Lacerations and soft-tissue injuries are among the most common reasons for children to present to the ED.¹ The basic goals of wound care are to assist in hemostasis, restore function, avoid infection, and achieve cosmetically pleasing results. Many techniques exist to maximize patient and parent satisfaction and clinical results.²

The appearance and function of a healed wound is somewhat predicted by the magnitude of the tension on the surrounding skin, but there is great intra- and inter-individual variability. The most cosmetically pleasing scar results when the long axis of the wound is in the direction of maximal static skin tension, along “Langer’s lines” (Fig. 33-1). Examination of the wound in the ED is a reliable method to predict the appearance of the healed wound in the absence of confounding variables, such as the development of an infection or keloid. Dynamic skin tension (caused by joint movement and muscle contraction) also has an impact on the degree of scar formation and post-repair function. A wound intersecting the transverse axis of a joint may result in a significant contracture, as scars do not have the elasticity of uninjured tissue.

Unfortunately, soft-tissue wounds are unplanned events and often have axes that are perpendicular to the direction of static skin tension or parallel to the dynamic skin tension. Therefore, warn the child and parent of possible adverse cosmetic outcomes.

LACERATIONS

Lacerations are the most common soft-tissue injury seen in the ED.¹ The face, scalp, and upper extremities are the most common sites of lacerations in children.³ As lacerations generally require more complicated treatment than other minor soft-tissue wounds, much of this chapter deals with the assessment and treatment of lacerations.

All lacerations can be associated with occult injuries and require thorough exploration to detect deeper injuries. The three main classes of lacerations are shear, tension, and compression.

Shear lacerations are caused by sharp objects and generally cause little damage to adjacent tissues but can cause nerve, tendon, and vascular damage. Shear injuries usually heal fastest and have the lowest incidence of wound infection.

Tension lacerations occur when stresses cause the skin to tear. There is often associated damage to the surrounding tissues, and these lacerations are irregularly shaped.

Compression lacerations occur during a crush injury and have irregular, often stellate, wound edges. They are often associated with a significant amount of injury to the adjacent skin, contusion to the underlying structures, and they have a higher incidence of wound infection than other types of lacerations.^4,5

ABRASIONS

Abrasions are injuries in which layers of the skin are scraped or sheared away. In superficial abrasions, only the cornified epidermis is removed and there is minimal or no bleeding. Healing is rapid. Deeper abrasions involving the dermis are prone to bleeding and are more susceptible to infection, pigment change, and prolonged healing.

CONTUSIONS AND HEMATOMAS

Contusions are the result of direct blows to the tissues and may injure underlying structures. Localized bleeding and edema can cause swelling and pain to the injured area, and on rare occasions may result in secondary ischemic injuries. Manage contusions with recommendations for elevation of the injured area, application of ice packs intermittently for the first 24 to 48 hours, and careful monitoring of circulation and neurologic function.

Hematomas are localized collections of extravasated blood that are relatively or completely confined within a space or potential space. Hematomas must be observed closely for signs of infection, and in some instances may benefit from drainage.

Prehospital care of minor wounds involves control of bleeding and minimizing further injury. Control blood loss by direct manual pressure or use of a pressure dressing. If bleeding is not controlled with these methods, inflate a sphygmomanometer or apply a tourniquet proximal to the bleeding site on an injured extremity even for prolonged (at least 2 hours) transport times.^6,7 Splint lacerations that transverse joints after dressings are applied. Do not remove impaled objects, but stabilize them to prevent movement and further injury. Document what patients, parents, and providers have done in the prehospital setting.

Begin the assessment of a child with a minor wound with an overall patient assessment to exclude more serious injuries that would take precedence in management. After overall assessment, focus your attention on wound care. Compartmentalize the management of soft-tissue injuries by addressing host factors, wound factors, and aftercare.

Include the time and mechanism of the injury, the full extent of the injured areas, and whether there could be possible contaminants or foreign bodies in the wound in the history. Obtain a detailed history of the patient’s host factors with particular attention to the child’s immunization status, immune status, medical problems, allergies, any medications that the child takes, and what prehospital wound care was performed prior to arrival in the ED. Always consider nonaccidental trauma, especially when the history and the injury pattern are inconsistent.

