Lacerations

What are they?

"Laceration" is the word doctors use to describe a cut in the skin. Almost all children get a laceration at some point before they reach adult age. Like so many childhood problems, lacerations happen most often to toddlers and teens, and for many of the same reasons. Children at these ages are busy exploring their worlds in new ways, and taking some risks. This is how children learn, but it is also how they can get hurt. Lacerations range from very mild scratches that need only a band-aid to serious wounds that need surgical repair. Doctors describe lacerations in terms of how deep they are, what their shape is, and what other structures (such as tendons or nerves) have injuries.

All lacerations leave scars. The scar is part the body’s normal healing process. The best way to keep a scar as small as possible is to prevent infection in the wound. This always means careful cleaning of the wound. Surprisingly, it does not always mean closing the wound with stitches or other closures. Doctors must always balance the risks of infection, sedation, and other treatment against the likelihood of a severe scar.

Major wounds can cause life-threatening bleeding and limb-threatening blood vessel, nerve, or bone injuries. They are also big infection risks. Doctors usually treat major wounds in the operating room and they usually hospitalize children who have those wounds. Most childhood lacerations are not major wounds (although the child often feels that they are!).

The most important concerns in most cases are controlling pain, anxiety, and bleeding, checking for other damage, preventing infection, and minimizing scar formation. It’s also important to be sure that there’s nothing in the wound, like a piece of glass, metal, or wood. Finally, but importantly, we want to be sure we’ve taken care of preventing tetanus by giving a booster or making sure the child’s shots are up to date.

Because infections are such a big concern, the most important first step is always to clean the wound. You probably did that at home with warm, soapy water. At the doctor’s office or emergency room the staff will have washed the wound out again. If it’s a large or painful wound, we normally give some local anesthetic before cleaning the wound. This makes it much more comfortable for the child, and that makes it easier to clean the wound as thoroughly as possible. Next, the doctor will have checked inside the wound to make sure there was not any foreign material in it, like dirt, glass, wood, or metal. If things like that remain in the wound, an infection is almost certain. The doctor will also have made sure that any bleeding was under control.

After cleaning and checking the wound, the doctor will have discussed wound closure with you. The main reasons to close a wound are to control bleeding and to minimize scarring. If the wound was dirty or contaminated, or is in an area where infection is likely, doctors often choose not to close the wound. This may mean a bigger scar in the short run, but can prevent big problems later on. Infected wounds make some of the worst scars, and infections can cause serious health problems as well.

Doctors also choose not to close cuts that are so shallow or small that closing them would cause trauma to the child for very little reason. If your doctor chose not to close the wound, s/he will advise you about care. Usually a daily gentle cleansing with warm soapy water and an application of an antibiotic ointment such as polysporin or neomycin is enough. A Band-Aid® or similar bandage helps keep the area clean, reminds your child to be careful, and is a great badge of courage.

If your doctor did decide to close the wound, s/he will have chosen from a number of options. Stitches are still the main choice. They are strong and reliable, and the doctor can control how they close the wound and when they come out. In deeper wounds, doctors may put in some deep or buried stitches. They use absorbable suture material that they will not remove. The top layer of stitches is usually made from a synthetic material that the doctor will remove later. Stitches stay in the wound for different amounts of time depending on the location of the cut, how deep it is, and how much the skin around it will move. Stitches on the face and scalp, can usually come out in 3 –5 days, on the hands and feet in 7 – 10 days, and on arms, legs, and other areas in 7 – 10 days. These are only estimates, of course. Your doctor will let you know how long the stitches should stay in your child’s wound.

Most doctors recommend keeping a stitched area dry for the first 24 hours. After that, please wash the wound gently with warm soapy water once a day and dry it gently right away, unless your doctor asks you to keep the wound dry for a longer period. Some doctors recommend cleaning along the suture line with a cotton swab dipped in hydrogen peroxide, instead of washing. The peroxide doesn’t kill germs very well, but the bubbling action helps to clear away dried blood and debris. Please never put peroxide into an open wound. After cleaning the wound, please apply antibiotic ointment such as bacitracin, polysporin, or neomycin. Please cover the wound with a dry gauze but avoid sealing it up under tape. This will help prevent infection.

In some cases doctors use absorbable material in the top layer. Some parents complain that this causes itching and that the stitches do not get completely absorbed. Please be sure you understand what kind of stitches your doctor used, and when to have them taken out, if necessary. Care for these stitches just as you would the non-absorbable kind, above.

