19 Soft-Tissue Injuries
Lacerations are common in the pediatric population. Iatrogenic injury includes intravenous extravasation during hospitalization. Management of soft tissue injuries depends on the etiology of the problem.
Soft-tissue injuries are one of the most common conditions treated by plastic surgeons. Parents, pediatricians, and emergency room physicians are particularly sensitive about scarring on a child. Consequently, plastic surgeons are frequently consulted to manage pediatric facial lacerations. Because wound management is the core of our specialty, plastic surgeons also are commonly asked to manage difficult and/or iatrogenic soft-tissue deficits throughout the body (e.g., extravasations, pressure ulcers, infections, etc.). Management of pediatric soft-tissue injuries is based on the principles of wound healing. This chapter will focus on two of the most common consultations for soft-tissue injuries: facial lacerations and intravenous extravasation injuries.
Soft-tissue injuries are evaluated by history and physical examination. Identification of the etiology of the wound is important because it will affect management. For example, if the facial wound was caused by a dog bite, the individual is at greater risk for infection compared to being lacerated by a clean piece of glass (Fig. 19‑1). The depth of the injury must be ascertained. Blood often camouflages the area and should be removed gently to identify the severity of the injury. A partial thickness wound and/or abrasion may not require intervention. In contrast, a full-thickness injury might necessitate laceration repair. Patients at risk for a foreign body should have the area visually inspected. Plain radiography may be indicated to rule out material in the wound. Soft-tissue injuries in children are managed differently than in adults. Patients usually require sedation and are more likely to have absorbable sutures because they less able to tolerate suture removal (Fig. 19‑2). Traumatic wounds are not managed the same as sterile operative incisions because they are at greater risk for infection and unfavorable scarring.
19.3 Nonoperative Treatment
Partial-thickness wounds do not require repair and can be managed similarly to an abrasion. The area is washed twice daily with gentle soap and water followed by antibiotic ointment for a few days. Epithelialization usually takes 7 to 10 days. The area can appear pink for several weeks and should be kept out of the sun for at least 12 months to avoid hyperpigmentation.
Heavily contaminated wounds can be allowed to heal secondarily; an open wound is a safe wound and is very unlikely to become infected (a treatment for an infected wound is to open it; Fig. 19‑3). Human or animal bite puncture wounds inoculate deep tissues with bacteria; closure of these injuries (even with antibiotics) is at high risk for infection. Washing the areas regularly and letting them heal secondarily will significantly reduce the risk of infection. If the scars heal unfavorably, they can safely be revised at a later time.
19.3.2 Intravenous Extravasations
The scalp is a common site for intravenous catheter placement in the neonate, and extravasation can cause alopecia. Other intravenous access sites include the upper or lower extremities. Most extravasations involve small volumes of benign fluids that do not cause morbidity. In one series of 1,800 extravasations, only 2% of resulted in skin injury, and no child had a compartment syndrome. Catheters are located in the superficial venous system, above the level of the muscle fascia; the risk of injury to deep structures is low.
The most important maneuver to eliminate the extravasated fluid is elevation of the extremity. Application of ice or heat is contraindicated because they may exacerbate the injury. Both ice and heat have been shown to worsen tissue damage after the extravasation of chemotherapeutic agents. Heat can cause thermal injury and ice may result in ischemia from vasoconstriction. Sensation in the extravasated area may be impaired and thus the patient might not be able to appreciate pain from the application of heat or ice. In addition, young children or intubated patients are unable to verbalize discomfort from hot or cold packs. Thus, heat or ice may cause a “second hit,” converting a partial-thickness skin injury into a full-thickness wound.
Our institution does not advocate for the use of antidotes after extravasations. Hyaluronidase and phentolamine are the most commonly prescribed, but randomized prospective studies on their efficacy are not available. If an antidote is to be effective, it must be administered early. Unfortunately, most extravasations are not appreciated immediately and by the time plastic surgical consultation arrives, the antidote is ordered and available for administration, the substance has already diffused or its effects have worn off. For example, phentolamine has been used to treat epinephrine extravasation, but the effects of epinephrine wear off in 60 to 90 minutes, and the added volume of phentolamine may worsen tissue injury. Injection of an antidote increases the volume of fluid and worsens pressure necrosis.
Partial-thickness skin injuries are managed by topical antibiotic ointment; they typically heal without scarring by epithelization in 7 to 10 days. Full-thickness injuries are managed with topical antibiotic ointment or dressings (Fig. 19‑4). Debridement is indicated for necrotic tissue to reduce the risk of infection and to facilitate healing by secondary intention. Following debridement, damp-to-dry saline dressing changes twice daily are used. Full-thickness skin injuries are allowed to heal secondarily. If a compartment release is performed, the wound is managed with a vacuum-assisted wound closure device for 1 to 2 weeks as the swelling resolves and is then allowed to heal secondarily or a delayed primary closure is performed. Skin grafts should be avoided because there is no loss of skin and grafts cause a significant deformity.
19.4 Operative Treatment
Before deciding on closing a laceration, the risks of infection, sedation, and trauma to the patient/family must be considered. All traumatic wounds are contaminated and the risk of infection can be significant if they are closed. Heavily contaminated wounds (e.g., dog bite) should be closed cautiously. The goal of repairing large, problematic injuries is to minimize the wound burden to the child while lowering the risk of infection as much as possible (Fig. 19‑5). If the wound becomes infected the child, who has already undergone a significant trauma and subsequent repair, must then undergo an incision and drainage followed by secondary healing and likely scar revision. In contrast, if small puncture wounds from a dog bite are allowed to heal secondarily, the child may only need a scar revision in the future.