Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 1143e1150

REVIEW

The tertiary management of pretibial lacerations

Steven Lo*, M.J. Hallam, Shona Smith, Tania Cubison

Department of Plastic and Reconstructive Surgery, Queen Victoria Hospital, Holtye Rd., East Grinstead RH19 3DZ,
United Kingdom

Received 21 September 2011; accepted 24 December 2011

KEYWORDS Summary Pretibial lacerations remain one of the commonest yet most neglected conditions
Pretibial laceration; facing emergency departments and plastic surgeons alike. Furthermore, these injuries afflict
Pretibial laceration the most vulnerable groups of adults - the elderly and the infirm. It is essential therefore to
management; have an approach to pretibial lacerations based on best available evidence, in order to opti-
Pretibial injury mize wound outcomes, but perhaps more importantly, to safeguard the general health of
the vulnerable individual. We present an evidence-based approach to the tertiary management
of these injuries and propose a treatment algorithm that we have utilized in our unit to
successfully manage 40% of tertiary referrals of pretibial lacerations in a conservative manner.
ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Introduction to safeguard the general health of the vulnerable indi-

vidual. However, the majority of evidence in the literature
comes from the primary care setting, and less information
Background
is available regarding the tertiary management of pretibial
lacerations, which tends to represent the more severe end
Pretibial lacerations remain one of the commonest condi-
of the spectrum of such injuries. There are a number of
tions facing Plastic Surgery units today. Yet not only do they
important questions that therefore need to be addressed in
garner little in the way of attention in comparison to more
the management of such injuries. Firstly, when can one
complex reconstructive procedures, but they also afflict
consider conservative management as opposed to skin
the most vulnerable groups of adults e the elderly and the
grafting? Secondly, what evidence is there to support
infirm. It is essential to have an approach to pretibial
a completely conservative approach in tertiary referrals of
lacerations based on best available evidence, in order to
pretibial lacerations? Thirdly, when choosing surgery
optimize wound outcomes, but perhaps more importantly,
should the skin flap be defatted and replaced or a primary
skin graft performed? Fourthly, should the patient be
mobilized or subjected to bedrest? Lastly, one must also
* Corresponding author. Tel.: þ44 7980 893887.
E-mail address: stevenjlo@gmail.com (S. Lo).
consider the evidence indicating the detrimental effects of

