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Primary and Secondary Management of Pediatric Soft Tissue Injuries

Primary and Secondary Management of Pediatric Soft Tissue Injuries







Oral and Maxillofacial Surgery Clinics, 2012-08-01, Volume 24, Issue 3, Pages 365-375, Copyright © 2012 Elsevier Inc.


Injury is the most common cause of death in pediatric patients, with a large proportion related to head injury. The craniofacial region in children develops rapidly and at an early age, making the area more prominent compared with the remainder of the body, increasing the likelihood of injury. This article reviews the primary management of pediatric soft tissue injuries, including assessment, cleansing, surgical technique, anesthesia, and considerations for special wounds. The secondary management of pediatric facial injury is also discussed, including scar revision, management of scar hypertrophy/keloids, and staged surgical correction.

Key Points

  • Pediatric facial injuries are common due to multiple factors.

  • Identification of the type and severity of the wound aids in the application of management strategies.

  • Anesthesia plays an important role in the accurate repair of soft tissue injuries in children.

  • Wound support and daily cleansing of wounds as well as measures to decrease wound tension help decrease scar formation.

  • Hypertrophic scars require special management and despite best intentions some scars require secondary revision.

  • The use of serial staged surgeries may be used to provide good functional and esthetic outcomes for pediatric patients with complex soft tissue injuries.


Introduction

Trauma remains the number one cause of mortality and morbidity in children. Although some safety measures have decreased the incidence of fatal head injuries, there has been a concomitant increase in nonfatal injuries. The popularity of manual high-speed wheeled devices, such as bicycles, skateboards, and scooters, in the pediatric population also contributes to the increased rate of injury. Additionally, the use of motorized vehicles, such as dirt bikes, go-karts, and all terrain vehicles, is implicated in high-velocity injuries, resulting in amplified peripheral damage. Engaging in sporting activities, whether on a playground or in a supervised environment, is also a common cause of pediatric injuries. Prevention is key: the use of helmets, protective gear, and restraints reduces but does not eliminate the occurrence of facial injury in users.

Injury is still the most common cause of death in pediatric patients, with a large proportion of trauma related to head injury. The craniofacial region in children develops rapidly and at an early age, making the area much more prominent in comparison to the remainder of the body; this increases the likelihood of injury to this area of the body. Craniofacial soft tissue injuries are commonly encountered by surgeons who are providing pediatric facial trauma coverage.

In this article, the primary management of pediatric soft tissue injuries is reviewed, including assessment, cleansing, surgical technique, anesthesia, and considerations for special wounds. The secondary management of pediatric facial injury is also discussed, including scar revision, management of scar hypertrophy/keloids, and staged surgical correction.


Primary surgical management

Soft tissue facial injuries are common in pediatric patients due to the prominence and relative size of the head in young children. Facial fractures are less frequent because of the elastic nature of the craniofacial skeleton in the pediatric population. The history of injury is often taken from a witness or caregiver who should be queried on the time, mechanism, and details of the injury (eg, striking objects, trees, or pavement; sharp or blunt injury; or loss of consciousness). This information helps give an indication of the type, extent, and severity of soft tissue injuries that may be encountered. This history may also help predict wound progression and guide management, particularly in older and contaminated wounds. For open wounds, the tetanus status of the child should be determined and early treatment should be initiated.

Initial evaluation can begin once a patient has been stabilized and a complete injury list has been determined. Pediatric patients with facial injuries often have concomitant injuries that require a multidisciplinary approach to management. Visual inspection is often initiated in the presence of the parents; thus, it is important to remain calm and positive during this initial encounter with a patient’s caregivers. They can provide information that is important in predicting the esthetic outcome of the scar healing and they become important members of the wound management team.

Physical examination of the head and neck proceeds from top to bottom. Visual inspection of the scalp is often made difficult by the presence of hair matted in blood. A superficial cleansing with removal of hair helps detect scalp lacerations. Care must be taken to visually inspect all aspects of the scalp due to its extensive vascularity, which can result in profound blood loss. An oft-neglected and commonly injured area is the posterior scalp. Although sometimes difficult to visualize, it is important to inspect, identify, and control any prominent bleeding vessels. A cranial pressure dressing may need to be applied to stabilize patients before definitive treatment ( Fig. 1 ).

