Patient Presentation
An 8-year-old male came to clinic after riding his bike into a pole. It was witnessed by his friend and both agreed he did not lose consciousness. His bike helmet had a dent in the front but was not broken. His friend brought him home and he was brought to the clinic because of a facial laceration. He and his mother reported that he had been acting normally, no sleepiness or emesis. His immunizations were current. The past medical history revealed a hernia repair as an infant.
The pertinent physical exam showed an alert male who was oriented x 4. His vital signs were normal. Head revealed a small bruise just above the right eyebrow. There was a laceration around the right alae nasa that extended along the right edge of the filtrum that ended approximately 7 mm from the vermilion border. The skin between the nose and lips had a moderate amount of abrasion. His nose also had some minor abrasions. His teeth and oral structures were intact, but his lips were slightly swollen without bruising. He had some minor abrasions on the palms of his hands and knees. His neurological examination was normal. The diagnosis of facial laceration and head trauma was made. Several general pediatricians looked at the wound and then discussed the best option for closing the wound. The patient was sent to plastic surgery for wound closure. The surgeon chose to use small sutures because of the relative tension so close to the mouth, and because there was an open abrasion, and that since adhesive was likely to become wet he did not want to use tissue adhesives. The surgeon also told the pediatrician that he felt this was a very appropriate referral because of the various lines of tension in the skin in this area, and that it was located in such a prominent area of the face The patient was also discharged with head injury instructions and told to replace his helmet. At two months follow-up the scar is healing well.
Discussion
About 7 million traumatic wound lacerations are repaired each year in emergency departments. Many more are repaired in practitioner’s offices. The ideal wound closure device and technique would be easy to perform consistently, quick to perform, be able to be performed in all clinical circumstances, painless, without the need to remove the device, have excellent cosmetic results and be cost effective. All of the current options for wound closure (i.e. sutures, staples, surgical tapes and tissue adhesives) do not meet all these criteria and therefore choosing among the options is necessary.
Sutures have been available for millennia. Staples and surgical tapes have been around for less time. The Federal Drug Administration has only sanctioned general use of tissue adhesives in about the last 20 years, although the first successful wound closure using a tissue adhesive was in 1959. The first randomized controlled clinical trial for pediatric facial lacerations using tissue adhesives was completed in 1993.
Learning Point
A wound closure comparison
- Tissue adhesives
- Examples: Dermabond®
- Indications: low tension lacerations, generally linear lacerations, use under casts and splits, fragile skin
- Contraindications: high tension laceration, inadequate hemostasis, proximity to wet areas, heavily infected or contaminated wound
- Pros: fast to learn and perform procedure, no need to remove device, no risk of needle stick, provides microbial barrier, may have less pain to perform, comfortable for patient to have on skin
- Cons: less tensile strength, some increased dehiscence risk, poor moisture resistance, may cause skin reactions
- Surgical Tapes
- Examples: Steri-stripsTM
- Indications: low tension lacerations, generally linear lacerations, use under casts and splits, fragile skin, also as secondary sound support for suture and staple removal
- Contraindications: high tension laceration, proximity to wet areas, uncooperative patients, circumferential use around digits, heavily infected or contaminated wound
- Pros: fast to learn and perform procedure, no risk of needle stick, may have less pain to perform, comfortable for patient to have on skin, inexpensive, generally does not cause skin reactions
- Cons: less tensile strength, increased risk of dehiscence, possible need to remove device, may fall off before wound heals, no moisture resistance, could cause skin reactions
- Staples
- Indications: long lacerations or incisions, linear lacerations, scalp wounds
- Contraindications: complex wounds, inadequate hemostasis, risk of foreign body ingestion in an impaired patient (e.g. psychiatric patient, several mental disability), heavily infected or contaminated wound
- Pros: very fast to learn and perform procedure, lower risk of needle stick, low risk of skin reactions
- Cons: painful, requires removal, less meticulous skin approximation, may have worse cosmetic results
- Sutures
- Indications: most lacerations and incisions, come in various sizes and types for most circumstances
- Contraindications: heavily infected or contaminated wound
- Pros: good tensile strength, low dehiscence risk, had been used for many years, most meticulous approximation
- Cons: longer to perform procedure, longer to learn to do procedure, requires removal, risk of needle stick, can cause skin reactions, may leave suture marks
Questions for Further Discussion
1. What are the indications for consulting a plastic surgeon for laceration repair?
2. If a plastic surgeon was not available, what other specialties could be consulted for laceration repair?
3. What are the pros/cons of using different type of sutures?
Related Cases
- Disease: Wounds
- Symptom/Presentation: Head Trauma
- Specialty: Emergency Medicine | General Pediatrics | Medical History | Surgery
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Wounds
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Farion K, Osmond MH, Hartling L, Russell K, Klassen T, Crumley E, Wiebe N. Tissue adhesives for traumatic lacerations in children and adults.
Cochrane Database Syst Rev. 2002;(3):CD003326.
Zempsky WT, Parrotti D, Grem C, Nichols J. Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive.
Pediatr Emerg Care. 2004 Aug;20(8):519-24.
Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. Am J Emerg Med. 2008 May;26(4):490-6.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 