Pretibial Lacerations

Pretibial lacerations are common injuries, especially among older adults, because the skin over the shin becomes thinner and more susceptible to tears with age.

Epidemiology

Pretibial lacerations may occur following minor trauma to the shin area, particularly in elderly individuals with fragile skin. The prevalence of these injuries is estimated at 5.2 per 1000 emergency department attendances in the UK (1). The average age of patients presenting with pretibial lacerations is in the mid-seventies, with a higher incidence in females. (1)

Assessment

History of Presenting Complaint:

  • Mechanism of Injury: Determine how the injury occurred (e.g., fall, bump against an object). Identify if it is a medical or mechanical cause of the fall. Enquire about any associated trauma such as head injuries and fractures.
  • Time of Injury: Note when the laceration happened, as this influences infection risk and treatment decisions.
  • Location: Identify the exact site of the injury and check for additional wounds.
  • Bleeding: Assess the extent of bleeding at the time of injury.
  • First Aid Measures: Document if any initial care has been done, such as cleaning or dressing the wound.

Systemic Symptoms:

  • Evaluate for signs of infection, including fever, redness, swelling, increased pain or pus.

Past Medical and Drug History

  • Comorbidities: Conditions like diabetes or peripheral vascular disease can affect healing.
  • Medications: Note any drugs that might influence bleeding, immune response or wound healing
  • Allergies: Record any known allergies, particularly to antibiotics or dressing materials.
  • Tetanus Immunization: Verify the patient’s vaccination status.

Social History

  • Assess factors that may impact wound care and healing, such as smoking, alcohol intake, and social support. (2)

Examination

The patient should be assessed with an ABCDE approach and you should have a low threshold for a secondary survey (top to toe) to exclude any associated injuries.

Inspection

  • Wound Assessment: Examine the size, depth, and condition of the wound edges.
  • Surrounding Skin: Check for bruising, swelling (haematoma), or signs of infection.

Palpation

  • Gently palpate to detect underlying hematomas or foreign bodies

Neurovascular Assessment

  • Evaluate distal pulses, capillary refill, and sensory function to ensure adequate blood flow and nerve integrity.

Movement

  • Ensure that a normal range of movement is possible for the affected limb as immediate mobilization is encouraged.

Documentation

  • Clearly record findings, including measurements and descriptions of the wound, and consider photographic documentation if appropriate.
Pretibial Laceration Illustration
Pretibial Lacerations Table Modified Dunkin Classification

Investigations

Imaging:

  • X-rays: Obtain if there’s suspicion of fractures or foreign bodies. Remember to request 2 views, usually AP and lateral

Laboratory Tests

  • Blood Tests: Consider if systemic infection or low Hb is suspected.
  • Wound Swabs: If signs of infection are present, to guide antibiotic therapy.

Management

An MDT approach may be required with input from the care of the elderly medical team, tissue viability nurses, plastic surgery team, district nurses, physio and occupational therapists as well as dieticians to optimize prevention and active treatment of pretibial lacerations.

Initial Management

  • Wound Cleansing: Thoroughly clean the wound to reduce infection risk. Haematoma evacuation is recommended to reduce risk of infection. (4)
  • Hemostasis: Achieve bleeding control through direct pressure or appropriate dressings.
  • Pain Management: Administer analgesics as needed.

Wound Closure

  • Steri-Strips: Suitable for simple, linear lacerations. 
  • Avoid Suturing: Do not suture the wound as the skin is friable; allow the wound to heal by secondary intention. 

Dressings

  • Non-Adherent Dressings: Prevent trauma during dressing changes.
  • Compression Bandaging: This may be beneficial if there are associated oedema, ensuring it’s appropriate for the patient’s vascular status.

Antibiotics

  • Prophylaxis: Not routinely indicated unless there’s a high risk of infection.
  • Infection Treatment: If infection develops, prescribe antibiotics based on local guidelines and culture results.

Tetanus Prophylaxis

  • Ensure tetanus immunization is up to date; administer booster if necessary. 

Elevation and Mobilisation

  • Advise elevating the affected limb to reduce swelling and promote healing while at rest.
  • Avoid bedrest to reduce the risk of associated complications.

Indications for Surgical Intervention

The plastic surgery team will consider the suitability for surgery when assessing the patient

  • Debridement: Removal of non-viable tissue to prevent infection.
  • Skin Grafting: This may be considered for extensive tissue loss or non-healing wounds.
  • Hematoma Evacuation: If a significant hematoma is present, surgical drainage may be required.

Follow-up

Wound care:

  • Schedule regular reviews and involve the district nurses to monitor healing progress and adjust treatment as needed.

Patient education:

  • Explain the signs of infection and the importance of adherence to care instructions.

References:

  1. Cahill, K. C., Gilleard, O., Weir, A., & Cubison, T. C. (2015). The epidemiology and mortality of pretibial lacerations. Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 68(5), 724–728. https://doi.org/10.1016/j.bjps.2015.01.011
  2. Gohil, K., Varma, P., Byford, G., Walsh, K., & Dutta, P. (2022). Pretibial lacerations. British journal of hospital medicine (London, England : 2005), 83(12), 1–7. https://doi.org/10.12968/hmed.2022.0080
  3. Singh, P., Khatib, M., Elfaki, A., Hachach-Haram, N., Singh, E., & Wallace, D. (2017). The management of pretibial lacerations. Annals of the Royal College of Surgeons of England, 99(8), 637–640. https://doi.org/10.1308/rcsann.2017.0137
  4. Lo, S., Hallam, M. J., Smith, S., & Cubison, T. (2012). The tertiary management of pretibial lacerations. Journal of plastic, reconstructive & aesthetic surgery : JPRAS65(9), 1143–1150. https://doi.org/10.1016/j.bjps.2011.12.036

Written by: Maged Elsafti (Plastic Surgery Registrar) and reviewed by Jonathan Van (Plastic Surgery Registrar)

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