Basic Boo-Boo and Owie Repair

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 12-24 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 • 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

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 • http://www.jpatrick.net/WND/woundcare.html

26. 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

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 • 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 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

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 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

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 10-14 days • Remove sutures if well approximated • Remove sutures early if wound infected

38. Questions?