Frenulum Tear

Torn FrenulumHave you ever been told that something “isn’t a big deal” only to later find out that it was? Of course, any one who is in a significant relationship with another person has experienced this phenomenon. I, myself, may be at fault (once in a blue moon). Often, when I evaluate intra-oral injuries I will tell families that the mouth heals very well and seldom requires primary repair (ex, Tongue Lacerations). Naturally, there are other intra-oral injuries that do warrant more contemplation and concern (ex, Tonsillar Injuries). A lip frenulum tear, however, is “no big deal.” Right? Well… let us just remain vigilant.

 

Frenulum Tear

  • The upper lip has the Superior Labial Frenulum and lower lip has the Inferior Labial Frenulum.
    • Also referred to as a Frenum.
    • These are folds of mucous membrane that are midline and extend from the gingiva to the lips.
  • They can be easily torn when the mouth is hit or the lip is pulled/stretched.
  • Often bleeds “a lot” (as many injuries to the face/mouth do), but usually will spontaneously stop bleeding.

 

Frenulum Tear: Management

  • This is easy… management is reassurance that it will heal fine on its own! 🙂
    • Let families know that they may bleed intermittently if people keep pulling open the lip to see the injury.
    • Simple pressure on outside of lip usually is enough to stop bleeding.
    • May want to advocate for a soft mechanical diet for a few days to help avoid reopening the wound with sharp crackers and chips (the typical diet of most American kids).
  • Does not typically require specific closure or intervention.
    • Heals well on its own without primary closure.
    • If the tear is more than the frenulum, extending to the surrounding gingiva, repair may be necessary – be sure to use absorbable sutures!

 

Frenulum Tear: It is Trauma!

  • Unfortunately, another consideration needs to cross your mind: Non-Accidental Trauma / Abuse.
    • A frenulum tear is NOT pathognomonic for abuse, but intra-oral injuries are seen in a significant number of abuse cases. [Maguire, 2007]
    • The history, obviously, plays an important role in helping to raise concern for abuse.
      • Knowing the developmental milestones can help determine whether an reported cause of injury would be reasonable.
        • A 2 month old would not have caused her/his own frenulum tear by falling.
        • An 18 month old may have fallen an hit the lips on a table edge.
        • Non-ambulatory children with facial injuries should raise your level of concern for abuse. [Starr, 2015; Thackeray, 2007]
      • The most frequently reported abusive injury to the mouth is injury to the lips, but a frenulum tear in isolation does not equate to abuse. [Maguire, 2007; Thackeray, 2007]
    • Several abusive mechanisms have been proposed to cause a frenulum tear: [Maguire, 2007]
      • Forceful feeding
      • Forceful placement of a pacifier
      • Gagging
      • Gripping or stretching of the lip
      • Vigorous rubbing of the lip
      • Direct forceful blow to lip

 

Moral of the Morsel

  • A frenulum tear can be managed with simple, non-surgical interventions.
  • A frenulum tear is intra-oral trauma. Remain vigilant and evaluate for other trauma.
  • Undress the child and look for other trauma. I know it is tempting to just look in the mouth… but be thorough and look for other signs of non-accidental trauma.
  • A frenulum tear is not pathognomonic for abuse, but make sure the story and developmental milestones make sense.

 

References

Starr M1, Klein EJ, Sugar N. A Perplexing Case of Child Abuse: Oral Injuries in Abuse and Physician Reporting Responsibilities. Pediatr Emerg Care. 2015 Aug;31(8):581-3. PMID: 25426684. [PubMed] [Read by QxMD]

Maguire S1, Hunter B, Hunter L, Sibert JR, Mann M, Kemp AM; Welsh Child Protection Systematic Review Group. Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries. Arch Dis Child. 2007 Dec;92(12):1113-7. PMID: 17468129. [PubMed] [Read by QxMD]

Thackeray JD1. Frena tears and abusive head injury: a cautionary tale. Pediatr Emerg Care. 2007 Oct;23(10):735-7. PMID: 18090110. [PubMed] [Read by QxMD]

Naidoo S1. A profile of the oro-facial injuries in child physical abuse at a children’s hospital. Child Abuse Negl. 2000 Apr;24(4):521-34. PMID: 10798841. [PubMed] [Read by QxMD]

da Fonseca MA1, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatr Dent. 1992 May-Jun;14(3):152-7. PMID: 1528783. [PubMed] [Read by QxMD]

