Pediatric emergency medicine trisk 836

FIGURE 109.2 Clinical photograph of a patient with an isolated flexor digitorum profundus rupture of the long finger Note the abnormal digital cascade and resting flexion posture of the long finger in relationship to the adjacent unaffected digits (Courtesy of Children’s Orthopaedic Surgery Foundation.) Amputations of the fingertip are not uncommon and can result in permanent deformity The current recommendation is to transport the amputated part in saline-moistened gauze in a sealed bag that is kept cool in an ice–water mixture The amputated part should not be in direct contact with the ice water Reimplantation has been recommended in most cases involving children, provided the distal piece is available and the tissues are not damaged beyond repair Even if the distal fragment does not remain viable, it serves a protective function and facilitates growth of the tissue beneath it ( Fig 109.3 ) Reimplantation may not be an option if the avulsed tip is too small, macerated, or grossly contaminated In such cases, if sufficient skin is present, it can be closed over the stump with sutures while taking care to protect the nail bed Small avulsions are best cared for with local wound care and petroleum-based dressing until granulation and healing occur If closure is not an option due to bone exposure or missing tissue, hand specialist consultation is indicated to determine if alternative surgical repair techniques may be beneficial If emergent surgical treatment is not an option, these patients may be treated with local wound care and petroleum-based dressing until they can be seen by a hand specialist as outpatients Following completion of the repair, these wounds should be dressed with a nonadherent dressing followed by splinting, especially when there is a fracture Even in the absence of a fracture, splinting protects the wound from reinjury As an alternative, a bulky dressing (often a mitten dressing for fingertip injuries) can be placed over the injured site Petroleum-laced mesh dressings are particularly effective at optimizing healing and minimizing discomfort and damage on removal Administration of prophylactic antibiotics continues to be controversial, but is not routinely indicated even with open fractures, although the risk of antibiotics is low Meticulous wound care is likely most beneficial at preventing infection Antibiotics should be considered for dirty wounds or those with significant devitalized tissue FIGURE 109.3 Images demonstrating the healing after reimplantation of a distal fingertip amputation Despite the appearance of the necrotic tissue (A ) early in follow-up, the long-term follow-up image (B ) shows substantial healing (Courtesy of Children’s Orthopaedic Surgery Foundation.) Subungual hematomas, the collection of blood between the nail and the nail bed, are common and generally occur with crushing injuries Small hematomas are generally cared for without intervention If the patient is having significant pain, draining the hematoma may provide relief Hematomas involving more than 50% of the nail bed surface are more likely to be associated with significant nail bed injury, particularly in the setting of an associated distal phalanx fracture, and likely benefit from intervention Nevertheless, the literature has demonstrated that if the nail is intact and well adhered, nail removal and nail bed reconstruction not impart improved outcome over simple trephination Nail trephination is best performed using an electrocautery pen when available Using a heated paper clip or rotating a large-bore needle in a circular motion to drill through the nail can also be effective HAND LACERATIONS CLINICAL PEARLS AND PITFALLS Topographic anticipation can aid in the diagnosis of key injuries A careful neurovascular examination and evaluation of tendon function are required with any hand or finger laceration, given the superficial location of key structures Uncomplicated extensor tendon injuries may be managed by the emergency physician, but more severe injuries or flexor tendon injuries should be managed by a hand specialist Clinical Considerations Clinical Recognition Lacerations involving the hand can be serious due to the possibility of injury to underlying structures including the neurovascular bundle or tendons Even seemingly small external injuries can be significant given that these important structures are relatively superficial compared to other areas of the body In the setting of significant vascular injury, immediate attempts at hemostasis should be initiated with direct pressure A tourniquet should be used only if direct pressure has failed to stop the bleeding A careful and complete sensory examination, using light touch, pin-prick, and two-point discrimination is required to assess for nerve involvement Given that this can be difficult in young children, the provider can assess for focal anhidrosis of the fingers or lack of skin wrinkling after water submersion ( Fig 109.4 ), as alternative indications of a nerve injury A hand specialist should be involved to evaluate for potential operative repair when arterial bleeding or neurovascular compromise is identified Lacerations in the fingers and hands can involve underlying flexor or extensor tendons Many injuries can be anticipated based on the location of the injury (topographic anticipation) Extensor tendon lacerations proximal to the MCP joints may be amenable to repair by the emergency physician Extensor tendon lacerations involving the MCP joints or digits, as well as all flexor tendon lacerations, require care by a hand specialist In consultation with the surgeon, closure of the skin and splinting may comprise appropriate care in the emergency department, with close follow-up for operative exploration and repair FIGURE 109.4 Image demonstrating a palmar laceration after sutured repair with the absence of skin wrinkling in a median nerve distribution suggestive of a median nerve injury (Courtesy of Children’s Orthopaedic Surgery Foundation.) PHALANGES ... superficial location of key structures Uncomplicated extensor tendon injuries may be managed by the emergency physician, but more severe injuries or flexor tendon injuries should be managed by a hand... anticipation) Extensor tendon lacerations proximal to the MCP joints may be amenable to repair by the emergency physician Extensor tendon lacerations involving the MCP joints or digits, as well as all... consultation with the surgeon, closure of the skin and splinting may comprise appropriate care in the emergency department, with close follow-up for operative exploration and repair FIGURE 109.4 Image