Wound Care Introduction

A wound is a break in the skin (the outer layer of skin is called the epidermis). Wounds are usually caused
by cuts or scrapes. Different kinds of wounds may be treated differently from one another, depending
upon how they happened and how serious they are.

Healing is a response to the injury that sets into motion a sequence of events. With the exception of bone,
all tissues heal with some scarring. The object of proper care is to minimize the possibility of infection and
scarring.

There are basically 4 phases to the healing process:

 Inflammatory phase: The inflammatory phase begins with the injury itself. Here you have
bleeding, immediate narrowing of the blood vessels, clot formation, and release of various chemical
substances into the wound that will begin the healing process. Specialized cells clear the wound of
debris over the course of several days. 

 Proliferative phase: Next is the proliferative phase in which a matrix or latticework of cells forms.
On this matrix, new skin cells and blood vessels will form. It is the new small blood vessels (known
as capillaries) that give a healing wound its pink or purple-red appearance. These new blood vessels
will supply the rebuilding cells with oxygen and nutrients to sustain the growth of the new cells and
support the production of proteins (primarily collagen). The collagen acts as the framework upon which
the new tissues build. Collagen is the dominant substance in the final scar. 

 Remodeling phase: This begins after 2-3 weeks. The framework (collagen) becomes more
organized making the tissue stronger. The blood vesseldensity becomes less, and the wound begins
to lose its pinkish color. Over the course of 6 months, the area increases in strength, eventually
reaching 70% of the strength of uninjured skin. 

 Epithelialization: This is the process of laying down new skin, or epithelial, cells. The skin forms
a protective barrier between the outer environment and the body. Its primary purpose is to protect
against excessive water loss andbacteria. Reconstruction of this layer begins within a few hours of the
injury and is complete within 24-48 hours in a clean, sutured (stitched) wound. Open wounds may take
7-10 days because the inflammatory process is prolonged, which contributes to scarring. Scarring
occurs when the injury extends beyond the deep layer of the skin (into the dermis).

Wound Care Signs and Symptoms

 Scrapes and abrasions are superficial (on the surface). The deeper skin layers are intact, and
bleeding is more of a slow ooze. They are usually caused by friction or rubbing against an abrasive
surface. 

 Lacerations (cuts) go through all layers of the skin and into the fat or deeper tissues. Bleeding
may be more brisk or severe. Severe blows by a blunt object, falls against a hard surface, or contact
with a sharp object are the most common causes of lacerations. 
 Puncture wounds are generally caused by a sharp pointed object entering the skin. Most
common examples are stepping on anail, getting stuck with a needle or a tack, or being stabbed with a
knife. Bleeding is usually minimal, and the wound may be barely noticeable. 

 Human bites and animal bites can be puncture wounds, lacerations, or a combination of both.

These wounds are always contaminated by saliva and require extra care.

Home Care

Scrapes and abrasions often do not require any more care than washing the area 4 times daily for the first
48 hours and keeping the area covered with a sterile bandage. Deeper wounds and bites will require
medical attention. 

 Stop the bleeding: If bleeding will not stop, apply a clean bandage to the area and press down
on it for 10 minutes.

 Clean the wound: Water under pressure is the best way to clean a wound. Either a
briskly running faucet or a hand-held shower nozzle is the best way to wash a wound. The wound
should be washed for 10-15 minutes. Make sure you remove all dirt and debris. Do not scrub deep
wounds or bites, just wash them out.

 Check when you last had a tetanus shot.

Prognosis

Most wounds heal just fine if given proper care. 

 Overall, the infection rate is 6.5%. Redness around the wound, a red line extending toward the
body from the wound, or yellowish drainage from the wound are signs of infection and require
immediate re-evaluation by a doctor. 

 Keeping the sutures clean and avoiding the formation of a scab over them aid in a good
cosmetic result. A dilute peroxide solution or plain water may be used. It is all right to wash a sutured
wound after 48 hours, but it should not be soaked. 

 Antibiotics are not necessary in most cases.

