(+)James Homme, MD
Assistant Professor of Pediatrics & Emergency Medicine;
Associate Program Director Pediatric and Adolescent
Medicine Residency; Department of Emergency Medicine,
Division of Pediatric Emergency Medicine, Mayo Clinic
College of Medicine
Advanced Pediatric Emergency
Medicine Assembly
March 23-26 2015
New York, NY
10 Little Fingers, 10 Little Toes
Anyone who has cared for a toddler with a smashed
finger or school aged child with an inflamed toe can
attest to the fact that these “little” issues can often
produce a great degree of distress for provider and
patient alike. In this session an expert lecturer will
discuss when to repair a nailbed/replace an avulsed nail,
treatment of common phalanx fractures, antibiotics (or
not) for tuft fractures, subungual hematomas,
management options for paronychia, and hair
tourniquets, and must not miss diagnoses such as
Seymour fractures, Herpetic Whitlow and felons will be
discussed with a smattering of the latest “tricks of the
trade”.
OBJECTIVES




Identify phalanx injuries at risk for associated Seymour
fracture
Discuss the evidence for and against nailbed repair and
prophylactic antibiotics for tuft fractures
Explain management options for paronychias, hair
tourniquets, and subungual hematomas
Recognize Herpetic Whitlows and initiate appropriate
treatment
3/24/2015
4:30 PM-5:00 PM
Grand Ballroom
TU-8
DISCLOSURES:
(+) No significant financial relationships to disclose
3/17/2015
Ten Little Fingers, Ten Little Toes?
Advanced Pediatric Emergency Medicine Assembly
March 24-26, 2015
©2014 MFMER | slide-1
Disclosures
• No financial disclosures
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Learning Objectives:
By the end of this lecture the learner will be able
to:
• Discuss indications for removal of a nail for
subungual hematoma and antibiotics for tuft
fractures
• Discuss management options for mallet finger
and recognize injuries at risk for associated
Seymour fracture
• Identify multiple “named” conditions in fingers
and toes commonly seen in pediatric patients
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11 yo ♀ 4th finger
vs car door
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12 yo ♂ hockey
player struck by
puck on fingertip
Increasing
swelling/pain
~ 30%
Subungual
Hematoma
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7 yo ♀ severe autism
crush Injury > 20 hrs
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15 mo ♂ sibling
closed finger in
hinge side of
bathroom door
Warning!
Danger Zone!!
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Controversies?
• How should we manage these injuries?
• Does the nail need to be removed?
• Antibiotics?
• Immobilization?
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Nailbed Anatomy
Hyponychium
Paronychium
Lunula
Nail Plate
Cuticle
Eponychium
(Sterile Matrix)
Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of
Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762.
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Nailbed Anatomy
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Trephination
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10 yo ♂ “jammed
fingertip” playing
basketball
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Mallet Finger
• Injury of the extensor
mechanism of the
DIP
• Forced flexion or
axial load on
extended DIP
• Soft tissue vs bony
• Exam – pain and
extensor lag
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Mallet Finger Treatment
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Mallet Finger Treatment
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Simple Mallet or more?
• 10 yo ♂ “jammed”
thumb from football
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Title
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Seymour Fracture
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Seymour Fracture
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Missed Seymour Fracture
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Missed Seymour Fracture
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Just a sprain?
• 7 yo ♀ jumps off chair,
catching little finger on
edge of desk.
• Swollen and bruised at
base of finger
• “You’re okay honey – go
practice your piano.”
• “Daddy – it hurts too
much when I try and
play.”
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Extra Octave Fracture
• Salter Harris II fracture –
base of proximal phalanx
• Abduction injury
• Ulnar deviation of finger ±
extension
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Reduction
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Just a sprain?
• 9 yo ♀ riding bike (with
helmet on) hits curb,
injuring thumb on
handlebars
• Swollen and bruised at
base of thumb
• “You’re okay honey – go
practice your piano.”
• “Daddy – it hurts too
much when I try and
play.”
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Skier’s Thumb (Ulnar Collateral Ligament Avulsion Fx)
• Cause by forced abduction of the
thumb
• Skeletally immature
• Avulsion fracture of insertion
site of UCL
• Salter Harris III
• Leads to instability of MCP joint
and ↓grip strength
• Exam - flex MCP, abduct
finger)
• Rx – Usually surgical
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Pseudo-skier’s Injury
• Salter Harris I or II fracture
• Exam shows apparent MCP joint instability
• Due to movement at the physis, not UCL
avulsion
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Jersey Finger
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Testing the FDS and FDP Tendons
• Flexor Digitorum
Profundus (FDP)
• Isolate DIP
• Flexor Digitorum
Superficialis (FDS)
• Isolate PIP
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Testing the FDS and FDP Tendons
• Flexor Digitorum
Profundus (FDP)
• Isolate DIP
• Flexor Digitorum
Superficialis (FDS)
• Isolate PIP
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Jersey Finger - Anatomy
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Examination pearl - Tenodesis
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Acute vs Chronic Paronychia
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Acute vs Chronic Paronychia
• Acute: Medical Management
• Warm soaks
• Antibiotics
• Obvious pus → drainage
• Chronic: Surgical Management
• Partial or complete nail
removal
• Matrix ablation
• Silver nitrate or Phenol
• Antibiotics
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Felon
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2 y.o. thumb sucker
Herpetic Whitlow
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Herpetic Whitlow
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Fussy Baby
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Why didn’t I think of that?
