Clinical Practice Guidelines

Lacerations

  • Background

    Minor lacerations are extremely common in childhood, and there are a variety of different methods of management available. It is important when active treatment is required that this is undertaken in a way which allows the best functional and cosmetic result, with the least distress to the child. The worst surgical results are achieved in children who are "uncooperative" or terrified. All children with lacerations should be fasted from arrival.

    Assessment

    • Are there likely to be other injuries? (eg. head / cervical spine in falls, eye in facial trauma or teeth with mouth injuries). 
    • Is the wound likely to be contaminated by dirt or foreign bodies? 
    • Is there injury to deeper structures (eg. tendons, nerves)? In the face, remember facial nerve, parotid / lacrimal ducts, medial canthus of the eye. If a deep laceration cannot be examined adequately to exclude damage to such structures, general anaesthesia may be required. 
    • Is blood supply impaired? If a flap or area of soft tissue distal to the laceration appears dusky or poorly perfused, the wound requires specialist assessment. Areas with end-arteriolar supply (extremities such as the tip of the nose, finger tips, and ear lobes) require special care. Do not use local anaesthesia with adrenaline on such wounds.

    Management

    Before embarking on treatment in a child, consider whether you have the necessary resources for optimum surgical result and experience for the child eg. sedation, analgesia, anaesthesia, appropriate experience, time & instruments, assistance (medical and nursing). If in any doubt discuss with Emergency Registrar or Consultant. Plastic surgical consultation may be advisable.

    Sedation 

    See Sedation Guideline

    Anaesthesia

    See Sedation Guideline

    Adequate anaesthesia is necessary for complete examination, cleansing and repair of wounds.

    1. Topical anaesthesia 
      • ALA (adrenaline/lignocaine/amethocaine) 0.1 ml/kg.
      • EMLA or AnGel applied to the wound (most effective on limb wounds)
    2. Local anaesthesia
      • eg. 1% lignocaine with adrenaline slowly infiltrated into the wound, (care should be taken not to use adrenaline on finger tips)
    3. Regional block 
      • eg. infiltrate nerve proximal to injury (ring block digits - use plain lignocaine, no adrenaline) Nitrous oxide may facilitate a more comfortable injection. 
    4. Bier's Block (i.v.) 
      • To be done by doctor of appropriate training only - see Bier's Block guideline. 

    Cleaning Wounds

    Superficial Wounds

    Can be cleansed with saline or aqueous chlorhexidine.

    Deep Wounds

    • Those which require exploration should be anaesthetised first to allow more thorough cleaning. Foreign bodies must be removed. Grease can be removed using Bacitracin or Polysporin ointment. 
    • Thorough irrigation with saline under pressure (with a 19 Ga needle on a 10-20 ml syringe) is advisable

    Gravel Rash

    • Bitumen and dirt is ground into the skin and there is associated skin abrasion. After anaesthesia, scrub with a brush to remove ground in dirt and prevent tattooing. Small area - local anaesthetic. Larger areas - general anaesthetic.

    Ragged Wounds

    • Trim edges of wound where the viability is in doubt.

    Glass Injuries

    • These should be x-rayed if there is the possibility of retained glass. If glass fragments are present, the wound needs exploration. All haematomas should be evacuated as glass is usually found within.

    Closure

    a) Non-surgical

    • Dressing only (see wound dressing guideline)
      • Simple lacerations (small, superficial wounds which are not gaping or contaminated) can be managed with dressings alone. 
      • Puncture wounds are usually best left open although they may require exploration or debridement if deep or contaminated. 
         
    • Tissue adhesive ("Dermabond glue")
      • Can be used on wounds which have clean edges, do not require deep sutures and are not under tension. 
      • Best for wounds of less than 3cm in length with edges easily held together. 
      • Do not use on mucosal surfaces. 
      • If glueing the forehead or in the vicinity of the eye, the eye should be padded to avoid any glue dripping into the eye or onto the eyelashes. 
      • Oppose the edges of the wound and apply very small amount of glue to the surface, holding the edges together for 30 secs. 
      • Do not allow glue to enter wound itself (non-absorbable - acts as foreign body). Generates heat (may be uncomfortable if applied too thickly).
      • Care should be taken not to apply too much tissue glue and to avoid placement over currently bleeding wounds as the polymerisation is exothermic and the patient will notice a heat sensation. The tensile strength of the bond will be reduced also. 
      • Does not require removal; comes off in 1-2 weeks. 
         