Addressing the wound factors by assessing the length and depth of the injury, circulatory status, motor and sensory function, the presence of foreign bodies and contaminants, and the involvement of surrounding and underlying structures (nerves, tendons, muscles, ligaments, vessels, bones, joints, and ducts). To avoid fear in the child, anxiety in the parents, and frustration for everybody else, use a calm, unhurried, reassuring, and honest approach throughout the evaluation and management.

Conduct a sensory examination prior to administration of anesthesia, but the remainder of the examination can be performed with adequate anesthesia. Perform sensation testing distal to injuries. In older children, two-point discrimination can be performed, and for children younger than 3 years, use an appropriate stimulus to provide a sensory and a partial motor assessment. Evaluate peripheral pulses, skin temperature, skin color, and rapidity of capillary refill. Test tendons, muscles, and ligaments distal to an injury. With cooperative older children test these structures’ functions individually. However, with younger, less cooperative children, rely on observation of symmetry, function, and exploration of the wound. Use a toy or penlight that requires manipulation by the child to help in evaluating motor function. Involve child life providers and observe the child at play to evaluate wounds that might involve underlying motor structures.⁸

INSTRUMENTS, SUTURES, STAPLES, SURGICAL TAPE, AND TISSUE ADHESIVES

The technical approach for wound closure depends on the host and wound factors of the laceration. Sutures, staples, surgical tape, closure devices, and tissue adhesives each have intrinsic pros and cons for their use (Table 33-1). Most wound repairs can be accomplished with basic instruments and supplies (Fig. 33-2), gloves,⁹ anesthetic agent(s), and irrigation equipment.

A number of needle types are available for use, and manufacturers generally place a life-size and cross-sectional diagram of the needle on each suture package. Typical ED wound repair can be accomplished with reverse precision point cutting needles that are manufactured in various sizes, curvatures, and paired with differing suture types.

Suture choice is one of the most fundamental decisions in laceration repair. Each suture type has inherent characteristics that are suited for specific uses. The most basic choice is absorbable versus nonabsorbable suture material. Historically, absorbable suture was relegated to use as a deep (nonepidermal) closure, whereas nonabsorbable sutures were used externally (epidermal). However, recently, absorbable sutures have been found to have similar cosmetic outcomes, rates of infection, and rates of wound dehiscence, along with the added advantage of not requiring suture removal (Fig. 33-3).^10–14 Understand the characteristics of each suture type, as each wound requires a certain tensile strength for a certain amount of time (Table 33-2).

Surgical staples are a useful alternative to suturing for selected wounds. Use staples to close linear lacerations of the scalp, trunk, and extremities rapidly and effectively. Staples induce a minimal inflammatory reaction and produce similar cosmetic results compared with suturing. Staples are often not well suited for use in stellate or angulated wounds, hand wounds, or wounds that sit in recessed contours of the body. Staples are hard and relatively non-malleable when compared with sutures, so may cause discomfort if placed in areas of pressure or weight bearing. When stapling the scalp, consider the sleep position preference for patients or the position in which they will lay while hospitalized. Metallic staples require specialized removal tools, are radiopaque, and give off a significant artifact on CT imaging. MRI of metallic staples is safe if consideration is given to the heat that may be generated during the MRI. Absorbable intradermal staples offer the advantage of rapid closure without the side effects of CT scan artifact, MRI heat development, or need for special removal tools.

Microporous surgical tape (also known as the genericized brand name steri-strips) is an effective alternative for the closure of small linear lacerations that are under minimal tension (Fig. 33-4). For appropriate wounds, tape offers an advantage over suturing wounds in that it is quick to apply, does not require sedation, and does not require a return visit for removal. Tape can also be used for skin closure of partial-thickness wounds and of wounds that are closed in a layered fashion with well-approximated wound edges. Tape closure is a reasonable alternative technique for the repair of multiple tangential skin flaps.

