CCFP priority topic 58 of 105
Lacerations on the CCFP exam
7 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 7 key features for Lacerations. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 7
Not a simple cut
Recognize cuts whose site or depth calls for an expert repair.
CFPC skill Clinical reasoning, selectivityPhase Diagnosis, physical
On the exam
After a vaginal birth, a tear reaches the anal sphincter. Expect one best answer on who repairs it and where.
Pick who repairs it, and where.
Common mistakes
Calling a sphincter tear second degree and closing it at the bedside. A missed sphincter injury can leave lasting incontinence.
Approach
- After every vaginal birth, do a rectal exam before you repair. Feel for a gap in the anal sphincter.
- A tear into the sphincter is third degree. Into the bowel lining is fourth degree. Both need an experienced repairer, good light and full anesthesia.
- A lip cut that crosses the red edge (the vermilion border) needs exact alignment. Refer if you cannot line it up.
- An eyelid cut through the lid edge, near the inner corner, or with fat showing needs an eye surgeon. Check the eye itself first.
- Bright, pulsing bleeding that firm pressure does not stop means an artery. Keep pressure on and call a surgeon. Do not clamp blindly near nerves.
| Wound | Clue | Plan |
|---|---|---|
| Perineal tear | Sphincter gap on rectal exam | Experienced repairer, full anesthesia, good light |
| Lip | Crosses the red edge, or goes through into muscle | Align the red edge exactly; refer if you cannot |
| Eyelid | Through the lid edge, near the inner corner, or fat showing | Eye surgeon; examine the eye first |
| Artery | Pulsing bleed that pressure does not stop | Hold pressure; surgeon |
Key feature 2 of 7
Look beneath the cut
Look for injuries under the wound that simple stitches will not fix.
CFPC skill Clinical reasoningPhase Diagnosis, physical
On the exam
A man cuts the palm side of his finger on a broken mug. Expect a short menu (pick several from a list) of exam steps and tests.
Pick the exam steps and the first test.
Common mistakes
Trusting his strong fist, or testing the back of the hand or the wrist. A cut deep flexor still allows a firm grip.
Approach
- Test the deep flexor alone: hold the middle joint straight and ask him to bend the fingertip. No bend means it is cut.
- Test feeling on each side of the fingertip before any anesthetic. A palm-side finger cut threatens the digital nerves, not the median nerve at the wrist.
- Look into the wound in a bloodless field, through full range of motion. A tendon cut with the finger bent hides when it is straight.
- A cut from shattered glass or pottery can hide a piece. Look for one before you close.
- A wound over a broken bone is an open fracture. Cover it, splint it and refer.
- A cut over a knuckle from a punch is a human bite until proven otherwise.
Key feature 3 of 7
Clean before closing
Wash a deep or dirty wound with plenty of fluid and remove dead tissue first.
CFPC skill Clinical reasoningPhase Treatment
On the exam
Garden soil is ground into a hand cut with a dusky skin flap. Expect one best answer for the next step.
Pick the next step before closure.
Common mistakes
Antibiotics, a peroxide rinse or an iodine soak in place of irrigation. None flushes out soil, and the dusky flap stays to die.
Approach
- Numb the wound first, so you can clean it properly.
- Irrigate with a large volume of clean water or saline, under pressure, until no dirt is left.
- Cut away dead or dusky tissue and dirt ground into the edges.
- Skip peroxide and strong antiseptic soaks inside the wound. They harm healthy tissue and do not remove soil.
- Antibiotics never replace cleaning. Closing over dirt is what causes infection.
Key feature 4 of 7
Leave it open
Know which wounds are likely to get infected, and leave them unsutured.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generation, treatment
On the exam
A cat bit a woman's hand, leaving a deep puncture. Expect one best answer for wound closure.
Decide whether to close the wound.
Common mistakes
Suturing the bite because it looks small and she wants it tidy. Closing a puncture seals germs in deep tissue.
Approach
- Do not stitch puncture wounds. You cannot clean the depth, and closure traps germs.
- Leave cat bites, human bites and most hand bites open after cleaning.
- A punch to the mouth that cut the knuckle can carry germs into the joint. Leave it open and refer.
- A wound you cannot get fully clean stays open. Review it in a few days and close it later if it is clean.
- A clean facial dog bite is usually closed after thorough cleaning. The face has a rich blood supply, and the scar matters.
- For any animal bite, ask about rabies risk and involve public health.
| Wound | Close? | Why |
|---|---|---|
| Puncture wound | No | Cannot clean the depth |
| Cat or human bite, most hand bites | No | High infection risk; tendons and joints near |
| Wound still dirty after cleaning | Not yet | Review, then close later if clean |
| Clean facial dog bite | Usually yes, after cleaning | Rich blood supply; scar matters |
Key feature 5 of 7
Children: no restraint
In a child, control pain and movement with medicine, not by holding them still.
CFPC skill Clinical reasoningPhase Treatment
On the exam
An 11-month-old's lip cut runs across the red edge into muscle. Expect one best answer for pain and stillness.
Pick how to keep her calm and still.
Common mistakes
Wrapping her in a sheet, or relying on numbing gel alone. Restraint frightens her and still lets her move; the gel does not reach muscle.
