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Children commonly injure their hands. The most common problem is a crush injury of the distal phalanx, often with a coincident laceration and fracture. If not treated properly, these injuries may result in significant functional difficulties and cosmetic deformities.
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 specific management and often referral.
Initial management should include the following steps.
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 immunization 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 asymmetry. Neurosensory examination is limited in young infants. The most essential subtle component is assessment 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 overlapping (Figure 1).
Localized trauma to the finger will often compress the nail to the underlying phalanx, resulting in a simple or stellate laceration, fracture or nail avulsion. A nail may take up to four months to regrow.
Subungual hematomas are a collection of blood under the nail plate, with the resultant pressure creating significant pain. Various techniques for nail trephination include use of a nail drill, 18-gauge needle, scalpel point, heated paper clip or portable cautery.
Subungual foreign bodies are a common presenting problems. For difficult splinters that cannot be directly removed, analgesia, often with a digital block, may be required.
Uncover the foreign body either by scraping down the overlying area of the nail with a scalpel or by cutting out a wedge of overlying nail with fine scissors. Remove the foreign body with fine forceps.
Nail lacerations are controversial with respect to when to remove the nail and repair an underlying nail bed laceration. If there is no disruption or laceration of the nail and the nail folds are intact, this is not typically required.
Fingertip lacerations often bleed profusely causing distress to the family. Initial management should include direct pressure for 10 mins. After cleansing, a xerofoam and dry gauze dressing may be applied. For avulsions with exposed bone, refer for specific primary management. Loose tissue is often viable and should not be debrided but should be loosely reattached with sutures. Often partial or complete revasculariztion will occur. The injuries should be rechecked for infection and redressed at two to three day intervals as required. Reassessment for potential revision in six months may be appropriate.
Fractures of the distal phalanx or phalangeal tuft may occur in up to 50% of injuries. The wounds should be copiously irrigated. Tissue should not be debrided. The finger 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 fixation.
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 bed injuries including those with associated fracture. The patient should return in the case of ongoing bleeding and any sign of infection.
Metacarpal fractures occur most commonly from direct trauma, often when an adolescent strikes someone or something. Care should be taken to assess lacerations, especially human bites, for potential infection. Closed reduction 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 often require more specific management. Metaphyseal and Salter II fractures may require closed reduction if angulated. Salter III and IV physeal injuries, and ulnar deviation 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 with minimal 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. Reduction may be accomplished by anaesthetizing the finger with a digital block and using a pencil in the webspace as a fulcrum to assist reduction. Significantly angulated, comminuted or rotated fractures (less than 10%) require referral, reduction and often internal fixation.
Fractures should be reviewed within a week to assess stability and maintenance of reduction. Unstable fractures require referral; most will require further splinting for two to four weeks.
Finger dislocations occur usually in an older child at the proximal interphalangeal joint due to a hyperextension injury. Complex dislocations requiring referral often occur at the metacarpophalangeal joint with an avulsed volar cartilage plate or associated fracture. Reduction can be attempted for simple interphalangeal dislocations.
Splinting for immobilization is often indicated for fractures, lacerations or sprains of the fingers and interphalangeal joints. Fractures with articular involvement (more than 10%), rotary or significant angulated deformity, and specific ligamentous injuries, such as mallet, game keeper’s and Boutonniere finger deformities, require referral and more specific management.
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 results.
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