Blunt and penetrating trauma can lead to a myriad of soft tissue injuries. The management of many of these injuries is discussed elsewhere in this text. Some specific soft tissue injuries require detailed explanations for their repair. These injuries are discussed below. Administer immunoprophylaxis (e.g., tetanus and tetanus immune globulin) when indicated. Consider the use of procedural sedation (Chapter 159) in children.
MULTIPLE FOREHEAD LACERATIONS
Forehead lacerations are common in all age groups. They occur most frequently during early childhood. Their location demands a complete head and neck evaluation.1 Their visibility requires meticulous attention to detail. Knowledge of the principles regarding their repair allows for good cosmesis. The repair of forehead lacerations differs from other soft tissue injuries due to the role of skin tension lines, the lack of extra tissue, and scarring promoted by too many deep dermal sutures.2-4 They are broadly categorized into superficial and deep in relation to involvement of the frontalis muscle.
Forehead injury repair is governed by several principles. Skin tension lines run parallel to the skin creases and play a major role in the outcome of any forehead laceration. Lacerations angled more than 35° from lines of tension are more likely to heal with a poor result.5 Consider counteracting skin tension with deep stitches and undermining. Lacerations running perpendicular to skin tension lines are more likely to result in a noticeable scar.2,3 There is little excess tissue on the forehead to allow for later wound revisions. Resist the temptation to excise ragged wounds.4 This leaves enough tissue for the Surgeon to manipulate if further revision is required. Deep lacerations are closed with a layered repair to maintain muscle function, eliminate dead space, and reduce skin tension. Place as few deep sutures as possible. They tend to promote more tissue reaction and more noticeable scar formation.
Most forehead lacerations require repair to promote cosmesis and provide hemostasis. The rich blood supply to the area allows primary repair up to 24 hours after the initial insult.1 This allows referral to a consultant if there is any question about the ability to achieve satisfactory cosmesis or if the wounds are so extensive as to take the Emergency Physician away from their departmental responsibilities for an unacceptably long time. Primary closure beyond 24 hours may be considered after the risk of infection is weighed against the cosmetic benefit and discussed with the patient.1
Laceration repair is dependent on the type of laceration. Small uncomplicated lacerations and flaps smaller than 5 mm can be closed with 6–0 nonabsorbable suture (e.g., nylon or Prolene) or 6–0 absorbable suture (e.g., fast-absorbing gut) using simple interrupted stitches.1 Multiple studies in pediatrics have shown absorbable suture to have similar outcomes to nonabsorbable suture in cosmesis and adverse events.6 Close larger flaps using the half-buried horizontal mattress ...