Laceration Repair Decision for 1-Year-Old with Head Laceration
Yes, this 3cm x 0.6cm head laceration should be repaired with sutures or tissue adhesive to optimize wound healing and cosmetic outcome. 1, 2
Rationale for Closure
- Scalp lacerations of this size (3cm length) require closure to achieve hemostasis, prevent infection, and optimize cosmetic results, even though bleeding has stopped 2, 3
- The wound dimensions (3cm x 0.6cm) exceed the threshold where spontaneous healing would provide acceptable cosmetic outcomes 4
- Head/scalp wounds are particularly amenable to repair and heal well with appropriate closure 5
Optimal Closure Method for This Age
Tissue adhesive (octyl cyanoacrylate) or the hair apposition technique are preferred over traditional sutures for this 1-year-old patient 1, 6
Why Tissue Adhesive is Ideal:
- Provides essentially painless closure without need for needle injection or suture removal 1
- Eliminates the trauma and anxiety of suture removal in a young child 1, 6
- Equally effective as sutures for scalp lacerations with similar infection rates and cosmetic outcomes 6, 5
- Rapid application is particularly advantageous in young children who may be uncooperative 6
Hair Apposition Technique Alternative:
- For scalp lacerations specifically, the tissue adhesive hair apposition technique is highly effective 5
- This involves twisting hair strands from opposite wound edges together and applying tissue adhesive to hold them 5
If Traditional Sutures Are Used
Should tissue adhesive be unavailable or inappropriate:
- Use absorbable sutures to avoid painful suture removal in this 1-year-old 1
- Begin with topical anesthesia (LET solution: lidocaine, epinephrine, tetracaine) applied for 10-20 minutes until wound edges blanch 1
- If additional anesthesia needed, buffer lidocaine with bicarbonate, warm it, and inject slowly with small-gauge needle to minimize pain 1
Critical Safety Considerations
Rule Out Underlying Skull Fracture:
- While the child appears neurologically intact, consider imaging if there are any concerning features 7
- High-risk features requiring head CT include: altered mental status, loss of consciousness, severe mechanism of injury, or palpable skull depression 7
- In children <1 year with ANY concerning injury mechanism, maintain low threshold for head CT to rule out occult intracranial injury 7
Assess for Non-Accidental Trauma:
- Document mechanism of injury carefully - falls are common accidental injuries in 1-year-olds, but inconsistent history warrants further evaluation 7
- A simple fall causing isolated scalp laceration without skull fracture or intracranial injury is consistent with accidental trauma 7
Wound Preparation Protocol
- Perform hand hygiene with antimicrobial soap or alcohol-based hand rub 1
- Irrigate wound with potable tap water - this is safe and does not increase infection risk compared to sterile saline 2, 5
- Use nonsterile gloves for repair - evidence shows no increased infection risk versus sterile gloves 2
- Clean surrounding area with betadine or chlorhexidine 1
Post-Repair Care Instructions
- Keep wound clean and dry for 24-48 hours 1
- Watch for signs of infection (increasing redness, warmth, purulent drainage, fever) 1
- Pain control with acetaminophen or ibuprofen as needed 1
- If tissue adhesive used: it will slough off naturally in 5-10 days - no removal needed 6, 3
- If absorbable sutures used: no removal needed 1
- If non-absorbable sutures used: remove in 5-7 days for scalp 2, 5
Tetanus Prophylaxis
Common Pitfalls to Avoid
- Do not delay closure excessively - while there is no absolute "golden period," wounds can typically be safely closed up to 18+ hours after injury depending on contamination level 2
- Do not use excessive force when injecting local anesthetic as this dramatically increases pain 1
- Do not assume all head injuries in young children are benign - maintain appropriate vigilance for intracranial injury 7