Skin tears and shear injuries are common. Despite this, providers often overlook risks of skin tears during anesthesia and surgery — especially in immobile patients with fragile skin. There are 5 major types of skin injuries: punctures, cuts, abrasions, pressure injuries, and skin tears. Anesthesia providers tend to be less familiar with skin tears. Prevention depends on awareness, gentle handling, and coordinated care from all involved disciplines.
Case#1
A 75-year-old woman with morbid obesity (BMI 40) and severe sleep apnea required urgent upper GI endoscopy for bleeding. We close general anesthesia in order to avoid risks of conscious sedation. We were working in our tiny, “closet sized” GI lab and there were only 3 of us. During positioning, we inadvertently dragged the patient’s arm under her body, causing a 6-inch long skin tear. Aghast, but anxious to complete the urgent procedure, we realigned the flap edges into their original position without stretching then quickly dressed the wound. We obtained surgical and wound care consults post-procedure; the injury healed well with minimal scarring.
With better planning and assistance, we could have prevented the injury.
Case #2
An 80-year-old frail woman underwent laparoscopic cholecystectomy. Following extubation, we transferred her onto the gurney, without recognizing that her right arm remained tucked under the sheets. Friction caused a large skin tear. Fortunately, the flap remained attached. We repositioned the skin flap and protected the wound with a moisture-retentive dressing. We ordered a wound care consult. The flap appeared somewhat pale and dusky on the edge when we repositioned it in place. Some tissue loss occurred, requiring prolonged wound care. Scarring remained.
A simple moment of inattention led to a totally preventable injury.
Case #3
I was walking at home with my 92 y.o. mother when she tripped. I grabbed her upper arm to prevent the fall. Sadly, the torque of the friction of my hand against her paper thin skin also tore a palm sized skin flap from her upper arm. She refused to go to the E.R. Instead, we gently smoothed the flap into position and wrapped her arm with kerlix. The edges realigned nicely. The flap adhered and thankfully the wound healed without complication.
Prevention would have included removing trip hazards in the home.
Types of Skin Injuries
Just to review, there are 5 major types of OR related skin injuries: punctures, abrasions, cuts, lacerations, and tears:
1. Puncture: a wound made by a sharp, pointed object
- Lip/tongue injury from a sharp tooth
- Cut: wound usually caused by a sharp object with clean edges
- Patient movement when scalpel applied
2. Laceration: deep torn or jagged wound, often caused by a blunt trauma
- Patient body part dragged against hard, edged surface
3. Abrasion or scrape: superficial rub or wearing off the skin, usually caused by a scrape or brush burn
- Adhesive tape “burn” or blister from tension on the skin
- Sliding on a rough surface
4. Pressure injury: injury caused by pressure impairing the underlying blood supply
- Excessive local pressure
- Pressure on face/extremities while prone/lateralScalp laying on bobby pins or firm hairdos
- Pressure points, especially if the patient is “bony”
5. Tear or shear injury: a blunt force separation of skin layers
- Incautious transfers and handling
- Dragging rather than lifting
- Removing adhesive dressings
We are very familiar with punctures, cuts, scrapes and pressure injuries. We don’t often think about skin tears or skin shear injuries — which can be serious and disfiguring.
What is a Skin Tear or Skin Shear Injury?
A skin tear is a wound caused by shear, friction or blunt force resulting in separation of skin layers that can partial thickness (epidermis from dermis) or full thickness (separation of both epidermis and dermis from the underlying layers
Skin tears occur due to the traumatic separation of the epidermis from the dermis, typically caused by friction or shearing forces. Put simply, the top skin layer stays in place but the deep tissues move underneath, shearing and separating the layers.
The STAR Skin Tear Classification
Tears can be linear, producing a skin split or the skin splitting in a straight line. Or they can produce a flap: a segment of skin or skin and underlying tissue separated from the underlying structures.
The STAR classification system lists 3 major classes of skin tears. Severity of injury increases with the number.
