4 year old Dudley is brought into your emergency department by his hysterical mother. In between breathless sobs she tells you how she accidentally slammed the car door shut on his hand. She is convinced he has lost a finger given how much he is screaming.
Nailbed injuries are exceedingly common and can be distressing for both parent and child.
Simple first aid measures and distraction techniques make examination much easier.
Isolated tuft fractures heal with no intervention in about three weeks.
You do not need to prescribe antibiotics for open distal tip injuries unless they are heavily contaminated.
Nailbed injuries are very common in children with the problem ranging from a simple subungual haematoma to an avulsed nailbed. Before we look at how to manage these conditions it is important to understand a little of the underlying anatomy.
The perinychium comprises of the nail, the nailbed and the surrounding tissue.
The paronychium comprises the lateral nail folds (hence paronychia).
The hyponychium is the skin distal to and palmar to the nail.
The lunula is that white semi-moon shaped bit.
The matrix is made up of a sterile portion that is deep to the nail, adheres to it and is distal to the lunule. The germinal portion is proximal to the sterile matrix and is responsible for nail growth.
You need to gain control of the situation before you can have a look. How are you going to do this?
You are going to need some help.
A parent is the greatest ally you can have in calming down a distressed child so if you approach him/her in a calm and confident manner, forearmed with knowledge then they can be of great help.
Simple first aid measures do help so, the direct pressure can help control the bleeding, and elevation helps with the incessant throbbing pain. Get some ice cubes or an icy pole for the child to hold and play with and, of course, Don’t Forget The Bubbles.
Examining the fingers can still be tricky and so, once adequate analgesia is on board, watch the child playing and see how they use their hand.
What is a sub-ungual haematoma?
The answer is in the name.
A blow to the finger tip leads to bleeding under the nail. As anyone who has ever accidentally struck their own finger with a hammer can attest to the fact that it is incredibly painful.
What is the treatment for a subungual haematoma?
Treatment options vary according to local practice and resources available as well as according to haematoma size.
If the haematoma involves less than 50% of the visible nail then there are a number of techniques that can be used to relieve the pressure. Kane Guthrie has a couple of great videos here on how to fashion your own cautery device (though spirit lamps and lighters are becoming harder to find in the ED these days). Sometimes drilling slowly with a green needle is less threatening. It is a highly satisfying procedure, both for the patient and the practitioner, but beware the blood under pressure can spray so wear appropriate protective gear. I can still remember the first one I did as a medical student, 15 years ago!
If more than 50% of the nail bed is involved then it may be necessary to lift up the nail to evacuate the haematoma. In appropriately aged children (or adults) a ring block can be used.
The nail is almost hanging off and has lots of red grue attached to it – should you just cut the nail off and let it regrow?
It can take six to twelve weeks for the nail to regrow and if the germinal matrix is damaged it may become either ridged or deformed. The partially attached nail provides the best protection for the underlying finger tip so don’t remove it, and certainly don’t scrape off the red stuff.
You x-ray the finger and find a small tuft fracture – it’s technically an open fracture so you are going to give antibiotics, right?
Isolated tuft fractures are treated conservatively and should heal on their own in two to three weeks. You can fashion your own finger tip protector with either an aluminium splint or with the simple plastic fake finger tips.
A number of authors have questioned the role of prophylactic antibiotics. There appears to be very little evidence for their benefit, especially if proper wound toilet has been carried out. Don’t give them!
What happens in theatre?
Sometimes the only way of really examining the wound is using a general anaesthetic.
The wound is cleaned and often the nail lifted up or removed. There is some debate in the plastics literature as to what the best thing to do with nail bed lacerations is. Some surgeons argue that proper nail bed repair reduces the rate of infection and limits abnormal nail growth and ridging, though tissue adhesive has also been used for a speedier repair.
Trapping a finger tip in the hinge side of the door can often lead to a co-existent nail bed laceration and crush fracture of the distal phalanx. It is often difficult to make out exactly what is going on without first thoroughly cleaning the wound. Trying to do this to a young child is futile and often they need a general anaesthetic or procedural sedation to fully evaluate the injury.
Dudley is given some intranasal fentanyl and his mother is given a cup of tea. You soak off the toilet roll and find a crushed finger tip that is going to need a plastic surgeon. The x-ray shows a small tuft fracture and you print out a copy of the BestBets summary on antibiotic use in fingertip injuries and subtly place it in the notes before Dudley goes up to theatre.
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de Alwis W. Fingertip injuries. Emerg Med Australas. 2006 Jun;18(3):229-37.
Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial J Hand Surg Br 2003 28(5): 388-94.
Altergott C, Garcia FJ, Nager AL. Pediatric fingertip injuries – do prophylactic antibiotics alter infection rates? Pediatric Emergency Care 2008. 24(3): 148-52.