Modified hair apposition technique as the primary closure method for scalp lacerations

[Head injuries and their wound treatment]

Head injuries are frequent occurrences in emergency departments worldwide and are notable for the fact that attention must be paid to the sequelae of intracranial and extracranial trauma. It is crucial to assess potential intracranial injuries and to strive for both medically sound and esthetically pleasing extracranial outcomes. The aim of this continuing education article is to provide a refresher on knowledge of head injuries and the associated nuances for wound care.

Comparing the hair apposition technique with traditional closure in scalp lacerations: a literature review

This literature review aimed to explore the clinical outcomes for adult and child patients with scalp lacerations using the hair apposition technique (HAT) compared with the traditional options of sutures and staples for wound closure in the emergency department (ED). Although the research is scant, in the studies examined HAT was received positively by patients, had limited complications, was cost-effective and was suitable for use in the age ranges that met the criteria for its application. Further research is required to support the existing evidence, but the use of HAT for low-risk scalp lacerations in the ED should be considered and is within the scope of all healthcare professionals who undertake appropriate practice of this clinical skill.

Scalp Staples Placed in a Pediatric Emergency Department: Feasibility and Benefits of Home Removal

OBJECTIVES

Scalp lacerations are a common occurrence in the pediatric population. A preferred method of closure in a busy pediatric emergency department (PED) is skin staples, because of their ease of use and rapid application. However, using skin staples also demands that the child have a follow-up visit for their removal. This study examines whether caregivers can be taught how to safely remove their child's skin staples at home, obviating the need for a return clinic visit and its associated costs.

METHODS

This is a prospective, convenience study of 30 children older than 4 years presenting with a scalp laceration that the attending physician chose to close with skin staples. Caregivers of enrolled children completed an initial survey and received training in skin staple removal in the PED. Upon discharge, caregivers were given the staple removal device and specific instructions indicating the date for staple removal and how to access an online video reviewing proper staple removal technique. Caregivers were contacted after anticipated staple removal for completion of a follow-up survey. We recorded caregiver success rate at staple removal and measured potential benefits with regard to lost wages, transportation costs, and missed school time. Data were analyzed using descriptive statistics.

RESULTS

Twenty-eight (93%) of 30 enrolled caregivers were successful in completely removing their child's staples; one caregiver did not attempt removal and another was lost to follow-up. Twenty-five caregivers (83%) completed follow-up surveys. All caregivers reported that if given a future choice, they would prefer to remove their child's staples at home rather than return to a clinic and all said that they would be "very comfortable" if they needed to remove staples again in the future. Sixty-four percent of caregivers estimated that it would have taken greater than 2 hours to attend a clinic for staple removal. Thirty-two percent of caregivers would have lost greater than US $100 in wages. Eighty-eight percent of children would have missed school time, with 46% having to miss an entire school day.

CONCLUSIONS

Caregivers who were taught how to remove their child's scalp staples in the PED before discharge were highly successful at home. Ninety-three percent of enrolled patients had their staples completely removed and no complications were reported. Benefits included avoiding lost wages, lost time attending a follow-up clinic, and lost time from school. Staple removal is a simple technique that can easily be taught to caregivers in a matter of minutes and lead to greater patient and parent satisfaction.

Outcomes of laceration suture repair in the emergency department

OBJECTIVE

To assess patient satisfaction with laceration management, post-ED care, cosmesis and complication rates.

METHODS

We undertook a prospective observational study of adult patients with lacerations sutured in two EDs over a 4-month period. ED data included participant demographics, laceration characteristics and management. A telephone survey was undertaken approximately 14 days post-ED discharge. Patient satisfaction with post-ED pain management, advice on wound care and follow up, overall management and wound cosmesis were evaluated using a six-item satisfaction scale (very dissatisfied to very satisfied). Details of wound infection, dehiscence and suture failure were recorded.

