Management of Pediatric Hand Injuries in the Acute Setting Part 3: Lacerations and Fingertip Injuries

Abstract

This is the third article in a series on the assessment and management of pediatric hand trauma. Building on the foundational principles established in the previous articles, this segment focuses on lacerations and fingertip injuries—frequently encountered open pediatric hand injuries in emergency departments. Prompt recognition and appropriate initial treatment are essential to optimize functional outcomes and prevent complications.

Key Concepts

• (1)Examination of arm and hand function in children with a laceration can be difficult.
• (2)Recommendations are made for examination of children to identify tendon, nerve and arterial injury.
• (3)Fingertip injuries can often be treated in the emergency department.
• (4)Hand lacerations and amputations at all levels should include a consultation with a hand surgeon.

Lacerations

Treatment principles and examination techniques

Upper extremity, hand and wrist lacerations range from superficial to complex neurovascular injuries.

• •Physical exam and topographic anticipation remain central to assessment and guide management [1,2]. The difficulty in performing an accurate physical examination should not be underestimated [1,2].
• •Always apply basic wound care, institute hemostasis, and perform thorough physical examination. Glass lacerations are easily underestimated, so a careful exam is essential (Fig. 1) [3,4].
• •Obtain radiographs to assess for a foreign body or fracture after a laceration. If there is high index of suspicion for foreign body but it is not visualized on radiographs, ultrasound or computed tomography (CT) can be obtained for further evaluation [5].

Figure 1.

Do not underestimate lacerations caused by glass. A 2-year-old child has a puncture wound on the arm from glass (a), which led to a radial nerve laceration (b). The radial nerve injury was diagnosed clinically because of the wrist drop observed during examination.

Antibiotics are generally not indicated for clean, simple lacerations without contamination or deep structural injury [[6], [7], [8], [9], [10], [11]]. However, consider antibiotics for contaminated wounds or those involving deeper structures. Update tetanus as needed.

Vascular exam

• •
  Inspection is a useful first tool for assessing digital perfusion.

  • ○
    Clean the hand of blood with soap and water or diluted 3% hydrogen peroxide, and then visually assess perfusion.
  • ○
    Measure capillary refill time on the fingertip pulp—not the nailbed—by gently pressing for 5 seconds; a refill ≤2 seconds is normal in children [12,13].
  • ○
    Measure pulse oximetry; values of ≥95% indicate an extremity is unlikely to have underlying ischemic injury, while values ≤ 92% should prompt further assessment for suspected vascular injury [14].
  • ○
    Palpate for radial and ulnar pulses and document this. If not palpable, assess with a pulse oximeter and Doppler for triphasic signals. While one can listen to the arteries at the base of the digits, the laceration may be distal to this, requiring listening for signals either overlying the isolated digital artery or centrally at the pulp. Both digital arteries and pulp should be investigated.
  • ○
    If a radial or ulnar artery injury is suspected, the Allen test should be performed to evaluate the integrity of the palmar arch in patients who can cooperate (typically ≥6 years old).
  • ○
    The examiner must remember that due to pain and/or fear related to the injury and examination, this may not be possible in the acute setting.

Allen test: Hand.e physical exam [15]:

• ○The examiner occludes the radial and ulnar arteries while the patient first opens and closes their fist several times, then tightly clenches it. The examiner then occludes both arteries.
• ○The examiner relieves pressure on an artery and checks for blush in the hand, usually within 6 sec [16].
• ○The test is repeated to relieve pressure from the other artery.
• ○If the palmar arch and at least one of the arteries are intact, blush will occur.
• ○
  If achieving this is difficult due to the child's age or pain in the hand or finger from injury, a Doppler can also be used at the palmar arch to perform a modified version of this test [17].

  • ⁃
    When listening for the ulnar artery in the palm, the probe should be placed between the pisiform and the hook of the hamate, with the pisiform being the most reliable, palpable landmark.
  • ⁃
    The hook of the hamate is 1 cm distal and radial to the pisiform in adults.

