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Boo-Boo and Owie Repair. Carmen M Lebron, MD Dept. of Pediatric Emergency Medicine August 1, 2007. 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

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boo boo and owie repair

Boo-Boo and Owie Repair

Carmen M Lebron, MD

Dept. of Pediatric Emergency Medicine

August 1, 2007

pathophysiology
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
pathophysiology1
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
evaluation
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
evaluation1
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
decision to close
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
wound preparation
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
wound preparation1
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
wound preparation2
Wound Preparation
  • Only scrub dirty wounds and consider non-ionic detergents
  • Remove embedded foreign material (road rash) to avoid tattooing of skin
wound closure equipment
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
wound closure equipment1
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
wound closure
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
suture techniques
Suture Techniques
  • Deep sutures – to reduce skin tension and repair deep structures
    • Buried subcutaneous suture
suture techniques1
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)
suture techniques2
Suture Techniques
  • Vertical mattress – for deep wounds, reduces tension, closes dead space
  • http://www.jpatrick.net/WND/woundcare.html
suture techniqes
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
suture techniques3
Suture Techniques
  • Corner stitch (half-buried mattress stitch) – to close a flap
suture alternatives glue
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
antibiotics
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
suture removal
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
forehead lacerations
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
eyebrow lacerations
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
eyelid lacerations
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
eyelid lacerations1
Eyelid Lacerations
  • Vertical lacerations involving lid margin require precision to repair.
    • Injuries involving:
      • levator palpebrae
      • medial canthal ligament
      • lacrimal duct
    • require ophthalmologic referral
external ear lacerations
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
external ear lacerations1
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
external ear lacerations2
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
external ear lacerations3
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
cheek laceration
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
lip laceration
Lip Laceration
  • Vermilion border – pale junction of dry oral mucosa and facial skin
    • Important landmark in repair
    • Avoid epinephrine use which may obscure border
lip laceration1
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
buccal mucosa lacerations
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
tongue laceration
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
fingertip avulsions
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
fingertip avulsions1
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
subungual hematoma
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
subungual hematoma1
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
subungual hematoma2
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
nail bed injuries
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
nail bed injuries1
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