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High-Yield Facts

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  • In assessing a child with a minor wound, exclude more serious, sometimes occult, injuries that take precedence in management.

  • Assess the length and depth of the injury, circulatory status, motor and sensory function, and the presence of foreign bodies and contaminants.

  • Topical anesthetics provide effective anesthesia and are a necessary adjuvant for pediatric lacerations.

  • Many lacerations are suitable for closure using noninvasive methods of closure.

  • Splint a wound overlying a joint in the position of function for 7 to 10 days.

  • Antibiotics are indicated for patients who have significant immune-compromising disease, who present with a wound infection, who present for care late (12–24 hours), and in certain specific instances (intraoral lacerations, wounds of the hand, and cat bites).

  • Patient and parents should be given thorough after-care instructions about care of the wound and what to expect.

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Lacerations and soft-tissue injuries are among the most common reasons for children to present to the ED.1 These encounters, if handled incorrectly, can be difficult for the child, parent, and physician.2 To maximize cosmetic and functional results, ensure meticulous wound care and repair. Many techniques exist to maximize the satisfaction and clinical results. A solid understanding of the basic tenets of wound care is necessary to do so.

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Skin and Soft Tissue

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The appearance and function of a healed wound is somewhat predicted by the magnitude of the tension on the surrounding skin, but there is great intra- and interindividual variability. The most cosmetically pleasing scar results when the long axis of the wound is in the direction of maximal static skin tension, along “Langer's lines” (Fig. 32-1). Examination of the wound in the ED is a reliable method to predict the appearance of the healed wound in the absence of confounding variables, such as the development of an infection or keloid. Dynamic skin tension (caused by joint movement and muscle contraction) also has an impact on the degree of scar formation and post repair function. A wound intersecting the transverse axis of a joint may result in a significant contracture, as scars do not have the elasticity of uninjured tissue.

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Unfortunately, soft-tissue wounds are unplanned events and often have axes that are perpendicular to the direction of static skin tension or parallel to the dynamic skin tension. Therefore, it is always essential to warn the child and parent of possible adverse cosmetic outcomes.

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Classification of Minor Injuries

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Lacerations
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Lacerations are the most common soft-tissue injury seen in the ED. The face, scalp, and hands are the most common sites of injury in children. As lacerations generally require more complicated treatment than other minor wounds, much of this chapter deals with the assessment and treatment of ...

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