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100 EMERGENCY MEDICINE PRACTICE POINT 100

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Childhood finger injuries 25

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0 David Warren MD FRCPC, Department of Paediatrics, Children’s Hospital of Western Ontario, London, Ontario 0

C hildren commonly injure their hands. The most

common problem is a crush injury of the distal pha-
lanx, often with a coincident laceration and fracture. If not
treated properly, these injuries may result in significant
functional difficulties and cosmetic deformities.

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Children sustain relatively fewer bony injuries than
adults, but they may experience a wide variety of avulsion
and physeal fractures. Displaced, intra-articular and
fractures with rotation and joint instability require spe-
cific management and often referral.

INITIAL MANAGEMENT
Initial management should include the following steps.
· Control bleeding with direct pressure.
Figure 1) Fingers in flexion – a rotational deformity is identified by finger
· Elevate the extremity. malalignment
· Apply ice to the swollen region (for a young infant,
have him or her play with ice cubes in bowl). stellate laceration, fracture or nail avulsion. A nail may
· Remove rings or any constricting object on the hand. take up to four months to regrow.

· Radiographs are indicated in all but insignificant

injuries.
The history should include the mechanism and time of
the injury. In the older child history may identify motor or
sensory changes. One should always obtain the immuni-
zation status, history of allergies, previous injuries and
underlying health problems.
Physical assessment is often hindered, especially in
the young infant, by fear, small structure size and poor
cooperation. Observation of how the child uses the hand
and spontaneous positioning are often useful. The finger
should be examined for tenderness, swelling and asym-
metry. Neurosensory examination is limited in young in-
fants. The most essential subtle component is assess-
ment for angulation and rotational deformity of the
fingers. These may be checked by having the child hold a
pen and checking that the fingers in flexion are almost
parallel pointing in the same direction with no overlap-
100 ping (Figure 1).
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NAIL BED INJURIES
Localized trauma to the finger will often compress the
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nail to the underlying phalanx, resulting in a simple or
25
Correspondence: Dr David W Warren, 82 Valleyview Crescent,
Dorchester, Ontario N0L 1G0 Telephone 519-685-8331,
5 eign body with fine forceps.
fax 519-685-8156, e-mail dwarren@julian.uwo.ca
0 0
Subungual hematomas
Subungual hematomas are a collection of blood under
the nail plate, with the resultant pressure creating signifi-
cant pain. Various techniques for nail trephination in-
clude use of a nail drill, 18-gauge needle, scalpel point,
heated paper clip or portable cautery.
Procedure
· Clean the nail.
· Anaesthesia is usually not required.
· Apply the heated paper clip or cautery to the nail
over hematoma to make one or two holes large
enough for continued drainage.
· Remove the trephine quickly when blood released to
avoid damage to underlying nail bed.
· Follow up for ongoing bleeding or any sign of
infection.
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Subungual foreign bodies
Subungual foreign bodies are a common presenting 95
problems. For difficult splinters that cannot be directly
removed, analgesia, often with a digital block, may be re- 75
quired.
Uncover the foreign body either by scraping down the
overlying area of the nail with a scalpel or by cutting out a 25
wedge of overlying nail with fine scissors. Remove the for-
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5 occur in up to 50% of injuries. The wounds should be co-
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Figure 2) Dynamic splinting. Buddy taping is appropriate for minor frac-
tures and dislocations
Nail lacerations
Nail lacerations are controversial with respect to when
to remove the nail and repair an underlying nail bed lac-
eration. If there is no disruption or laceration of the nail
and the nail folds are intact, this is not typically required.
Procedure
· Anaesthetize the finger with a digital block.
· In simple lacerations of the distal half nail, remove
the distal fragment and trim the nail back only
enough to allow suture of bed.
· In more proximal injuries remove the nail by gently
opening small forceps under the nail to dissect it
from the underlying tissue.
· Close the laceration with chromic 5-0 or finer
sutures. Complex lacerations require close
approximations of all parts.
· Replace the nail to original location after washing
with saline. Do not remove tissue under nail.
· If the nail is not available, trim various materials –
xerofoam, silicone sheeting, adaptic – and fit under
nail fold to cover nail bed.
· Place a hole in centre of nail to allow blood drainage
and suture in place with monofilament nylon suture
through distal nail and finger tip.
· Check wound for infection and hematoma in two to
three days and remove distal suture in three weeks to
allow new nail to push out old.
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Fingertip lacerations
95 Fingertip lacerations often bleed profusely causing dis-
tress to the family. Initial management should include di-
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rect pressure for 10 mins. After cleansing, a xerofoam
and dry gauze dressing may be applied. For avulsions
with exposed bone, refer for specific primary manage-
25 ment. Loose tissue is often viable and should not be
debrided but should be loosely reattached with sutures.
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Often partial or complete revasculariztion will occur. The
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Emergency Medicine Practice Point
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injuries should be rechecked for infection and re- 95
dressed at two to three day intervals as required. Reas-
sessment for potential revision in six months may be 75
appropriate.
Fractures of the distal phalanx or phalangeal tuft 25
Fractures of the distal phalanx or phalangeal tuft may
5
piously irrigated. Tissue should not be debrided. The fin-
ger should be splinted with the distal interphalangeal
joint in extension for three weeks. If alignment cannot be
achieved or maintained by splinting, refer for K-wire fixa-
tion.
Nail bed avulsions often lead to deformity and a non-
adherent nail, and should be referred for primary repair.
Prophylactic antibiotics are unnecessary for most nail
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bed injuries including those with associated fracture. The
patient should return in the case of ongoing bleeding and
any sign of infection.
FINGER FRACTURES
Metacarpal fractures
Metacarpal fractures occur most commonly from di-
rect trauma, often when an adolescent strikes someone
or something. Care should be taken to assess lacerations,
especially human bites, for potential infection. Closed re-
duction after a local anaesthetic block is performed for
angulated fractures greater than 30° in the fifth finger and
progressively less angulation is tolerated in the fourth,
third and second metacarpals. Nondisplaced fractures
may be managed by gutter casting or plaster resting hand
splint with the wrist in slight extension and 70° flexion of
the metacarpophalangeal joint.
Thumb fractures are less common in children but of-
ten require more specific management. Metaphyseal and
Salter II fractures may require closed reduction if angu-
lated. Salter III and IV physeal injuries, and ulnar devia-
tion require referral and often open fixation. A common
specific injury is a game keeper’s thumb, avulsion of the
ulnar collateral ligament of the proximal phalanx of the
thumb, which requires specific management.
Proximal and middle phalangeal fractures
Proximal and middle phalangeal fractures with mini-
mal angulation and no rotation can often be managed
with splinting with or without buddy taping (Figure 2).
Laterally angulated Salter II fractures of the proximal
phalanx, especially of the fifth finger, are common. Re-
100
duction may be accomplished by anaesthetizing the finger
with a digital block and using a pencil in the webspace as 95
a fulcrum to assist reduction. Significantly angulated,
comminuted or rotated fractures (less than 10%) require 75
referral, reduction and often internal fixation.
Fractures should be reviewed within a week to assess
stability and maintenance of reduction. Unstable frac- 25
tures require referral; most will require further splinting
for two to four weeks. 5
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Emergency Medicine Practice Point