RESULTS

Eighty-nine patients participated. The number (% [95% confidence interval]) of patients very satisfied with their laceration management were: post-ED pain management 55 (62.5% [51.5-72.4]), wound care advice 51 (57.3% [46.4-67.6]), follow-up advice 39 (43.8% [33.5-54.7]), overall management 61 (68.5% [57.7-77.7]) and cosmetic appearance 46 (51.7% [40.9-62.3]). Infection, dehiscence and suture failure occurred in 5 (5.6%), 8 (9.0%) and 8 (9.0%) cases, respectively. These complications were not associated with being very satisfied overall (P = 0.96). Patients very satisfied with post-ED pain management, wound care advice, follow-up advice or wound cosmesis were much more likely to be very satisfied overall (P < 0.001).

CONCLUSIONS

Most patients are very satisfied with their laceration management. However, there is scope for improvement, especially for follow-up and wound care advice. Complications are infrequent and not associated with overall satisfaction.

[General principles of wound management in emergency departments]

Wound management is one of the major tasks in emergency departments. The surrounding intact skin but not the wound itself should be disinfected before starting definitive wound treatment. Hair should first be removed by clipping to 1-2 mm above the skin with scissors or clippers as shaving the area with a razor damages the hair follicles and increases the risk of wound infections. Administration of local anesthetics should be performed directly through the exposed edges of the wound. After wound examination, irrigation is performed with Ringer's solution, normal saline or distilled water. The next step is débridement of contaminated and devitalized tissue. There are several wound closure techniques available, including adhesive tapes, staples, tissue adhesives and numerous forms of sutures. Management of specific wounds requires particular strategies. A bleeding control problem frequently occurs with scalp lacerations. Superficial scalp lacerations can be closed by alternative wound closure methods, for example by twisting and fixing hair and the use of tissue adhesives, i.e. hair apposition technique (HAT). For strongly bleeding lacerations of the scalp, the epicranial aponeurosis should be incorporated into the hemostasis. Aftercare varies depending on both the characteristics of the wound and those of the patient and includes adequate analgesia as well as minimizing the risk of infection. Sufficient wound aftercare starts with the treating physician informing the patient about the course of events, potential complications and providing relevant instructions.

Wound management

The care of wounds is common in pediatric practice. Most simple wounds can be handled by clinicians in the office or by trained emergency medicine clinicians. Knowledge of appropriate wound care, wound repair techniques, and judicious use of antibiotics for prophylaxis ensures the best possible long-term outcomes. The following review describes appropriate recommendations for acute and long-term wound care, management, and special circumstances common to pediatric practice.

A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations

Aim

Scalp lacerations are commonly encountered in patients presenting to emergency department with trauma. Lacerations are repaired with suturing, stapling, adhesive tapes, and tissue adhesives. In this study, we aimed to compare the effectiveness of suturing, stapling, and hair apposition techniques used in repair of scalp lacerations in patients who presented to emergency department with scalp laceration.

Materials and method

After obtaining approval of local ethics committee, we examined the effects of the three technique used to repair scalp lacerations on wound healing, complication rate, and patient satisfaction by recording data. Categorical variables were expressed as n and %. X² test was used for statistical analysis. A p value less than 0.05 was accepted statistically significant.

Results

Our study included a total of 134 patients of whom were treated 37 (27.6%) with hair apposition technique 49, 48 (35.8%) with suturing, and (36.6%) with stapling. There was a significant difference between the scalp repair technique and 7th and 15th day patient satisfaction rates in favor of the hair apposition technique (p < 0.05). There was a significant difference between the scalp repair technique and cosmetic problems after 15 days (p < 0.05). Cosmetic problems 15 days after the procedure were significantly lower in the hair apposition technique.

Conclusion

In patients presenting to emergency departments with linear scalp laceration suturing, stapling, and hair apposition techniques can be safely applied. However, hair apposition technique has the advantages of being more satisfying, and having lower cosmetic problem and complication rates compared with other techniques.