Pediatric emergency medicine trisk 3403 3403

reimplantation by a surgeon for amputations proximal to the distal interphalangeal joint (see Chapter 109 Hand Trauma ) Nail Bed Lacerations Trauma to the distal fingers is often associated with nail and nail bed (matrix) injuries Nail avulsion can be partial or complete and may or may not be associated with nail bed laceration An underlying fracture of the distal phalanx may also be present, so an x-ray is recommended prior to any repairs Generally, minor tuft fractures will heal with splinting and not require an initial surgical evaluation Injury to the fingertip is often associated with subungual hematoma In evaluating these injuries, the emergency provider should determine the need to explore the nail bed for a laceration Unrepaired nail bed lacerations may permanently disfigure the growth of the new nail from the cicatrix nail bed If the nail is partially avulsed but is firmly attached to its bed, exploring the nail bed is difficult and is probably not warranted Good outcome is expected because the nail holds the underlying lacerated nail bed tissues in place When the nail is completely avulsed or is attached loosely, remove the nail and assess the nail bed for laceration If the nail bed is lacerated, repair it using 6-0 absorbable material or skin adhesive Traditional approaches have included splinting the nail fold (eponychium) away from the nail bed This is accomplished by cleansing and trimming the soft proximal portion of the nail, and inserting it into the original space It can then be anchored into place with sutures or skin adhesive If the nail itself is too damaged to replace, a nonadherent sterile gauze or sterile foil from a suture packet can be placed carefully under the nail fold Preservation of this space may help the new nail grow undisturbed (see Chapter 109 Hand Trauma ) The preferred method of anesthesia for nail bed repair is a digital block, and the use of a finger tourniquet during the repair allows a bloodless field The repaired fingertip can be dressed with sterile petrolatumimpregnated gauze and covered with sterile dry dressing A finger splint after repair is recommended if there is an associated fracture or for added protection against reinjury in young children Consultation with a hand specialist is recommended if the fingertip injury includes a large or complex laceration, an associated tendon injury, a fracture other than a minor tuft fracture, a dislocation or amputation with exposure of bone, or if there is any question about the optimal management After repair of fingertip injuries, small lacerations can be followed up by the primary care provider All other injuries should see a hand specialist to ensure appropriate healing