Boo-Boo and Owie Repair

Boo-Boo and Owie Repair

Carmen M Lebron, MD

Dept. of Pediatric Emergency Medicine

August 1, 2007

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Pathophysiology

Wounds regain 5% strength in 2 weeks

Collagen synthesis begins within 48 hours of injury and peaks at 1 week

30% strength in 1-2 months

Full tensile strength in 6-8 months

Remodeling can occur up to 12 months

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Pathophysiology

Normal skin is under constant tension produced by underlying joints and muscles.

Lacerations parallel to joints and skin folds heal more quickly and better

Tension widens scars

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Evaluation

History:• Mechanism of injury - Shearing, Tension (Blunt),

or Compression (Crush)• Age of wound• Possibility of foreign body• Location and damage to adjacent structures• Environment in which injury occurred• Patient’s health status: diabetes,

immunocompromised, cyanotic heart disease, chronic respiratory problems, renal insufficiency

• Medications – steroids• Allergies to latex, antibiotics or anesthetics• Tetanus status

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Evaluation

Physical:• Foreign material

Glass and metal are radiopaque, so X-ray Ultrasound is useful for other foreign bodies Explore for foreign bodies after anesthesia

• Bones Palpate nearby bones for tenderness or

crepitance and X-ray if found Refer vascular, nerve or tendon injuries or deep,

extensive lacerations to the face• HAND: Ortho and Plastics alternate days• FACE: ENT, Plastics, and OMFS alternate

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Decision to Close

Infection rate for children is 2% for all sutured wounds.

“Golden period” is within 6 hours for primary closure Low risk wounds can be primarily closed 12-24

hours after injury

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Decision to Close

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Wound Preparation

Do not shave hair• Secure with petroleum jelly or clip with scissors if

needed to keep hair from entering wound Clean the wound periphery with 10% povidone-

iodine• A 1% solution may also be used for dirty wounds

• Avoid chlorhexidine, H2O2, Alcohol, and surgical scrub in the wound

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Wound Preparation

Anesthetize locally or with a regional block

Pressure irrigation to wound (7-8 PSI) with Saline 100 ml per 1cm of laceration

Do not soak wounds – causes skin maceration and edema

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Wound Preparation

Only scrub dirty wounds and consider non-ionic detergents

Remove embedded foreign material (road rash) to avoid tattooing of skin

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Wound Closure Equipment

Choose suture material that has adequate strength while producing little inflammatory reaction• Non-absorbable sutures for skin

Nylon or polypropylene Silk causes tissue reaction Use 4-5 throws per knot

• Absorbable for skin or deep sutures Monocryl, Vicryl, Dexon – synthetic Guts are natural and cause more reaction Fast Gut for face or scalp

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Wound Closure Equipment

• Size: 5-0 to 6-0 for face 4-0 for deep tissues with light tension 3-0 for tissues with strong tension (joints, sole

of foot or thick skin) 3-0 to 4-0 for oral mucosa 4-0 to 5-0 for everything else

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Wound Closure

Evert the wound edges• Enter skin at 90 degrees

perpendicular and pronate wrist

• Use slight thumb pressure on the wound edge as needle enters the opposite side

• Take equal bites on both sides

• Do not pull the knot tightly. Causes puckering

• Minimize skin tension with deep sutures

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Suture Techniques

Deep sutures – to reduce skin tension and repair deep structures• Buried subcutaneous suture

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Suture Techniques

Simple interrupted• Loop knot allows

minimal tension and allows for edema

Running sutures – used to close large, straight wounds or multiple wounds• Horizontal dermal stitch

(subcuticular)

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Suture Techniques

Vertical mattress – for deep wounds, reduces tension, closes dead space

http://www.jpatrick.net/WND/woundcare.html

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Suture Techniqes

Horizontal mattress – relieves tension

http://www.jpatrick.net/WND/woundcare.html http://

www.bumc.bu.edu/Dept/Content.aspx?DepartmentID=69&PageID=5236

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Suture Techniques

Corner stitch (half-buried mattress stitch) – to close a flap

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Suture Alternatives - Glue

Tissue Adhesives• Rapid and painless closure• Sloughs off in 7-10 days so no follow up

required• Antimicrobial effects against Gram positives• High viscosity adhesives are less likely to

migrate during repair• Clean and dry wound, achieve hemostasis• Hold edges together manually and apply.• Avoid getting into wound, it acts as a foreign

body• Dry for 30 seconds between layers• Don’t use over high tension areas

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Antibiotics

Antibiotics are not recommended for routine use Proper irrigation is more efficacious than antibiotics

to prevent wound infection Consider antibiotics for heavily contaminated

wounds, bites, crush injuries, or wounds > 12 hours old

Use antibiotics for • oral wounds• wounds of the hands, feet or perineum• open fractures or exposed cartilage, joints or

tendons 1st generation cephalosporin or Augmentin

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Suture Removal

Follow up all but very simple wounds in 24-48 hours

Remove Sutures in:• Neck 3-4 days• Face, scalp 5 days• Upper extremities, trunk 7-10

days• Lower extremities 8-10 days• Joint surface 10-14 days

Remove sutures if well approximated

Remove sutures early if wound infected

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Forehead Lacerations

Evaluate for head and neck injury Superficial transverse lacerations require

simple repair with suture or tissue adhesive

Deep lacerations require layered closure• If deeper tissue not closed, then

frontalis muscle eyebrow elevation may be hampered

Vertical lacerations have a wider scar due to tension lines

Complex wounds such as stellate lesions from windshield impact require referral to surgeon

