Dermatology

PCP submission

36 y/o male patient presents for follow-up of open wound to right inner thigh last Thursday while at work with razor blade. Patient brought pictures on his cell phone of the wound prior to closure. Wound was opened to subcutaneous (dermis) layer. Patient was taken by his employer to local family practice clinic where they performed a single layer closure (per patient) with ten sutures and updated his tetanus vaccination. No antibiotic therapy was given. They told him it was a “clean wound” and that he did not need antibiotics. Patient has been experiencing severe pain and redness. Today’s clinic vitals: temperature 100.4 F. Other vitals were stable. On exam wound shows no active drainage, ten sutures in place, moderate tenderness w/touch, mild redness with warmth to touch. Consulted Envision Radiology this morning, who recommended Initial order of ultrasound of right thigh region with the possibility of needing MRI evaluation of soft tissue later.This was d/w patient, and he agreed. Patient has been referred to radiology for STAT ultrasound of the right inner thigh with the possibility of MRI study later. Explained to patient he has a significantly deep laceration. We will try to manage this at the clinic, but may have to refer him to wound clinic if not healing timely or worsening. He understood. Rx Cephalexin 500 4 times daily x10 days has been sent to his pharmacy. Home wound management instructions have been given to patient. Patient will follow up tomorrow and 2-3 days for wound recheck. Sutures usually removed 7-14 days after placement. F/U in 1 week for possible removal of sutures. ED protocols reviewed with patient. Patient understood and agreed with this plan. Cuts Closed With Staples: Care Instructions material was printed.

1. Was a single layer closure appropriate for this depth of laceration?
2. Assuming there is no subcutaneous infection requiring opening of this wound (awaiting results of today’s radiology report); should the sutures be removed after 7 days or left in place longer because of the initial depth of the laceration?
3. Was the antibiotic appropriate for this type of injury/ infection?
4. Was an ultrasound appropriate or should I order MRI of the wound?
5. When should I refer to wound clinic?

Specialist response

Hello Thank you for the consult. Given the fever, redness, and the peau d’orange appearance of the surrounding skin (If you look at the inferior aspect, the skin looks rippled), this wound is infected and the patient has cellulitis. The stitches appear too tight and there is swelling. The patient has cellulitis with systemic symptoms such as a fever despite taking Ibuprofen and Tylenol. If he also complains of not feeling well (fatigue or malaise), I would be concerned that this infection is deeper. In a case like this, I would cut 1-2 sutures, and see if any purulence is expressed and send for culture. I would also mark the area of redness and see if it is spreading. It is okay to start with Keflex as your antibiotic (doxycycline may be better but wound must be cultured), but opening the wound is VERY important at this time. I would not wait or rely on imaging for this. This is a clinical diagnosis. Next, I would have a VERY low threshold to have this patient admitted to the hospital for IV antibiotics if this infection has seeded deeper. Hence, if he continues to have fevers, there is more pain, redness spreads, etc. Below are answers to your questions: 1. Was a single layer closure appropriate for this depth of laceration? – Ideally this should be a two layer closure with possible antibiotics at that time; however, the two layer closure is more for better healing. It isn’t the reason for the infection. 2. Assuming there is no subcutaneous infection requiring opening of this wound (awaiting results of today’s radiology report); should the sutures be removed after 7 days or left in place longer because of the initial depth of the laceration? – There is subcutaneous infection given findings. Sutures should be removed sooner to relieve pressure and release any purulence. 3. Was the antibiotic appropriate for this type of injury/ infection? – Keflex is fine. I would even consider doxycycline or Clindamycin to cover for MRSA – Threshold for IV antibiotics and treatment should be low. 4. Was an ultrasound appropriate or should I order MRI of the wound? – Neither imaging is necessary. This is a clinical diagnosis. Imaging should play a role if there is pain out of proportion to findings, etc but the initial management should not be based on imaging. 5. When should I refer to wound clinic? – Wound clinic comes into the picture when the wound is NOT healing after several weeks. This is too soon. What is most important to adequately control the infection and then see if secondary healing doesn’t do well.