Prevention

 Take care when using sharp objects such as knives, scissors, saws, and trimmers.

 Wear shoes or boots on your feet.

 Use helmets when riding a bicycle.

 Use helmets, kneepads, wrist protectors, and elbow pads when using in-line skates.

 Avoid picking up broken pieces of glass and handling razor blades.

 Neonatal and Pediatric Wound Care: Best Practices
 for our Sm allest Patients
 Glossary
 Acute pain – see nociceptive pain; Pain that begins quickly but lasts a short or definitive time.
 Adult skin – quality is age-related: decreased dermal thickness & epidermal regeneration.
 Autolysis - disintegration or liquefaction of tissue or of cells by the body’s own mechanism, such as leukocytes and
enzymes.
 Childhood - starts at 1 year of age and extends until teenage years of 13.
 Chronic pain -A persistent state of pain that lasts for an extended period of time.
 Collagen – major structural protein found in the dermis and is secreted by dermal cells; main protein of connective
tissue;
 makes up to 25%-35% of the whole body’s protein content.
 Cyclic acute pain -Periodic pain that recurs due to repeated treatments or interventions.
 Dermal – related to skin or dermis; synonym is “integumentary”.
 Dermal-Epidermal Junction – the area that separates the epidermis from the dermis; also referred to as the basement
 membrane zone.
 Dermis – inner layer of the skin that lies under the epidermis; contains blood vessels, lymph vessels, hair follicles,
glands and
 nerves.
 Dermatitis – dermatological condition, inflammation of the skin.
 Desiccate – to dry out.
 Dressings – Materials applied to a wound for protection, absorption and drainage:
 • Hydrogel dressing- glycerin, saline or water-based dressings
 • Gauze dressing -usually made of cotton or synthetic that is absorptive and permeable to water, water vapor, and
oxygen.
 The gauze may be impregnated with sodium chloride, petrolatum, antiseptics, or other agents.
 • Hydrocolloid dressing - formulations of elastomeric, adhesive, and gelling agents. Semi-occlusive and impermeable
to
 fluids and bacteria.
 • Polyurethane film dressing- semi-permeable, transparent and non-absorptive, polymer-based adhesive dressing.
 • Foam dressing- cellulose or polyurethane dressing that may be impregnated or coated with other material and has
some
 absorptive properties. May have adhesive or soft silicon borders or be non-bordered.
 • Composite dressing-a non-adherent contact layer covered with an absorbent material and water-proof backing.
 • Alginate dressing – highly absorbent, biodegradable dressing derived from seaweed
 • Hydrofiber dressing-highly absorbent, with gelling properties derived from carboxymethylcellulose.
 • Contact layer – applied next to the wound bed to protect from trauma; some have absorptive properties and are coated
 with soft silicone.
 • Soft Silicon dressing- unique material that does not adhere to the wound because it does not contain traditional
 adhesive; Available in many forms, such as a contact layer, absorptive foams, or impregnated dressings.
 Edema – presence of abnormally large amounts of fluid in the interstitial space.
 Elastin – protein found in the dermis; provides the skin’s elastic recoil.
 Epidermis – outermost layer of the skin.
 Epidermolysis bullosa (EB) – genetic disorder characterized by skin and mucosal blistering. Three types: simplex,
junctional,
 and dystrophic.
 Epithelial migration – the movement of epithelial cells across the wound bed in the resurfacing or repair process.
 Epithelial stripping – (skin stripping) the remove of the epidermis by mechanical means; denude.
 Epithelialization - regeneration of the epidermis across a wound surface.
 Exudate – any fluid that has been extruded from a tissue or its capillaries, such as fluid, cells, or cellular debris, which
has
 escaped from blood vessels and has been deposited in tissue surfaces.
 Extravasation – leakage of a vesicant from the vein into surrounding soft tissue.
 Fetal skin – gelatinous and extremely thin skin; produces scarless healing of wounds due to special dermal proteins
(hyaluronan,
 collagen, transforming growth factor beta).
 Fibroblast- a cell that is responsible for building collagen and granulation tissue.
 Fissure –a groove or deep furrow in the skin.
 Friction – the force of two surfaces moving across one another, such as the mechanical force exerted when skin is
dragged
 across a coarse surface.
 Full-term skin - full development (36-40 weeks gestational period): is relatively same as post-term skin.
 Granulation tissue – pink to red, moist tissue that contains new blood vessels, collagen, fibroblasts, and inflammatory
cells that
 fills an open, previously deep wound when it begins to heal.
 Growth factors - proteins that stimulate the deposition of collagen and matrix formation in a wound; called cytokines,
stimulate
 cell-activity.
 Infant - 30 days to 1 year of age.
 Infant skin - thinner skin & nails, collagen and elastin more rapidly produced than in adults.
 Infection – the presence and growth of a microorganism that produces tissue damage.
 Keratinocytes – cells in the skin that synthesize keratin; (the outer layer of cells) forms the epidermal barrier.
 Maceration – over-hydration or softening of the stratum corneum.
 NPUAP – National Pressure Ulcer Advisory Board, www.npuap.org.
 Neonate/Newborn - the time from delivery to 30 days delivery.
 Neonatal skin - immature stratum corneum, far fewer cell layers, and increased permeability, especially first 2 weeks;
 fibroblasts present in greater numbers than in adults.
 Neuropathic pain - Pain that originates from nervous system damage or malfunctioning nerve fibers; burning or
