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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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 hours after injury

10. 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

11. 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

12. 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)

13. Decision to Close

14. 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.

15. 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

16. 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

17. Wound Preparation
Only scrub dirty wounds and consider non-ionic detergents
Remove embedded foreign material (road rash) to avoid tattooing of skin

18. 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

19. 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

20. 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

21. 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

22. 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

23. Suture Techniques
Deep sutures – to reduce skin tension and repair deep structures
Buried subcutaneous suture

24. 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)

25. Suture Techniques
Vertical mattress – for deep wounds, reduces tension, closes dead space

26. Suture Techniqes Horizontal mattress – relieves tension

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

28. 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

29. 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

30. 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

31. Suture Alternatives - Glue

32. 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

33. Dressings
Dressings should remain in place for 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

34. 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

35. 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

36. Discharge and Follow-Up
Return for signs of infection: increasing pain, redness, edema, wound discharge or fever
Keep wound elevated
Bathing allowed after 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

37. 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 days
Remove sutures if well approximated
Remove sutures early if wound infected

38. Questions?