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Lacerations

  • See also

    Acute pain management
    Procedural sedation
    Management of tetanus-prone wounds

    Key points

    1. Lacerations require thorough assessment prior to closure
    2. Ensuring suitable analgesia and anaesthesia (local +/- sedation) will improve wound outcomes (function, risk of infection, and cosmesis), as well as the child’s experience
    3. Children that require sedation for wound closure may need similar for removal of sutures. Use absorbable sutures where clinically appropriate

    Background

    • Minor lacerations are extremely common in childhood, and there are different methods of management available
    • Treatment should be aimed at the best functional and cosmetic result, with the least distress to the child. A poor result may be achieved in children who are distressed

    Assessment

    Assess the laceration for:

    • Contamination by dirt or foreign bodies
    • Associated injuries (eg head/ cervical spine in falls, eye in facial trauma, teeth with mouth injuries)
    • Injury to deeper structures (eg tendons, joints or 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, refer for relevant surgical specialty advice
    • Impairment of blood supply to surrounding tissue
      • if a flap or area of soft tissue distal to the laceration appears dusky or poorly perfused, the wound requires specialty assessment
      • areas with end-arteriolar supply (extremities such as the tip of the nose, fingertips, and ear lobes) require special care
    • Causes (eg animal or human bites) which require consideration for tetanus prophylaxis and/or antibiotics

    Management

    All children with lacerations should be fasted from arrival
    Consider availability of resources required for optimal outcome, including:

    • Appropriately experienced staff
    • Sedation/analgesia/anaesthesia
    • Time
    • Equipment and instruments
    • Assistance (medical and nursing)

    If in any doubt, discuss with senior emergency clinician. Specialist advice from the relevant surgical specialty may be required

    Consider sedation (eg nitrous or ketamine) and analgesia in addition to anaesthesia for complete examination, cleaning, and repair of wounds.

    Anaesthesia

    • Topical anaesthesia
      • ALA (adrenaline (epinephrine)/ lidocaine (lignocaine)/ tetracaine (amethocaine)) gel (Laceraine®) applied directly to wound and covered with an occlusive dressing, 20-30 minutes prior to intervention
      • EMLA®(lidocaine (lignocaine) 2.5% and prilocaine 2.5%) and AnGel®(tetracaine (amethocaine) 4%) are suitable alternatives; most effective on limb wounds
    • Local anaesthesia
      • 1% lignocaine with or without adrenaline slowly infiltrated into the wound (use adrenaline with caution in body parts with end arteries)
    • Regional block
      • eg ring blocks and digital nerve blocks
      • 1% lignocaine (without adrenaline)
    • Intravenous regional anaesthesia (Bier block)
      • To be done by a clinician of appropriate training only - see Bier block
      • Consider the ability of the child to tolerate torniquet time for up to 20 minutes
    • General anaesthesia
      • For wounds requiring extensive debridement or complex management in theatre

    Cleaning wounds

    Superficial wounds

    Use 0.9% sodium chloride or aqueous chlorhexidine (alcohol-based chlorhexidine should not be used)

    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 water and cetrimide
    • Thorough irrigation (approximately 50-100 mL per cm of wound) with 0.9% sodium chloride under pressure (eg with a 19 gauge needle on a 10-20 mL syringe)

    Gravel rash (Bitumen/dirt ground into the skin with associated skin abrasion)

    • After anaesthesia, scrub with a brush to remove ground in dirt and prevent tattooing
    • Small area may only need local anaesthesia, however larger areas may require debridement under procedural sedation or general anaesthesia

    Ragged wounds

    • Trim edges of wound where the viability is in doubt, prior to closure

    Glass injuries

    • Glass can cut deep to bone and will need thorough exploration
    • These injuries should be x-rayed if there is the possibility of retained glass, however small fragments of glass may not be visualised on x-ray 
    • All haematomas should be evacuated as glass may be found within

    Closure

    Non-surgical

    Dressing only (see Wound dressings - acute traumatic wounds)

    • 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

     Adhesive strips (eg Steri-Strips)

    • May be adequate for simple lacerations which require opposition of slightly separated wound edges
    • Do not remain in place for long periods and should not be used if there is movement or tension across wound
    • Prepare skin distant from the laceration 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

    Tissue adhesive (eg Dermabond™)

    • Can be used on wounds which have clean edges, do not require deep sutures and are not under tension
    • Best for wounds <3 cm in length with edges easily held together
    • Do not use on mucosal surfaces
    • If gluing the forehead or in the vicinity of the eye, the eye should be padded and the patient positioned appropriately to avoid any glue dripping into eye or onto eyelashes (if glue incorrectly applied, saline-soaked gauze can be applied over the glue to assist removal)
    • Oppose edges of wound and apply very small amount of glue to surface, holding edges together for 30 seconds
    • Do not allow glue to enter wound itself as it is non-absorbable (acts as foreign body) and may result in wound dehiscence
    • For actively bleeding wounds, control bleeding first. Do not use glue as it may result in polymerisation, causing an uncomfortable heat sensation and reduced tensile strength of the bond
    • Does not require removal; comes off in 1-2 weeks