Controlling bleeding. Elevation and direct compression are the first tools to control bleeding and should be maintained for 10–15 min without interruption. Removing a dressing to inspect the wound can disrupt the clot. Pulsatile bleeding suggests an arterial injury, which can be very difficult to control if the injury is partial, as the artery may not exhibit spasm enough to occlude. If precise, direct compression for an adequate duration does not stop the bleeding, additional compression should be applied. A tourniquet can be temporarily used by a specialist to allow wound inspection. If a partial arterial injury is suspected, surgical exploration will be necessary.

Expert opinion.

Dr. Andrea Bauer: Assessing perfusion of a digit can be very challenging. Capillary refill that is too brisk, or immediate, is a sign of worrisome venous congestion. Assessing the contralateral hand can help to understand what normal turgor, color, and capillary refill for the patient is being examined. For severe injuries, a prick of the fingertip with a hypodermic needle can be used in a child who is sedated or in the case of an insensate digit. The speed and color of the bleeding after a needle prick can be very helpful in assessing perfusion in extreme cases.

Dr. Randy Bindra: Digital nerves and arteries run closely together, with the nerve in front (volar) of the artery. If both sides of a finger are numb, the radial and ulnar digital nerves and arteries are likely injured, and a pediatric hand surgeon should be consulted emergently for repair.

Dr. Felicity Fishman: A pediatric adhesive pulse oximeter may be easier to apply to the injured digit than a pediatric or adult-sized plastic “clip” type oximeter in order to accurately measure the perfusion. Additionally, it may be helpful to warm the room in order to decrease the potential for vasospasm in an anxious pediatric patient.

Neurologic exam

A sensory examination should be performed to assess each of the major nerves innervating the hand: median, ulnar, and radial.

• •Light touch sensation may be assessed. If patients are old enough to participate, we recommend using two-point discrimination to provide an objective assessment of neurological status, with normal values being typically ≤6 mm [18].
• •When examining the hand, often 2-point discrimination is not possible due to the patient's age or their inability to concentrate because of the injury. The exam can be simplified by having the patient report which finger they feel being touched with their eyes closed (“No peeking!”). This may require naming the fingers beforehand. Sometimes, they will describe the finger, such as, “the one next to the pinky finger,” and that is enough for the exam.

A motor exam can be conducted on children and adolescents who are able to participate and follow directions. If they cannot, Table 1 offers suggestions for activities to assess motor function in children. Even simply using your badge for them to reach for and grasp may be enough.

Expert opinion.

Dr. Andrea Bauer: The “wrinkle test” can be very helpful in children under 8 years of age, in whom direct sensory testing is unreliable. Because the process that causes skin to wrinkle underwater is mediated by sensory nerves, this wrinkling does not occur when the sensory nerve is injured. Immersing the injured hand in water (not saline!) and watching for wrinkling can help identify a nerve injury in a young child, as the digit with the injured nerve will not wrinkle after immersion.

Table 1.

Motor examination in children.

Nerve	Test	Child-Friendly Assessment
Anterior interosseous (AIN)	Thumb interphalangeal joint and index distal interphalangeal joint flexion (“OK” sign)	Giving a bottle or sippy cup to hold, reaching for a dangling toy or badge
Median	Finger flexion	Performing a fist bump
Ulnar	Abduction of the digits or crossing the index and middle fingers	“Chop like scissors”
Radial/Posterior interosseous (PIN)	Thumb extension and wrist extension	Giving a thumbs up

Tendon exam. The flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) control flexion of the index, long, ring, and small fingers. Start by examining the resting posture of the digits (Fig. 2). For suspected tendon laceration with partial digital flexion remaining, tendons should be assessed separately. To evaluate the FDP, block the middle phalanx of the finger and check for isolated distal interphalangeal (DIP) flexion. To evaluate the FDS, extend all digits with the palm facing up on a flat surface and flex the injured finger while holding the others in extension.

Expert opinion.

Dr. Randy Bindra: Pain or limited range of motion may indicate partial tendon injury requiring urgent referral to a pediatric hand specialist.