Risks and Contributing Factors
As one might imagine, anything that might impair tissue integrity predisposes to the injury. Skin tears often occur during routine patient care, when our guard is down. It’s essential to maintain a safe environment. Reduce the risk of these injuries by identifying and removing potential hazards, particularly for older adults. Be mindful of details when repositioning or moving a patient to protect their skin. Imagine yourself in that position for hours — this will alert you to potential problems. Let’s look at some risk factors.
Patient-Related Risk Factors
- Age: Elderly patients have thinner, less elastic skin and diminished subcutaneous fat, making them more prone to tears and shearing.
- Nutritional status: Malnutrition or low protein levels reduce skin integrity and healing capacity.
- Hydration status: Dehydrated skin is more susceptible to damage.
- Medications: Chronic corticosteroid use, anticoagulants, and chemotherapy agents can increase skin fragility and bleeding risk.
- Comorbidities: Diabetes, vascular disease, and certain autoimmune conditions may impair skin and tissue resilience.
Perioperative Risk Factors
- Positioning: Prolonged immobility or poorly supported limbs can lead to friction, pressure, and shear.
- Adhesive devices: Removal of adhesive tapes, ECG leads, or dressings can easily tear fragile skin.
- Moisture and chemical exposure: Don’t let povidone‑iodine or chlorhexidine solutions pool under the patient. Contact can macerate or chemically damage the skin.
- Use gentle handling: Always lift—never drag—the patient during transfers or repositioning. Use slide sheets, transfer boards, or air-assisted devices.
- Avoid use of coarse linens which can cause shear and friction injuries.
- Thermal factors: Apply warming devices, heat packs, or electrocautery grounding pads properly. Improper use can cause burns or contribute to tissue injury.
Preventive Measures
- Optimize nutrition and hydration where possible.
- Identify high‑risk patients (elderly, frail, steroid users, etc.) before anesthesia. Have a low threshold for using extra protection.
- Remove jewelry gently before transfer to the procedure room or OR.
- Remove adhesives gently
- Use skin-barrier films or protective dressings in high-risk areas (heels, elbows, sacrum).
Wound Care Measures
- Careful removal of dressings and monitoring leads.
- Take time to remove dressings slowly
- Early detection: Inspect skin for tears, redness, or blistering immediately after repositioning and at handover to recovery staff.
- Remove adhesive low and slow in the direction of the hair growth, keeping tape parallel to the skin and pushing the skin away from the tape with the other hand
- Use adhesive removers when removing the dressing in order to minimize trauma
- Documentation and communication: Record any skin concerns or preventive steps taken to ensure continuity of care.
- Don’ tape a flap down. There is too much risk of further damage.
- Mark the dressing over a skin tear with an arrow to indicate the correct direction of removal to avoid pulling the flap off with the dressing. Make sure that this is clearly explained in the notes, like this:
Full wound care for skin tears is beyond the scope of this article. More information can be found:
The Managing Skin Tears In Practice Quick Guide from Wounds International
Skin Tears: An Introduction to STAR
Case #4
You can’t always recognize the patient at risk. This injury was mine. At 65, I had a small cut on my arm. As a healthy, active, half marathon runner working 60 hour weeks I considered myself low risk. As a result, I ripped the bandaid abrupty from my arm when I removed it on day 5, . I wanted to get the discomfort of the “removal over with” quickly. A 1 inch x 3/4 inch flap of skin sheared off with it. This STAR class 3 injury took over 3 months to heal — far worse that the original cut. It resulted in a visible scar. And yes, that’s my wound as the header image on this article.
Key Takeaway
Skin tears and shear injuries under anesthesia are largely preventable with careful attention to patient fragility, gentle handling, and proper positioning. Our patient population is aging. Prevention requires teamwork among anesthesiologists, nurses, and surgical staff. Accordingly, we have to follow a proactive approach toward identifying risk and maintaining skin integrity from preoperative to postoperative phases.
