Pediatric emergency medicine trisk 850

Vertical forehead lacerations tend to have a more visible scar because they
traverse the skin tension lines. Complex forehead wounds, such as stellate
lacerations from windshield impact and those with tissue loss, particularly
secondary to animal bites, may require consultation with a plastic surgeon.
Forehead lacerations are rarely associated with skull fractures, but facial or
intracranial injuries should be ruled out.

Eyebrow Lacerations
Eyebrow lacerations are common. Repairing an eyebrow laceration is
complicated by the presence of hair. It is advisable not to shave the eyebrow for
wound preparation because it serves as a landmark during repair. Also, eyebrow
regrowth is unpredictable; it may be either slow or incomplete, potentially leading
to poor cosmetic outcome. Debridement, if required, should be minimal and along
the same axis of the hair shafts to avoid damage to hair follicles; otherwise,
alopecia of the brow will result. Closure with simple interrupted stitches using
nonabsorbable material is usually sufficient. Attention must be paid to avoid
inverting the hair-bearing edges into the wound. It is also important to pay
attention to proper alignment of both ends of a wound along an eyebrow.

Eyelid Lacerations
Most eyelid lacerations are simple transverse wounds of the upper eyelid just
inferior to the eyebrow. Repairing these wounds does not require any special
skills. Well-approximated lacerations in the transverse crease of the eyelid will
heal well if left alone. However, recognizing complicated eyelid lacerations is
crucial for proper repair and optimal outcome (see Chapter 114 Ocular Trauma ).
Vertical lacerations involving the lid margin require precision in approximation to
avoid deformity and malfunction of the eyelid. Injuries potentially involving the
levator palpebrae muscle, medial canthal ligament, or lacrimal duct should be
considered for ophthalmology referral. A high index of suspicion for lacrimal
duct injury is particularly important when evaluating a medially positioned lower
eyelid laceration. If not repaired, inferior duct injury may lead to chronic tearing

as the lower lacrimal duct is the main drain of tears from the conjunctival sac.
Evaluation for an associated injury of the globe is a must, particularly if
periorbital fat is exposed or tarsal plate penetration is present (see Chapter 114
Ocular Trauma ).

External Ear Blunt Trauma and Lacerations
Although the ears are subject to trauma because of their exposed position,
lacerations involving the ears are rather rare. The auricle contains a cartilaginous


structure that provides the framework for the complex shape of the ear. The
perichondrium covering the cartilage provides it with nutrients and oxygen.
Traumatic separation of the cartilage from the perichondrium may lead to
necrosis, leaving the auricle deformed. The overlying skin is thin but well
vascularized. Skin flaps with small pedicles often survive and should not be
hastily debrided. Simple auricular lacerations can be repaired without
consultation. To avoid chondritis, approximation of the skin is important so no
cartilage is exposed. It is imperative to avoid catching the auricular cartilage with
the needle tip because the skin and perichondrium are in close proximity to each
other. Occasionally, debridement of the cartilage is needed to obtain complete
coaptation of the wound; however, cartilage debridement should be kept to a
minimum and only performed by providers comfortable with this type of repair.
Complex auricular lacerations with significant skin damage and involvement of
the auricular cartilage can be difficult to repair and may require consultation with
a surgical specialist. In general, when repairing auricular cartilage, 5-0 absorbable
sutures should be used to approximate the edges. Landmarks of the auricle should
be used for proper alignment. The perichondrium should be included in the
sutures so the suture material does not tear through the friable cartilage and also
to ensure restoration of nutrient and oxygen supply. For the same reason,
excessive tension should be avoided. Closure of the skin should follow as

described previously. If the laceration involves the anterior and posterior aspects
of the ear, closure of the posterior aspect first is recommended.
To avoid a deep scar line (notching) in repairing the earlobe or the auricular
rim, the skin edges should be everted at the time of closure because fibrotic tissue
will eventually pull the scar line down, leading to notching.
For partial avulsion or total amputation of the ear, make every effort to reattach
the amputated part because tissue survival and cosmetic outcome are often
favorable. Furthermore, blunt ear trauma can lead to a simple contusion or a
significant subperichondrial hematoma that can comprise the auricular cartilage.
Classically, a significant perichondrial hematoma is tense and appears as smooth
ecchymotic swelling that disrupts the normal contour of the auricle. This injury is
particularly common among wrestlers. Auricular hematoma should be promptly
drained to avoid necrosis of the cartilage and deformed auricle or cauliflower ear
(see Chapter 106 ENT Trauma ).
After repair of ear lacerations or evacuation of an auricular hematoma, a
pressure dressing should be applied. Follow-up in 24 hours to evaluate vascular
integrity to the area is recommended.