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Is there a “Fungus Amongus?”
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Granuloma Annulare
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Final Finger Condition
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Final Finger Condition
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Oral Therapy Recommended
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References
Fingernail and Fracture References
• Pediatric Hand Fractures. Techniques in Orthopaedics. 2009; 24 (3):150-162.
• Fingertip Injuries: An Update on Management. J Am Acad Orthop Surg 2013;
21:756-766.
• Pediatric Fingertip Injuries: Do Prophylactic Antibiotics Alter Infection Rates? Pediatr
Emer Care 2008; 24(3):148-152.
• Comparison of Nail Bed Repair Versus Nail Trephination for Subungual Hematomas
in Children. J Hand Surg 1999; 24A(6):1166-1170.
• Fingertip-Nail Bed Injuries in Children: Current Concepts and Controversies of
Treatment. J of Craniofacial Surg 2009; 20(4): 1033-1035.
• Management of Uncomplicated Nail Bed Lacerations Presenting to a Children’s
Emergency Department Pediatr Emer Care 2011; 27(5):379-383.
• Pediatric Nailbed Repair Study: Nail Replacement Increases Morbidity. Plast
Reconstr Surg 2012; 129(2):394-395e.
• A Prospective, Randomized, Controlled Trial of 2-Octylcyanoacrylate Versus Suture
Repair for Nail Bed Injuries. J Hand Surg 2008; 33(A): 250-243.
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References
• Interventions for treating fingertip entrapment injuries in children. Cochrane
Database of Systematic Reviews. 4, 2014.
• Conservative Treatment of Stable Volar Plate Injuries of Proximal Interphalangeal
Joint in Children and Adolescents: A prospective study. Pediatr Emer Care 2009;
25(9):547-549.
• Juxta-epiphyseal fracture of the terminal phalanx of the finger. J Bone Joint Surg Br.
1966; 48:347-349.
• Images in Emergency Medicine: Seymour Fracture. Ann Emerg Med 2014;63:656.
• Interventions for treating mallet finger injuries. Cochrane Bone, Joint and Muscle
Trauma Group Cochrane Database of Systematic Reviews. 4, 2009.
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References
Miscellaneous References
• Effect of a Depilatory Agent on Cotton, Polyester, and Rayon Versus Human Hair in
a Laboratory Setting. Ann Emerg Med 2015 Mar;65(3):256-9
• Pediatric herpetic hand infections. J Hand Surg 1990; 15(1):176-180.
• Images in clinical medicine: Herpetic Whitlow. NEJM 2014; 371(17):e25
• Herpetic Whitlow. CMAJ Canadian Medical Association Journal. 2012;
184(17):E924
• Recurrent primary paediatric herpetic whitlow of the big toe. BMJ Case Rep. BMJ
Case Rep 2013 Feb 21;2013
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References
Digital Blocks
• Epinephrine in Local Anesthesia in Finger and Hand Surgery: The Case for Wideawake Anesthesia. J Am Acad Orthop Surg 2013;21:443-447
• A Critical Look at the Evidence for and against Elective Epinephrine Use in the
Finger. Plast Reconstr Surg 2007 119(1);260-266.
• Randomized comparison of the single-injection volar subcutaneous block and the
two-injection dorsal block for digital anesthesia. Plast Reconstr Surg 2006;
118(5):1195-2000.
• Randomized double-blind comparison of duration of anesthesia amongst three
commonly used agents in digital nerve block. Plast Reconstr Surg 2006;
118(2):429-432.
Toenail
• “Nailing” the Management of the Ingrown Great Toenail. Block, Stan L. Pediatric
Annals 2014; 43(11):434-439.
Link to article: http://www.healio.com/pediatrics/journals/pedann/2014-11-4311/%7Bfc4bfb2d-ef92-4892-9299-cab34cf12f69%7D/nailing-the-management-of-theingrown-great-toenail
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References
• Interventions for ingrowing toenails. Cochrane Skin Group Cochrane Database of
Systematic Reviews. 4, 2012.
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