Advanced Boo-Boo and Owie Repair

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Advanced Boo-Boo and Owie Repair

• Kalpesh Patel, MD
• Dept. of Pediatric Emergency Medicine
• July 19, 2006

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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

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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?id3235

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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

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Eyebrow Lacerations

• Dont 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

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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 dont get it in the eye

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Eyelid Lacerations

• Vertical lacerations involving lid margin require
  precision to repair.
• Injuries involving
• levator palpebrae
• medial canthal ligament
• lacrimal duct
• require ophthalmologic referral

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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

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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

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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

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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_tre
  atment.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

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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

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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

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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

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Lip Laceration

• Vermilion border pale junction of dry oral
  mucosa and facial skin
• Important landmark in repair
• Avoid epinephrine use which may obscure border

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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 (lt2cm), not involving the border
  dont need repair
• Child may bite the sutures off while still
  anesthetized, so parents should distract patient
  to avoid this

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Buccal Mucosa Lacerations

• Small lacerations lt 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

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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

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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

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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

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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

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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

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Digital Block
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Digital Block
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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

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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

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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

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Questions?