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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 Remodeling can occur up to 12 months 2 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 3 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 4 Evaluation 5 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 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 6 Decision to Close 7 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% povidoneiodine • A 1% solution may also be used for dirty wounds • Avoid chlorhexidine, H2O2, Alcohol, and surgical scrub in the wound 8 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 9 Wound Preparation Only scrub dirty wounds and consider non-ionic detergents Remove embedded foreign material (road rash) to avoid tattooing of skin 10 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 11 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 12 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 13 Suture Techniques Deep sutures – to reduce skin tension and repair deep structures • Buried subcutaneous suture 14 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) 15 Suture Techniques Vertical mattress – for deep wounds, reduces tension, closes dead space 16 http://www.jpatrick.net/WND/woundcare.html Suture Techniqes Horizontal mattress – relieves tension 17 http://www.jpatrick.net/WND/woundcare.html http://www.bumc.bu.edu/Dept/Content.aspx?De partmentID=69&PageID=5236 Suture Techniques Corner stitch (half-buried mattress stitch) – to close a flap 18 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 19 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 20 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 21 Forehead Lacerations 22 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 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 23 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 24 Eyelid Lacerations Vertical lacerations involving lid margin require precision to repair. • Injuries involving: levator palpebrae medial canthal ligament lacrimal duct • require ophthalmologic referral 25 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 26 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 27 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 28 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 29 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 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 30 Lip Laceration Vermilion border – pale junction of dry oral mucosa and facial skin • Important landmark in repair • Avoid epinephrine use which may obscure border 31 Lip Laceration 32 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 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 33 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 34 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 35 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 36 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 37 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 38 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 39 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 40 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 41 Questions? 42