Laceration & wound: documentation that holds up

A laceration looks like the most routine thing in the ED — which is exactly why missed tendons, nerves, and retained foreign bodies are among the most-litigated outcomes in wound care. The defensible chart documents the neurovascular and tendon exam before anesthesia, the wound exploration, the foreign-body assessment, and the tetanus decision.

01What's at stake

The failures are predictable: a partial tendon laceration that wasn't tested through range of motion, a digital nerve injury charted as "neurovascularly intact" only after lidocaine, a glass or wood fragment left in the wound, and a knuckle laceration that was really a fight bite closed primarily into a joint. The exam that matters happens before you anesthetize and while you explore.

02Can't-miss issues

• Tendon injury — test each tendon individually through full range of motion; a partial laceration moves but is weak/painful.
• Nerve injury — two-point discrimination distal to the wound, tested before local anesthetic.
• Retained foreign body — glass, wood, metal; high-risk mechanisms and a gritty wound → image.
• Deep-structure / joint / vascular involvement — open joint, fracture through the wound, arterial injury.
• Fight bite / infection-prone wound — laceration over the MCP from a tooth; don't close primarily.

03The exam (before anesthesia)

• Neurovascular first — sensation (two-point discrimination), distal pulses/perfusion, and motor — documented before infiltrating local anesthetic. → before lidocaine
• Tendon testing — each tendon individually, against resistance, through full range of motion (a retracted end hides out of the wound at rest). → full ROM
• Explore the wound to its base in a bloodless field — depth, foreign body, joint capsule, bone.
• Foreign-body imaging — radiographs detect glass and metal; ultrasound for radiolucent wood/organic material when suspicion persists.

04Irrigation, closure & prophylaxis

• Irrigation — copious irrigation with normal saline or potable tap water (roughly 50–100 mL per cm of wound) at adequate pressure is the workhorse of infection prevention.
• Timing of closure — the "golden period" is a guide, not a hard rule; well-vascularized wounds (face/scalp) can be closed later, while older or contaminated wounds may be left for delayed primary closure or healing by secondary intention.
• Closure method — sutures, staples (scalp/trunk), tissue adhesive (low-tension, dry wounds), or wound tape, matched to location and tension.
• Tetanus — update per immunization history and wound type (tetanus-prone vs clean/minor); give immunoglobulin for tetanus-prone wounds in the under-/unimmunized.
• Antibiotics are not routine for simple lacerations; reserve for bites, heavily contaminated wounds, open fractures/joints, and the immunocompromised.

05What to document

06Where charts fail

• Charting "neurovascularly intact" only after local anesthetic — the sensory exam is no longer reliable.
• Not testing tendons through full range of motion — missing a partial or retracted laceration.
• Closing a wound without exploring to the base — missing a retained foreign body or open joint.
• Closing a knuckle laceration without recognizing the fight bite.
• No documented irrigation, tetanus decision, or wound-care/return precautions.

07Sources

• Duvidovich M, Sanders JE. Pediatric wound care and laceration repair in the emergency department. Pediatric Emergency Medicine Practice (EB Medicine). 2025.
• Forsch RT, Little SH, Williams C. Laceration repair: a practical approach. Am Fam Physician. 2017;95(10):628-636.
• Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the 'golden period' of laceration care disappeared? Emerg Med J. 2014;31(2):96-100.
• American College of Surgeons / CDC. Tetanus prophylaxis in wound management. MMWR / ACS guidance.

© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from EB Medicine and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.