Advanced Boo-Boo and Owie Repair Kalpesh Patel, MD Dept. of Pediatric Emergency Medicine July 19, 2006

2 Objectives  Understand the basic principles of wound preparation and repair  Learn to perform selected regional anesthesia for laceration repair  Learn to perform: Vermillion border repair Forehead laceration repair Eyebrow and Eyelid repair Nose repair Ear repair Cheek repair Fingertip injuries – hematoma, avulsion, nail bed repair

3 Anesthesia  Topical EMLA/LMX LET TAC  Lidocaine/Bupivacaine – Remember maxes Lidocaine 4.5mg/kg, 7 with epi, Bupivicaine 3mg/kg  Regional Blocks Supraorbital - pink Infraorbital - yellow Supratrochlear - brown Submental - purple Digital 

4 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

5 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

6 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

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

8 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

9 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

10 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 eccymotic swelling that disrupts normal contour Common among wrestlers Drainage is imperative

11 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  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

12 Nose Lacerations  Not common, but usually from blunt trauma  Must evaluate the underlying nasal bones (LaForte fracture) and look for septal hematoma  Simple, non-gaping wounds on the upper half of the nose, are easily repaired  Gaping wounds, usually in the lower part of the nose are difficulty to approximate. Skin is also very fragile  6-0 absorbable simple interrupted sutures should be used and deep sutures are recommended to relieve tension

13 Nose Lacerations  Full thickness lacerations require layered closure starting with nasal mucosa using subcuticular stitch  Nasal cartilage rarely needs sutures, but may need for alignment  When free rim of nares is involved, precise alignment is imperative for good cosmetic outcome  Complex lacerations, lacerations with tissue loss or fractures should be referred to surgeon

14 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

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

16 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

17 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 hygene

18 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

19 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

20 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

21 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

22 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

Digital Block

25 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

26 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

27 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

28 Questions?