Superficial abrasions not associated with embedded foreign matter require only thorough cleansing with an appropriate antiseptic agent, removal of the agent by irrigation or cleansing of the wound with normal saline, application of an appropriate antibacterial ointment and a sterile dressing, recleansing and reapplication of antibacterial ointment at 24-hour intervals until healing is complete, and a wound check at 48 to 72 hours if indicated. Instructions regarding the signs and symptoms of infection should also be provided and antitetanus prophylaxis administered as discussed pp. 464 and 465.

Deeper abrasions not associated with embedded material are treated similarly; however, an occasional patient with more significant injuries will require a wound check ‘at 24 to 48 hours. If signs of infection have developed at that time, a wound culture should be obtained and antibiotics instituted. In addition to the administration of antitetanus prophylaxis as needed, analgesics may be required for 24 to 48 hours.

When embedded foreign material is present, aggressive treatment is required to prevent permanent “tattooing” of the skin. The use of povidone-iodine-impregnated brushes and forceps will facilitate cleansing of the wound. Excision may occasionally be required in wounds with devitalized tissue or deeply embedded material not otherwise extractable. Locally applied or topical anesthetic agents are required for adequate cleansing of abrasions in these patients. In patients with relatively small abrasions, topically applied 2% lidocaine or tetracaine or locally instilled 0.5% to 1% lidocaine will be reasonably effective. Topically applied agents generally require 10 to 15 minutes to become maximally effective. It is important to note that topically active anesthetic agents are absorbed extremely rapidly from abraded skin; therefore, the total maximally acceptable dose should be reduced. In addition, in patients with large injuries, if local instillation of 0.5% to 1% lidocaine is elected, the use of solutions containing epinephrine should be avoided.

When injuries are extensive, when the patient is uncooperative, or when the maximally safe dose of anesthetic is likely to be exceeded, early surgical consultation is recommended, because regional or general anesthesia may be required in the operating room.

When the fingertip is involved, the general rule is that avulsions exposing more than 1 cm² of fat require grafting, whereas lesions smaller than this will heal completely without grafting. When the avulsed tissue is available, it should be thoroughly cleansed, defatted, and tacked in place with fine suture material. When grafting is not required, an antibacterial ointment, a nonadherent dressing next to the skin, and a bulky dressing should be provided. Most patients with fingertip injuries will require an analgesic for several days; patients should be instructed to strictly elevate the hand to reduce bleeding and discomfort. Patients should be seen in 48 to 72 hours for a dressing change, at which time, despite the use of a nonadherent dressing, hydrogen peroxide as a soak may be required to facilitate removal of the dressing without severe pain. A similar dressing should be applied, which can be changed at 24- to 48-hour intervals until healing is complete—usually within 2 weeks. Partial avulsions are defined as tangentially oriented lacerations that result in an undermined flap of tissue. Before considering the various treatment options for such injuries, the pathophysiology of the injury as it relates to vascular disruption and subsequently to scar formation and contracture should be noted.

Clearly, when tissue is undermined, local vascular structures, including arteries, veins, and lymphatics, are disrupted. Because of venous and lymphatic compromise, swelling and edema of the flap evolve over several hours to several days. Such expansion of the flap places increasing traction on the wound edges that results in the spreading or widening of the scar as it forms. In addition, flaps tend to become “boggy” or edematous as intradermal scar tissue increases in density; this further aggravates the tendency of the scar to widen. Furthermore, as the peripheral skin scar contracts, a “heaping up” of the tissue that composed the original flap occurs. Last, particularly in patients with distally attached flaps, the blood supply may be inadequate to support the most proximal tissue, resulting in ischemic necrosis at or near the suture line. The combination of these processes in patients with injuries occurring in cosmetically significant areas often produces less than optimal results, unless special measures are taken to minimize their impact on the healing process. Flap-type avulsions of the nasal bridge and forehead often have such outcomes; for this reason, in selected patients, subspecialty consultation for repair is often appropriate.

In patients with somewhat larger flaps, conservative excision of very thin or beveled edges of the flap to produce a more perpendicular union of tissue will reduce subsequent scar formation. In patients with extremely small flaps, excision of the flap and primary closure are acceptable therapeutic options and will often produce a cosmetically superior result.

A special problem is the elderly patient with very atrophic or thin skin who presents with a superficial avulsing injury of the distal anterior tibial area, dorsal hand, or forearm. Such lesions are typically quite superficial and impossible to suture without further tearing of the skin. Occasionally, in patients with only superficial involvement, the application of a light pressure dressing or Steri-strips alone after routine cleansing will be sufficient. In other patients, the placement of one or two large, interrupted mattress sutures, the outermost pass of which should be placed at some distance from the wound edge, followed by the application of Steri-strips to complete the closure and a bulky dressing will produce optimal healing. Importantly, when an extremity is involved, the importance of strict elevation for 48 to 72 hours,