Tissue adhesives have been used for many years and remain another option for rapid repair of pediatric lacerations. Adhesives have less tensile strength across wound edges and are therefore best suited for use in low-tension wounds.¹⁵ The failure of adhesives is typically because of the poor choice of wound type for adhesive use. Do not use adhesives on wounds in areas that are weight bearing, have high mobility, are exposed to friction, or are moist. If you have concern that adhesives would not provide the strength, consider using deep absorbable sutures under the tissue adhesives to provide the necessary strength, or avoid adhesives altogether. If using tissue adhesives near the eye, position the patient such that if the adhesive drips, it would not go into the eye. Furthermore, apply a ribbon of petroleum, or a physical barrier to protect against inadvertent instillation of the adhesive into the eye. If the eye is accidentally glued shut, apply ophthalmic ointment to loosen the bond—do not cut the lashes. If there is inadvertent contact with other skin areas, use small amounts of acetone to remove the tissue adhesive. Although tissue adhesives provide their own waterproof and antimicrobial barrier, wound preparation remains as important for wounds repaired with tissue adhesives as it does with any other wound closure method. Ensure that adequate anesthesia, wound irrigation, and wound exploration occur regardless of the method of closure. With the right choice of wound, noninvasive repair can be faster, less painful, require no suture removal follow-up, and result in patient and parental satisfaction.¹⁶

ANALGESIA, LOCAL ANESTHESIA, NERVE BLOCKS, AND SEDATION

In pediatric patients, the use of topical anesthetics on small lacerations often provides adequate analgesia for irrigation and repair. Specifically, topical lidocaine–epinephrine–tetracaine (LET) provides effective anesthesia for many pediatric lacerations.¹⁷ Apply the mixture to the wound by using saturated sponges, gauze pads, or cotton swabs held in place by a parent or caregiver wearing gloves. You may also obtain transient anesthesia by applying a solution of 4% lidocaine to a wound prior to infiltration anesthesia or to an abrasion that requires mechanical scrubbing.

Deeper wounds or those requiring extensive debridement or decontamination may require local infiltration of lidocaine, 1% to 2%, with or without epinephrine. Most wounds are adequately anesthetized using lidocaine, which has a rapid onset of action and duration of action of approximately 1 to 2 hours. Commercial preparations/dilutions of epinephrine containing anesthetics are safer than older literature suggests, and their use in regions supplied by end-arteries has been shown to be safe.¹⁸ Consider the use of a longer-acting agent, such as bupivacaine, to spare the patient repeated injections if wound repair may be interrupted. Limit use to the recommended dose per kilogram of the local anesthetic agent. For plain lidocaine and lidocaine with epinephrine, 4.5 and 7 mg/kg are the recommended maximum doses, respectively.¹⁹ Consider topical anesthetics, buffering lidocaine with bicarbonate in a 10:1 dilution, and warming the anesthetic agent to reduce the pain of injection.^20,21

Perform anesthetic infiltration prior to irrigation; however, for grossly contaminated wounds, irrigate away any gross contaminates first. Achieve infiltration by means of a 25- to 27-gauge needle, injected slowly into the wound margins.²²

For large lacerations and lacerations in areas where the anatomy would be distorted if local infiltration is performed, use regional nerve blocks. They are especially useful for anesthetizing digits, for facial lacerations, and for wounds of the foot.

Moderate sedation is usually not required for the management of wounds in older children. However, for the child who is too uncooperative to permit adequate wound management, consider sedation with agents such as midazolam, nitrous oxide, or ketamine. Perform appropriate cardiac and respiratory monitoring during sedation, with appropriate personnel and equipment and access to rescue medications. The patient should be discharged after the agents have worn off and the child has returned to an appropriate level of consciousness (see Chapter 13on procedural sedation).

Some form of physical restraint during wound assessment and management may be necessary for children younger than 2 years and sometimes is required for children up to 5 or 6 years. Older methods of immobilization using a folded sheet or a commercially available papoose board have been employed. Neither method provides adequate immobilization of the head. Carefully balance the perceived time benefit obtained through the use of physical restraints against the potential psychologic stressors that physical restraints might put on a child and/or the parents. Carefully consider the case for either chemical and/or physical restraint and include a thorough discussion of the risk/benefit of each modality with the parents.

HEMOSTASIS