Overview
Definition:
Laceration repair refers to the closure of skin wounds to promote healing and minimize scarring
In pediatric practice, the choice between tissue adhesives (e.g., cyanoacrylates) and sutures is a common consideration for managing superficial to moderately deep lacerations.
Epidemiology:
Pediatric lacerations are frequent emergency department visits, with falls, playground injuries, and sports accidents being common etiologies
The incidence varies by age group and activity level, with a significant proportion amenable to non-invasive or minimally invasive closure methods.
Clinical Significance:
Appropriate laceration management in children is crucial for optimal wound healing, prevention of infection, and cosmetic outcomes
Understanding the nuances of tissue adhesives versus sutures allows for evidence-based decision-making, impacting patient satisfaction and reducing the need for complex reconstructive procedures later.
Clinical Presentation
Symptoms:
Parents typically present with a history of acute injury
Chief complaints include visible bleeding, pain, and the presence of a cut
Parents may express concerns about the cosmetic appearance of the wound.
Signs:
Physical examination reveals a skin defect with varying degrees of depth, length, and tissue loss
Assessment includes evaluating the wound for foreign bodies, contamination, underlying neurovascular compromise, and the need for tetanus prophylaxis or antibiotics
Vital signs should be assessed, particularly in cases of significant blood loss or potential systemic injury.
Diagnostic Criteria:
No specific diagnostic criteria are required for laceration identification
Diagnosis is primarily clinical based on physical examination of the wound and a clear history of trauma
The decision for closure is based on wound characteristics: depth, length, location, and degree of separation.
Diagnostic Approach
History Taking:
Key history points include the mechanism of injury, time of onset, wound contamination, previous tetanus immunization status, allergies (especially to local anesthetics or adhesives), and any history of bleeding disorders
Red flags include signs of infection (erythema, purulent discharge), foreign body presence, suspected underlying fractures, or significant neurovascular involvement.
Physical Examination:
A systematic approach involves inspecting the wound for depth, width, and edge approximation
Palpate for crepitus (suggesting subcutaneous air or foreign body)
Assess for distal pulses, sensation, and motor function to rule out neurovascular compromise
Clean the wound thoroughly with saline or antiseptic solution
Irrigate the wound copiously to remove debris and reduce bacterial load.
Investigations:
Routine laboratory investigations are generally not required for simple lacerations
Imaging (e.g., X-ray) may be indicated if there is suspicion of a retained foreign body (especially radiopaque ones) or an associated fracture
Wound cultures are typically reserved for signs of infection or highly contaminated wounds.
Differential Diagnosis:
While lacerations are straightforward, consider other skin injuries that may mimic lacerations, such as abrasions, avulsions, or bite wounds, which may require different management strategies
Deep tissue injuries or crush injuries should be distinguished from simple lacerations.
Management
Initial Management:
The immediate priority is hemostasis
Apply direct pressure with sterile gauze
Local anesthetic infiltration (e.g., lidocaine without epinephrine for facial or digit wounds) is essential for pain control and to facilitate wound exploration and cleaning
Thorough wound irrigation with saline is critical to reduce the bacterial burden and remove foreign material.
Medical Management:
Tetanus prophylaxis should be administered according to current guidelines based on wound characteristics and immunization history
Antibiotics are generally not indicated for clean, uncomplicated lacerations but may be considered for heavily contaminated wounds, human/animal bites, or in immunocompromised patients
Topical antibiotic ointments can be used post-closure to prevent infection.
Surgical Management:
The choice between tissue adhesives and sutures depends on wound characteristics, location, patient age, and clinician preference
Tissue adhesives are ideal for superficial, linear lacerations on low-tension areas (e.g., face, trunk, extremities) with minimal gaping
Sutures are preferred for deeper wounds, high-tension areas, irregular edges, or when longer-term support is needed
Specialized pediatric sutures (e.g., absorbable sutures for deeper layers, fine non-absorbable for skin) are chosen based on wound depth and location.
Supportive Care:
Post-closure care involves keeping the wound clean and dry
Advise parents on signs of infection to monitor for
Pain management with oral analgesics (acetaminophen or ibuprofen) is usually sufficient
Instructions on wound care, including showering and avoiding strenuous activity, are important
Follow-up is determined by the type of closure and wound characteristics.
Comparative Analysis
Tissue Adhesives:
Advantages: rapid application, no need for local anesthesia in some cases (if wound is not actively bleeding and is superficial), good cosmetic outcomes, reduced patient discomfort
Disadvantages: not suitable for high-tension areas, deep wounds, or areas prone to moisture
potential for allergic reactions
not ideal for contaminated wounds
limited tensile strength compared to sutures.
Sutures:
Advantages: versatile for various wound types and depths, provide superior tensile strength, suitable for high-tension areas and complex wounds
Disadvantages: require local anesthesia, can be more time-consuming, may lead to more patient discomfort, risk of suture track marks or stitch abscesses, need for removal (unless absorbable).
Indications For Adhesives:
Superficial, low-tension lacerations on the face, scalp, trunk, and extremities
Lacerations less than 4-5 cm long
Wounds with clean, apposed edges
Patients with needle phobia where appropriate.
Indications For Sutures:
Deeper wounds requiring layered closure
Wounds under significant tension
Lacerations with irregular or gaping edges
Wounds in areas of high movement (e.g., joints)
Animal or human bites
Wounds requiring prolonged closure support.
Complications
Early Complications:
Infection: local erythema, swelling, purulent discharge
Wound dehiscence: separation of wound edges
Allergic reaction: to adhesive or anesthetic
Hematoma formation: bleeding into the wound site.
Late Complications:
Scarring: hypertrophic or keloid scars
Granuloma formation: around foreign material (sutures or adhesive)
Chronic pain or paresthesia: related to nerve involvement.
Prevention Strategies:
Meticulous wound cleaning and irrigation
Appropriate antibiotic use
Proper wound edge approximation
Choice of closure method based on wound tension and location
Careful technique to avoid foreign body retention
Educating parents on wound care and signs of infection.
Key Points
Exam Focus:
Understand the indications and contraindications for tissue adhesives versus sutures in pediatric lacerations
Recall the importance of thorough wound irrigation and tetanus prophylaxis
Be aware of local anesthetic choices and their potential complications.
Clinical Pearls:
For facial lacerations, consider the cosmetic outcome and opt for techniques that minimize scarring
Always assess for neurovascular status distal to the injury
Use absorbable sutures for deeper layers to avoid the need for removal
For children with needle phobia, tissue adhesives can be a valuable tool for superficial wounds.
Common Mistakes:
Inadequate wound irrigation, leading to increased infection risk
Incorrect choice of closure method (e.g., using adhesives on high-tension wounds)
Failure to provide tetanus prophylaxis
Overlooking neurovascular compromise
Inappropriate use of antibiotics.