Transcript Boo-Boo and Owie Repair for Dummies

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
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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
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 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
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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% povidoneiodine
• 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

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http://www.jpatrick.net/WND/woundcare.html
Suture Techniqes
 Horizontal mattress –
relieves tension

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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
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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
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 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
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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
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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
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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
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 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
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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?
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