    • Adhesive strips ("Steristrips")
      • May be adequate in simple lacerations which require opposition of slightly separated wound edges. 
      • They do not remain in place for long periods, and should not be used if there is movement or tension across the wound. 
      • Prepare skin with tincture of benzoic compound to aid adhesion. 
      • Place strips with sufficient space between each to allow drainage of fluid from the wound to avoid infection. 
      • Keep dry for 72 hours.

    b) Surgical

    NB: Young or anxious children will require sedation prior to wound repair  See sedation guideline 

    • Scalp 
      • Bleeding may be profuse, but usually ceases with firm digital pressure along the margins of wound. Comb hair out of wound (vaseline often helps). It is not usually necessary to shave much hair. 
      • Close in 2 layers: 
        • GALEA 3/0-5/0 Chromic Cat Gut (CCG) or PDS (absorbable) 
        • SCALP 4/0-5/0 Nylon (Removal of sutures [ROS] ~7 days) 
           
    • Forehead 
      • Minimal debridement. Do not shave eyebrow
      • Superficial scratches should be cleaned only and left to epithelialise (± steristrips) 
      • Sutures 5/0, 6/0 Nylon (ROS 5-7 days) or Fast gut or Vicryl absorbable sutures 
         
    • Cheek 
      • Check for fractures (zygoma, blow out of orbit) and involvement of facial nerve and muscle. 
      • Ophthalmology opinion if hyphaema or "closed eye with swelling".
      • Close  as for forehead
         
    • Eyelids 
      • If involving the lid margin then refer to Ophthalmology.
      • Look for tarsal plate involvement - refer Ophthalmology
      • Simple lacerations can be glued or sutured under low tension. Use 6/0 Vicryl or Fast Gut absorbable sutures.
         
    • Lips 
      • Superficial lacerations can be closed in Emergency by person with appropriate experience if the child is cooperative. Otherwise will need GA and Plastic surgical repair. 
      • NB: Need accurate approximation of vermilion border and skin. Sutures: skin - 6/0 Nylon (ROS 5 days) or Fast Gut (absorbable); mucosa and muscle - 4/0 CCG, Vicryl
      • Lacerations of the inner lip rarely need any intervention. 
      • Lacerations of the gum margin (e.g. degloving injury) need referral to Dental or Facio-Maxillary. 
         
    • Limbs
      • Immobilise area of laceration and joint above and below, following repair eg. plaster slab or sling.
      • Upper Limbs: May require arterial tourniquet control. 4/0, 5/0 Nylon.  Deep sutures 4/0 PDS.
      • Lower Limbs: Debridement important. Do not close if under undue tension especially pretibial, 
      • ROS 7-10 days.
         
    • Trunk 
      • Debridement can be more generous. Fat layer: 3/0 PDS. Skin: 4/0, 5/0 Nylon. ROS 10-14 days. 
         
    • Digits & Hand 
      • Subungual Haematoma: 
        • Usually caused by blunt trauma to the finger tip.
        • If < 50% of nail bed - treat with ice and analgesia only 
        • If > 50% and significant pain - then burn hole in nail to relieve the pressure 
      • Small lacerations of finger tips with skin loss are very common. 
        • Areas of skin loss up to 1 cm2 are treated with dressings and heal with good return of sensation. Any greater degree of tissue loss should be referred for plastic surgical opinion. 
      • Partial-amputation / crush injury. 
        • Need to assess the integrity of the nail bed - if damaged needs plastic surgery repair. X-ray to look for fracture of distal phalynx. A fracture implies damage to the nail bed. Discuss management with Plastics.
      • Palm: 
        • Be careful in assessing wound especially in very young children as deeper structures (eg nerves and tendons) may be involved. If in doubt consult Plastics. 
        • Compound injuries (i.e. fracture and laceration) should have antibiotic cover. 
           
    • Palate 
      • Beware: sharp objects in the mouth may injure the posterior pharynx. Consult with senior staff.
      • These rarely require suturing unless gaping widely, extending through posterior free margin or continuing to bleed. 
         
    • Tongue 
      • Most lacerations do not require suturing. However, if the laceration is large, extending through the free edge, full thickness or associated with ongoing bleeding, Plastics opinion is necessary. 
         
    • Ear 
      • If full thickness involving cartilage, needs Plastic opinion.

    Tetanus Prophylaxis

    See  Management of tetanus-prone wounds

    Antibiotics

    Antibiotics are not indicated for simple lacerations. They are usually given for bites and wounds with extensive tissue damage, or massive contamination, but are secondary in importance to the initial decontamination of the wound. Recommended antibiotics are procaine penicillin 25-50 mg/kg i.m. once and augmentin (10-20 mg amoxycillin/kg) 8-hourly for 5 days.