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Finger dislocations than 10%), rotary or significant angulated deformity, and 95
Finger dislocations occur usually in an older child at specific ligamentous injuries, such as mallet, game keep-
75 the proximal interphalangeal joint due to a hyperexten- er’s and Boutonniere finger deformities, require referral 75

sion injury. Complex dislocations requiring referral often and more specific management.
occur at the metacarpophalangeal joint with an avulsed Procedure
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volar cartilage plate or associated fracture. Reduction can · Young infants can often be splinted in a bulky hand 25
be attempted for simple interphalangeal dislocations. dressing. Use dorsal splint with aluminum splint cut
5 Procedure to appropriate length to immobilize site of injury at 5

· Perform neurovascular examination. least to next proximal and distal joint. Wrist should
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· Perform radiographic examination pre- and be in 15 to 25° extension, metacarpophalangeal joint
postreduction to confirm dislocation and absence of in 45 to 90° flexion and interphalangeal joints in 5 to
associated fracture. 20° flexion.

· Administer digital block. · Dynamic splint-buddy taping. A piece of gauze or

foam is placed between fingers. The injured finger is
· Apply gentle axial traction, as little as required.
taped to an adjacent noninjured finger. Do not tape
· Hyperextend digit slightly and push dislocated

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phalanx into place.
· Failure to reduce often implies a complex dislocation
requiring surgery.
· Evaluate for joint instability and splint proximal
interphalangeal joint in 15° flexion, distal
interphalangeal joint in full extension for three
weeks.
Splinting
Splinting for immobilization is often indicated for frac-
tures, lacerations or sprains of the fingers and interpha-
langeal joints. Fractures with articular involvement (more
over joint lines.
Tenosynovitis and bite wounds may be associated with
finger injuries that require specific management due to
their high morbidity.
Most lacerations can be closed with simple sutures but
always visualize the deep tissue for tendon involvement
that will require referral for repair.
The majority of common finger injuries in children can
be effectively managed in the office, clinic or emergency
room setting using simple equipment and procedures.
Complicated injuries and persistent deformities should
be referred early for best functional and cosmetic re-
sults.

EMERGENCY PAEDIATRICS SECTION

Executive members: Drs Carolyn Davies, BC’s Children’s Hospital, Vancouver British Columbia; David McGillivray, The Montreal Children’s Hospital,
Montreal, Quebec; Cheri Nijssen-Jordan, Alberta Children’s Hospital, Calgary, Alberta; Martin Osmond, Children’s Hospital of Eastern Ontario, Ottawa,
Ontario; David Warren, Children’s Hospital of Western Ontario, London, Ontario (president and principal author); Patricia Wren, IWK-Grace Health
Center, Halifax, Nova Scotia

Reviewed by the Canadian Paediatric Society Board of Directors

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