electric
 shock-like.
 Nociceptive pain - Pain arising from stimulation of pain receptors; a normal pain response to injury or tissue damage;
acute pain
 Noncyclic pain -Single episode pain, usually acute pain.
 Occiput – the back part of the skull.
 Pain - An unpleasant sensory or emotional experience associated with actual or potential tissue damage.
 Pediatric – concerning the treatment of children.
 Peristomal - the skin surrounding a stoma.
 Pressure ulcer - is a localized injury to the skin and or underlying tissue, usually over a bony prominence that is a
result of
 pressure, or pressure in combination with shear and friction.
 Pre-term skin (premature) - before term or full development (before the normal 36-40 weeks gestational period;
epidermis is
 thin and a weak protective barrier.
 Procedural pain – pain that occurs due to a procedure and usually stops after procedure completed.
 Rete ridges or pegs - fingerlike projections in the epidermis that interlock with upward projections of papillary dermis;
helps
 anchor the epidermis to the dermis
 Sepsis – the spread of an infection from its initial site to the blood stream.
 Shear – the mechanical force that is parallel rather than perpendicular to the surface area of the body; trauma caused by
tissue
 layers sliding against each other, results in disruption or angulation of blood vessels.
 Skin Tear - result of friction alone or shearing and friction forces that separate the epidermis from the dermis or that
separate
 both the epidermis and dermis from underlying structures.
 Stratum Corneum – the outermost horny layer of the epidermis.
 Subcutaneous tissue - superficial fascia, forms beneath the dermis; also referred to as hypodermis.
 Syndactylism – a fusion of two or more digits.
 Toddler/Childhood skin - fast epidermal turnover time, granulation tissue forms more quickly than in adults
 Wound bed – uppermost viable tissue layer of the wound; may be covered with slough or eschar.
Minor injuries in children are extremely common.
The combination of a developing physical ability,
lack of recognition of dangerous situations and a
willingness to robustly explore their environment
means that children are more likely than adults to
injure themselves.
The most common types of wounds that children sustain
are soft tissue bruising, abrasions, lacerations and puncture
wounds (including human and animal bites). Management
goals of these wounds are to avoid infection, minimise
discomfort, facilitate healing and minimise scar formation.
Meticulous attention to wound care and repair should
ensure the best possible outcome and functional result.
In children this will often require sedation in addition to
adequate local anaesthesia and analgesia.
Wound assessment
The care of the patient as a whole should be the first
management priority. The airway, breathing and circulation
should be assessed and treated as appropriate. A thorough
secondary survey may then be undertaken; if serious injuries
are detected, immediate intervention may be required.
Wounds can be classified into various types including
abrasions, lacerations, avulsions, punctures, and bites.
Regardless of the type of wound, there are basic steps in
the initial evaluation and management of skin wounds that
all clinicians should be familiar with (Table 1).
History
While haemostasis is being achieved, a thorough history
should be taken to include the following:
• time of injury
• mechanism of trauma (cut, crush, fall, bite, burn)
including details of inflicting object
• likelihood of foreign body
• motor function and sensation distal to the affected area
• health status of the patient especially with regard to
chronic illness that may impact wound healing
• current medications (important for both drug
interactions with antibiotics that may be prescribed and
for medications that may interfere with wound healing)
• history of allergies, and
• immunisation history.
In wounds that require general anaesthesia or sedation,
a history of when the child last ate or drank is important.
Nonaccidental injury should be considered, especially when
the history and injury are inconsistent.
Ronan O’Sullivan
MBBCh, BAO, FRCSI, FCEM, is
Fellow in Paediatric Emergency
Medicine, Emergency
Department, Royal Children’s
Hospital, Melbourne, Victoria.
Ed Oakley
MBBS, FACEM, is a paediatric
emergency physician,
Emergency Department, Royal
Children’s Hospital, Melbourne,
Victoria.
Mike Starr
MBBS, FRACP, is a
paediatrician, infectious
diseases physician, and
Paediatric Emergency
Consultant, Emergency
Department, Royal Children’s
Hospital, Melbourne, Victoria.
[email protected]
BACKGROUND
Minor injuries in children are extremely common in the general practice setting.
OBJECTIVE
This article describes a systematic approach to the assessment and treatment of wounds in children.
DISCUSSION
Wound management goals are to avoid infection, minimise discomfort, facilitate healing and minimise scar formation.
The care of the patient as a whole should be the first management priority. Successful examination requires gaining
the child’s trust, relieving pain early, and using a flexible and creative examination technique. Superficial abrasions
and lacerations can be safely cleaned with good quality water, and all foreign material removed. Deeper wounds with
suspected damage to nerves, tendons or circulation need formal exploration under general anaesthetic. Good local
anaesthesia can be produced by topical preparations, and many wounds can be closed with tissue adhesives with an
excellent cosmetic result. All children with injuries should be checked for adequate tetanus cover for prophylaxis.