Dr. Felicity Fishman: As it is not uncommon for an injured child to refuse to participate in the physical exam, passive tenodesis with comparison to the contralateral side can be used to supplement your observations of the resting hand position.

Figure 2.

Flexor tendon lacerations. a) Extension of the small finger at rest indicates a flexor tendon laceration, likely through both flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. Because of the location of the laceration, the wound should also be suspected of having a digital nerve laceration. b) An FDS-only laceration of the middle finger in Zone 3, with minimal impact on finger movement. This wound should be surgically explored due to the potential for nerve injury; the FDS and common digital nerve were repaired.

Superficial lacerations in pediatric patients

Anesthesia. For patients old enough to tolerate it, perform a digital block with 1% lidocaine ±0.25% bupivacaine for finger lacerations (Hand.e video [19]), or infiltrate the wound edges with anesthetic. Use a 25G or smaller needle for injection. 5 mL–10 mL is typically sufficient for the finger, adjusted for patient weight. Both volar and dorsal approaches to digital blocks are acceptable, though we usually start with a single injection volar block in the finger's midline, superficial to the A1 pulley. An additional dorsal anesthesia can be achieved with a second, smaller volume infiltration over the dorsal web spaces through one needle insertion. For patients who may not tolerate local anesthesia alone, conscious sedation should be administered alongside local anesthetic.

Hand.e digital block [19]:

Suture choice: Use fast-absorbing sutures in children, such as 5-0 or 6-0 plain gut, chromic gut, Monocryl™, or Vicryl Rapide™ (Ethicon, Cincinnati, OH). Sutures that need removal in clinic, like nylon, should be avoided due to pain during removal and the potential for fear and psychological trauma for both children and their caregivers [20].

After laceration repair in children, apply a bulky dressing and often place a splint or club cast. This helps prevent young children from putting fingers in their mouths or contaminating the wound, and also keeps older children from accidentally reinjuring the area. For children aged 6 or younger, apply a club cast that extends above the elbow. For patients nearing skeletal maturity, a forearm-based splint may be used depending on which digit(s) are affected.

Patients should follow up in 1–2 weeks for their first wound check.

Hand lacerations with underlying muscle, tendon, or neurovascular injury

Lacerations with vascular compromise require urgent intervention. A hand surgeon should be consulted immediately. Hemostasis should be achieved, and the wound dressed as a temporary measure. Antibiotics should be given. The wound should be irrigated, temporarily closed, and a protective splint applied. Often, there is a delay in transferring the patient to the operating room. Therefore, this approach provides temporization and reduces the risk of infection.

Lacerations to large nerves, excluding the digital nerves, require urgent assessment by a hand surgeon to determine whether immediate repair or reconstruction is needed.

Flexor tendon lacerations (Fig. 2) should be evaluated by or discussed with an on-call hand surgeon regarding the urgency of surgery. For temporary management, local wound care may be performed, including irrigation and loose wound closure. The patient should be placed in a dorsal blocking splint that crosses the wrist, with the wrist in slight flexion, the fingers flexed at the metacarpophalangeal (MP) joints and extended at the interphalangeal (IP) joints (Fig. 4, Part 1) [21]. Excessive wrist flexion should be avoided [22]. Flexor tendon laceration repair is ideally performed within 1–2 weeks and should be referred immediately to a hand surgeon for evaluation.

Figure 4.

Nail anatomy relevant for nailbed injuries.

Extensor tendon lacerations are most often managed with wound care, primary repair, and immobilization in extension [23]. Whether this should be done in the emergency department and the specific techniques involved should be discussed with an on-call hand surgeon. Usually, they can be treated similarly, with loose skin closure and urgent referral for repair in the operating room. The wound should be cleaned and temporarily closed. Appropriate dressings should be applied. The splint should be placed on the volar side of the hand and forearm, with the fingers and wrist in extension.

