Basic Boo-Boo and Owie Repair

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Basic Boo-Boo and Owie Repair

• Kalpesh Patel, MD
• Dept. of Pediatric Emergency Medicine
• July 26, 2006

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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

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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

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Pathophysiology

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

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Wound Infections

• Areas of high bacteria counts (gt100,000/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

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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
• Patients health status diabetes,
  immunocompromised, cyanotic heart disease,
  chronic respiratory problems, renal insufficiency
• Medications steroids
• Allergies to latex, antibiotics or anesthetics
• Tetanus status

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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

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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

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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

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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

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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

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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)

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Decision to Close
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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.

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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

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Wound Preparation

• Anesthetize locally or with a regional block
• http//www.mainehealth.org/em_body.cfm?id3235
• Pressure irrigation to wound (7-8 PSI) with
  Saline 100 ml per 1cm of laceration
• Do not soak wounds causes skin maceration and
  edema

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Wound Preparation

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

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Wound Preparation

• Trim irregular lacerations, debride necrotic skin
• Subcutaneous fat can be removed in small amounts
  or undermined
• Dont remove facial fat as it may leave
  depressions
• Stellate or highly irregular lesions may need
  excision to minimize scar

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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

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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

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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

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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

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Suture Techniques

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

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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)

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Suture Techniques

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

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Suture Techniqes

• Horizontal mattress relieves tension
• http//www.jpatrick.net/WND/woundcare.html
• http//www.bumc.bu.edu/Dept/Content.aspx?Departmen
  tID69PageID5236

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Suture Techniques

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

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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)
• Dont pull tape or wound edges wont approximate
  well, apply perpendicularly across wound
• Do not bandage if possible to minimize moisture
• Dont tape in moist areas palms or axillae

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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

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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
• Dont use over high tension areas

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Suture Alternatives - Glue
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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

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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

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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 gt 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

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Tetanus

• Document immunization status of patients with
  wounds
• For minor or clean wounds, 3 previous doses of
  tetanus toxoid and a booster given gt 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

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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

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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

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Questions?