Basic Boo-Boo and Owie Repair Kalpesh Patel, MD Dept. of Pediatric Emergency Medicine July 26, 2006

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

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

Pathophysiology All wounds leave scars, but shallow ones heal better Fibroblasts cause wound contraction – Evert edges!

Wound Infections Areas of high bacteria counts (>100,000/gm) are more prone to infection: Axilla, perineum, hands, face and feet Areas of high vascularity, resist infection despite high bacteria counts: face and scalp Sharp wounds (i.e. knife wounds) rarely infected Blunt injury causes irregular wounds, flaps and crushes underlying skin. More likely to be infected and cause unacceptable scarring

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

Evaluation Physical: Vascular damage – pressure for active bleeding Brisk dark blood = vein, can be ligated; Brisk bright blood = artery Tourniquet if needed for up to 2 hours Nerve damage – when sensation is intact, motor function is usually intact Tendon injury check full ROM of nearby joints Inability to withdraw from noxious stimuli implies injury

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 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

Decision to Close Face can be primarily closed up to 24 hours after injury with excellent cosmetic effect Some contaminated wounds (animal or human bites, barnyard injuries) or immunocompromised host should not be sutured even if presenting immediately

Decision to Close Secondary intention healing (secondary closure) should be allowed for infected wounds, ulcers, many animal bites, small puncture wounds Small wick of iodoform gauze placed inside wound to keep edges open and removed in 2-3 days to allow subsequent granulation

Decision to Close Delayed primary closure (tertiary closure) considered for heavily contaminated wounds or extensive wounds Considered after 3-5 days, once infection risk decreases due to re-epithelialization (about 1mm/day)

Decision to Close

Management Preparation: Tell the patient and family what is going to happen, unhurried and with confidence Arrange distractions: Child life, TV, music, etc Keep parents in the room, sitting and focusing on the child Consider pain medication and sedation/anxiolysis prior to procedure Prepare injections, use needles, and open your kit away from child Immobilization for young children – use staff to hold the wounded body part and the family to hold the rest. Avoid papoose.

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 Preparation Anesthetize locally or with a regional block http://www.mainehealth.org/em_body.cfm?id=3235 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 Preparation Only scrub dirty wounds and consider non-ionic detergents Remove embedded foreign material (road rash) to avoid tattooing of skin

Wound Preparation Trim irregular lacerations, debride necrotic skin Subcutaneous fat can be removed in small amounts or undermined Don’t remove facial fat as it may leave depressions Stellate or highly irregular lesions may need excision to minimize scar

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 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 Needles 3/8 reverse cutting needle satisfies most needs Round needles for oral mucosa High grade plastic for face (P or PS) Fine needle (P3) for fine cosmesis

Wound Closure 2 goals: Match the layers of injured tissue Identify all skin layers and appose each layer as closely as possible to original location

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 Deep sutures – to reduce skin tension and repair deep structures Buried subcutaneous suture

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

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 Techniques Corner stitch (half-buried mattress stitch) – to close a flap

Suture Alternatives - Tape Leaves no marks, minimal tissue reaction Can be placed between sutures to relieve tension Can be used primarily for small lacerations Can be used for loose approximation of dirty wounds Use benzoin to adjacent skin (not wound) Don’t pull tape or wound edges won’t approximate well, apply perpendicularly across wound Do not bandage if possible to minimize moisture Don’t tape in moist areas: palms or axillae

Suture Alternatives - Staples Best for scalp, trunk, and extremity wounds Use when saving time is important, such as mass casulties Does not allow for meticulous cosmetic repair Should not be used on face, neck, hands or feet Should not be used prior to MRI or CT as they may interfere with imaging More painful to remove

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

Suture Alternatives - Glue

Dressings Dressings protect the wound, absorb secretions and immobilze the part For simple wounds a clean absorbent gauze is sufficient with bacitracin or polysporin (not neosporin) A non-adherent gauze (Telfa or Xeroform) can be used underneath if desired Tegaderm can be used for small wounds of the face and trunk Scalp wound need no dressing

Dressings Dressings should remain in place for 24-48 hours or for active children, until sutures removed Daily dressing changes should be done and wound inspected Dressing changed sooner if soiled, wet or saturated If the wound overlies a joint, splint it for no more than 72 hours

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

Tetanus Document immunization status of patients with wounds For minor or clean wounds, 3 previous doses of tetanus toxoid and a booster given > 10 years, then give tetanus (DTaP, or Tdap) For a dirty wound, give tetanus toxoid if last tetanus was more than 5 years ago If unknown status and a dirty wound, then give tetanus toxoid and tetanus immune globulin (TIG) If massive tissue destruction and contamination have occurred, consider hospitalization

Discharge and Follow-Up Return for signs of infection: increasing pain, redness, edema, wound discharge or fever Keep wound elevated Bathing allowed after 24-48 hours, but PAT dry and recover Notify family that the wound was inspected for foreign body, but retained foreign body or undetected injury cannot be excluded All wounds leave a scar and scar appearance is not complete for 6-12 months Minimize sun exposure and use sunscreen for 6 months to prevent hyperpigmentation Massage frequently to soften scar after sutures removed

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

Questions?