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HIGH-YIELD FACTS

  • In assessing a child with a soft tissue injury, 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, involvement of deep structures, 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 for optimal healing.

  • Antibiotics are indicated for patients who have significant immune-compromising disease, who present with a wound infection, who present with a heavily contaminated wound, and in certain specific instances (intraoral lacerations, animal and human bites).

  • Patient and parents should be given thorough aftercare instructions about care of the wound, what to expect, and return precautions.

Lacerations and soft-tissue injuries are among the most common reasons for children to present to the ED.1 The basic goals of wound care are to assist in hemostasis, restore function, avoid infection, and achieve cosmetically pleasing results. Many techniques exist to maximize patient and parent satisfaction and clinical results.2

SKIN AND SOFT TISSUE

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 inter-individual 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. 33-1). 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.

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, warn the child and parent of possible adverse cosmetic outcomes.

CLASSIFICATION OF MINOR INJURIES

LACERATIONS

Lacerations are the most common soft-tissue injury seen in the ED.1 The face, scalp, and upper extremities are the most common sites of lacerations in children.3 As lacerations generally require more complicated treatment than other minor soft-tissue wounds, much of this chapter deals with the assessment and treatment of lacerations.

All lacerations can be associated with occult injuries and require ...

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