Pediatric emergency medicine trisk 826

result in brain injury. On examination, by grasping the maxilla at the level of the
central incisors, the clinician may be able to appreciate crepitus or mobility when
traction is applied. Clear rhinorrhea in the setting of midface trauma may be a
sign of a cerebrospinal fluid (CSF) leak and warrants neurosurgical consultation.
All patients suspected of having a midface fracture require CT imaging to
determine whether surgical reduction is necessary.

Frontal Bone Fractures
CLINICAL PEARLS AND PITFALLS
Clear rhinorrhea or leakage of clear fluid from a forehead laceration
should raise suspicion for fracture of the posterior wall of the frontal
sinus with dural tear and CSF leak.
Clinical Considerations
Fractures of the frontal bone are rare in young children because the frontal
sinuses do not develop until 8 years of age. Injury to the frontal sinus may reveal
a palpable or visible depression if the anterior wall of the sinus has been
compressed. Displaced fractures of the anterior wall of the frontal sinus require
surgical elevation. In patients with severe frontal sinus fractures associated with
forehead lacerations, a fracture of the posterior wall of the sinus and dural tear
may allow CSF to leak from the wound. Leakage of clear fluid from the wound,
or clear rhinorrhea, should raise suspicion for such a leak and warrant CT
imaging and neurosurgical consultation.

SOFT TISSUE INJURIES
Lacerations
Goals of Treatment
The goal of laceration repair is to achieve hemostasis and provide an optimal
cosmetic result.
CLINICAL PEARLS AND PITFALLS

Deep lacerations to the cheek or lateral periorbital region should raise
suspicion for facial nerve injury.
Lacerations to the medial periorbital region near the medial canthus
should be evaluated for injury to the lacrimal canaliculi.
Fast-absorbing plain gut sutures have demonstrated equivalent
cosmetic outcome compared to nonabsorbable sutures in repair of
facial lacerations.
Clinical Considerations
The goal of laceration repair is to achieve hemostasis and provide an optimal
cosmetic result. Knowledge of the deep structures of the face, particularly the
facial nerve and the lacrimal apparatus, will aid in the evaluation and
management of children with deep facial lacerations. Lateral periorbital
lacerations should raise suspicion of injury to the frontal branch of the facial
nerve, which travels superficially along a line from just above the tragus to a
point 1.5 cm above the lateral eyebrow. Lacerations in the medial periorbital
region near the medial canthus should raise suspicion for lacrimal duct injury.
Because 85% of tears are drained via the lower canaliculus, failure to repair a
laceration to the lacrimal duct may result in excessive tearing (epiphora). If deep
lacerations are present in the cheek region, the clinician must determine whether
injury to the buccal branch of the facial nerve and to the parotid duct has occurred
( Fig. 107.6 ).
When injury to the facial nerve is suspected, function can be tested by having
the patient move specific muscles of facial expression. This testing should take
place before infiltration with local anesthetic. The frontal branch of the facial
nerve can be tested by asking the patient to frown in order to look for symmetry
of frontalis muscle action. The marginal mandibular (motor) branch may course
as much as 1 to 2 cm below the border of the mandible and is responsible for the
depression and eversion of the lower lip. Injury to this branch results in a
characteristic inward rotation of the lower lip on the affected side as a result of
unopposed orbicularis oris tone on that side. The buccal branches are in close

proximity to Stensen (parotid) duct, usually close to a line between the tragus of
the ear and the mid upper lip. Pure motor injuries to the facial nerve are quite
amenable to microsurgical repair if detected and repaired in a timely fashion.
Therefore, all suspected motor nerve injuries warrant appropriate surgical
consultation to allow for the best functional recovery.


FIGURE 107.6 Deep lacerations to the cheek can injure the facial nerve, parotid gland, or
parotid duct. The facial nerve becomes more superficial as it branches and proceeds distally.
Distal nerve injuries can thus occur with more superficial wounds.

Examination for potential injury to Stensen duct is accomplished by grasping
the commissure between the thumb and index finger and gently everting the
buccal mucosa to identify Stensen duct, which lies on a vertical line along the
maxillary second premolar. With the opposite hand, gentle massage of the parotid
gland is accomplished by pressing in the preauricular region. The appearance of
clear fluid from Stensen duct suggests an uninjured duct. The absence of fluid
after several minutes of inspection, or bloody fluid, suggests injury to the gland or
duct. In this case, inspection of the depth of the wound may reveal salivary fluid
and severed ends of the duct may be identified. A sialogram can be a useful
adjunct in the diagnosis of parotid duct injuries, as well as subspecialty
consultation.
Although most lacerations should be repaired within 8 to 12 hours, clean
lacerations of the face can often be reapproximated up to 24 hours after the injury
was sustained. Later closure may be considered after the risks of infection in
closing such a wound are weighed against the benefits of reducing the facial
scarring that will result if the wound is allowed to heal secondarily. Factors such
as mechanism of injury, immunocompetence, and hygiene must be considered.

Anesthesia, copious irrigation, and tension-free approximation are vital to a
successful closure. Subspecialty consultation may be warranted for latepresentation lacerations or heavily contaminated wounds, in which the risk of
infection is high.
If possible, facial lacerations should be repaired using buried absorbable
sutures, to reduce tension on the wound and to help with eversion of the edges.
All wounds contract as scar formation occurs and thus eversion of the skin should
be achieved for facial lacerations, particularly those involving the nares, eyelids,
helix of the ear, and vermilion border of the lower lip. Inadequate eversion of the
wound edges at these sites may lead to a depressed scar or notching at the site of
the laceration. For simple scalp lacerations, stapling is a fast and cosmetically
acceptable alternative to suturing.
Repair of complex injuries to laminated structures (e.g., ear, eyelid, nose, lip)
requires that each layer of the structure be reapproximated. For example, a fullthickness laceration to the nose at the nostril rim requires closure of three separate
layers. The nasal lining is usually closed first with an absorbable suture material.
Next, the cartilage must be repaired, also with absorbable material. Finally, the
overlying skin of the nose can be reapproximated. Similarly, complex injuries of
the ear, the eyelid, or the lip require layered closure to achieve the best cosmetic
result. Careful attention should be paid to lip lacerations that traverse the
vermilion border. Cosmetic outcome is predicated on successful alignment of
tissue at this junction. Subspecialty consultation may be considered for
lacerations involving the external ear, nasal mucosa and cartilage, as well as
complex lip lacerations traversing the vermilion border.
Informed consent should be obtained from patients and families undergoing
laceration repair, and this information should be documented in the medical
record. The physician should provide a careful assessment and natural history of
the injury if left untreated to heal on its own. The physician should also describe
the recommended treatment, as well as alternative treatments, with likely
outcomes and possible complications. Patients with lacerations resulting from dog
bites and those who present for care after a delayed period of time should be
advised of the high risk of infection. Complicated facial laceration repair and

laceration repair in young children may be facilitated by the use of a short-acting
benzodiazepine or procedural sedation.
Current Evidence
Randomized controlled trials that compared fast-absorbable plain catgut to
nonabsorbable nylon sutures have demonstrated no significant difference in short-