Pediatric emergency medicine trisk 847

to 1 cm away from the wound edge deeply into the wound. It is then passed
through the opposite side and reenters the wound parallel to the initial suture. To
avoid “buckling” and to provide some eversion of the wound edges, the skin must
be entered perpendicularly, and the wound must be entered and exited at the same
depth ( Fig. 110.8 ).

FIGURE 110.8 The horizontal mattress stitch is useful for closing the deep layer in shallow
lacerations and in body areas with little subcutaneous tissue. Certain dyed suture materials may
cause a tattooing of the skin if placed in such a shallow position. (From Grisham J. Wound care.
In: Dieckmann RA, Fiser DH, Selbst SM, eds. Illustrated Textbook of Pediatric Emergency &
Critical Care Procedures . St. Louis, MO: Mosby; 1997:678, reprinted with permission.)

The modified horizontal mattress stitch (half-buried) is often used to close a
flap. It is also called the corner stitch. It relieves intrinsic tension and avoids
vascular compromise when approximating the tip of the flap. Using 5-0 or 6-0
sutures, the provider should enter intact skin across from the apex of the flap and
exit the wound just below the subcuticular plane. The needle should be brought to
the tip of the flap, entering and exiting at the subcuticular plane. Then, the needle
is brought across the edge of the flap in the subcuticular plane and the skin is
exited. A knot should be tied in the usual manner and the tip of the flap brought to
the apex of the wound ( Fig. 110.9 ).
Placing the needle in the flap edge first can be done to repair wounds in which
there is ample perfusion to the flap. The edge of the flap can then be moved back


and forth until proper alignment with the opposite fixed side is obtained. After the
tip of the flap is sutured, the sides of the flap are brought together. Care must be
taken to ensure there is no tension on sutures at the tip of the flap. For wounds
with several stellate flaps, subcuticular sutures should be used to hold the tips of
the flap together. Then, a single suture at the tip will provide good apposition
without further damage. Other interrupted sutures can be placed on the lateral

margins of the wound to provide further support. If the wound has many narrowbased stellate flaps or necrotic flap tips, the wound may be better managed with
excision and simpler repair ( Fig. 110.10 ). Surgical specialty consultation should
be considered in these complex wound repairs.

FIGURE 110.9 The corner stitch. Also called the half-buried horizontal mattress stitch, this
technique allows repair of flap-type lacerations without further compromising blood flow. Place
additional simple interrupted sutures along the sides of the flap if necessary. (From Grisham J.
Wound care. In: Dieckmann RA, Fiser DH, Selbst SM, eds. Illustrated Textbook of Pediatric
Emergency & Critical Care Procedures . St. Louis, MO: Mosby; 1997:676, reprinted with
permission.)


FIGURE 110.10 Variation in laceration injuries and suggestions for management: Simple
laceration (A ), elliptical excision of damaged wound margins (B ), excision and closure of
stellate laceration (C ,D ), and flap-type laceration (E ).


Staples can be applied more rapidly than sutures and have a lower rate of
infection, with less of a foreign-body reaction. They are best for wounds of the
scalp, trunk, and extremities when saving time is important and cosmesis is less
of a concern. Therefore, they are particularly helpful when treating mass
casualties, or when restraining a patient with a suitable wound is challenging.
Staples are left in place for the same length of time as sutures. They are somewhat
more painful to remove and should be removed with a specially designed
instrument to avoid tissue damage. Staples do not allow for meticulous cosmetic
repair as with sutures. Thus, they should not be used for lacerations of the face,
neck, hands, or feet. They should also not be used if the patient requires magnetic
resonance imaging (MRI) or computed tomography (CT).

Painless Alternatives to Sutures

Skin tape causes no suture marks, minimal tissue reaction, and fewer wound
infections than sutures. Tape strips, cut to size, can be used to take up tension at
the wound margins and can be placed between sutures, or can be placed over
absorbable sutures for additional protection. These strips are also useful as the
only means to close simple lacerations that extend just through the dermis. They
may be as useful as tissue adhesives for facial lacerations in children. Multiple
tangential, triangular skin flaps (e.g., those created when an unrestrained
passenger hits the windshield of a car) are closed well with tape strips. Likewise,
old or contaminated wounds, such as dog bites on the extremities, can be loosely
approximated with skin tape.
When tape is used, the wound should be cleansed as any other wound. Care
must be taken to properly realign the dermis and epithelium. If the tape is pulled
too tightly, the margins of the wound may overlap, causing the wound to heal
with a raised ridgelike area where the overlap occurred. The tape is applied
perpendicularly across the wound with some space between to allow the wound to
drain. An adhesive such as benzoin can keep the strips more secure if it is applied
to the adjacent skin (not the wound) and allowed to dry before applying the tape
strips. Importantly, benzoin can cause intense burning sensation if it comes into
contact with the wound and should be applied at least 2 to 3 mm away from the
wound edge but within a reaching distance of the tape. Some recommend leaving
the taped wound uncovered because a bandage may increase moisture and cause
the tape to fall off prematurely.
Tape strips should not be used on wounds subject to tension, such as those over
flexor surfaces of joints. They should not be applied in areas of the body that are
moist, such as the palms or axillae, because they will not adhere. They may be