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or long-term cosmesis or complications such as infection or wound dehiscence.
Additionally, caregivers had a significantly higher future preference for the
absorbable sutures. Tissue adhesives such as 2-octylcyanoacrylate have also
demonstrated similar cosmesis, less pain, and shorter procedure times when
compared to sutures for simple lacerations, but may have a slightly increased risk
of wound dehiscence.

Regional Nerve Blocks
CLINICAL PEARLS AND PITFALLS
Important areas for regional nerve blocks on the face include the
medial third of the eyebrow (supraorbital nerve), the infraorbital
foramen (infraorbital nerve), and 2 to 3 cm above the inferior border of
mandible (mental nerve).
Clinical Considerations
Local or regional anesthesia may be used to aid in the suturing of facial
lacerations in children. Regional anesthesia has the distinct advantage of allowing
the physician to perform a painless procedure, without distorting the anatomic
structures under repair. In addition, regional blocks, in general, require fewer
anesthetics (see Chapter 130 Procedures ).
The supraorbital nerve exits the supraorbital rim in the medial third of the
eyebrow approximately 2 to 3 cm from the facial midline. Local infiltration in
this region can effectively provide anesthesia to the ipsilateral hemiforehead. The
infraorbital nerve exits through the infraorbital foramen, approximately 5 mm
inferior to the infraorbital rim. Effective block of this nerve can provide
anesthesia to the ipsilateral medial cheek and upper lip. Anesthesia of the lower
lip and chin may be achieved by infiltration of the ipsilateral mental (infraoral)
nerve. This nerve exists approximately 2 to 3 cm superior to the inferior border of
the mandible. The supraorbital and infraorbital nerves, as well as the mental
nerve, exit the facial skeleton from foramen, which are in-line with the first
premolar tooth.

Guidelines for Subspecialty Consultation
CLINICAL PEARLS AND PITFALLS


Lacerations that require subspecialty consultation include those with
injury to deep structures such as nerves or ducts, are associated with
tissue loss, or that involve the cartilage of the ear or nose.
Clinical Considerations
Most facial lacerations can be repaired by the pediatric emergency medicine
physician. Injuries that require subspecialist consultation include (i) lacerations
with evidence of injury to deep structures (a major motor nerve or a glandular
duct), (ii) cases in which a substantial amount of devitalized tissue exists or actual
tissue loss has occurred, (iii) wounds in which the amount of bleeding cannot be
easily controlled, (iv) full-thickness defects of the ear and nose that involve
cartilage, and (v) cases in which it is unclear exactly which tissue to approximate
to restore preinjury anatomy and aesthetics (e.g., lips, eyelids, nostrils, ears).
Suggested Readings and Key References
Goals of Emergency Therapy
Druelinger L, Guenther M, Marchand EG, et al. Radiographic evaluation of the
facial complex. Emerg Med Clin North Am 2000;18:393–410.
Eggensperger Wymann NM, Holzle A, Zachariou Z, et al. Pediatric craniofacial
trauma. J Oral Maxillofac Surg 2008;66:58–64.
Imahara SD, Hopper RA, Wang J, et al. Patterns and outcomes of pediatric facial
fractures in the United States: a survey of the National Trauma Data Bank. J
Am Coll Surg 2008;207:710–716.
Ryan ML, Thorson CM, Otero CA, et al. Pediatric facial trauma: a review of
guidelines for assessment, evaluation, and management in the emergency
department. J Craniofac Surg 2011;22:1183–1189.
Vyas RM, Dickinson BP, Wasson KL, et al. Pediatric facial fractures: current
national incidence, distribution, and health care resource use. J Craniofac Surg

2008;19:339–349.
Facial Fractures
Dogan S, Kalafat UM, Yüksel B, et al. Use of radiography and ultrasonography
for nasal fracture identification in children under 18 years of age presenting to
the ED. Am J Emerg Med 2017;35:465–468.
Foulds JS, Laverick S, MacEwen CJ. “White-eyed” blowout fracture: a case
series of five children. Arch Dis Child 2013;98:445–446.


Gerbino G, Roccia F, Bianchi FA, et al. Surgical management of orbital trapdoor
fracture in a pediatric population. J Oral Maxillofac Surg 2010;68:1310–1316.
Lee DH, Jang YJ. Pediatric nasal bone fractures: does delayed treatment really
lead to adverse outcomes? Int J Pediatr Otorhinolaryngol 2013;77:726–731.
Lee MH, Cha JG, Hong HS, et al. Comparison of high-resolution ultrasonography
and computed tomography in the diagnosis of nasal fractures. J Ultrasound
Med 2009;28:717–723.
Miller AF, Elman DM, Aronson PL, et al. Epidemiology and predictors of orbital
fractures in children. Pediatr Emerg Care 2018;34:21–24.
Paek SH, Jung JH, Kwak YH, et al. Clinical decision rule to identify orbital wall
facture among children: retrospective derivation and validation study. Pediatr
Emerg Care 2017. [Epub ahead of print]
Yilmaz MS, Guven M, Kayabasoglu G, et al. Efficacy of closed reduction for
nasal fractures in children. Br J Oral Maxillofac Surg 2013;51:e256–e258.
Soft Tissue Injuries
Al-Abdullah T, Plint AC, Fergusson D. Absorbable versus nonabsorbable sutures
in the management of traumatic lacerations and surgical wounds: a metaanalysis. Pediatr Emerg Care 2007;23:339–344.
Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic
lacerations: a systematic review of randomized controlled trials. Acad Emerg
Med 2003;10:110–118.
Karounis H, Gouin S, Esiman H, et al. A randomized, controlled trial comparing

long-term cosmetic outcomes of traumatic pediatric lacerations repaired with
absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med
2004;11:730–735.
Khan AN, Dayan PS, Miller S, et al. Cosmetic outcome of scalp wound closure
with staples in the pediatric emergency department: a prospective, randomized
trial. Pediatr Emerg Care 2002;18:171–173.
Luck RP, Flood R, Eyal D, et al. Cosmetic outcomes of absorbable versus
nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care
2008;24:137–142.
Luck R, Tredway T, Gerard J, et al. Comparison of cosmetic outcomes of
absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr
Emerg Care 2013;29:691–695.


CHAPTER 108 ■ GENITOURINARY TRAUMA
R. CALEB KOVELL, GREGORY E. TASIAN, ROBERT A. BELFER

INTRODUCTION
Genitourinary trauma in children is common with approximately 28,000 children
presenting to emergency departments (EDs) in the United States annually with
genitourinary injuries. Approximately 10% of patients with serious multisystem
trauma have genitourinary injuries and 3% of pediatric patients admitted with
trauma will have a genitourinary injury. Most injuries (90%) are the result of
blunt trauma that involves crush injury and acceleration/deceleration forces
related to motor vehicle collisions, and falls of high-velocity injuries such as
sledding, skateboarding, or skiing.
The clinical approach to the injured child follows advanced trauma life support
guidelines. Figure 108.1 provides an algorithm for diagnostic evaluation of
pediatric patients with genitourinary trauma. Management of genitourinary
injuries in the emergency setting generally involves fully identifying the location

and extent of the injury, prevention of ongoing injury by establishing urinary
drainage and planning for operative procedures, when necessary.
KEY POINTS
The goal of emergency therapy for genitourinary injury is to maximize
organ preservation and minimize future morbidity.
Assessment of the genitourinary system can be undertaken once lifethreatening conditions have been identified and the child has been
resuscitated.
Management of hemodynamically stable children with renal injuries
should proceed on the basis of radiographic staging of the traumatic
injury.
RELATED CHAPTERS