Pediatric emergency medicine trisk 3404 3404

Subungual Hematoma
A subungual hematoma is a collection of blood in the interface of the nail and the
nail bed. It is commonly seen with blunt fingertip injuries. The usual presentation
is throbbing pain and discoloration of the nail. Subungual hematomas may be
associated with nail bed injury or fracture of the distal phalanx. If the injury >48
hours old, the blood is typically clotted and fluid is less likely to be released with
trephination. There are no clear data on the percentage of nail bed surface area
that should prompt intervention. Drainage is commonly performed when greater
than 50% of the nail bed surface area is involved, to evaluate for underlying nail
bed laceration, or for symptomatic relief of pain regardless of hematoma size.
Usually, drainage of the hematoma provides relief of the symptoms. Generally,
no local anesthesia is required for a simple trephination by cauterization of the
nail since there are no nerve endings on the nail plate. After drainage, care for
simple subungual hematoma includes elevation of the hand and warm soaks for a
few days. Inform the family about the possibility of nail deformity in the future.
When the injury is more involved, digital block is advised. If the hematoma is
large and extends to the tip of the nail or around the eponychium, consider
separating the nail from nail bed using either a sharp or blunt method to allow
drainage. Outcomes with nail trephination and nail removal are similar. A
subungual hematoma in the presence of a distal phalangeal fracture is considered
an open fracture, regardless of trephination. Limited data suggest that antibiotic
coverage is not required routinely in otherwise healthy patients, but can be
considered when specific concerns exist.

GENITOURINARY LACERATIONS
CLINICAL PEARLS AND PITFALLS
If needed, perform female genital examination under sedation with help
from surgical specialists.
Consider testicular ultrasound if there is suspicion of testicular injury.
Testicular hematoma or rupture, vaginal wall lacerations, and urethral
injuries may all accompany lacerations to the external genitals. Careful

physical examination should be performed, and diagnostic imaging
pursued as necessary.
Genitourinary lacerations can occur in children after straddle injuries. These
injuries are discussed in detail in Chapter 108 Genitourinary Trauma . They