Cranial pressure dressing to support tissues and prevent hematoma formation.
Fig. 1
Cranial pressure dressing to support tissues and prevent hematoma formation.

Once the scalp and cranium have been thoroughly evaluated, inspection of the remainder of the face and neck can be completed. Careful attention should be given to the soft tissue coverage and integrity of the cartilage of the nose and ear. Examination of the periorbital region should include the eyelids, conjunctiva, cornea, and globe. Signs of globe injury—asymmetric pupils, hyphema, torn bulbar conjunctiva, corneal damage, and so forth—should prompt immediate evaluation by an ophthalmologist.


Principles of soft tissue repair in children

The sequence and timing of the various stages of surgical management are important and may depend on a multitude of factors, including the extent of other injuries to the patient. In general, a more predictable result is obtained if the repair is undertaken closer to the time of injury. Due to the extensive collateral circulation that is present in the vessels of the head and neck, however, some soft tissue injuries can wait up to 24 hours. Waiting beyond this point to repair wounds may compromise the final result because accumulation of edema, reduced tissue compliance, and difficulty in accurately approximating the wound edges all interact unfavorably.

Principles of soft tissue repair in children must take into account the differences in wound healing response in children, which is intense and more accelerated. If not managed properly, this can result in hypertrophy and scarring. Children are more apt to heal quickly and more predictably because most children are free of systemic disease and habits that impair wound healing, such as alcohol use and tobacco smoking.

Initially wounds should be thoroughly cleansed with copious amounts of irrigating solution to reduce the bacterial load and the excessive inflammatory wound responses that can be the result of the presence of wound contaminants. Consideration can be made for use of an antibiotic cleansing solution. This eases the identification and removal of foreign bodies, which can tattoo adjacent skin, if a wound is inadequately rinsed and debrided ( Fig. 2 ). This is particularly true for pigmented and petroleum-related materials.

Scar with tattoo from insufficient removal of road tar after injury.
Fig. 2
Scar with tattoo from insufficient removal of road tar after injury.

Suturing of the skin is most predictable if the skin is sutured below the skin. Suture choices can include the use of monofilament sutures; however, braided resorbable or nonresorbable nylon sutures are also popular. Care should be taken in suture choice depending on skin type and the likelihood of patients prone to keloid formation. Surface skin sutures should be avoided if possible in children due to the potential for inflammation and infection and the difficulty in removing skin sutures. If some skin closure is necessary, the use of fast resorbing skin sutures is recommended, which are exfoliated quickly within 3 to 5 days and do not necessitate removal. Cyanoacrylate glues or skin tapes, which are better tolerated by young patients, are commonly used in many emergency departments. If a wound is leaky or moist, however, these may not adhere to the skin sufficiently. Also, skin glue should not be relied on to approximate wounds that are under tension ( Fig. 3 ). Another choice is the use of over-the-counter adhesive dressings in infants because of the reduced cost and the lower concentrations of potential inflammatory chemicals.

Dehisced wound secondary to inadequate closure with skin glue.
Fig. 3
Dehisced wound secondary to inadequate closure with skin glue.

Wounds need to be securely and adequately dressed to protect from subsequent injury. Wounds should be protected from excessive or intense drying or moisture as well as from widely fluctuant temperature variations. Parents or caregivers need to be actively involved in postoperative wound care. Frequent cleansing of the wounds with removal of debris and scabs provides a better result as does appropriate dressing changes and scar management. Some children are pickers; therefore, attention must be directed to protecting wounds from constant irritation and scratching. Also, children with atopic dermatitits or eczema do not tolerate well a healing wound, which may become intensely pruritic. Consideration should be given to the use of topical corticosteroids and antihistamines, which may help in reducing the dermatitic response and itching during wound healing and prevent further inflammation, infection, or scarring. In these patients it is important to avoid cyclic changes in skin temperatures, hydration, topical dressings, and lotions, which may trigger increased skin sensitivity.


