Most suspected injuries to the carpal bones can be managed in the urgent setting with splinting and outpatient follow-up within to weeks Scaphoid fractures have different patterns depending on the age of the patient Younger patients have a significant incidence of fractures involving the distal third of the bone, although fractures in the middle third (i.e., the waist) are still the most common in children Adolescents and adults tend to fracture at the waist of the scaphoid A unique fracture to young patients is the avulsion of the distal radial aspect of the scaphoid This injury often is not diagnosed on first presentation and is seen on radiographs to weeks later In the emergency department, confirmed and suspected scaphoid fractures should be managed with a thumb spica splint or cast Most scaphoid fractures are nondisplaced and ultimately managed with cast immobilization, though displaced fractures may require surgical reduction and internal fixation to prevent nonunion In addition, those who present late with evidence of nonunion should be immobilized and referred to a hand specialist for possible surgical repair FIGURE 109.16 Radiographs depicting perilunate dislocation, best seen on the lateral radiograph (Courtesy of Children’s Orthopaedic Surgery Foundation.) In addition to fractures, suspicion for ligamentous injuries should be high, particularly in late childhood and adolescence An important part of radiologic evaluation is assessment of the distance between the scaphoid and lunate bones In a true scapholunate dissociation, this space is widened, often called the Terry Thompson sign This can be difficult to assess in children in whom this space is naturally widened, as the carpals are not fully ossified The normal plain radiograph scapholunate interval decreases with age in children It is also important to note that dynamic scapholunate instability may not be shown on routine x-ray, and may only be obvious under stressed view Perilunate dislocation is best identified with the lateral wrist radiograph, with the bone displaced from its typical midaxial location over the radius ( Fig 109.16 ) This can be easily missed, and therefore recognition requires careful physical and radiologic assessment High-energy trauma and marked swelling can be indicators of this injury pattern Concern for dissociations and dislocations requires urgent attention by a hand specialist Suggested Readings and Key References Alterfott C, Garcia FJ, Nager AL Pediatric fingertip injuries: prophylactic antibiotics alter infection rates? Pediatr Emerg Care 2008;24(3):148–152 Capstick R, Giele H Interventions for treating fingertip entrapment injuries in children Cochrane Database Syst Rev 2014;2014(4):CD009808 Cornwall R Finger metacarpal fractures and dislocations in children Hand Clin 2006;22(1):1–10 Edwards S, Parkinson L Is fixing pediatric nail bed injuries with medical adhesives as effective as suturing?: a review of the literature Pediatr Emerg Care 2019;35(1):75–77 Gellman H Fingertip-nail bed injuries in children: current concepts and controversies of treatment J Craniofac Surg 2009;20(4):1033–1035 Jauregui JJ, Seger EW, Hesham K, et al Operative management for pediatric and adolescent scaphoid nonunions: a meta-analysis J Pediatr Orthop 2019;39(2):e130–e133 Liao JCY, Chong AKS Pediatric hand and wrist fractures Clin Plast Surg 2019;46(3):425–436 Nellans KW, Chung KC Pediatric hand fractures Hand Clin 2013;29(4):569– 578 Patel L Management of simple nail bed lacerations and subungual hematomas in the emergency department Pediatr Emerg Care 2014;30(10):742–748; quiz 746–748 Strauss EJ, Weil WM, Jordan C, et al A prospective randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries J Hand Surg Am 2008;33(2):250–253 CHAPTER 110 ■ MINOR TRAUMA CHRISTINE S CHO GOALS OF EMERGENCY CARE Each year, an estimated 12 million wounds are treated in emergency departments (EDs) in the United States The first priority is stabilization of patients who have sustained trauma and recognizing significant injuries The care of minor injuries focuses on addressing pain, evaluating associated injuries, and wound closure The key drivers in optimal wound repair are obtaining hemostasis, preventing infection, and achieving the best long-term cosmesis while minimizing pain and anxiety Patient and parental satisfaction is driven in the short term by timeliness of care, length of stay, and minimizing pain, and in the long term by avoidance of complications, including infection, hypertrophic scarring or keloid formation, and poor cosmetic results KEY POINTS ... Hesham K, et al Operative management for pediatric and adolescent scaphoid nonunions: a meta-analysis J Pediatr Orthop 2019;39(2):e130–e133 Liao JCY, Chong AKS Pediatric hand and wrist fractures Clin... 2019;46(3):425–436 Nellans KW, Chung KC Pediatric hand fractures Hand Clin 2013;29(4):569– 578 Patel L Management of simple nail bed lacerations and subungual hematomas in the emergency department Pediatr... 2008;33(2):250–253 CHAPTER 110 ■ MINOR TRAUMA CHRISTINE S CHO GOALS OF EMERGENCY CARE Each year, an estimated 12 million wounds are treated in emergency departments (EDs) in the United States The first priority