1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2011.12.036
1144
hospitalization on the elderly. This review aims to provide
evidence-based answers to these questions and others, and
focuses on the highest level of evidence for each topic. It is
hoped that this will provide guidance on the management
of tertiary referrals of pretibial lacerations, and in doing so
reduce unnecessary surgery and safeguard the at-risk
elderly patient.
Epidemiology
Pretibial lacerations constitute approximately 2 per 1000
admissions to Accident & Emergency departments in the
United Kingdom, with skin tears of both upper and lower
limbs estimated to affect 1.5 million adults in Nursing
Homes in the United States per year.3,4 However the
exact number referred for subsequent tertiary manage-
ment remains undefined. Tertiary referrals are usually
made with the expectation that surgical management is
required, but to provide a clearer picture of the potential
risks involved in operating upon these patients, it is worth
reviewing the associated co-morbidities of this particular
patient subpopulation. A review of patients presenting to
an Accident and Emergency Department in the United
Kingdom found an average patient age of 82, and multiple
co-morbidities including ischaemic heart disease in 25%,
history of stroke 29%, chronic obstructive pulmonary
disease 29%, dementia 12.5%, diabetes 8.5%, cancer
12.5% and renal failure 12.5%.3 It is self-evident that this
is a group of patients for which surgery, particularly
under general anaesthesia, is not to be undertaken
lightly.
Literature search
A MEDLINE and EMBASE search was conducted with no
date restrictions using a combination of thesaurus terms
(Lacerations OR Laceration) and keywords (pretibial, pre
ADJ tibial). The searches were combined and a total of 37
articles were identified. Inclusion criteria: Systematic
review of meta-analysis of randomized controlled trials,
randomized controlled trials, review articles, and cohort
retrospective comparative reviews/studies. Included
articles have been rated on their quality of evidence
(Box 1) and grade of recommendation (Box 2). Exclusion
criteria: Case reports, expert opinion, and laboratory
studies.
Box 1: Scholarly articles investigating the results of treatment are assigned a level of evidence
on a scale from 1 to 5 based on the quality of their research methodology.1
Levels of Evidence
Level I: Meta-analysis of randomized control trials or high quality randomized control trials
Level II: Lesser quality randomized control trials (e.g. improper randomization or blinding) or prospective compar-
ative studies.
Level III: Case control studies or retrospective studies.
Level IV: Case series without the use of comparison or control groups
Level V: Case reports and expert opinion
S. Lo et al.
Conservative management
There is conflicting evidence whether to manage the
majority of tertiary referrals of pretibial lacerations by
surgical or conservative means. From a conceptual stand-
point, an analogy can be made with venous ulceration of
the lower limb. These often represent a greater area of skin
loss than pretibial lacerations, yet they are managed
virtually exclusively with dressings, with 93% healing at 5.3
months with compression hosiery and simple dressings
alone.5 Therefore, there should be no reason why a preti-
bial laceration, which lacks much of the abnormal wound
healing pathophysiology of a venous ulcer, will fail to heal
with dressings alone. Moreover, one must consider the co-
morbidities of the typical patient with a pretibial lacera-
tion, and assess whether an operation and prolonged
inpatient stay are in their best interest.
Historically, the management of these wounds in the
1960s and 1970s was inpatient bedrest, with secondary skin
grafting once it was deemed that the wounds had failed to
make progress. This led to a lengthy average inpatient stay
by today’s standards of 10 weeks. Tandon in 1973 addressed
these concerns regarding long hospital inpatient stays by
primarily skin grafting all tertiary referrals on admission to
the Plastic Surgery unit, with a subsequent reduction in
inpatient stay to a still rather excessive 5 weeks.6 In
contrast Crawford et al. adopted a different approach to
avoid prolonged inpatient stays, by utilizing an exclusively
conservative approach to these wounds. As a result of an
episode of prolonged bed occupancy crisis, precipitated by
multiple patients with pretibial lacerations on their wards
in Sheffield in 1975, Crawford and Gipson made the decision
not to admit any future pretibial laceration patients but
instead provide ambulant care. Their paper in 1977
summarises their outcomes.7 They treated 48 patients with
a mean age of 65, none of whom were admitted to hospital
at any stage. The mean time to healing was 65 days with
a range of 41e100 days. It should be noted that all of the
wounds healed with conservative management and none of
the patients required delayed skin grafting. Thus, based on
the success of a completely conservative approach, this
policy was subsequently adopted at that time for all future
tertiary referrals of pretibial lacerations.
Recommendation: Tertiary referrals of pretibial lacerations
can be managed exclusively with conservative management
Level of Evidence: IV
Strength of Recommendation: C
The tertiary management of pretibial lacerations
Box 2: Grades of recommendation are assigned according to the level of the evidence and its
applicability to a target population.2
