Advanced Boo-Boo and Owie Repair

Kalpesh Patel, MD

Dept. of Pediatric Emergency Medicine

July 19, 2006

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Objectives

Understand the basic principles of wound preparation and repair

Learn to perform selected regional anesthesia for laceration repair

Learn to perform:• Vermillion border repair• Forehead laceration repair• Eyebrow and Eyelid repair• Nose repair• Ear repair• Cheek repair• Fingertip injuries – hematoma, avulsion, nail bed

repair

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Anesthesia

Topical• EMLA/LMX• LET• TAC

Lidocaine/Bupivacaine – Remember maxes• Lidocaine 4.5mg/kg, 7 with epi, • Bupivicaine 3mg/kg

Regional Blocks• Supraorbital - pink• Infraorbital - yellow• Supratrochlear - brown• Submental - purple• Digital

http://www.mainehealth.org/em_body.cfm?id=3235

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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 eccymotic 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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Nose Lacerations

Not common, but usually from blunt trauma Must evaluate the underlying nasal bones (LaForte

fracture) and look for septal hematoma Simple, non-gaping wounds on the upper half of the

nose, are easily repaired Gaping wounds, usually in the lower part of the

nose are difficulty to approximate. Skin is also very fragile

6-0 absorbable simple interrupted sutures should be used and deep sutures are recommended to relieve tension

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Nose Lacerations

Full thickness lacerations require layered closure starting with nasal mucosa using subcuticular stitch

Nasal cartilage rarely needs sutures, but may need for alignment

When free rim of nares is involved, precise alignment is imperative for good cosmetic outcome

Complex lacerations, lacerations with tissue loss or fractures should be referred to surgeon

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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 hygene

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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

Digital Block

Digital Block

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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?