In some cases where the doctor wants to close the wound but is concerned about infection, s/he may put a "drain" in the wound. The drain is a piece of plastic or gauze that prevents fluid from collecting in the wound, but allows the doctor to close the skin over it. The doctor will remove the drain later, when the risk of infection is lower. You can also care for this kind of wound just as you would a fully closed wound with stitches, above. Please take care not to disturb or pull out the drain. If it does come out, there’s no need to be upset – just call your doctor for instructions.

Doctors often use skin staples for wounds above the hairline or over knees and elbows, where the need for strength overrides concerns about appearance. Staples are fast and easy to apply, and easier to remove than sutures. Doctors normally use local anesthetics before stapling, just as they do for stitches. Staples can usually come out in about 5 – 10 days, depending on location.

Some doctors choose "butterfly" or "Steri-Strip®" or similar closures. These are thin paper strips with some strengthening material in them. They are sticky on one side, and they can do a good job of holding skin edges together. They work well in any area where there isn’t much tension trying to pull the wound apart. Unlike stitches, they don’t leave any marks of their own once they are gone. They also fall off on their own in about 5 days, so your doctor does not have to remove them. The down side to these closures is that of course they can come off too early, especially if they get wet or if the child picks them off.

Most doctors ask that you keep these closures dry until they come off on their own. You may want to cover them with a dry gauze or a Band-Aid® or similar bandage to keep curious fingers away.

For small cuts on the face or in other areas with good blood flow and little tension on the skin, doctors often use "skin glue" like Dermabond® and others. This glue is basically like "superglue" – it binds the skin almost immediately. It is strong enough to hold skin edges together, but it doesn’t hold well under a lot of tension. Its advantages are that it is fairly easy to apply, leaves very little scarring, and comes off on its own as the wound heals. Its disadvantages are that it can be difficult to apply accurately in a squirming child, and that it does not hold up well in very most environments (like the lip or chin of a teething toddler). Children may also dig or pick it off their skin if it bothers them.

The makers of the skin glue usually provide written instructions for their particular product. In general, please try to keep the area dry and clean until the wound heals under the glue. This usually takes about a week. Ask your doctor about washing – in some cases you can wash the skin gently after 24 – 48 hours. Please be sure to dry the skin right away.

Children’s skin tends to heal very rapidly and smoothly. Although all cuts leave some scar, the scar is often quite small when it completely heals. Please remember that it takes most cuts about six weeks to heal completely. Before that time, it is normal for the wound to appear pink or even red, and to feel raised above the skin surface. The most important thing with any cut is to prevent infection, or to catch it early if one develops. Here are some things to look for:

• Redness or swelling of the wound within the first 2-3 days, especially redness that spreads rapidly
• Red streak or streaks that extend away from the wound toward the body
• Persistent bleeding for more than 24 hours
• Persistent pain, or new pain after the first 24 hours
• Pus or cloudy drainage from the wound or from a drain (clear drainage is usually normal)
• Opening of the wound or tearing out of stitches
• Pain or swelling in areas not connected with the cut itself
• Fever
• Vomiting and/or diarrhea

Infection is the most serious concern following a laceration. It is also important to keep in mind that no matter how carefully your doctor examined the wound, there can be hidden damage that does not show up until later. This is especially true in a crying and frightened toddler where it can be hard to get a thorough examination. A foreign body (scrap of material) can remain buried in the wound. That can cause infection later. An injured nerve or tendon can cause weakness or numbness. Please let your doctor know right away if you have concerns about these things.

Most clinics and hospitals that care for children these days offer some kind of sedation (calming medicine) to children if they require long or painful procedures. If your child had sedation, please remember that s/he may still have some effects for up to six hours afterwards. Please either carry your child until s/he gets into bed, or walk with one hand on his or her arm to steady him or her. An unsteady gait or attack of dizziness can cause a fall and a whole new injury.

In very rare cases, wound infections can cause dangerous and even life-threatening infections. Toxic-shock syndrome can happen in children with Staph or Strep wound infections, especially in deep wounds or those with drains or packing. The condition known as "flesh-eating strep" infection can also cause serious disease. Both of these are rare, but if your child develops fever, changes in level of consciousness, peeling skin, and/or vomiting and diarrhea within a week of a wound closure, please call your doctor right away.

Most lacerations are simple and easy to fix. Sometimes, however, they lie over a more serious injury. Especially if your child got his or her laceration from a high-speed accident like a car crash or a fall, there could be a broken bone in the area. Lacerations on the face can distract our attention from a head injury or concussion. Children with cuts on their lips or chins can have jaw or tooth injuries, or cuts on their tongues. Your doctor will have checked for these things, but if you develop any concerns, please let your doctor know.