unfavorable appearance to the healed wound Injuries that occurred in a field, farm, or a wet, swampy area may have high bacterial loads The patient’s health status and past medical history should be addressed to determine if there are additional risk factors for poor healing If the patient has diabetes, immunosuppression, malnutrition, or other chronic conditions, such as cyanotic heart disease, chronic respiratory problems, or renal insufficiency, higher infection rates may be anticipated Bleeding disorders and current medications should be determined because some drugs, such as corticosteroids, may also have an impact on wound healing A history of allergies to latex, antibiotics, and local anesthetics, as well as the child’s tetanus status should be determined Physical Examination A careful physical examination is essential before giving local anesthesia First, determine whether there is an associated injury distant from the obvious wound It is important to assess the wound for vascular damage and to control bleeding if present Brisk flow of blood may indicate injury to a major vessel This vessel can usually be safely tamponaded and later ligated or sutured The source must be identified, although it is often obscured by profuse bleeding Pressure applied to the site or temporary use of a tourniquet or inflated blood pressure cuff (less than hours) can help control hemorrhage and allow for identification of the bleeding vessel Blind clamping of an artery should be avoided except in the scalp Palpation of pulses and capillary refill distal to the site of injury must be checked Next, potential nerve damage must be assessed For example, in a cooperative child, the provider should always test the median and ulnar nerves of an injured upper extremity If a young child does not permit this, sensation may be tested with use of pinprick Fortunately, when sensation is intact, motor function of the nerve is usually also intact Next, the wound must be evaluated for possible tendon injury The superficial location of extensor tendons of the dorsum of the hand predisposes them to injury Tendon injuries are sometimes visible if the wound is wide and deep For example, a torn tendon on the flexor surface of the forearm may be seen when the patient with a laceration to the wrist is asked to flex the hand and wrist Unless the tendon injury is obvious, wounds over joints and tendons should be put through a full range of motion A young patient may not be cooperative enough to flex and extend the fingers on command Therefore, it is important to inspect the resting position of the injured hand in a young child to note a flexor tendon injury to the finger One digit may be found extended at rest, while the other uninjured