Nasal Lacerations


Blunt injuries to the nose are much more common than lacerations. When a nasal
laceration results from blunt trauma, careful evaluation of underlying nasal bones
and examination for a nasal septal hematoma are essential. Other associated
injuries, such as facial bone fractures or injuries to the orbit, should also be ruled
out.
The skin overlying the nose is taut and stiff. Approximating the edges of
simple, nongaping nasal wounds, mostly along the upper half of the nose, is
usually straightforward. Wounds with any gaping, commonly in the lower part of
the nose, can be difficult to coapt because of the nature of the skin in this

location. The suture material can tear through the skin easily. Absorbable
subcutaneous stitches are recommended before skin closure to relieve tension and
prevent tearing through the wound edges. Skin closure should be with simple
interrupted 6-0 absorbable material. Early removal of the sutures is advised for
the same reason.
Full-thickness nasal lacerations involving the alae nasi or entering the vestibule
require layered closure. The procedure should start with the nasal mucosa, using
absorbable material and finish with the skin, preferably using continuous
subcuticular suture technique.
The nasal cartilage, when involved, rarely requires sutures. When alignment is
difficult, a few fine sutures (Vicryl or plain catgut) will help hold it in place.
When the free rim of the nare is involved, precise alignment is imperative for
good cosmetic outcome. For complex nasal lacerations, lacerations associated
with fractures, or when there is tissue loss, consultation with a surgical specialist
is recommended.

Lip Lacerations
Lip lacerations are a particular concern because of the importance of the lip as a
facial landmark. The lip is a vascular structure with multiple layers. The
vermilion border, the junction of the dry oral mucosa and facial skin, serves as an
important landmark for proper repair when involved. The vermilion border is
easily identified by its relative pallor compared to the neighboring lip and skin.
Therefore, the use of epinephrine with local anesthesia should be avoided so the
landmark is not obscured. When parted, the vermilion border should be precisely
reapposed using a 6-0 suture. The buccal mucosal surface is then closed with 5-0
absorbable material, followed by the skin, using 6-0 nonabsorbable sutures. Fastabsorbing gut is also an alternative when suture removal is likely to be
challenging. The parents should be warned that, while the lip is still anesthetized,
there is a chance that the child will bite the sutures off and that they should
distract the child from doing so.

In general, lip lacerations should be closed in layers, depending on the depth of
the wound. In full-thickness lip lacerations, a three-layer repair is required. The
emergency provider should begin with the oral mucosa, using 5-0 absorbable
material, followed by the orbicularis oris muscle layer to include the inner and
outer fibrofatty layers, and finish with the skin, using 6-0 nonabsorbable or fastabsorbing gut, interrupted sutures. Small wounds, less than 2 cm, on the inner
aspect of the lip without communication to the skin surface need not be repaired.
External lip wounds not communicating with the mucosal surface can be closed
by either single- or double-layer closure, depending on the depth and degree of
gaping of the wound. Absorbable sutures (5-0) for the subcutaneous layer and
either absorbable or nonabsorbable (6-0) sutures for closure of the skin can be
used, depending on the ease with which they can be removed.
Extensive lip injuries with tissue loss or those caused by electric burns,
especially those that involve the angle of the mouth, should be referred to a
plastic surgeon. Associated injuries such as dental trauma, mandibular fractures,
and closed head injuries should be ruled out.

Cheek Lacerations
When managing lacerations involving the cheeks, the provider must evaluate the
integrity of the underlying structures. The parotid gland and duct, the facial nerve,
and the labial artery are in close proximity to the surface of the skin and can be
injured, often as a result of an animal bite. If parotid gland or duct injury is
identified, consultation with a surgical specialist is advised. Puncture wounds
resulting from animal bites should be debrided and irrigated thoroughly. Some of
these puncture wounds are better off left without closure to reduce infection rate,
especially if the cosmetic outcome is unlikely to be compromised. Otherwise,
simple interrupted 6-0 absorbable sutures can be used to close uncomplicated
lacerations of the cheeks.

Tongue Lacerations

The tongue is a vascular and muscular organ. Tongue lacerations often
hemorrhage excessively in the beginning, but the bleeding usually ceases quickly
as the lingual muscle contracts. Controversy exists surrounding the indications for
closure, which is in part related to the challenge of repair given the inaccessibility
of these wounds.
Most tongue lacerations can be left alone with good results. However, large
lacerations involving the free edge may heal with a notch causing dysfunction of
the tongue. Generally, this type of laceration should be repaired. Large flaps and
lacerations that continue to bleed or are likely to become contaminated with food