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