Boo-Boo and Owie Repair

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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Decision to Close

8. 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

9. 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

10. Wound Preparation • Only scrub dirty wounds and consider non-ionic detergents • Remove embedded foreign material (road rash) to avoid tattooing of skin

11. 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

12. 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

13. 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

14. Suture Techniques • Deep sutures – to reduce skin tension and repair deep structures • Buried subcutaneous suture

15. 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)

16. Suture Techniques • Vertical mattress – for deep wounds, reduces tension, closes dead space • http://www.jpatrick.net/WND/woundcare.html

17. 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

18. Suture Techniques • Corner stitch (half-buried mattress stitch) – to close a flap

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Eyelid Lacerations • Vertical lacerations involving lid margin require precision to repair. • Injuries involving: • levator palpebrae • medial canthal ligament • lacrimal duct • require ophthalmologic referral

26. 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

27. 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

28. 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

29. 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

30. 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

31. Lip Laceration • Vermilion border – pale junction of dry oral mucosa and facial skin • Important landmark in repair • Avoid epinephrine use which may obscure border

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. Questions?