Falls, traffic accidents, animal bites, hot liquids, electrical equipment, lawn care machinery and physical abuse have all led to soft-tissue injuries in children. Treatment in an emergency department is often adequate, but failure to provide appropriate or definitive treatment in the emergency setting may produce permanent injury or disfigurement. It is important for the primary care physician to recognize when consultation with a plastic surgeon is indicated for definitive treatment.
Soft-Tissue Injuries of the Face
Facial injuries require special attention because of their potential for permanent disfigurement. Contusions, lacerations, puncture wounds, tattoos with debris and especially avulsive injuries all have the capacity to permanently disfigure the patient. Inadequate suturing of even small lacerations on the face can result in poor healing and scarring.
Definitive repair of facial soft-tissue injuries is best carried out in an operating room rather than an emergency room – and preferably by a plastic surgeon. Should the injuries be complex or severe, the plastic surgeon can perform procedures that will be definitive or will lay the foundation for later revision surgery.
Injuries to particularly vulnerable facial features require special attention. Injuries to the forehead and eyebrow, eyelids, ears, nose, cheeks and chin have the most potential to result in disfigurement. Injuries to the cheek and/or chin may result in loss of function if facial nerves or muscles are injured. Repair to facial nerves and muscles should be performed by a plastic surgeon experienced in this type of surgery.
Animal bites can present special problems – e.g., most dog bite wounds are to the face in children and are usually result in a tearing-type of soft-tissue wound. Aggressive cleaning and meticulous repair by a plastic surgeon can frequently salvage a serious injury – both cosmetically and functionally.
Snakebite presents the possibility of envenomation in addition to the bite injury. If the type of snake is unknown, emergency treatment proceeds with observation and suspicion of envenomation. Bites inflicted by rattlesnakes may result in tissue necrosis – often severe – which requires wide dissection and debridement. Skin grafting or reconstruction with skin-flap technique may be necessary after primary healing of the wound site.
Most burns suffered by infants and young children are hot-liquid scalds, and as many as 15 percent of scald burns may be due to child abuse. Scald burns on the buttocks are especially likely to be the result of child abuse, such as sitting the child in hot water as punishment.
The immediate concern in scald injury is estimation of the extent of injury. The ratio of head-to-total-body burn must be calculated differently in infants and children than in adults, due to inherent differences in relative size of head to body. Estimation of the severity of the burn depends on (1) temperature of the scalding liquid and (2) amount of time the skin was exposed to the liquid.
Good emergency management of a superficial burn – i.e., limited extent, less-than-full thickness – should result in healing without complications. Elements of good management include (1) evaluation, (2) rinsing with saline solution and light cleaning with mild soap-and-water solution, (3) debridement of any blisters that interfere with function, such as blisters on the eyelids, (4) instruction to the child's family in how to care for the burn after the patient is released from the hospital, and (5) examination of the patient by the treating physician within two days after the first dressing change to rule out the possibility of wound-site infection.
Burns of the ears and hands require special attention. Even superficially burned ears may later develop scarring or deformation. Burned hands can potentially develop scarring and contracture that limit function. A plastic surgeon should be called into consultation for burns on vulnerable sites such as ears and hands.