Severe proximal lacerations

Severe lacerations to the volar forearm, sometimes called ‘spaghetti wrist’, often damage multiple structures, including arteries, nerves, and tendons. These injuries are typically caused by glass, animal bites, or self-harm, and they vary in severity. The functional outcome depends on how many structures are injured (Fig. 3) [24]. In the emergency department, management should include: (1) routine wound care, (2) a detailed neurovascular and tendon examination, and (3) immediate consultation with a hand surgeon. Severe injuries often require urgent or emergent surgery to explore and repair involved structures, especially if an artery is damaged. As a temporary step, IV antibiotics should be given, the wound should be cleaned and temporarily sutured. A clean dressing and a dorsal blocking splint with the wrist in slight flexion can be applied (Fig. 4, Part 1) [25].

Figure 3.

Complex forearm laceration from putting the arm through a glass window. The injury involved lacerations to the flexor tendons, median and ulnar nerves, and artery. This requires urgent treatment.

Fingertip lacerations and crush injuries

Pediatric fingertip injuries are common and warrant separate discussion due to the unique structures and neurovascular considerations of the fingertip (Fig. 4). Fingertip injuries typically result from a crush mechanism, such as getting caught in a door or window, damaging the nail bed, skin, and distal phalanx (Fig. 5) [26]. In severe cases, this may lead to complete amputation, which is covered in the finger amputations section.

Figure 5.

A fingertip laceration with associated tuft fracture. This injury underwent laceration and nailbed repair and was placed into a club cast.

These injuries are often managed in the emergency department with good outcomes [6]. Simple lacerations can be treated as described in the superficial lacerations section. Nailbed injuries should undergo removal of the nail and nailbed repair. Nailbed injuries with an underlying distal phalanx fracture are open fractures and should be managed accordingly. A physeal (growth plate) fracture of the distal phalanx associated with a nailbed injury is considered a Seymour fracture and has been previously described.

Initial evaluation should include high-quality anteroposterior (AP) and lateral x-rays of the injured finger to assess for a tuft fracture and rule out a Seymour fracture.

All lacerations to the fingertip should be repaired with an absorbable suture, typically 5-0 or 6-0 chromic gut or similar, as discussed in the superficial lacerations section.

Expert opinion.

Dr. Felicity Fishman: When repairing the delicate tissue of a pediatric fingertip injuries, consider lubricating the chromic or plain gut suture with bacitracin ointment to help it glide more easily through the tissue. Additionally, it is helpful to borrow smaller instruments from the operating room if possible.

Dr. Randy Bindra: Fingertips heal remarkably well, especially in children. Minimal sutures and nonadhesive dressing that protects the tip is generally adequate for epithelialization. Replacing the amputated fingertip as a composite graft without microsurgical repair yields good results in children aged under 5. The graft should not be disturbed for up to 4 weeks even if it appears to have failed.

• •If there is a fully or partially avulsed piece of skin, we recommend cleaning the skin and suturing it back in place as a composite graft (Figure 5). Although fully avulsed grafts are likely to partially necrose, they provide soft tissue coverage while the finger re-epithelializes, maintain cosmetic appearance and digital length, and result in high patient satisfaction [27]. If the avulsed skin is not available, the volar and dorsal skin should not be sutured together, as this can lead to a hook nail deformity. Instead, occlusive dressings can be an option to manage distal fingertip injuries.
• •Occlusive dressings can be used temporarily, especially if urgent soft tissue coverage is needed [28]. Using occlusive dressings requires early dressing changes, which can cause discomfort for the patient and caregivers.
• •In children under age 5, depending on the extent of skin loss, the finger can often be treated nonsurgically, allowing for re-epithelialization over the fingertip (Figure 6).
• •With greater volar tissue loss or in older patients, local or regional flap coverage can be considered. These patients should be evaluated by a pediatric hand surgeon within the first week following injury.

Expert opinion.

Dr. Andrea Bauer: In these cases, young children may need to be casted until the wound is re-epithelialized, to prevent them biting or sucking on the injured digit. Fortunately, this process is quick, and a cast is typically not needed beyond 2–3 weeks.

Figure 6.

Evolution of healing of a fingertip laceration in a 4-year-old child with exposed bone at initial presentation, allowed to heal by secondary intention without shortening.