Anesthesia

A combination of sedation and local anesthesia can be useful when suturing facial lacerations in children. Midazolam syrup is helpful even when used in subtherapeutic doses. The addition of inhalational agents, such as nitrous oxide and/or sevoflurane, alone or in combination with oral agents can be helpful adjuncts during stimulating portions of the surgical repair, such as administration of local anesthesia or tissue advancement under tension. Intravenous benzodiazepines, opioids, or general anesthetic agents, such as propofol, can be used in an infusion or small bolus doses to deepen the sedation at appropriate points during the surgical repair. This advanced level of sedation necessitates increased levels of monitoring and airway support as well as increased support staff. Consideration should be made to complete more complex procedures in an operating room environment depending on the training and level of comfort of the surgical and the anesthesia support teams.

Under some circumstances, general anesthesia is required to accomplish diagnostic and surgical goals. Any periorbital work requires a general anesthetic to prevent movement of the patient, which can result in corneal abrasion or more severe globe injury. Nerve or duct repair is often completed under the use magnification in an operating room environment.


Special wounds

Special wounds, such as those involving either eyelid or ear and nasal cartilage, require thorough cleansing and removal of any foreign bodies whose presence in a contaminated wound can lead to cartilage necrosis and loss of tissue support. Once the wounds have been cleansed, then meticulous closure of skin and cartilage is required. Consideration to the use of tissue support, including the possible use of acrylic supports or bolster dressing, should be made. Cartilage requires less oxygen than bone but it needs complete soft tissue coverage and some support or bolster dressing to prevent hematoma or seroma formation ( Figs. 4 and 5 ). Bolster dressings can be removed in 7 to 14 days. Patients and parents should be informed of the possibility of growth disturbances or deformity as a result of cartilaginous disruption. This is particularly true for pediatric nasoseptal injury, which may result in the late development of nasoseptal deviation and deformity.

Bolster dressing on ear wound to support injured cartilage and prevent hematoma formation.
Fig. 4
Bolster dressing on ear wound to support injured cartilage and prevent hematoma formation.

Bolster and nasal stent sutured in place to support torn cartilage and prevent collapse.
Fig. 5
Bolster and nasal stent sutured in place to support torn cartilage and prevent collapse.

Injuries to the eyelids require an ophthalmologic assessment to rule out injuries to the globe before surgical closure. Any significant injury to the periorbital area necessitates ophthalmologic evaluation, including the use of pupillary dilation and slit lamp examination to rule out significant or penetrating injury. Staining with fluorescein dye can reveal corneal and lacrimal injuries. If the canaliculi or punctum has been torn or bruised, then obstruction, stasis, and infection can result. Most children do not tolerate a thorough lacrimal and canalicular evaluation, so a detailed evaluation is often completed under general anesthesia. Canalicular injury requires intubation of the lacrimal and canalicular system with silicone tubes. These tubes remain in place for 6 to 8 weeks until the lacrimal system has redeveloped and re-epithelialized.

The eyelids are composed of anatomic layers called lamellae: the anterior lamella—skin and muscle; the middle lamella—includes the tarsal plate and either the levator (upper lid) or depressor (lower lid) aponeurosis; and the posterior lamella—conjunctiva ( Fig. 6 ). Each lamaella should be addressed by ensuring that either direct repair or support has been provided to regain full function of the eyelids.

Diagram of basic eyelid anatomy. CON, conjunctiva; DEPR, depressors; GL, gray line; MG, meibomian gland; OOM, orbicularis oculi muscle; TP, tarsal plate.
Fig. 6
Diagram of basic eyelid anatomy. CON, conjunctiva; DEPR, depressors; GL, gray line; MG, meibomian gland; OOM, orbicularis oculi muscle; TP, tarsal plate.

Surgical repair of the eyelids is completed under general anesthesia in the operating room with the patient paralyzed to prevent movement during the detailed and meticulous repair of the eyelids and related structures. The tissue must be irrigated thoroughly and any loose flaps of tissue carefully debrided and retained if possible. A lubricated pediatric corneal shield should be placed preoperatively to prevent corneal abrasion, which is an extremely painful postoperative complication ( Fig. 7 ). The eyelid is sutured in a layered fashion using anatomic landmarks for closure. The gray line is carefully coapted to ensure lid alignment. This can be accomplished with inverted 7-0 or 8-0 Vicryl passed through meibomian gland orifices or everted suture with the tails left long to stabilize away from the conjunctiva ( Fig. 8 ). The tarsal plate is then repaired because this structure provides the supportive element of the eyelid. If the septum has been violated, then the periorbital fat may be seen protruding. The septum must be reapproximated to prevent orbital fat herniation, which can result in deformity, dysfunction, and possibly diplopia.

