Pediatric emergency medicine trisk 3404 3404

Subungual Hematoma A subungual hematoma is a collection of blood in the interface of the nail and the nail bed It is commonly seen with blunt fingertip injuries The usual presentation is throbbing pain and discoloration of the nail Subungual hematomas may be associated with nail bed injury or fracture of the distal phalanx If the injury >48 hours old, the blood is typically clotted and fluid is less likely to be released with trephination There are no clear data on the percentage of nail bed surface area that should prompt intervention Drainage is commonly performed when greater than 50% of the nail bed surface area is involved, to evaluate for underlying nail bed laceration, or for symptomatic relief of pain regardless of hematoma size Usually, drainage of the hematoma provides relief of the symptoms Generally, no local anesthesia is required for a simple trephination by cauterization of the nail since there are no nerve endings on the nail plate After drainage, care for simple subungual hematoma includes elevation of the hand and warm soaks for a few days Inform the family about the possibility of nail deformity in the future When the injury is more involved, digital block is advised If the hematoma is large and extends to the tip of the nail or around the eponychium, consider separating the nail from nail bed using either a sharp or blunt method to allow drainage Outcomes with nail trephination and nail removal are similar A subungual hematoma in the presence of a distal phalangeal fracture is considered an open fracture, regardless of trephination Limited data suggest that antibiotic coverage is not required routinely in otherwise healthy patients, but can be considered when specific concerns exist GENITOURINARY LACERATIONS CLINICAL PEARLS AND PITFALLS If needed, perform female genital examination under sedation with help from surgical specialists Consider testicular ultrasound if there is suspicion of testicular injury Testicular hematoma or rupture, vaginal wall lacerations, and urethral injuries may all accompany lacerations to the external genitals Careful physical examination should be performed, and diagnostic imaging pursued as necessary Genitourinary lacerations can occur in children after straddle injuries These injuries are discussed in detail in Chapter 108 Genitourinary Trauma They