Wound repair in
children
THEMEMinor injuries in children are extremely common.
The combination of a developing physical ability,
lack of recognition of dangerous situations and a
willingness to robustly explore their environment
means that children are more likely than adults to
injure themselves.
The most common types of wounds that children sustain
are soft tissue bruising, abrasions, lacerations and puncture
wounds (including human and animal bites). Management
goals of these wounds are to avoid infection, minimise
discomfort, facilitate healing and minimise scar formation.
Meticulous attention to wound care and repair should
ensure the best possible outcome and functional result.
In children this will often require sedation in addition to
adequate local anaesthesia and analgesia.
Wound assessment
The care of the patient as a whole should be the first
management priority. The airway, breathing and circulation
should be assessed and treated as appropriate. A thorough
secondary survey may then be undertaken; if serious injuries
are detected, immediate intervention may be required.
Wounds can be classified into various types including
abrasions, lacerations, avulsions, punctures, and bites.
Regardless of the type of wound, there are basic steps in
the initial evaluation and management of skin wounds that
all clinicians should be familiar with (Table 1).
History
While haemostasis is being achieved, a thorough history
should be taken to include the following:
• time of injury
• mechanism of trauma (cut, crush, fall, bite, burn)
including details of inflicting object
• likelihood of foreign body
• motor function and sensation distal to the affected area
• health status of the patient especially with regard to
chronic illness that may impact wound healing
• current medications (important for both drug
interactions with antibiotics that may be prescribed and
for medications that may interfere with wound healing)
• history of allergies, and
• immunisation history.
In wounds that require general anaesthesia or sedation,
a history of when the child last ate or drank is important.
Nonaccidental injury should be considered, especially when
the history and injury are inconsistent.
Wounds
Reprinted from Australian Family Physician Vol. 35, No. 7, July 2006 477