    Surgical

    • Ensure conditions are appropriate for adequate wound closure
    • A young child will likely need sedation. See Acute pain management and Procedural sedation
    • If a child requires sedation for suturing, anticipate that they will likely need similar sedation for suture removal
    • Use absorbable sutures where practicable: Monofilament sutures are less inclined to become infected than braided sutures – consider this with potentially contaminated wounds. Vicryl Rapide is a braided suture with a worse potential for scarring – use with caution for facial lacerations

    Scalp

    • Bleeding may be profuse, but usually ceases with firm digital pressure along the margins of wound. Comb hair out of wound (Petroleum jelly often helps). It is not usually necessary to shave hair
    • Consider hair ties (+/- glue or tincture of benzoic compound) to improve wound apposition (or also to definitively close a wound)
    • Sutures: close in 2 layers
      • Galea – 3/0 or 5/0 Chromic catgut (CCG) or Polydioxanone Suture (PDS) (absorbable)
      • Scalp – 4/0 or 5/0 Nylon or absorbable Vicryl/ Monocryl sutures
      • Removal of sutures (ROS) 7 days

     Forehead

    • Minimal debridement. Do not shave eyebrow
    • Superficial scratches should be cleaned only and left to epithelialise (+/- Steri-Strips)
    • Sutures: 5/0, 6/0 Nylon or absorbable catgut or Monocryl sutures
    • ROS 5-7 days

    Cheek

    • Check for fractures (zygoma, orbit) or involvement of facial nerve and muscle
    • Specialist advice from ophthalmology if hyphema or "closed eye with swelling"
    • Close as for forehead

    Eyelids

    • If involving lid margin or tarsal plate, seek specialist advice from ophthalmology
    • Simple lacerations can be glued or sutured under low tension. If suturing, use absorbable 6/0 Monocryl or catgut sutures

    Lips

    • Superficial lacerations can be closed in the emergency department by a clinician with appropriate experience if the child is cooperative and/or adequate sedation can be achieved. Otherwise, GA and repair by a surgeon will be required
    • Accurate approximation of vermilion border and skin is required for optimal cosmesis
    • Sutures
      • Skin: 6/0 Nylon (ROS 5 days) or fast absorbing catgut sutures
      • Mucosa and muscle: 4/0 CCG, Vicryl Rapide
    • Lacerations of inner lip rarely require surgical closure
    • Lacerations of gum margin (eg de-gloving injury) need referral to dentist or maxillofacial surgery

     Hand and digits

    • Subungual haematoma
      • Usually caused by blunt trauma to fingertip
      • If <50% of nail bed, treat with ice and analgesia only
      • If >50% and significant pain, trephine nail to relieve pressure
    • Small lacerations of fingertips with skin loss
      • Areas of skin loss up to 1 cm2 can be treated with dressings and heal with good return of sensation. Any greater degree of tissue loss, refer for relevant surgical specialty advice
    • Partial-amputation/crush injury
      • Need to assess integrity of nail bed: if damaged, needs repair by relevant surgical specialist
      • X-ray for distal phalanx fracture, which implies damage to nail bed matrix and can also represent an open fracture requiring management in theatre
      • Refer for relevant surgical specialty advice  
    • Palm
      • Careful neurovascular assessment of the wound is critical, especially in very young children, as deeper structures may be involved. If in doubt, refer for relevant surgical specialty advice
      • Compound injuries need antibiotic cover and specialist management

    Palate

    • Sharp objects in mouth may injure posterior pharynx. Consult senior clinician
    • Rarely require suturing unless gaping widely, extending through posterior free margin or continuing to bleed

    Tongue

    • Most lacerations do not require suturing
    • If the laceration is large, extending through free edge, full thickness or associated with ongoing bleeding, refer for plastic surgery advice

    Ear

    • If full thickness laceration involving cartilage, refer for relevant surgical speciality advice

    Limbs

    • Upper limb: may require arterial tourniquet control
      • Sutures: 4/0 or 5/0 Nylon or fast absorbing Vicryl sutures; Deep sutures 4/0 PDS
    • Lower limb: Debridement is important. Do not close if under undue tension, especially pretibial region
    • Following repair, immobilise area of laceration and joint above and below with back-slab or sling
    • ROS 7-10 days

    Trunk

    • Sutures
      • Fat layer: 3/0 PDS
      • Skin: 4/0 or 5/0 Nylon or fast absorbing Vicryl sutures
    • ROS 10-14 days

    Tetanus prophylaxis

    See Management of tetanus-prone wounds

    Antibiotics

    • Not indicated for simple lacerations
    • Reserved for bites and wounds with extensive tissue damage or massive contamination, but secondary in importance to initial decontamination of wound

    See Cellulitis and skin infections

    Consider consultation with local paediatric team when

    Lacerations in specific locations (eg hands, lips) often require specialty surgery advice or repair, see management section above for more information

    The appropriate surgical specialist (including plastic surgery, orthopaedics, general surgery etc) may differ based on hospital and availability

    Consider transfer when

    The child requires care beyond the comfort level of the health service

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    Laceration adequately cleaned and closed
    Refer all patients for early wound review with their primary care physician

    Parent information

    Wound care
    Reducing your child's discomfort during procedures
    Stitches and glue care

     

    Last updated May 2022

  • Reference List

    1. Lawton B, Hadj A. Laceration repair in children. Aust Fam Physician. 2014 Sep;43(9):600-2.