Grade of Recommendation
Grade A : Level 1 evidence that is directly applicable to the target population
Grade B : Extrapolated level 1 evidence, or directly applicable level 2 evidence
Grade C : Extrapolated level 2 evidence or directly applicable level 3 or 4 evidence
Grade D : All other evidence from case reports and expert opinion
Dressings in conservatively managed pretibial
lacerations
Managing these injuries necessitates wound irrigation with
saline or another non-toxic cleanser such as chlorhexidine
gluconate scrub in order to decontaminate and reduce
opportunistic bacterial infection before the application of
supportive dressings.8 There are a plethora of different
dressings available for consideration when deciding optimal
wound coverage material, including paraffin gauzes, sili-
cone, silver, and alginate dressings. At present there is
insufficient evidence within the literature to advocate one
specific dressing type over another in pretibial lacerations.8
Soft silicone dressings such as Mepitel are advocated by
some nurse specialists, and are the most frequently used
dressing type, either alone or in conjunction with adhesive
strips in 29e50% cases of pretibial lacerations.3 There is
a single prospective study looking at skin tears in a geriatric
sample of 20 patients, using cyanoacrylate tissue adhesive
bandages, which are neither widely available nor commonly
used. 18 out 20 patients healed without complication, with
a high satisfaction rate with their use due to the lack of
need for repeated dressings changes.9 Although there are
advocates for the use of cyanoacrylate tissue adhesives in
pretibial lacerations, much of the work on their use is
derived from surgical or traumatic facial lacerations.8,10
Direct extrapolation of the results should be made with
care as the skin edges of pretibial lacerations often do not
come into direct apposition, a requirement for the use of
tissue adhesives.
As multiple randomized trials exist for venous ulcers, one
can draw some analogies with pretibial lacerations. A 1993
Cochrane systematic review of 42 randomized controlled
studies assessed the effectiveness of different wound
dressings for the treatment of venous leg ulcers.11 A large
number of different dressings were compared but the main
types evaluated in the trials were hydrocolloids, foams,
alginates, and hydrogels. The results of the meta-analysis
showed there to be no significant difference between
dressings in terms of ulcer healing rates. More recently the
2009 VULCAN randomized trial found no difference in
healing outcomes when comparing silver-donating antimi-
crobial or simple non-adherent dressings in venous ulcers.12
As there is a lack of evidence for choosing the most suitable
dressings in pretibial lacerations, one may extrapolate the
information from venous ulcer trials as a relative substitute.
Recommendation: There is insufficient evidence to
strongly recommend a specific dressing in pretibial lacera-
tions. Soft silicone dressings such as Mepitel are advocated
and utilized by most nurse specialists
1145
Level of Evidence: V
Strength of recommendation: D
Indications for surgery
Given that Crawford et al. demonstrated that conserva-
tively managed pretibial lacerations will heal with dressings
alone, the indications to operate need to be carefully
considered, especially given a frail patient population with
multiple co-morbidities. The non-discriminative approach
in skin grafting all tertiary referrals, as advocated by Tan-
don, is therefore not recommended. There are no objective
criteria on which one can base the decision to operate, as
no studies have been performed in this regard. Thus indi-
cations for surgical management represent expert opinion
only. Our suggestions for surgical intervention are elabo-
rated later in our classification to aid surgical management.
Briefly, based on the morphology of the wound, lacerations
that may require operative intervention include those with
large necrotic skin flaps, large area of skin loss or major
haematoma. Relative indications also include the failure of
conservative management after 2e3 months. Furthermore,
cases in which there is gross contamination or infection may
also necessitate debridement and grafting. Wound size per
se should not necessarily be an over-riding factor in
deciding upon the need for skin grafting, as all the patients
in Crawford’s 1977 series healed regardless of size.7
Nonetheless, a sensible approach should be adopted and
larger wounds > 1% body surface area should be considered
for grafting. It should also be noted that the approach to
the surgical management of pretibial lacerations has
changed significantly in some ways since the landmark
papers of Tandon and Crawford in the 1970s, particularly in
terms of post-operative rehabilitation, inpatient stay and
use of local anaesthesia, factors which we consider later.6,7
Recommendation: There is no clear evidence regarding
specific indications for surgical intervention, and recom-
mendations represent expert opinion only.
Level of Evidence: V
Strength of Evidence: D
Surgical technique
Anaesthetic
It is preferable to minimize anaesthetic risk by performing
these cases under local anaesthesia where possible.
Indeed Shankar and Khoo performed skin grafting and
debridement in the Casualty department under local
anaesthesia, with 92% graft take.13 Yet there is the
perception that General Anaesthesia is preferable as it
may allow a more thorough debridement, and therefore
1146 S. Lo et al.

