Basic Boo-Boo and Owie Repair

Kalpesh Patel, MD

Dept. of Pediatric Emergency Medicine

July 26, 2006

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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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Pathophysiology

All wounds leave scars, but shallow ones heal better Fibroblasts cause wound contraction – Evert edges!

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Wound Infections

Areas of high bacteria counts (>100,000/gm) are more prone to infection: • Axilla, perineum, hands, face and feet• Areas of high vascularity, resist infection despite

high bacteria counts: face and scalp Sharp wounds (i.e. knife wounds) rarely infected Blunt injury causes irregular wounds, flaps and

crushes underlying skin. More likely to be infected and cause unacceptable scarring

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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:• Vascular damage – pressure for active bleeding

Brisk dark blood = vein, can be ligated; Brisk bright blood = artery Tourniquet if needed for up to 2 hours

• Nerve damage – when sensation is intact, motor function is usually intact

• Tendon injury check full ROM of nearby joints Inability to withdraw from noxious stimuli

implies injury

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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

Face can be primarily closed up to 24 hours after injury with excellent cosmetic effect

Some contaminated wounds (animal or human bites, barnyard injuries) or immunocompromised host should not be sutured even if presenting immediately

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Decision to Close

Secondary intention healing (secondary closure) should be allowed for infected wounds, ulcers, many animal bites, small puncture wounds• Small wick of iodoform gauze placed inside

wound to keep edges open and removed in 2-3 days to allow subsequent granulation

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Decision to Close

Delayed primary closure (tertiary closure) considered for heavily contaminated wounds or extensive wounds• Considered after 3-5 days, once infection risk

decreases due to re-epithelialization (about 1mm/day)

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Decision to Close

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Management

Preparation:• Tell the patient and family what is going to

happen, unhurried and with confidence• Arrange distractions: Child life, TV, music, etc• Keep parents in the room, sitting and focusing on

the child• Consider pain medication and sedation/anxiolysis

prior to procedure • Prepare injections, use needles, and open your

kit away from child• Immobilization for young children – use staff to

hold the wounded body part and the family to hold the rest. Avoid papoose.

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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

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

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 Preparation

Trim irregular lacerations, debride necrotic skin• Subcutaneous fat

can be removed in small amounts or undermined

• Don’t remove facial fat as it may leave depressions

• Stellate or highly irregular lesions may need excision to minimize scar

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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

• Needles 3/8 reverse cutting needle satisfies most

needs Round needles for oral mucosa High grade plastic for face (P or PS) Fine needle (P3) for fine cosmesis

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Wound Closure

2 goals:• Match the layers of

injured tissue Identify all skin

layers and appose each layer as closely as possible to original location

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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 - Tape

Leaves no marks, minimal tissue reaction

Can be placed between sutures to relieve tension

Can be used primarily for small lacerations

Can be used for loose approximation of dirty wounds

Use benzoin to adjacent skin (not wound)

Don’t pull tape or wound edges won’t approximate well, apply perpendicularly across wound

Do not bandage if possible to minimize moisture

Don’t tape in moist areas: palms or axillae

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Suture Alternatives - Staples

Staples• Best for scalp, trunk, and extremity

wounds• Use when saving time is important,

such as mass casulties• Does not allow for meticulous

cosmetic repair• Should not be used on face, neck,

hands or feet• Should not be used prior to MRI or

CT as they may interfere with imaging

• More painful to remove

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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

Suture Alternatives - Glue

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Dressings

Dressings protect the wound, absorb secretions and immobilze the part

For simple wounds a clean absorbent gauze is sufficient with bacitracin or polysporin (not neosporin)

A non-adherent gauze (Telfa or Xeroform) can be used underneath if desired

Tegaderm can be used for small wounds of the face and trunk

Scalp wound need no dressing

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Dressings

Dressings should remain in place for 24-48 hours or for active children, until sutures removed

Daily dressing changes should be done and wound inspected

Dressing changed sooner if soiled, wet or saturated If the wound overlies a joint, splint it for no more

than 72 hours

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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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Tetanus

Document immunization status of patients with wounds

For minor or clean wounds, 3 previous doses of tetanus toxoid and a booster given > 10 years, then give tetanus (DTaP, or Tdap)

For a dirty wound, give tetanus toxoid if last tetanus was more than 5 years ago

If unknown status and a dirty wound, then give tetanus toxoid and tetanus immune globulin (TIG)

If massive tissue destruction and contamination have occurred, consider hospitalization

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Discharge and Follow-Up

Return for signs of infection: increasing pain, redness, edema, wound discharge or fever

Keep wound elevated Bathing allowed after 24-48 hours, but PAT dry and

recover Notify family that the wound was inspected for foreign

body, but retained foreign body or undetected injury cannot be excluded

All wounds leave a scar and scar appearance is not complete for 6-12 months

Minimize sun exposure and use sunscreen for 6 months to prevent hyperpigmentation

Massage frequently to soften scar after sutures removed

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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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Questions?