Approach
- Put numbing gel on a skin cut early, at triage, so it works by the time you repair.
- Gel numbs skin only. A cut into muscle or the moist inner lip needs injected anesthetic or a nerve block as well.
- Inject local anesthetic slowly through the wound edge with a fine needle.
- For a small child who must stay still for exacting work, use procedural sedation with a trained team and monitoring.
- Keep the parent at the bedside and use distraction: videos, bubbles, songs.
- Use tissue glue only on small, clean, low-tension skin cuts. Never on the moist lip, bites, or dirty wounds.
Key feature 6 of 7
Repair for the scar
Give a repair the time and technique it needs for the best-looking scar.
CFPC skill Clinical reasoningPhase Treatment
On the exam
A woman has a gaping cut across her upper lip into the muscle. Expect a short menu (pick several from a list) of repair steps.
Pick the steps for a good result.
Common mistakes
Infiltrating local anesthetic into the lip edge, which swells it and hides the line. Or leaving it to heal alone, which leaves a notch.
Approach
- Block the nerve to the lip instead of injecting the edge. Infiltration swells the tissue you must line up.
- Place the first stitch exactly at the red edge of the lip. Then work outward.
- Close in layers: absorbable stitches in the muscle, then the skin. Less tension means a narrower scar.
- On the face, use fine sutures, good light and enough time. Do not rush a repair the patient will see every day.
- Warn that a scar keeps changing for many months. A wide or raised scar can be revised later.
- Advise sun protection on the healing scar.
Key feature 7 of 7
Tetanus
Ask about tetanus doses at every wound visit and give what the record calls for.
CFPC skill Clinical reasoningPhase History, treatmentSources Public Health Agency of Canada / NACI
On the exam
A man cut his hand gardening. Soil is in the wound; his last booster was 7 years ago. Expect one best answer.
Pick the tetanus care for today.
Common mistakes
Giving nothing because the booster is under 10 years old. Or adding immune globulin because the wound is dirty, when his series is complete.
Approach
- Ask how many tetanus doses he has had, and when the last one was. Check the written record.
- Soil, feces or dead tissue in a wound makes it tetanus-prone. Even a small wound can cause tetanus if dead tissue is present.
- Three or more doses: a clean, minor wound needs a booster after 10 years. Any other wound needs one after 5.
- Immune globulin is for an unknown history or fewer than 3 doses, with any wound that is not clean and minor.
- The dose is 250 units deep into muscle for adults and children 7 or older. Use a different site and syringe from the vaccine.
- An adult who never had a pertussis dose as an adult gets Tdap (tetanus, diphtheria and pertussis). Otherwise, Td.
- A child with 3 or more doses, the last under 5 years ago, needs nothing today.
| Tetanus history | Clean, minor wound | Any other wound |
|---|---|---|
| Unknown, or fewer than 3 doses | Vaccine | Vaccine plus immune globulin |
| 3 or more, last under 5 years ago | Nothing | Nothing |
| 3 or more, last 5 to under 10 years ago | Nothing | Vaccine |
| 3 or more, last 10 or more years ago | Vaccine | Vaccine |
Flashcards
Answer it first, then check.
KF 1A lip cut crosses the red edge. Where does the first stitch go?
Exactly at the red edge, the vermilion border. A small step there shows for life.
KF 2A palm-side finger cut. How do you test the deep flexor on its own?
Hold the middle joint straight and ask for a fingertip bend. No bend means it is cut.
KF 3Soil is ground into a hand cut with a dusky flap. What comes before closure?
Anesthetic, then high-volume pressure irrigation and trimming the dead flap. Antibiotics do not replace either.
KF 4A cat bite punctured the palm. Do you suture it?
No. Clean and irrigate it, leave it open, and review it soon. Closure seals germs in.
KF 5A toddler needs an exact lip repair and will not stay still. What instead of holding down?
Procedural sedation by a trained team with monitoring, plus a nerve block or injected anesthetic.
KF 7Soil in the wound, 3 doses in childhood, last booster 7 years ago. What does the adult need?
A booster today: Tdap if no adult pertussis dose yet. No immune globulin. Source: Public Health Agency of Canada / NACI
KF 7An adult with an unknown tetanus history has a soil-filled wound. What do you give?
Tetanus vaccine plus 250 units of immune globulin, at separate sites. Then finish the series. Source: Public Health Agency of Canada / NACI
FAQ
Td or Tdap for an adult with a wound?
Tdap if the adult has never had a pertussis dose as an adult. Otherwise Td. Either covers tetanus; the choice depends on the pertussis record, not the wound.
Is there a time limit for closing a cut?
No single cut-off decides it. Older wounds carry more infection risk. Weigh the wound's age, its site and how dirty it is. Face wounds are often closed later than limb wounds.
Do all bites stay open?
No. Punctures, cat bites, human bites and most hand bites stay open. A clean dog bite on the face is usually closed after thorough cleaning, because the scar matters there.
When is tissue glue enough?
For a small, clean skin cut whose edges meet without tension. Not on the moist lip, over a cut into muscle, on bites, on dirty wounds, or over a moving joint.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Canadian Immunization GuidePublic Health Agency of Canada / NACI