Examination
Assessing wounds in children can be challenging. The
cooperation achieved and the comprehension level of
the child influence wound examination and therefore the
information gained. A calm, unhurried, friendly approach
with assistance from parents will maximise the chances of
cooperation. Useful strategies include:
• bobbing down to the child’s eye level
• leaving the child in a parent’s arms
• gaining trust by talking to the child, as well as to the
parents, and explaining what is happening in a manner
appropriate for the child’s age
• dealing with pain early by using analgesics, splinting
and distraction.
It is important to minimise the amount of additional pain by
handling limbs slowly and sensitively, soaking dressings off
wounds, and avoiding unnecessary movement.
Observe the wound, looking for the site, shape and size,
the presence of a tissue flap, and possible contamination
by dirt or other foreign material. Decide what deeper
structures may be involved and specifically test for each.
In children, testing the integrity of nerves and tendons
needs to be done creatively and flexibly, using simple
instructions relayed through parents. This may involve the
use of mimicry, toys and playing. Assess the circulation
locally and distally to the wound. While conducting the
examination, make an assessment of the likelihood of the
child being cooperative during a procedure and the type of
analgesia and sedation that may be necessary.
Unfortunately, even despite good preparation and
technique, not all examinations will be successful. If the
wound is deep or there is any doubt as to the integrity of
nerves, tendons or circulation, the wound must be formally
explored, a procedure best done in hospital under sedation
or general anaesthesia.
Investigation
If the presence of a foreign body is expected, radiological
investigation is advised. In wounds caused by glass, all but
superficial wounds should be investigated with plain, soft
tissue X-ray to exclude a glass foreign body. Ultrasound can
also be useful to both confirm the presence of a foreign
body and to provide a guide to its depth and location in
the wound. Plain X-rays may also be indicated for injuries
where underlying fracture is possible (eg. crush injury to
the finger).
Wound treatment
After assessment of the wound and the child in general, a
treatment strategy can be devised. This should include:
• whether the child needs analgesia and sedation
• how the wound will be anaesthetised
• how the wound will be closed, and
• whether any other treatment such as splinting,
tetanus vaccination or antibiotics is needed.
Clearly, the expertise of the doctor and other treating staff,
the availability of drugs and equipment and the wishes of the
parents and the child will influence treatment.
Pain management
Analgesia and sedation
A number of therapeutic options are possible.1,2 Select the
appropriate agent depending on the wound, the degree of
pain, the experience of the staff, and the procedure that
is likely to be performed. A summary of options is listed
in Table 2. Some agents such as morphine provide both
analgesia and sedation. Be generous with the provision of
analgesia and allow time for it to work, as poor pain control
is one of the major causes of procedural failure in children.
Local anaesthesia
Local anaesthesia options are listed in Table 2. Topical
anaesthesia is painless, easy to apply and has a similar
efficacy to infiltrated lignocaine.3 EMLA (an eutectic mixture
of lignocaine and prilocaine) is a cream usually applied to
intact skin, however, it appears to be safe and effective for
simple extremity lacerations even though it is not licensed
for this use.4,5
Regional nerve blocks, such as digital, ulna or
femoral nerve blocks, are very effective in children. A
number of reference books are available that provide the
anatomical knowledge and practical instruction necessary
to perform them.2
Cleaning wounds
All dirt and foreign material in the wound must be located
and removed before closure. Superficial wounds may be
safely cleaned with good quality tap water.6 Preparations
such as aqueous chlorhexidine are painful to apply and
of doubtful benefit. Irrigation with saline under pressure
(using a 19 gauge needle on a 10–20 mL syringe) is a good
way of dislodging and removing foreign material. Abrasions