Corneal shield placed during eyelid repair.
Fig. 7
Corneal shield placed during eyelid repair.

Diagram of eyelid repair. (1) Note that the suture tails are left long to tape to the skin and out of harm’s way. (2) A suture is passed in a buried manner through the meibomian gland orifice to help align the gray line (GL).
Fig. 8
Diagram of eyelid repair. (1) Note that the suture tails are left long to tape to the skin and out of harm’s way. (2) A suture is passed in a buried manner through the meibomian gland orifice to help align the gray line (GL).

When treating periorbital lacerations, which communicate intraorbitally, hemostasis must be rigorously achieved. Subsequent bleeding can result in a retrobulbar hematoma, which may lead to excessive pressure on the globe and optic nerve with consequent blindness. Postoperative ophthalmologic evaluation should be performed routinely with evaluation for pain, proptosis, and pupillary function, which can be indicative of an evolving hematoma or ocular contusion. Emergent treatment includes release of sutures and/or canthotomy to evacuate clot, relieve pressure, and prevent permanent optic nerve damage. Although controversial, use of perioperative intravenous steroids is thought to decrease the progression of intraorbital edema and pressure. In summary, expedient and expert maxillofacial care is necessary for management of pediatric orbital soft tissue injuries if a good result is to be obtained.


Nerve and Duct Injuries

During evaluation, particular attention should be given to the wounds that may involve the facial nerve. Grossly, wounds may evidence depth of injury if the fat is exposed in young children, indicating high likelihood of facial nerve injury ( Fig. 9 ). Preoperative clinical assessment may reveal facial nerve paralysis, although in a young or disconsolate and uncooperative child this may be unreliable. A line drawn from the lateral canthus to the midbody of the mandible gives an indication of potential for nerve regeneration after injury. As a general rule, lacerations proximal to this line, depending on their depth and length, require exploration under magnification and microsurgical repair to regain function.

Toddler with depth of injury likely involving the facial nerve (mandibular branch).
Fig. 9
Toddler with depth of injury likely involving the facial nerve (mandibular branch).

Injuries that extend into the subcutaneous fat of the cheek in the parotid region should be evaluated for injury to Stensen duct. A small-gauge lacrimal probe or small intravenous catheter can be useful in exploring the continuity of the parotid duct ( Fig. 10 ). This can be introduced transorally via the parotid papilla to reveal any injury or interruption of the proximal duct within the wound bed.

Lacrimal probes through severed parotid duct before microsurgical repair.
Fig. 10
Lacrimal probes through severed parotid duct before microsurgical repair.

Ductal injury may require microsurgical repair with permanent sutures or repair over a temporary stent. Repaired parotid ducts, which have been stented, should be monitored until epithelial continuity of the lumen of the duct has been achieved. This can take up to 2 to 4 weeks and the stent should be left in place until ductal continuity and integrity have been restored. Both types of repairs may result in temporary salivary stasis at the site of repair; therefore, consideration should be given to 1 to 2 weeks of antibiotics. Parents should be alerted to the possible development of prolonged stasis and parotid enlargement. Salivary stimulation, through the use of sugar-free lozenges or gum, is recommended to increase saliva production and the resultant increased flow.


Bites

Children are eager to play with family pets as well as other animals and pets they encounter. Young children should not be left unsupervised in the presence of any animal for any length of time. Due to small stature and the prominence of the head in children, the face is often a target in animal attacks. Animal bites require prompt confirmation of rabies status and identification and quarantine of the animal. Initial surgical treatment involves thorough wound exploration and irrigation with closure of the linear aspects of the wound ( Figs. 11 and 12 ). Puncture wounds should be irrigated to their depth, kept open, and frequently inspected to detect the occurrence of infection. Animal bites result in intense inflammation that may last 2 to 3 days, but this eventually subsides. Particular attention should be given to attack dog (pit bull breeds) bites to the head in young children because penetrating skull injuries have been reported with late development of intracranial abscess and meningitis.

