Pediatric emergency medicine trisk 3343 3343
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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 do
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