skin graft take. This perceived advantage has not been discharged versus those who were confined to bedrest for 7
demonstrated in a study by Budny et al., with the use of days. There was no difference in percentage graft area take
General Anaesthetic resulting in a final graft take of 94.5% between the two groups (mobilized 89.7% versus bedrest
compared to 90.5% with Local Anaesthesia (p Z 0.40).14 92.8% p Z 0.55). Inpatient stay was 2 days as opposed to 12
Although this was a randomized trial, it was not random- days. Although complications as a result of inpatient stay
ized for anaesthesia per se, therefore the level of were not formally reported, they mention that about one
evidence is IV. third lost mobility as a result of bedrest. No thromboembolic
Recommendation: Local Anaesthetic is equivalent to episodes were noted but thromboprophylaxis was given to all
General Anaesthetic in graft success in pretibial lacerations patients.14 Chest infections and other iatrogenic morbidities
Level of Evidence IV were also not reported but it is reasonable to assume that
Strength of recommendation C a reduction of inpatient morbidity would follow a reduction
in bedrest time. In the current fiscal climate, it is also worth
Steristrips versus suture closure considering the financial implications of saving 10 bed days
A prospective randomized trial looking at 76 patients found per patient.
no difference between steristrips and suturing in terms of Recommendation: Immediate mobilization and early
infection or proceeding to ‘rescue’ skin grafting.15 However discharge
it did favour the use of steristrips in terms of faster healing Level of Evidence: II
times and lower rates of skin necrosis. In flap lacerations Strength of recommendation: B
the healing time with steristrips was 39 days and with
sutures 53 days. The sutured wounds were twice as likely to Antibiotics
suffer from skin necrosis. It is therefore recommended that Prophylactic antibiotics have little proven role to play in
wound closure be performed with steristrips. There are also pretibial lacerations. There is no good evidence to suggest
numerous cohort studies looking at various alternative they are of benefit, furthermore, cohort studies suggest that
techniques of closure in pretibial lacerations, but these confirmed infections in pretibial wounds do not alter final
provide only Level IV evidence.16 wound healing outcomes.21 A review of antibiotic prophylaxis
Recommendation: Pretibial lacerations should be managed in relation to pretibial haematomas failed to find any suffi-
with steristrips not suturing cient evidence to adequately support or reject their use.22
Level of Evidence I Recommendation: There is insufficient evidence to
Strength of recommendation A support the use of prophylactic antibiotics
Level of Evidence N/A
Defatting of skin flap versus excision of flap and primary Strength of recommendation: N/A
graft
There is only one prospective randomized trial comparing
defatting of flap lacerations versus excision of flap and
primary skin grafting from a secondary donor site.17 All cases
in this study were performed under local anaesthetic. This
trial favoured primary excision of the flap and skin grafting,
as it resulted in shorter inpatient stay (11 vs. 16 days),
reduced number of further operations (0% vs. 28% cases), and
shorter healing time (13 vs. 40 days). Furthermore, defatting
of the flap did not always result in complete coverage of the
wound, with the area uncovered being 28% of the original
wound size at 10 days. Although this study was strongly in
favour of primarily grafting from a secondary donor site, it
did not elaborate on complications from the donor site itself.
There are numerous cohort studies describing the use of
excision of the flap and use as sheet or pinch graft but these
provide only Level IV evidence.18,19
Recommendation: Non-viable flap lacerations should be
managed by excision and primary grafting, rather than
defatting of the flap.
Level of Evidence II
Strength of Recommendation B

