Pediatric emergency medicine trisk 3402 3402

Fingertip injuries should be evaluated for an associated nail bed injury
and for possible fractures of the phalanges.
Under 2 years of age, conservative management of simpler injuries
without repair will often yield excellent results.
Not recognizing open fractures, injuries involving the distal
interphalangeal joint space or injuries associated with tendon
lacerations can lead to serious complications.
Attempting to drain subungual hematoma after 48 hours is unlikely to
be effective.

Fingertip Avulsion
Fingertip injuries are rather common in children. In the young child, most of
these injuries are blunt and secondary to entrapment of the finger in closing
doors. Most of these injuries are contused lacerations or partial avulsions.
Complete amputation of the fingertips is less common. Sharp injuries such as
with knives or equipment are more common in the older child and less likely to
be associated with fractures. Fingertip injuries should be evaluated clinically for
an associated nail bed injury and radiographically for possible fractures of the
phalanges. In general, this type of injury is managed by the emergency provider,
especially in the preadolescent child, because tissue regeneration is remarkable
and management is mostly conservative. Lacerations can be repaired using
absorbable chromic gut.
The management of amputations of fingertips (distal to the distal
interphalangeal joint) can be approached based on the absence or presence of
bone exposure. If no or minimal bone is exposed, conservative management is
advised. In children under 2 years of age, complete distal tip spontaneous
regeneration is possible even without a surgical repair. The wound should be
cleansed, dressed in nonadherent gauze, and splinted for protection. When tissue
from the distal tip is available and has retained its morphology, it can be tacked
on to serve as a nonsurviving biologic dressing while underlying tissue develops.
Frequent dressing changes and appropriate follow-up should be planned.

Antibiotic coverage is recommended. When a significant amount of bone is
exposed, consultation with a hand specialist should be considered. Shortening of
the distal phalanx and covering the tip with volar skin flap is usually the treatment
of choice. However, some hand specialists advocate for various skin-grafting
procedures to avoid permanent shortening and deformity. Consider microscopic