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Boo-Boo and Owie Repair
Carmen M Lebron, MD
Dept. of Pediatric Emergency Medicine
August 1, 2007
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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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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:• 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
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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
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 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
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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 - 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
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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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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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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 ecchymotic 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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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 hygiene
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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
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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?