nail surface, is associated with a distal phalanx fracture, or the nail or its margins are disrupted, the presence of a significant nail bed injury should be suspected Nail trephination facilitates drainage with relief of pressure and pain Trephination is most effective within 24 to 48 hours (before clotting limits its success), but may be attempted in older subungual hematomas if significantly symptomatic In addition to pain control, the procedure also reduces risk of secondary infection This treatment alone suffices for uncomplicated subungual hematomas with intact nail margins, regardless of the size of the hematoma The trephined opening should be large enough (larger than to mm) to allow for ongoing drainage without risk of closure by a new clot Producing two openings in the nail may promote more complete drainage (see Chapters 109 Hand Trauma and 130 Procedures ) When the nail or its margins are disrupted and/or a displaced phalangeal fracture is present, the nail should be removed and the nail bed repaired and splinted While current data have failed to show improvement in fingertip injuries treated with antibiotics, they are often prescribed for patients with underlying fractures and those with severe soft tissue injuries Subungual Foreign Body Foreign bodies such as wood splinters or metallic shavings can become embedded under the nail and cause pain and/or infection When the foreign body is only partially embedded, the nail can be trimmed close to the nail bed, and the object’s projecting end grasped with splinter forceps and gently extracted If a portion remains or the foreign body is deeply embedded from the outset, a digital block should be performed The portion of the nail overlying the object can be shaved down with a scalpel until the foreign body is exposed and can be extracted Alternatively, the nail can be lifted and the object removed (see Chapter 130 Procedures ) After removal, the finger should be soaked in warm, soapy water, and an antibiotic ointment and protective dressing applied The finger should be soaked three times a day for to days In the unusual case of a child with multiple subungual splinters or fragments, it is best to remove the nail, clean out the foreign material, irrigate thoroughly, and then replace the nail (after trephining it to allow drainage) When there is concern for concurrent infection, antibiotic treatment should be provided Hair Tourniquet A hair tourniquet injury is unique to the pediatric population It involves strangulation of a digit (or genitalia) by a hair or fine thread Hair tourniquets are most common in young infants and can be the cause of unexplained irritability or crying In these cases, hair becomes unintentionally entwined around an infant’s digit or genitalia This often occurs during a bath, or as a result of wiggling of the toes in a sock, shoe, or mitten that inadvertently has a hair or loose thread in it A hair shed from a parent during diapering is the probable source of penile tourniquets As the hair or thread becomes more tightly entwined, it produces a tourniquet effect, impairing blood flow Initially, lower pressure venous blow flood is impaired This results in increased swelling, ultimately leading to impairment in arterial blood flow and ischemia if not identified and treated When noted early, the hair is often visible in a crease just proximal to the swollen area If identified later, the hair may have cut through the skin, making it difficult to visualize ( Fig 120.3 ) In rare cases, frank ischemic necrosis of the distal digit may be seen on presentation Removal requires fine-tipped forceps and the aid of a thin loupe or probe that is inserted proximally under the constricting hair Usually the hair can be unwound from the digit intact or cut with scissors When the hair is deeply embedded or there is any question of a remaining constricting band, a nerve block should be performed and a perpendicular incision made over the hair (see Chapter 130 Procedures ) To avoid damage to the underlying neurovascular structures, such an incision should be made on the lateral or ulnar aspect of a finger or toe at or o’clock or at or o’clock along the penile shaft While the use of depilatory creams for hair tourniquet removal has been described in case reports, their effectiveness has not been well established and should be avoided in children with lacerated skin When the entire hair cannot be removed with certainty, consultation with a plastic surgeon is indicated FIGURE 120.3 Hair tourniquets (Reprinted with permission from Fleisher GR, Ludwig S, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Ganglion A ganglion is a cystic outgrowth of the synovial lining of a tendon sheath or joint capsule Common locations of ganglions include the dorsal or volar surface of the wrist (usually on the radial side), the dorsum of the foot, and near the malleolus of an ankle ( Fig 120.4 ) Occasionally, a flexor tendon sheath ganglion may present on the palmar surface of the hand at the base of a digit The cause is believed to involve prior trauma that causes partial disruption of the synovium and subsequent herniation of synovial tissue The cysts are soft, slightly fluctuant, and transilluminate Most are painless or are only mildly uncomfortable However, those on the foot or ankle may cause pain when shoes are worn Ganglions rarely require emergent intervention Elective surgical excision with obliteration of the base is indicated only if function is impaired or the lesion is of cosmetic significance However, recurrent rates after excision are as high as 20% Striking the cyst with a heavy object, a folk remedy, should be strongly discouraged because the cystic fluid may be dispersed through the surrounding soft tissue, inciting diffuse scar formation FIGURE 120.4 Ganglion cyst (Reprinted with permission from Salimpour RR, Salimpour P, Salimpour P Photographic Atlas of Pediatric Disorders and Diagnosis 1st ed Philadelphia, PA: Lippincott Williams & Wilkins; 2013.) FACE AND SCALP LESIONS CLINICAL PEARLS AND PITFALLS ... tourniquets (Reprinted with permission from Fleisher GR, Ludwig S, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Ganglion A ganglion... cyst (Reprinted with permission from Salimpour RR, Salimpour P, Salimpour P Photographic Atlas of Pediatric Disorders and Diagnosis 1st ed Philadelphia, PA: Lippincott Williams & Wilkins; 2013.)