Certain upper extremity conditions are commonly seen or are important for timely diagnoses and treatment or referral. This section is not meant to be comprehensive or inclusive of all upper extremity conditions that may be seen, but rather is a brief overview of those that every pediatric resident and practicing pediatrician should know about. A “triage” list is provided at the end.
Physical examination of the hand injured by trauma is critical to determine if tendons or nerves have been damage. The active range of motion of the fingers distal to the injury should be assessed, and the depths of the wound should be inspected directly for partial or complete injuries to tendons. Sensation in all fingers and function of the intrinsic muscles in the hand should be assessed while inspecting the wound fro evidence of nerve injury. The presence of arterial injury renders the possibility of nerve injury much higher. If an injury is confirmed or suspected, refer the patient to a hand surgeon.
All open wounds should be gently cleansed and assessed for nerve, vessel, and tendon injury. If bleeding cannot be adequately controlled by direct pressure or if the distal circulation has been compromised, the patient should be referred to an emergency department for further evaluation. Open wounds should never be clamped to control bleeding. If sensation is normal in all fingers, and tendon function is intact, the wound can be closed and the entire forearm and hand splinted to allow the wound to heal. If there are deficits in tendon or nerve function, follow-up evaluation and definitive treatment by a hand surgeon should be arranged within the next 5 to 7 days.
An important note is that some fingertip amputations do not have to go to the emergency department when they occur. If no bone is exposed, the finger wound can be gently cleansed and then covered with a nonadherent dressing (Telfa, Adaptic, Xeroform gauze, petrolatum gauze, etc). Fluffed gauze can then be put between all the fingers and then over the injured finger, which can then be wrapped with cast padding, followed by a short or long arm cast, and examined subsequently by a hand surgeon for further care. If a child is younger than 5 years, a long arm cast with the elbow bent to 90° is preferred. For a child older than age 5 years, a short arm cast is appropriate. The wound will heal by secondary intention, and after approximately 3 weeks in a cast, most of these minor injuries will be healed and pain free. If bone is exposed or if the nail plate has been pulled out of the eponychial fold (otherwise known as an open Seymour physeal fracture), the patient should be referred to an emergency department for urgent care.