Generally, after repairing fingertip injuries in the emergency department, a cast or splint should be used (Fig. 2). For patients aged 6 years or younger, a long arm club cast is recommended. For patients older than 6 years, a short arm club cast should be applied. For patients nearing skeletal maturity, a gutter splint or individual finger splint may be suitable if only one digit is affected. In this age group, local or regional flaps could provide additional coverage. For injuries involving multiple digits, an appropriately fitted forearm-based splint should be used to cover the affected digits.

There are no definitive guidelines on whether antibiotics should be prescribed at discharge after fingertip injury. A randomized trial did not show a difference in infection rates between children treated with 7 days of oral (PO) antibiotics and those not treated with antibiotics; however, this study may have been underpowered [29]. We recommend a 7-day course of PO antibiotics with gram-positive coverage, such as cephalexin, clindamycin, ciprofloxacin, or Bactrim, for severe or contaminated injuries and those with an associated fracture [6].

Nailbed injuries

If there is a hematoma under the nail that involves more than approximately 50% of the nail plate or a displaced distal phalanx fracture, a nailbed repair should be performed (see Fig. 7). In most pediatric patients, conscious sedation is necessary to carry out an adequate nailbed repair. The general steps for performing a nailbed repair include the following.

• 1.Perform a digital block (Hand.e video [19]).
• 2.Clean and inspect the injured nail.
• 3.Remove the traumatized nail plate.
• 4.Repair nail bed and associated skin lacerations.
• 5.Splint the eponychial fold with the native nail plate after cleaning and trimming or foil from the suture package as a replacement nail.
• 6.Dress the wound with bacitracin and a nonadherent dressing.
• 7.Place a splint or cast (Fig. 2).

Figure 7.

A nailbed injury with a subungual hematoma involving less than 50% of the nail plate. When the ecchymosis extends greater than 50% of the nail plate, approximately 2x the width of the lunula, removal of the nail and repair of the nail bed should be considered.

We refer readers to the detailed video:

Hand.e full nailbed repair [30]:

If it is difficult to see the field because of bleeding, a finger tourniquet can be made by cutting the finger off a sterile glove into a tube with both ends open and rolling it into a donut shape around the base of the finger. It is important to remove this tourniquet at the end of the procedure. It is recommended to attach an instrument, such as a hemostat, to the tourniquet to show that it is still in place.

There are several techniques for securing a nail bed splint. While suturing is considered the gold standard, the figure-of-8 technique is technically simpler. Although evidence suggests that medical adhesives may be effective, it is advised to avoid using them in the acute setting, as they are most often used as a substitute for proper nail bed injury management [31].

Hand.e horizontal mattress technique for nailbed stenting [32]:

Hand.e figure of eight technique for nailbed stenting [33]:

A fracture linked to a nailbed injury is considered an open fracture. Patients should be discharged after 7 days on oral antibiotics that cover gram-positive bacteria, such as cephalexin, clindamycin, ciprofloxacin, or Bactrim [6]. Displaced fractures of the distal phalanx may require nail bed repair and fracture stabilization, although in some cases, nail bed repair with approximation of the injured nail plate may be enough to realign the distal phalanx [34].

A physeal fracture of the distal phalanx with an overlying nailbed injury is a Seymour fracture, which requires urgent consultation with hand surgery for surgical repair. In some centers with skilled personnel under the supervision of a hand surgeon, it may be possible to repair these injuries in the emergency department [35]. We recommend each center discuss its resources and preferred management setting. We discuss Seymour fractures in further detail in the Fractures section.

After repair, dress the wound by placing gauze between the fingers for padding, then cover the hand with gauze and apply a club cast.

Expert opinion.

Dr. Andrea Bauer: Whenever possible, the nail plate itself, rather than petroleum gauze, suture packaging, or other material, should be used to stent open the nail fold in children. This prevents any need for removal of these other materials in the office, which can be challenging for children.

Dr. Randy Bindra: Replacing the nail plate and applying a figure of 8 suture can reduce and splint a distal phalanx fracture without the need for additional K-wire fixation. The nail plate will spontaneously fall off by 6 weeks and new nail will appear by 3 months.