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Eyebrow Lacerations

Don’t shave the eyebrow, it is a landmark for repair and may not grow back well

Supraorbital nerve block may be helpful Debride wound in the same axis as hair shafts to avoid

damage Align the top and bottom edges of the hairline first Avoid inverting hair bearing edges into wound Simple interrupted sutures should suffice

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Eyelid Lacerations

Most eyelid lacerations are simple transverse wounds to upper eyelid and can be repaired simply

Evaluation for globe injury is a must and consider especially if periorbital fat is exposed or tarsal plate is penetrated

Dermabond works well, just don’t get it in the eye

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Eyelid Lacerations

Vertical lacerations involving lid margin require precision to repair. • Injuries involving:

levator palpebrae medial canthal

ligament lacrimal duct

• require ophthalmologic referral

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External Ear Lacerations

Auricle contains cartilage, which the perichondrium supplies with nutrients and oxygen. • Separation can lead to

cartilage necrosis, leaving deformity

Skin flaps with small pedicles often survive due to high vascularity, so minimize debridement

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External Ear Lacerations

Simple lacerations• Repaired easily, but

ensure that no cartilage remains exposed

• Avoid catching cartilage with needle tip

• Evert skin edges to avoid notching of auricular rim

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External Ear Lacerations

Auricular hematoma• Blunt ear trauma can cause a

subperichondrial hematoma which can lead to necrosis, deformity and cauliflower ear

• Appears as a tense, smooth ecchymotic swelling that disrupts normal contour

• Common among wrestlers• Drainage is imperative

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External Ear Lacerations

Complex auricular lacerations may require referral to surgeon• Repair with 5-0 absorbable sutures to

approximate edges. • Pericondrium should be included in the suture

http://intermed.med.uottawa.ca/procedures/wc/e_treatment.htm

• Avoid excessive tension• If laceration is involved on both sides of the ear,

repair the posterior aspect first Partial avulsion or total amputation – call a surgeon

• Every effort should be made to reattach the amputated part for favorable cosmetic outcome

Apply a pressure dressing and follow up in 24 hrs to evaluate vascular integrity

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Cheek Laceration

Check underlying structures for fracture or damage to parotid gland and duct, facial nerve, or labial artery.• If involved, then refer

to surgeon If no damage, then

close with simple 6-0 interrupted sutures

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Lip Laceration

Vermilion border – pale junction of dry oral mucosa and facial skin• Important landmark

in repair• Avoid epinephrine

use which may obscure border

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Lip Laceration

For full thickness lacerations, close the mucosal surface first with 5-0 absorbable suture, then orbicularis oris muscle

Approximate vermilion border first with 6-0 suture, then finish with simple interrupted sutures

Small lip lacs (<2cm), not involving the border don’t need repair

Child may bite the sutures off while still anesthetized, so parents should distract patient to avoid this

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Buccal Mucosa Lacerations

Small lacerations < 2 cm do not need repair Close 2-3 cm lacerations with flaps with 4-0 coated

vicryl on a round needle• Easier to work with than chromic gut

For through-and-through wounds, close mucosa first, then muscle layer, and skin last

D/C home with a soft diet, non-irritating foods and vigilant mouth hygiene

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Tongue Laceration

Most do not need repair Large bleeding lacerations

or lacs involving the free edge need repair to avoid notch deformity

Mouth kept open with padded tongue depressor between teeth

Gently pull tongue with towel clip

Repair with 4-0 interrupted absorbable suture with full thickness bites

Multiple knots and buried sutures are recommended

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Fingertip Avulsions

Usually due to entrapment of finger into a closing door Fingertip should be evaluated for nail bed injury and

underlying fracture of phalanges

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Fingertip Avulsions

Amputation of fingertips evaulated based on bone exposure• No or minimal bone – conservative management

Clean and dress wound in non-adherent gauze and splint

Frequent Dressing changes Antibiotics

• Significant bone exposure or amputation proximal to DIP – refer to surgeon

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Subungual Hematoma

Collection of blood in the interface of the nail and nail bed

Throbbing pain and nail discoloration

May be associated with nail bed injury or underlying fracture

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Subungual Hematoma

Drainage relieves symptoms No anesthesia required Make a hole over the hematoma with an eye

cautery or a needle• Beware artificial nails, they are flammable

If hematoma is large, place a digital block, then separating distal nail from nail bed to allow drainage

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Subungual Hematoma

Elevate the hand and warm soaks for a few days Warn family about possibility of nail deformity in the

future Antibiotics if associated fracture

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Nail Bed Injuries

Often associated with subungual hematoma and underlying fractures

Unrepaired nail bed lacerations may permanently disfigure new nail growth

Digital block and finger tourniquet

Partial avulsion, but firmly attached nails do not warrant exploration

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Nail Bed Injuries

If nail completely avulsed or attached loosely, then remove nail and look for laceration.

• Repair with 6-0 absorbable suture

• Clean and trim soft part of nail, punch a hole in the center of the nail and place between nail bed and nail fold (eponychium) and suture into place with 1 suture through hole. (Some use tissue adhesive)

• Apply a finger splint Antibiotics if underlying fracture

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Questions?