health System Statistics 2018-2019. Briefing paper #7821, 31 May 2019, House of Commons Library
  4. Singh P et al The management of pretibial lacerations Ann R Coll Surg Engl 2017:99:637-640
  5. Cahill, K et al The epidemiology and mortality of pretibial lacerations J Plast Reconstr Aesthet Surg 2015:68(5) 724-8.
  6. Kindle, N. Improvised skin graft for a large superficial hematoma JWOCN 2017 40(5), 40-45.


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