Pediatric emergency medicine trisk 841

Most suspected injuries to the carpal bones can be managed in the urgent
setting with splinting and outpatient follow-up within 1 to 2 weeks. Scaphoid
fractures have different patterns depending on the age of the patient. Younger
patients have a significant incidence of fractures involving the distal third of the
bone, although fractures in the middle third (i.e., the waist) are still the most
common in children. Adolescents and adults tend to fracture at the waist of the
scaphoid. A unique fracture to young patients is the avulsion of the distal radial
aspect of the scaphoid. This injury often is not diagnosed on first presentation and
is seen on radiographs 1 to 2 weeks later.
In the emergency department, confirmed and suspected scaphoid fractures
should be managed with a thumb spica splint or cast. Most scaphoid fractures are
nondisplaced and ultimately managed with cast immobilization, though displaced
fractures may require surgical reduction and internal fixation to prevent
nonunion. In addition, those who present late with evidence of nonunion should
be immobilized and referred to a hand specialist for possible surgical repair.


FIGURE 109.16 Radiographs depicting perilunate dislocation, best seen on the lateral
radiograph. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

In addition to fractures, suspicion for ligamentous injuries should be high,
particularly in late childhood and adolescence. An important part of radiologic
evaluation is assessment of the distance between the scaphoid and lunate bones.
In a true scapholunate dissociation, this space is widened, often called the Terry
Thompson sign. This can be difficult to assess in children in whom this space is
naturally widened, as the carpals are not fully ossified. The normal plain
radiograph scapholunate interval decreases with age in children. It is also
important to note that dynamic scapholunate instability may not be shown on
routine x-ray, and may only be obvious under stressed view. Perilunate

dislocation is best identified with the lateral wrist radiograph, with the bone
displaced from its typical midaxial location over the radius ( Fig. 109.16 ). This
can be easily missed, and therefore recognition requires careful physical and
radiologic assessment. High-energy trauma and marked swelling can be
indicators of this injury pattern. Concern for dissociations and dislocations
requires urgent attention by a hand specialist.
Suggested Readings and Key References
Alterfott C, Garcia FJ, Nager AL. Pediatric fingertip injuries: do prophylactic
antibiotics alter infection rates? Pediatr Emerg Care 2008;24(3):148–152.
Capstick R, Giele H. Interventions for treating fingertip entrapment injuries in
children. Cochrane Database Syst Rev 2014;2014(4):CD009808.
Cornwall R. Finger metacarpal fractures and dislocations in children. Hand Clin
2006;22(1):1–10.
Edwards S, Parkinson L. Is fixing pediatric nail bed injuries with medical
adhesives as effective as suturing?: a review of the literature. Pediatr Emerg
Care 2019;35(1):75–77.
Gellman H. Fingertip-nail bed injuries in children: current concepts and
controversies of treatment. J Craniofac Surg 2009;20(4):1033–1035.
Jauregui JJ, Seger EW, Hesham K, et al. Operative management for pediatric and
adolescent scaphoid nonunions: a meta-analysis. J Pediatr Orthop
2019;39(2):e130–e133.
Liao JCY, Chong AKS. Pediatric hand and wrist fractures. Clin Plast Surg
2019;46(3):425–436.
Nellans KW, Chung KC. Pediatric hand fractures. Hand Clin 2013;29(4):569–
578.
Patel L. Management of simple nail bed lacerations and subungual hematomas in
the emergency department. Pediatr Emerg Care 2014;30(10):742–748; quiz
746–748.
Strauss EJ, Weil WM, Jordan C, et al. A prospective randomized, controlled trial
of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg

Am 2008;33(2):250–253.


CHAPTER 110 ■ MINOR TRAUMA
CHRISTINE S. CHO

GOALS OF EMERGENCY CARE
Each year, an estimated 12 million wounds are treated in emergency departments
(EDs) in the United States. The first priority is stabilization of patients who have
sustained trauma and recognizing significant injuries. The care of minor injuries
focuses on addressing pain, evaluating associated injuries, and wound closure.
The key drivers in optimal wound repair are obtaining hemostasis, preventing
infection, and achieving the best long-term cosmesis while minimizing pain and
anxiety. Patient and parental satisfaction is driven in the short term by timeliness
of care, length of stay, and minimizing pain, and in the long term by avoidance of
complications, including infection, hypertrophic scarring or keloid formation, and
poor cosmetic results.
KEY POINTS