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

2. 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. 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  http://www.mainehealth.org/em_body.cfm?id=3235 http://www.mainehealth.org/em_body.cfm?id=3235

4. 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. 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. 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. 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. 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. 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. 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. 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  http://intermed.med.uottawa.ca/procedures/wc/e_treatment.htm 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

12. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

23. Digital Block

25. 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. 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. 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. 28 Questions?