( A ) Repair of puncture-type dog-bite wound in 2-year-old girl. ( B ) Scar result 1 year later.
Fig. 11
(
A ) Repair of puncture-type dog-bite wound in 2-year-old girl. (
B ) Scar result 1 year later.

Avulsive dog bite to cheek of 4-year-old. ( A ) Avulsive wound. ( B ) Immediate closure with venous stasis evident.
Fig. 12
Avulsive dog bite to cheek of 4-year-old. (
A ) Avulsive wound. (
B ) Immediate closure with venous stasis evident.

Human bites to the face are more problematic and are often associated with Eikenella corrodens , Streptococcus , and Staphylococcus , which are more virulent and resistant organisms. The infectious status (hepatis, HIV, and so forth) of the offending person should be ascertained and appropriate documentation obtained. In children, bite wounds are mostly inflicted at play or fighting and directed to the limbs of another child. Bite wounds of the face should be thoroughly cleansed and debrided and a decision made to repair the wound based on the status of the wound. An open wound with nonmacerated margins may be closed immediately; wounds with questionable viable components should be left open and dressed, to be closed later. An exception is that puncture wounds should be left open for daily cleansing and to see patients on frequent recall. After a wound has declared itself as noninfected, revision and primary closure may be performed, if desirable.

Antibiotic prophylaxis is advisable for both human and animal bites. Amoxicillin/clavulanate provides excellent coverage for most bite pathogens in both animals and humans. The choice of antibiotics in penicillin-allergic patients is controversial. Clindamycin or azithromycin alone or in combination with trimethoprim/sulfamethoxazole can be an appropriate choice in children. Bite wounds typically result in an intense inflammatory response but this does not suggest infection; rather, it is the host response to foreign microorganisms. This response should subside in 2 to 3 days. Increasing erythema and pain beyond 3 days suggest infection. A recall appointment to check the wound is important.


Avulsive Wounds

High-velocity recreational activities can result in avulsive wounds of the craniofacial region. Bicycles, skateboards, and motorized off-road vehicles, such as dirt bikes and all-terrain vehicles, are commonly implicated in these injuries. Under general anesthesia in an operating room, careful exploration is performed under magnification. Pulse irrigation with an antibiotic-containing solution is completed before identification and débridement of poorly vascularized flaps of tissue ( Fig. 13 ). If the tissue cannot be approximated, local or regional flaps may be required and in larger defects vascularized or nonvascularized tissue may be required to close the defect. Passive or active suction drains are used to prevent hematoma formation. Pressure dressings are applied with careful attention to allow both arterial inflow and venous outflow. Leech therapy may be necessary in distal portions of compromised tissue flaps (see Fig. 13 C).

Avulsive scalp wound. ( A ) Preservation of vascular pedicle and inspection of wound. ( B ) Pulse irrigation of wound bed. ( C ) Leech therapy for venous outflow insufficiency in distal portion of avulsed tissue.
Fig. 13
Avulsive scalp wound. (
A ) Preservation of vascular pedicle and inspection of wound. (
B ) Pulse irrigation of wound bed. (
C ) Leech therapy for venous outflow insufficiency in distal portion of avulsed tissue.

Wounds with extensive loss of tissue require a staged approach to reconstruction. The initial effort is to cleanse and debride wounds to prevent infection and further tissue loss. Serial wound debridement and dressing changes may be required in the first 2 weeks after injury ( Fig. 14 ). Vacuum-assisted drainage can be helpful in evacuation of debris, circumferential diminishment of wounds, and stimulation of the wound vascular bed in preparation for final repair.

( A ) Full-thickness, infected scalp wound in 15-month-old boy. ( B ) Scalp defect after debridement of necrotic tissue and placement of pexing sutures. ( C ) Placement of a cranial dressing for preparation of the wound bed before staged reconstruction.
Fig. 14
(
A ) Full-thickness, infected scalp wound in 15-month-old boy. (
B ) Scalp defect after debridement of necrotic tissue and placement of pexing sutures. (
C ) Placement of a cranial dressing for preparation of the wound bed before staged reconstruction.

Frequent inspection of wounds is necessary to preserve viable tissue. If tissue viability is a concern, care is taken for enhanced wound support and drainage and early suture removal may be undertaken if necessary. Hyperbaric oxygen may be beneficial for hypoxic wounds with portions of tissue that area marginally viable.


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