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Incision and Loop Drainage of Abscess

Incision and Loop DrainagePerforming procedures is obviously an important aspect of what we do in the Emergency Department. Our procedural prowess is depended upon by our patients and their families. We have discussed several procedural strategies previously (ex, Suturing, Tongue lacerations, Spinal Tap, ETT placement, Pigtail Thorocostomies, Transillumination of Ptx, and many more). One common condition that often requires a procedure is the subcutaneous abscess. We have previously discussed whether antibiotics are needed for abscesses. Now let us look at whether there is another strategy to the classic incision and drainage: Incision and Loop Drainage.

 

 

Loop Drainage: The Technique

This technique is described by several paper – [Aprahamian, 2016; Ladde, 2014; Ladd, 2010; Tsoraides, 2010]

Aprahamian, 2016 recommends it as the “definitive treatment of choice for subcutaneous abscesses in children.”

  1. Incise lateral edge of abscess cavity.
    • Small, 4-5 mm incision.
  2. Break up the loculations.
    • Insert small curve hemostat or small needle driver through small incision.
    • Gently explore abscess cavity and break up loculations.
  3. Find edge of abscess cavity.
    • While probing the cavity, determine the dimensions of the cavit.
  4. 2nd incision in this region.
    • Ideally, make second small (4-5mm) incision within 4 cm of the first.
    • For very large abscess cavities, you can use additional small incisions.
      • 3 or 4 incisions with each being ~ 4cm apart from the other.
  5. Irrigate and get the pus out!
    • Now with an ingress and an egress, you can decompress the abscess.
    • Irrigation can help remove debris.
  6. Pass vessel loop, sterile rubber band, or Penrose Drain though two incisions.
    • Vessel loop work very well for this as it is a small calibre and is easy to tie.
    • Vessel Loop
    • Vessel Loop Drainage 1
    • Passing the Vessel Loop
  7. Tie ends together, ensuring no tension on skin.
    • Use a surgeon’s knot for the first tie.
    • Ensure that there is plenty of slack to avoid tension on the skin.
    • Surgeon's Knott for Loop Drainage
    • Tie multiple other knots tightly on top of the surgeon’s knot to ensure security.
    • Loop Drainage tied
    • (yes… I know this abscess looks like it has a lot of Vitamin C…)

 

Loop Drainage: Home Care

  • Keep area clean.
  • Can cover with gauze to absorb the residual drainage.
  • Can shower and/or bathe.

 

Loop Drainage: The Removal

  • The loop drain can removed once:
    • Drainage has stopped.
    • Cellulitis has improved.
  • Usually is within 7-10 days.

 

Loop Drainage: The Benefits

  • Minimizes scarring (two small incisions instead of one large one). [Aprahamian, 2016]
  • Eliminates the need for repeat visits for wound packing changes. [Aprahamian, 2016]
  • This saves the patient / family the time of returning multiple times.
  • Also saves the patient the pain and anxiety of having the packing changed.
  • Also saves ED visit cost.
  • In theory, the loop could be removed by any provider (PCP, Urgent Care, etc).

 

References

Aprahamian CJ1, Nashad HH2, DiSomma NM3, Elger BM4, Esparaz JR5, McMorrow TJ4, Shadid AM4, Kao AM3, Holterman MJ1, Kanard RC4, Pearl RH6. Treatment of subcutaneous abscesses in children with incision and loop drainage: A simplified method of care. J Pediatr Surg. 2016 Dec 30. PMID: 28069270. [PubMed] [Read by QxMD]

Ladde JG1, Baker S2, Rodgers CN3, Papa L4. The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. Am J Emerg Med. 2015 Feb;33(2):271-6. PMID: 25435407. [PubMed] [Read by QxMD]

Kessler DO1, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012 Jun;28(6):514-7. PMID: 22653459. [PubMed] [Read by QxMD]

Ladd AP1, Levy MS, Quilty J. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children. J Pediatr Surg. 2010 Jul;45(7):1562-6. PMID: 20638546. [PubMed] [Read by QxMD]

Tsoraides SS1, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010 Mar;45(3):606-9. PMID: 20223328. [PubMed] [Read by QxMD]

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