should be covered with a nonstick dressing and secured
with tape or a bandage.
Table 1. Overall wound management
• Haemostasis
• History of wound mechanism and patient health (including tetanus
immunisation history)
• Thorough wound cleansing, removal of debris
• Debridement of devitalised tissue
• Closure of wound (if indicated)
THEME Wound repair in children
478 Reprinted from Australian Family Physician Vol. 35, No. 7, July 2006
Wound closure
Small superficial wounds with opposed edges do not
require closure and can be managed with dressings alone.
Other wounds may be closed with tissue adhesives,
adhesive strips, sutures or a combination of these.
Tissue adhesives
Tissue adhesives are most successful on wounds that
are less than 3 cm long, have clean straight edges, do not
require deep sutures, and are not under tension when the
edges are opposed. They do not require local anaesthesia
and are quick and easy to apply. The cosmetic result for
a wound closed with tissue adhesives is the same as for
wound closure achieved with sutures, staples or adhesive
strips.7 There is a small increase in the incidence of wound
dehiscence with tissue adhesives compared with sutures,
but all other wound complications appear to be the same
for both wound closure methods.7
Any area of the skin may be glued, however, gluing in
the vicinity of the eye requires extreme care to prevent
any glue dripping into the eye or onto the eyelashes. If
gluing the scalp, remove any hair from the wound but do
not shave or cut the surrounding hair. Before gluing, the
wound must be dry and not bleeding.
To apply tissue adhesive, position the child so the
wound is uppermost to minimise the glue running.
Ensure the operator is wearing gloves; this is not only for
hygiene reasons, but to ensure that it is the glove, not the
operator, that is stuck to the child if adhesive inadvertently
runs on to the operator’s fingers. The hand can then
be removed from the glove, and the glove fingers cut
close to the child’s skin and left to spontaneously detach.
The edges of the wound are brought together with
the edges slightly everted and a thin layer of adhesive
applied on each side of the wound; the wound is then
bridged by applying a layer from side-to-side. Take care
not to get adhesive in the wound. The child and parents
should be informed that the adhesive will feel warm
as it polymerises.
The wound should be kept clean and dry, but a dressing
is usually not required as the wound is covered by the
adhesive. The adhesive does not require removal and
comes off spontaneously in 1–2 weeks.
Adhesive strips
Adhesive strips are adequate for closing simple wounds
that require opposition of slightly separated skin edges on
nonhairy areas of the body. They are particularly useful for
aligning small flaps of skin back over a wound. They do not
remain in place for long periods and should not be used
if there is skin movement or tension across the wound.
Make the strips as long as possible and separate them
with sufficient space between each to allow drainage of
fluid from the wound. Dress the wound and ask the parent
to keep it dry for 72 hours.
Sutures
The techniques of suture placement vary with the size,
shape and position of the wound. Detailed description
of these techniques can be found in reference books
on emergency medicine.8,9 Adequate analgesia and
anaesthesia of the wound is essential before commencing
suturing; this is often more difficult and time consuming
than the suturing itself.
Scalp wounds can often be closed by the nonsurgical
techniques already described. However, deep wounds will
often need to be sutured in two layers to prevent a cavity
forming in the tissues.
Forehead wounds should have minimal debridement
and the eyebrow should not be shaved. Modern absorbable
sutures should be used in small children.
Wounds on the chin are often much deeper than they
first appear and are prone to scarring. Deep sutures are
often necessary to prevent tension on the skin sutures.
Eyelid lacerations involving the lid margin or tarsal plate
require accurate opposition and repair, and children with
Table 2. Pain management in children with minor injuries
Analgesia and sedation
Options include:
• paracetamol 20 mg/kg orally as an initial dose (ongoing doses should
be 15 mg/kg)
