Lacerations

Background

Mild lacerations occur frequently in childhood; we’re all prone to bumps and scrapes. The priorities in the treatment of these injuries are minimal distress to the child, and the best cosmetic and functional result. Local analgesia or inhaled sedation may be required in the Emergency Department depending on the size of the laceration and the age, understanding, and anxiety levels of the child. 

Assessment

There are a number of characteristics of the wound to consider when choosing the best approach, including:

  • The extent of the wound – site, size, shape, structure and sensation
  • Where on the body the injury is, and how to achieve the best cosmetic outcome
  • The presence of dirt or foreign bodies – these must be removed or appropriate healing cannot occur
  • Any other injuries that could have been masked by the laceration or injuries to the cervical spine
  • Any impairment of blood supply? If there is a poorly perfused or dusky segment of skin this suggests a much more serious laceration
  •  Any underlying fractures or injuries to deeper structures, such as tendons or nerves

Management

Gather the appropriate expertise, assistance (nurse or doctor) and equipment for addressing the laceration, with anaesthetic support if indicated. Consider whether you are comfortable with closing the laceration or if you need input from plastic surgery.

Anaesthesia

Pain management requires a multi-modal approach – pharmacological and non-pharmacological methods. Remember to involve your play therapists. For analgesia, graduation of pharmacological management is vital – starting with lower tier approaches such as sucrose or paracetamol, and then more intensive pain methods such as fentanyl, oromorph, and tramadol if needed. 

Anaesthesia may be required for adequate examination, cleaning and closure of wounds. There are a number of types of anaesthetic approaches; topical, local, regional blocks and bier’s block. 

There are options for sedation which will depend on several factors including the age and temperament of the child, and the intended procedure. Nitrous oxide may be fine for a compliant child and an easy to manage wound. Ketamine is a dissociative sedative, the use of which is popular in the ED due to its rapid onset, and anxiolytic and analgesic properties. See the DTFB article on ketamine for more details. Bear in mind that the procedure may require a general anaesthetic to manage optimally. 

Cleaning of wound

Superficial wounds are cleaned effectively with saline or chlorhexidine. Deeper wounds can be irrigated with pressurised saline and exploration with anaesthetic. 

Wound closure

Non-Surgical

Many wounds in the ED can be closed using a non-surgical approach. Minimal pain management will be required for these approaches. Perhaps paracetamol or non-pharmacological methods; distraction and comforting. Non-surgical approaches are used in cases where the laceration is minor and either an adhesive bandage, tissue adhesives/wound glue or steri-strips may be used. This might be suitable if the wound is superficial with clean edges that oppose easily. Wounds on the scalp can be closed using the hair tie method (or hair apposition technique).

Surgical 

Surgical management will require anaesthetic. Depending on the body site, different approaches will be required. Sutures or staples will be required in this management protocol. 

Body siteManagement
ScalpBleeding can be profuse but should cease with pressure applied to the site. Ensure that the wound is free from hair. Close the wound with sutures in two layers: Chromic CatGut or polydioxanone (PDS) sutures for the first layer and Nylon for the second. Sutures will then be removed in approximately 7 days.
Forehead Try to keep eyebrows intact – lacerations involving the eyebrows will usually need to be referred to plastic surgery. . Use nylon sutures
CheekEnsure that the zygoma is not broken. Ophthalmology review required if any damage to the eye
EyelidMost injuries associated with the eyelid will require ophthalmology review but if a simple laceration is present then a low tension absorbable suture can be used such as Vicryl or FastGut.
LipReferral to a plastic surgeon will be required for most injuries, simple low tension lacerations can be managed with Vicryl or FastGut.
Tongue and inside the mouthThe less severe of these lacerations will heal independently as this is a highly vascularised structure. However, injuries involving the border of the tongue or facial nerve and salivary ducts will require specialist intervention.
Ear If the wound is of full thickness and involves cartilage, ENT specialist required. 
Limbs Immobilise area of injury and joint above and below. Arterial tourniquet of the upper limb may be required. Use nylon or PDS deep sutures. For the lower limbs, debridement is important. Do not close under tension, especially if pretibial.Removal of sutures: 7-10 days. 
Trunk Debridement of tissue can be more generous than the limbs. For the fat layer use PDS deep sutures and for the skin use nylon. Removal of sutures: 10-14 days. 
Digits and HandSubungual hematoma – common with injuries to the fingertip. If <50% of nail, treat with analgesia and ice, if >50% then create hole in nail to remove pressure (with sterile needle). Lacerations are common to the hands – small lacerations can be treated with an adhesive dressing, anything bigger refer to plastic surgical opinion. Partial amputation/crush injury – assess the damage to the nail bed and perform x-ray to detect any injury to the phalynx. Requires orthopaedic opinion. Palm lacerations – care must be taken as deeper structures likely to be involved, consult plastic surgeon. 

Post repair wound care

Removal of stitches or staples have different removal times depending on the site. Stitches should be removed in 3-5 days for the face, 7 days for the scalp, upper limb and anterior trunk and 10-14 days for back and lower limb.  In general, adhesive tapes should be removed in 7-14 days. Staples should be removed in 7 days. 

Additional

Depending on the mechanism of injury, tetanus prophylaxis may be required and if the laceration was caused by an animal, antibiotic cover will be needed. Any laceration with an underlying fracture should be considered an open fracture and will also require antibiotic cover. Always consider whether there are any safeguarding concerns and if the history of the mechanism is consistent with the injury seen.

References

https://www.rch.org.au/clinicalguide/guideline_index/Lacerations/

https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Lacerations