Post-operative care

Mobilization versus bedrest

There is clear evidence that early mobilization is
more appropriate than bedrest in grafted pretibial lacera-
tions.14,20 A prospective randomized trial by Budny in 1993 Figure 1 Linear laceration without skin loss. This wound was
looked at patients who were mobilized immediately and managed with steristrips and dressings only.
The tertiary management of pretibial lacerations 1147

Figure 2 Flap laceration viable. This was managed with

steristrips and dressings.

Figure 4 Skin loss. This wound was debrided and managed

with dressings only.

Figure 5 Pretibial Laceration with Haematoma. The hae-

Figure 3 Flap laceration non-viable. matoma was evacuated and the defect grafted.
1148
Classification to aid surgical management
Payne and Martin described a skin tear classification in
1993, classifying them from Type I to III.23 Type I is a skin
tear without skin loss, and includes both linear and flap
lacerations. Type II is associated with tissue loss, and sub-
divided into less and greater than 25% loss of the flap. Type
III is a skin tear with complete loss of the flap. From
a surgical perspective, this is not entirely helpful as an aid
to management. It is our experience that linear and flap
lacerations require different surgical approaches and
should not be classified together. Neither have we found
a distinction between degree of flap loss or total loss. More
pertinent to the surgical management of the wound is
whether the remaining flap is viable, rather than its size as
a proportion of the wound. Therefore we would suggest the
following classification, a modification of that suggested by
Dunkin et al.., 2003, as a guide to management24:
I Linear laceration without skin loss (Figure 1)
Manage conservatively.
Level of Evidence IV (Crawford et al., 1973)
II Flap laceration viable (Figure 2)
Steristrip in casualty and manage conservatively.
Level of Evidence I (Sutton et al., 1985)
III Flap laceration non-viable (Figure 3)
A small non-viable flap may be excised and managed
conservatively with dressings. Larger skin flaps can be
primarily excised and skin grafted under local anaes-
thetic. Do not defat and replace skin.
Flowchart 1 Algorithm for management of pretibial
lacerations.
S. Lo et al.
Level of Evidence II (Hairt et al., 1990)
IV Skin loss (Figure 4)
Manage conservatively if less than 1% TBSA. If failure to
heal within 2e3 months e consider delayed primary
skin graft under local anaesthetic.
Alternatively, if local circumstances allow, primary skin
graft under local anaesthetic.
Level of Evidence V, expert opinion
V Laceration with haematoma (Figure 5)
Typically patients on anticoagulants, and will often
require surgery. Evacuate haematoma and graft.
Level of Evidence V, expert opinion.
Conclusions
The detrimental effects of hospitalization on the
elderly
Patients with pretibial lacerations are unfortunately often
neglected, and are frequently postponed on trauma lists to
make space for more urgent and interesting cases, thus
prolonging starvation times in an already frail and at-risk
patient. A prospective study on the surgical management of
pretibial lacerations found a cancellation rate of 50%, an
overall starvation time of over 18 h, and an average time
from referral to surgery of nearly 10 days.25 The mean
inpatient stay after surgery was 8.5 days, with delayed
discharge attributed to social rather than medical reasons.
It was also noted in this study that there had been 7 patient
deaths in 5 years in the subgroup of pretibial laceration
patients, but this is not further clarified. Bedrest, repeated
starvation, exposure to nosocomial infection and taking the
elderly out of their normal environment, all contribute to
physical and mental decline. A recent study found that
hospitalization results in the loss of at least one ADL
(Activity of Daily Living), with multivariate analysis showing
that hospitalization was an independent risk factor for
functional decline (Relative risk increased 1.1 times per
inpatient day).26
Prevention
Prevention is an essential component of the management of
these injuries, and it should not be considered superfluous
to the practice of Plastic Surgery. Education should be
targeted at units or Nursing Homes from which referrals are
made. Simple interventions such as staff education,
padding of side rails, skin sleeves for high-risk patients and
gentle skin cleansers, all have been prospectively shown to
reduce the incidence of skin tears in a Nursing Home
setting. These injuries were halved from approximately 19
per month to 9 (p < 0.001).27
A lack of consensus on surgical or conservative
management
Consensus of opinion on how best to manage these is often
quite divided. There is evidence to support either
a completely conservative or completely surgical approach
to these wounds. Most hospitals do not have a policy
The tertiary management of pretibial lacerations
allowing immediate inpatient surgical grafting or skin
grafting in the Casualty department as proposed by Shankar
& Khoo 1987.28 It is suggested therefore, that these prob-
lems are approached in a sensible and pragmatic way in
order to safeguard the frail individual, and to take into
account local hospital resources. One must consider care-
fully about operating on these patients, and if it is deemed
necessary to operate, then it is prudent to use local
anaesthesia and mobilize and discharge them as soon as is
safe. If it is not possible to accommodate this in an expe-
ditious manner, then it may be more appropriate to manage
these patients conservatively. The algorithm used in our
hospital for the management of these wounds is presented
(Flowchart 1), one that aims to minimize unnecessary
surgical intervention. Utilizing this algorithm we have
managed approximately 40% of tertiary referrals in
a conservative manner. With referrals from peripheral
hospitals, telemedicine is used to classify wound
morphology according to our grading system, the patient’s
co-morbidity taken into account and management plan
decided accordingly at consultant level. The use of tele-
medicine furthermore reduces unnecessary inter-hospital
transfer of the elderly, and all tertiary referrals that
require only conservative treatment are subsequently seen
and managed by our outreach specialist nursing team.
Patients requiring surgical intervention are medically pre-
assessed in the peripheral hospital prior to transfer in
order to minimize the risk of cancellation on transfer, and
are operated on scheduled lists rather than on the generic
trauma list. These strategies minimize cancellation,
repeated and prolonged starvation times, and inpatient
hospital stay Flowchart 1.
As there are no randomized trials to support the supe-
riority of either a conservative or surgical approach to these
wounds, it is suggested that such a trial is needed for
clarification. Factors that need to be addressed do not
simply include the tangible factors such as wound healing
and complication rates, but other validated quality of life
scores covering psychological wellbeing and activities of
daily living. With the ever-increasing financial constraints
on the National Health Service, one must also address the
financial implications of the two approaches, and their
impact on bed and trauma list occupancy.
In the mean time, until further evidence becomes
available, conservative treatment is an acceptable
approach in a substantial proportion of tertiary referrals of
pretibial lacerations. Furthermore, advocating conserva-
tive treatment should not be viewed as a failure of surgical
management. It is perhaps best to conclude by quoting
from Crawford et al. on the conservative approach to
managing pretibial lacerations in the 1970s, a quote which
is still applicable today: “Elderly ladies, often arthritic,
react badly to being bedfast, and we consider that the
somewhat longer healing time than could have been
achieved by several weeks’ inpatient care, is fully
acceptable when the patients remain ambulant and at
home”.
Conflict of interest/funding
None.
1149
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