• codeine 0.5 mg/kg orally
• paracetamol/codeine mixtures (at doses given for paracetamol above)
orally
• morphine 0.05–0.1 mg/kg intravenously
• midazolam 0.5 mg/kg orally
• nitrous oxide/oxygen mixture inhaled, concentration of nitrous oxide
up to 70%12
• supplement pharmacological agents with distraction and guided
imagery
Local anaesthesia
Topical anaesthetics
• lignocaine gel
• EMLA (eutectic mixture of 2.5% lignocaine and 2.5% prilocaine)
Infiltrated local anaesthetics
• 1% lignocaine; maximum dose 5 mg/kg (0.5 mL/kg)
• 1% lignocaine plus adrenaline; maximum dose 7 mg/kg (0.7 mL/kg)
Regional nerve block
• 1% lignocaine; maximum dose 5 mg/kg (0.5 mL/kg)
• 0.5% bupivacaine; maximum dose 2 mg/kg (0.4 mL/kg)
Wound repair in children THEME
Reprinted from Australian Family Physician Vol. 35, No. 7, July 2006 479
such injuries are best referred to an ophthalmologist or
plastic surgeon. Other simple lacerations can be glued or
sutured under low tension with fine absorbable sutures.
Wounds around the mouth need careful consideration.
If the wound crosses the vermilion border, very accurate
approximation of the edges is necessary to achieve a
good cosmetic result. In young children, this is often best
achieved under general anaesthesia. Wounds that pass
completely through the lip need to be closed in layers.
Lacerations of the inner lip rarely need any intervention.
Children with lacerations of the gum margin (eg. degloving
injury) need to be referred for debridement and repair
under general anaesthesia.
Wounds of the palate and tongue heal exceptionally
well with little or no intervention. They do not require
suturing unless they are gaping widely, extending through
the free side margin of the tongue or continuing to bleed.
Fingertip wounds with or without skin loss are very
common. Areas of skin loss up to 1 cm are treated with
tulle dressings and heal with good return of sensation.
Children with any greater degree of tissue loss should be
referred for plastic surgical opinion.
Partial amputation or crush injuries of the fingers or
toes need to have the integrity of the nail bed assessed. If
this is damaged, referring the child for plastic surgery repair
is warranted. Fracture of the distal phalanx implies damage
to the nail bed, therefore an X-ray may be warranted. If the
nail bed is intact, the wound may be closed using adhesive
strips or sutures.
Hand wounds need to be carefully examined, as
deeper structures are often involved. Lacerations through
the dermis risk tendon injury. If any such structures are
damaged or there is any doubt, refer for plastic surgical
opinion. Neurological function should be tested before
local anaesthetic infiltration.
Antibiotics and immunisation
For most lacerations, antibiotics are not indicated for
prophylaxis against infection, but wound cleaning and
decontamination are most important. Antibiotics should
be prescribed for specific circumstances such as animal
or human bites, and wounds with extensive contamination
or tissue damage. Recommended antibiotics for animal
or human bites are amoxicillin/clavulanic acid (22.5 mg
amoxicillin component per kg up to a maximum of 875 mg)
12 hourly orally for 5 days. Procaine penicillin (50 mg/kg
up to a maximum of 1.5 g) intramuscularly may be added
if there is likely to be a delay in commencing oral
antibiotic medication.10
All children should be checked for adequate tetanus
cover for prophylaxis. The recommendations of the National
Health and Medical Research Council should be followed in
determining the need for additional vaccinations (Table 3).11
Conflict of interest: none declared.
References
1. Algren JT, Algren CL. Sedation and analgesia for minor paediatric procedures.
Pediatr Emerg Care 1996;12:435–41.
2. McKenzie I, Gaukroger PB, Ragg P, Brown TCK. Manual of acute pain
management in children. New York: Churchill Livingston, 1997.
3. Ferguson C. Topical anaesthetic versus lidocaine infiltration to allow
skin closure in children. Available at www.bestbets.org/cgi-bin/bets.
pl?record=00381 [Accessed March 2006].
4. Zempsky WT, Karasic RB. EMLA versus TAC for topical anaesthesia of
extremity wounds in children. Ann Emerg Med 1997;30:163–6.
5. Bush S. Topical anaesthesia use in the management of children’s lacerations,
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