Quick response helps skin lacerations heal faster

Playing on a baseball team with a bunch of friends was fun, but waiting his turn at bat during weekday practice was certainly less entertaining.

With a nearby low chain-link fence beckoning, the boy wandered over and started climbing. As he jumped back down, his right arm caught one of the fence’s top metal points, opening a centimeter and a half wound along his inner forearm.

The injury was not as bloody as you might expect, but the laceration was deep enough that subcutaneous fat was visible. When the 9-year-old hurried over to his family to show his mom the laceration, she knew right away that stitches were needed.

Handing her younger kids to a good friend while calling her husband to the field, the pair headed to the emergency department for a two-layer repair job.

In their article “Wounds” published in the journal Pediatrics in Review, Dr. David M. Spiro and colleagues report that lacerations make up one third of all pediatric injuries.

The incidence of these traumatic skin wounds peaks at the tender age of two, with most of these injuries resulting from accidental falls. Sixty percent of pediatric lacerations occur on the face, while another 25 percent affect the arms.

The emergency medicine specialists recommend repair of most lacerations within six to eight hours of injury, with a wider window of 24 hours possible for most facial lacerations. As always, careful clinical decision-making about the timing and method of wound closure is required for each pediatric case.

Sutures or surgical threads are used for repair of most lacerations, but tissue adhesives (“glues”) are used to close some pediatric wounds that are linear, less than 4 centimeters long, and under low tension. Staples can provide a rapid, effective option for closure of scalp wounds and other simple, straight, longer wounds elsewhere, but are generally avoided in the repair of more “cosmetically sensitive” areas.

If a wound is clean and minor, tetanus shots are recommended only if a child’s immunization status is unknown, if he has had fewer than three previous tetanus vaccinations, or if his last tetanus shot was given 10 or more years before the injury.

For contaminated or complicated wounds, tetanus vaccines are needed if the last booster shot was given five or more years prior to the injury.

Dr. Spiro’s group finds that up to 8 percent of children with skin injuries can experience complications such as the opening of a repaired laceration or infection of a wound. Skin wounds at higher risk of infection include wounds older than 12 to 24 hours at the time of repair, wounds created by crushing, tearing, biting or puncturing the skin, or wounds to joints and extremities.

Preventive antibiotics are generally not indicated except in the case of animal or human bites to the hands and feet, when five to seven days of oral amoxicillin-clavulanate (Augmentin) is suggested for non-penicillin allergic children. Use of best clinical judgment is advised when considering antibiotic treatment of a bite to a child’s face.

The pediatric authors note that sutures on the face and scalp are usually removed in three to five days, while stitches on other areas of the body are generally removed 10 days after placement.