What is the appropriate management for a pediatric patient with a dog bite to the lower medial side of the left lower extremity requiring a bedside wound closure procedure?

Pediatric Surgery Consult: Dog Bite to Left Lower Extremity

Assessment and Initial Management

For pediatric dog bites to the lower extremity requiring bedside wound closure, thorough irrigation, appropriate antibiotic prophylaxis, tetanus prophylaxis, and careful wound closure technique are essential for optimal outcomes. 1, 2

Wound Evaluation

• Location: Lower medial aspect of left lower extremity
• Wound characteristics to document:
  • Size and depth of wound
  • Presence of devitalized tissue
  • Involvement of underlying structures (tendons, nerves, vessels)
  • Presence of foreign bodies
  • Time since injury (critical for management decisions)

Initial Wound Management

1. Irrigation

   • Perform copious pressure irrigation with sterile saline or water
   • Avoid antiseptics like povidone-iodine as they show no superiority over saline 2
   • Ensure thorough cleansing to reduce bacterial load

2. Debridement

   • Carefully debride devitalized tissue
   • Preserve viable tissue, especially in cosmetically sensitive areas
   • Remove any foreign material

Antibiotic Management

Preemptive antibiotic therapy for 3-5 days is recommended for moderate to severe dog bite injuries to the extremities. 1

Antibiotic Selection

• First-line: Amoxicillin-clavulanate 875/125 mg BID (weight-appropriate dosing for children) 1
• Alternative options if allergic to penicillin:
  • Doxycycline (for children >8 years)
  • Trimethoprim-sulfamethoxazole plus metronidazole
  • Clindamycin plus fluoroquinolone (for adolescents)

Rationale for Antibiotics

• Dog bites have mixed aerobic and anaerobic flora
• Common pathogens include:
  • Pasteurella species (found in 50% of dog bites)
  • Staphylococci and streptococci (40% of bites)
  • Anaerobes including Bacteroides, Fusobacteria, and Porphyromonas

Wound Closure Approach

Primary wound closure is appropriate for this dog bite wound after thorough irrigation and debridement, as it provides better cosmetic outcomes without increasing infection risk when proper wound care is performed. 3

Closure Technique

• Use Steri-strips for very small, superficial lacerations
• For deeper wounds, consider:
  • Simple interrupted sutures
  • Deep sutures only if necessary to eliminate dead space
  • Avoid excessive tension

Special Considerations

• If wound is >8 hours old, consider delayed primary closure
• If significant contamination or crush injury is present, consider leaving wound open
• Lower extremity wounds have higher infection risk than facial wounds

Tetanus Prophylaxis

Administer tetanus prophylaxis based on immunization status: 1, 2

• For dirty wounds:
  • If unknown/incomplete tetanus series: Tetanus immune globulin (TIG) plus tetanus toxoid
  • If complete series but >5 years since last dose: Tetanus toxoid booster
• For clean wounds:
  • If unknown/incomplete tetanus series: Tetanus toxoid
  • If complete series but >10 years since last dose: Tetanus toxoid booster

Rabies Consideration

Consult with local health officials regarding need for rabies post-exposure prophylaxis based on the circumstances of the bite and local rabies prevalence. 1

Factors to consider:

• Vaccination status of the dog
• Provoked vs. unprovoked attack
• Whether dog is available for observation
• Local rabies epidemiology

Post-Procedure Care

1. Wound Care Instructions

   • Keep wound clean and dry
   • Elevate extremity for 24-48 hours to minimize swelling
   • Apply ice intermittently for first 24 hours

2. Follow-up Plan

   • Schedule wound check in 24-48 hours
   • Return immediately for signs of infection:
     • Increasing pain, redness, swelling
     • Purulent discharge
     • Fever
     • Lymphangitis

3. Suture Removal

   • Lower extremity sutures: Remove in 10-14 days

Common Pitfalls to Avoid

1. Inadequate irrigation - Most important factor in preventing infection 4, 5
2. Overlooking deep structure involvement - Carefully assess for tendon, nerve, or vascular injury
3. Inappropriate antibiotic selection - Must cover both aerobic and anaerobic organisms
4. Premature closure of heavily contaminated wounds - Consider delayed closure if significant contamination
5. Failure to update tetanus prophylaxis - Essential for all bite wounds

This management approach prioritizes thorough wound cleansing and appropriate antibiotic coverage to minimize infection risk while achieving optimal functional and cosmetic outcomes.