Pediatric emergency medicine trisk 835

CHAPTER 109 ■ HAND TRAUMA
ANDREW F. MILLER, CARLEY VUILLERMIN

GOALS OF EMERGENCY CARE
Hand trauma is common in the pediatric emergency department, with a broad
spectrum of clinical presentations. Injuries include fractures, sprains and soft
tissue injuries, nail bed injuries, and lacerations. Understanding the anatomy,
injury patterns, and necessary management and referral for ideal recovery of the
hands is vital for future function. Further, the provider should recognize that
injury to the hands can result from nonaccidental trauma and be vigilant for
related findings and concerns.
KEY POINTS
Topographic anticipation (i.e., recognizing the vulnerable anatomy at
the site of injury) can aid the clinician in predicting the injury and
potential structures disrupted.
Lacerations and soft tissue injuries are more common in younger
children and fractures are seen more frequently in older children.
Thorough examination should include a visual inspection, assessment
of the general alignment of the hand and digits ( Fig. 109.1 ), focused
palpation, passive and active range of motion across each joint ( Fig.
109.2 ), and a neurovascular assessment.
Absorbable sutures are equally effective in fingertip wound repair and
require less intervention on follow-up.
A finger splint is not adequate immobilization for proximal phalanx
fractures; a hand- or forearm-based splint is more appropriate.
Skin wounds obtained during an altercation (“fight bites”) represent a
high-risk injury with a high incidence of infection due to human oral
flora.
Clinical vigilance is required for possible scaphoid fractures or carpal
ligamentous injuries as long-term issues can arise from inadequate
care.

FINGERTIP INJURIES


CLINICAL PEARLS AND PITFALLS
Digital block of the affected finger will likely be more successful than
attempts at local anesthesia.
Avulsed fingertips may be able to be reimplanted and should be
protected in a saline-moistened gauze in a bag that is kept cool in an
ice–water mixture.
Absorbable sutures are equally effective in fingertip wound repair and
require less trauma for removal.
Trephination for an acute subungual hematoma is generally indicated
when it involves more than 50% of the nail bed surface.

Clinical Considerations
Clinical Recognition
Fingertip injuries are very common, as the tips of the fingers are often the entry
point to exploration of our surroundings. Crush injuries are the most frequent
cause and can result in injuries ranging from minor lacerations and subungual
hematomas to complex open fractures and tissue loss. Beyond crush injuries,
lacerations are also common. While some injuries are superficial and
straightforward, more severe injuries such as complete fingertip amputations can
occur, particularly if the mechanism also has the force to damage the nail.
Although children often recover quite well, careful attention and care to these
wounds can help reduce the risk of permanent deformity to the fingertip and nail.
Initial Assessment
Adequate inspection of the injured fingertip is crucial in determining
management. Fingertip injuries are often associated with significant pain and
bleeding that may impede a provider’s assessment and repair efforts. Performing

a digital block of the affected digit will likely be required for adequate pain
control, after a careful examination of fingertip sensation to evaluate for digital
nerve injury. Consultation with a hand specialist is indicated if there is injury to
the digital nerve. Bleeding is a common feature of fingertip injuries, especially
once the tissue is manipulated, and an easily removable tourniquet device is
recommended to achieve hemostasis and facilitate adequate examination and
repair. Timely removal of the tourniquet at the conclusion of the procedure is
essential.


Copious irrigation is required with all wounds, with extra attention paid to
open fractures. If wound debridement is felt to be required, the emergency
physician should consult with a hand specialist to avoid debriding vital structures
such as the nail bed, which could result in permanent effects on subsequent nail
growth.
Management
Severe nail bed injuries require nail removal if nail avulsion was not part of the
initial injury. Wounds should be cleaned and the often friable tissue should be
repaired with 5-0 or 6-0 absorbable suture, typically chromic gut. Newer studies
in both adults and children have found equivalent outcomes using tissue adhesive.
Common practice is to keep the nail fold open for the new nail to form; available
placeholders include the salvaged nail, sterile aluminum (from suture packaging),
or a nonadhesive dressing. The placeholder should be secured to the fingertip,
commonly with sutures, both proximally and distally to ensure that it does not get
removed prematurely. Care must be taken to avoid further damage to the germinal
matrix and injury site when affixing the nail. Absorbable sutures are preferred; if
nonabsorbable sutures are used, they should be removed early in the course at
follow-up with a hand specialist, to prevent wound tracks during nail
development. Tissue adhesive has been used as an alternative to sutures to secure
the placeholder. While some recent literature suggests that stenting the nail fold

may not be necessary, supporting data are limited at this time and therefore
current recommendations are to aim to maintain a patent nail fold.


FIGURE 109.1 Abnormal tenodesis. Clinical photographs depicting abnormal rotation of the
ring finger in the setting of a malrotated phalanx fracture. Note the clinical overlap of the ring
finger over the long finger and increased gap between the ring finger and the small finger, with
passive wrist extension (A ) that is not clinically as apparent with the wrist in neutral position
and the digits extended (B ). (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Fingertip lacerations are managed similarly to lacerations in other locations
with a few caveats. Nearly circumferential wounds are common in pediatrics and
are managed as partial amputations. Some literature recommends nonabsorbable
suture material for the repair of these injuries, though we favor absorbable suture
because swelling and discomfort often preclude suture removal in children at the
time of follow-up.