Pediatric emergency medicine trisk 835

CHAPTER 109 ■ HAND TRAUMA ANDREW F MILLER, CARLEY VUILLERMIN GOALS OF EMERGENCY CARE Hand trauma is common in the pediatric emergency department, with a broad spectrum of clinical presentations Injuries include fractures, sprains and soft tissue injuries, nail bed injuries, and lacerations Understanding the anatomy, injury patterns, and necessary management and referral for ideal recovery of the hands is vital for future function Further, the provider should recognize that injury to the hands can result from nonaccidental trauma and be vigilant for related findings and concerns KEY POINTS Topographic anticipation (i.e., recognizing the vulnerable anatomy at the site of injury) can aid the clinician in predicting the injury and potential structures disrupted Lacerations and soft tissue injuries are more common in younger children and fractures are seen more frequently in older children Thorough examination should include a visual inspection, assessment of the general alignment of the hand and digits ( Fig 109.1 ), focused palpation, passive and active range of motion across each joint ( Fig 109.2 ), and a neurovascular assessment Absorbable sutures are equally effective in fingertip wound repair and require less intervention on follow-up A finger splint is not adequate immobilization for proximal phalanx fractures; a hand- or forearm-based splint is more appropriate Skin wounds obtained during an altercation (“fight bites”) represent a high-risk injury with a high incidence of infection due to human oral flora Clinical vigilance is required for possible scaphoid fractures or carpal ligamentous injuries as long-term issues can arise from inadequate care FINGERTIP INJURIES CLINICAL PEARLS AND PITFALLS Digital block of the affected finger will likely be more successful than attempts at local anesthesia Avulsed fingertips may be able to be reimplanted and should be protected in a saline-moistened gauze in a bag that is kept cool in an ice–water mixture Absorbable sutures are equally effective in fingertip wound repair and require less trauma for removal Trephination for an acute subungual hematoma is generally indicated when it involves more than 50% of the nail bed surface Clinical Considerations Clinical Recognition Fingertip injuries are very common, as the tips of the fingers are often the entry point to exploration of our surroundings Crush injuries are the most frequent cause and can result in injuries ranging from minor lacerations and subungual hematomas to complex open fractures and tissue loss Beyond crush injuries, lacerations are also common While some injuries are superficial and straightforward, more severe injuries such as complete fingertip amputations can occur, particularly if the mechanism also has the force to damage the nail Although children often recover quite well, careful attention and care to these wounds can help reduce the risk of permanent deformity to the fingertip and nail Initial Assessment Adequate inspection of the injured fingertip is crucial in determining management Fingertip injuries are often associated with significant pain and bleeding that may impede a provider’s assessment and repair efforts Performing a digital block of the affected digit will likely be required for adequate pain control, after a careful examination of fingertip sensation to evaluate for digital nerve injury Consultation with a hand specialist is indicated if there is injury to the digital nerve Bleeding is a common feature of fingertip injuries, especially once the tissue is manipulated, and an easily removable tourniquet device is recommended to achieve hemostasis and facilitate adequate examination and repair Timely removal of the tourniquet at the conclusion of the procedure is essential Copious irrigation is required with all wounds, with extra attention paid to open fractures If wound debridement is felt to be required, the emergency physician should consult with a hand specialist to avoid debriding vital structures such as the nail bed, which could result in permanent effects on subsequent nail growth Management Severe nail bed injuries require nail removal if nail avulsion was not part of the initial injury Wounds should be cleaned and the often friable tissue should be repaired with 5-0 or 6-0 absorbable suture, typically chromic gut Newer studies in both adults and children have found equivalent outcomes using tissue adhesive Common practice is to keep the nail fold open for the new nail to form; available placeholders include the salvaged nail, sterile aluminum (from suture packaging), or a nonadhesive dressing The placeholder should be secured to the fingertip, commonly with sutures, both proximally and distally to ensure that it does not get removed prematurely Care must be taken to avoid further damage to the germinal matrix and injury site when affixing the nail Absorbable sutures are preferred; if nonabsorbable sutures are used, they should be removed early in the course at follow-up with a hand specialist, to prevent wound tracks during nail development Tissue adhesive has been used as an alternative to sutures to secure the placeholder While some recent literature suggests that stenting the nail fold may not be necessary, supporting data are limited at this time and therefore current recommendations are to aim to maintain a patent nail fold FIGURE 109.1 Abnormal tenodesis Clinical photographs depicting abnormal rotation of the ring finger in the setting of a malrotated phalanx fracture Note the clinical overlap of the ring finger over the long finger and increased gap between the ring finger and the small finger, with passive wrist extension (A ) that is not clinically as apparent with the wrist in neutral position and the digits extended (B ) (Courtesy of Children’s Orthopaedic Surgery Foundation.) Fingertip lacerations are managed similarly to lacerations in other locations with a few caveats Nearly circumferential wounds are common in pediatrics and are managed as partial amputations Some literature recommends nonabsorbable suture material for the repair of these injuries, though we favor absorbable suture because swelling and discomfort often preclude suture removal in children at the time of follow-up  ... wounds, with extra attention paid to open fractures If wound debridement is felt to be required, the emergency physician should consult with a hand specialist to avoid debriding vital structures such... to lacerations in other locations with a few caveats Nearly circumferential wounds are common in pediatrics and are managed as partial amputations Some literature recommends nonabsorbable suture