Finger amputations

Digital amputations disproportionately affect younger children (0–5 years), older children (15–17 years), and males at a 3:1 ratio compared to females. The rate of attempted digit replantation in children is approximately 37%–40%, with broader indications than in adults. The failure rate for digit replantation in children is 20% [36].

For managing a digital amputation in the emergency department, we recommend carefully preserving the amputated part by wrapping it in moist sterile gauze, placing it in a waterproof bag, and keeping the bag on ice water [37]. If hemostasis has not already been achieved in the field, it should be done, and the patient should be adequately resuscitated in preparation for potential replantation. If the decision to proceed with replantation is made, the stump does not need to be examined directly by the emergency department, as it will undergo a thorough examination in the operating room. However, it should be evaluated radiographically in the emergency department to plan for operative fixation if replantation is attempted. It can be radiographed separately or along with the injured digit or hand.

For any complex laceration that may involve bone, tendon, or neurovascular structures, obtain a pulse oximetry reading on the affected digits. A pulse oximetry reading of ≥95% indicates adequate perfusion to the digit [14].

Document the time of injury, injury mechanism that led to amputation, the level of amputation, and conduct a physical examination. Obtain radiographs with the amputated part included in the film, note the patient's primary or secondary smoking status, handedness, and how the amputated part was preserved since the injury.

Management depends on the level of amputation and the condition of the amputated part and should be determined by a hand surgeon. Generally, guidelines for replantation time for areas distal to the metacarpophalangeal (MCP) joint include: less than 24 h for a well-preserved digit (cold ischemia time) or less than 12 h if the digit was not kept on ice (warm ischemia time). For amputations involving the hand, from the carpus to the digits, which only involve intrinsic muscles, cold ischemia time is less than 12 h and warm ischemia time is less than 6 h. A detailed discussion on amputations proximal to the distal interphalangeal (DIP) joint is outside the scope of this article. However, a consulting surgeon should be contacted immediately to decide whether to proceed with replantation.

For amputations distal to the nail or involving only fingertip pulp, we generally recommend composite grafting by suturing the amputated part back in place, as discussed in the fingertip lacerations section. These injuries can be evaluated by a hand surgeon during follow-up, who will decide whether to maintain the composite graft, proceed with revision with acute shortening and primary closure, or perform a local advancement or other flap. We never recommend acute shortening or trimming of exposed distal phalanx in a pediatric patient the emergency department.

If the amputated part is unavailable in a fingertip injury, the fingertip should be covered with an occlusive dressing including nonstick gauze. These injuries in children often heal by secondary intention, even if the bone is exposed, as described in the fingertip laceration section. In older children, where these injuries may not heal as reliably, we recommend performing further procedures in the operating room instead of the emergency department. If closure is done in the emergency department, it is crucial that the nail bed is not sewn over the fingertip and tethered to the volar skin, which could result in a hook nail.

Expert opinion.

Dr. Andrea Bauer: Given the well-established norm of attempting replantation of any digit in a child, the decision of whether to replant a given digit is best made in the operating room, at a center with resources capable of replantation. In the operating room, the exact nature of the injury and the quality of the vessels can be determined. Therefore, expedited transfer of any child with an amputation to an appropriate replant center is essential.

Dr. Randy Bindra: Decision to replant is a complex one and requires careful discussion with the patient/family. A checklist of relevant questions is useful for discussion with the referral center.

Summary

This review combines current evidence with our experience as a trauma and tertiary referral center to offer practical guidance for managing acute pediatric hand trauma. Achieving optimal outcomes depends on mastering basic principles, using appropriate techniques, and establishing effective consultation pathways with hand surgery specialists. By systematically applying these strategies, providers can deliver care that preserves function and reduces long-term morbidity in this vulnerable population.

Author contributions

Micah K. Sinclair: Conceptualization, Writing – original draft, Writing – review & editing. Daniel Santana: Writing – review & editing. M. Claire Manske: Writing – original draft.

Ethics approval and consent

The author(s) declare that no patient consent was necessary as no images or identifying information are included in the article.

Funding

None.

Declaration of competing interests

None declared.