Pediatric emergency medicine trisk 836

FIGURE 109.2 Clinical photograph of a patient with an isolated flexor digitorum profundus
rupture of the long finger. Note the abnormal digital cascade and resting flexion posture of the
long finger in relationship to the adjacent unaffected digits. (Courtesy of Children’s
Orthopaedic Surgery Foundation.)

Amputations of the fingertip are not uncommon and can result in permanent
deformity. The current recommendation is to transport the amputated part in
saline-moistened gauze in a sealed bag that is kept cool in an ice–water mixture.
The amputated part should not be in direct contact with the ice water.
Reimplantation has been recommended in most cases involving children,
provided the distal piece is available and the tissues are not damaged beyond
repair. Even if the distal fragment does not remain viable, it serves a protective
function and facilitates growth of the tissue beneath it ( Fig. 109.3 ).
Reimplantation may not be an option if the avulsed tip is too small, macerated, or
grossly contaminated. In such cases, if sufficient skin is present, it can be closed
over the stump with sutures while taking care to protect the nail bed. Small
avulsions are best cared for with local wound care and petroleum-based dressing
until granulation and healing occur. If closure is not an option due to bone
exposure or missing tissue, hand specialist consultation is indicated to determine
if alternative surgical repair techniques may be beneficial. If emergent surgical
treatment is not an option, these patients may be treated with local wound care
and petroleum-based dressing until they can be seen by a hand specialist as
outpatients.


Following completion of the repair, these wounds should be dressed with a
nonadherent dressing followed by splinting, especially when there is a fracture.
Even in the absence of a fracture, splinting protects the wound from reinjury. As
an alternative, a bulky dressing (often a mitten dressing for fingertip injuries) can
be placed over the injured site. Petroleum-laced mesh dressings are particularly
effective at optimizing healing and minimizing discomfort and damage on

removal. Administration of prophylactic antibiotics continues to be controversial,
but is not routinely indicated even with open fractures, although the risk of
antibiotics is low. Meticulous wound care is likely most beneficial at preventing
infection. Antibiotics should be considered for dirty wounds or those with
significant devitalized tissue.

FIGURE 109.3 Images demonstrating the healing after reimplantation of a distal fingertip
amputation. Despite the appearance of the necrotic tissue (A ) early in follow-up, the long-term
follow-up image (B ) shows substantial healing. (Courtesy of Children’s Orthopaedic Surgery
Foundation.)

Subungual hematomas, the collection of blood between the nail and the nail
bed, are common and generally occur with crushing injuries. Small hematomas
are generally cared for without intervention. If the patient is having significant
pain, draining the hematoma may provide relief. Hematomas involving more than
50% of the nail bed surface are more likely to be associated with significant nail


bed injury, particularly in the setting of an associated distal phalanx fracture, and
likely benefit from intervention. Nevertheless, the literature has demonstrated that
if the nail is intact and well adhered, nail removal and nail bed reconstruction do
not impart improved outcome over simple trephination. Nail trephination is best
performed using an electrocautery pen when available. Using a heated paper clip
or rotating a large-bore needle in a circular motion to drill through the nail can
also be effective.

HAND LACERATIONS
CLINICAL PEARLS AND PITFALLS
Topographic anticipation can aid in the diagnosis of key injuries.
A careful neurovascular examination and evaluation of tendon function

are required with any hand or finger laceration, given the superficial
location of key structures.
Uncomplicated extensor tendon injuries may be managed by the
emergency physician, but more severe injuries or flexor tendon injuries
should be managed by a hand specialist.

Clinical Considerations
Clinical Recognition
Lacerations involving the hand can be serious due to the possibility of injury to
underlying structures including the neurovascular bundle or tendons. Even
seemingly small external injuries can be significant given that these important
structures are relatively superficial compared to other areas of the body.
In the setting of significant vascular injury, immediate attempts at hemostasis
should be initiated with direct pressure. A tourniquet should be used only if direct
pressure has failed to stop the bleeding. A careful and complete sensory
examination, using light touch, pin-prick, and two-point discrimination is
required to assess for nerve involvement. Given that this can be difficult in young
children, the provider can assess for focal anhidrosis of the fingers or lack of skin
wrinkling after water submersion ( Fig. 109.4 ), as alternative indications of a
nerve injury. A hand specialist should be involved to evaluate for potential
operative repair when arterial bleeding or neurovascular compromise is identified.
Lacerations in the fingers and hands can involve underlying flexor or extensor
tendons. Many injuries can be anticipated based on the location of the injury
(topographic anticipation). Extensor tendon lacerations proximal to the MCP


joints may be amenable to repair by the emergency physician. Extensor tendon
lacerations involving the MCP joints or digits, as well as all flexor tendon
lacerations, require care by a hand specialist. In consultation with the surgeon,
closure of the skin and splinting may comprise appropriate care in the emergency

department, with close follow-up for operative exploration and repair.

FIGURE 109.4 Image demonstrating a palmar laceration after sutured repair with the absence
of skin wrinkling in a median nerve distribution suggestive of a median nerve injury. (Courtesy
of Children’s Orthopaedic Surgery Foundation.)

PHALANGES