Interventions for treating fingertip entrapment injuries in children

The authors have no financial relationships or conflicts of interest to declare. For the current issue of the Journal, we asked Drs Sarah Reid and Mary Jean Duncan to comment on and put into context the recent Cochrane Review interventions for treating fingertip entrapment injuries in children. Fingertip entrapment injuries, which involve lacerations to the pulp and nail, and often a fracture of the underlying bone, commonly occur in children usually as the result of a crushing injury. Treatment is either conservative (wound cleaning and fingertip dressing) or surgical (repair of lacerations, reduction and stabilization of fractures); however, no consensus currently exists regarding the most appropriate treatment modality. A search was conducted of the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, the World Health Organization Clinical Trials Registry Platform and reference lists of articles up to April 30, 2013. No restrictions were applied for language or publication status. Randomized controlled trials (RCTs) and quasi-RCTs comparing interventions for treating fingertip entrapment injuries in children were selected. The primary outcomes included fingertip function, nail growth, nail deformity and adverse events such as infection. The two authors independently screened studies for inclusion, assessed the risk for bias in each included trial and extracted data. Disagreements were resolved through discusson. The authors included two RCTs involving a total of 191 young children, 180 of whom were included in the analyses. The two trials tested different comparisons. Both trials were at high risk for bias, particularly from lack of blinding of participants and personnel, and of outcome assessment. The trials did not record fingertip function, nail growth or nail deformity. The quality of the evidence for the reported outcomes was judged to be ‘low’ using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (ie, further research is very likely to have an important impact on the authors’ confidence in the estimate of the effect and is likely to change the estimate). One trial compared a seven-day course of antibiotics with no antibiotics after formal surgical repair of fingertip entrapment injuries. One child in each group experienced an infection at day 7 (one of 66 from the antibiotic group versus one of 69 from the no antibiotic group; RR 1.05 [95% CI 0.07 to 16.37]). Both participants with infections experienced a more severe injury (partial fingertip amputation). The second trial compared two different dressings (silicone net and paraffin gauze) for use after either surgical or initial conservative management of fingertip entrapment injuries. It reported that two of 20 children in the silicone group versus one of 25 in the paraffin group experienced complications of wound infection (RR 2.50 [95% CI 0.24 to 25.63]), and that one of 20 children in the silicone group versus two of 25 in the paraffin group experienced skin necrosis (RR 0.63 [95% CI 0.06 to 6.41]). All complications healed with conservative treatment. The results for mean healing times and mean number of dressing changes were similar between groups; however, benefits of either silicone or paraffin dressings could not be excluded (mean healing time of 4.1 weeks and 4.0 weeks for silicon and paraffin, respectively; mean difference [MD] 0.10 weeks [95% CI −0.61 to 0.81]); (mean number of dressing changes were 4.3 and 4.2 for silicon and paraffin, respectively; MD 0.10 [95% CI −0.57 to 0.77]). The trial found that a silicone dressing was less likely to adhere to the wound or cause distress for the child at the one-week dressing change. There is a lack of evidence from RCTs to inform all key treatment decisions for the management of fingertip entrapment injuries in children. Given that the quality of evidence was low from one trial, we do not have conclusive evidence that prophylactic use of antibiotics after surgical repair fails to reduce the risk for infection. The two children who experienced infection sustained more severe wounds. Similarly, the low-quality evidence from one trial has not enabled us to draw firm conclusions regarding the effect on healing time or complications (infection, skin necrosis) at four-week follow-up between a silicone net dressing and a paraffin gauze dressing when applied postsurgery or after simple wound irrigation; however, the silicone net dressing may be easier to remove in the first week. Further RCTs are required in this area, preferably comparing surgical with conservative methods of managing fingertip entrapment injuries. Outcome assessment should include fingertip function, nail growth and nail deformity for a minimum of three months post-treatment. The full text of the Cochrane Review is available in The Cochrane Library: Capstick R, Giele H. Interventions for treating fingertip entrapment injuries in children. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD009808. DOI: 10.1002/14651858.CD009808.pub2. Finger entrapment/crush injuries are common in preschool children. Ideally, significant injuries should be assessed and treated in the emergency department (ED) and followed by a hand specialist to ensure optimal cosmetic and functional outcome. The heterogeneity of injuries encountered in the current review highlight the difficulty in performing clinical trials in this population. In light of the paucity of evidence guiding management, we will summarize the current standard of care based on clinical experience in the pediatric ED and plastic surgery clinic. In the ED, radiography is performed to rule out underlying fractures of the fingertip (‘tuft’) or phalanges. The Seymour fracture (juxta-epiphyseal fracture of the distal phalanx in conjunction with flexion deformity at the fracture site, laceration of the nail bed and/or nail subluxation) must be ruled out because these may develop osteomyelitis if the diagnosis is missed or delayed. The current review describes two management options: conservative or operative repair under general anesthetic. In our experience, the more common approach is repair with local anesthesia (digital block) and Child Life techniques (distraction). Occasionally, sedation in the ED may be required. The Pulp Nail Bone classification (1) outlined in the review, is a helpful guide to approaching these injuries. We have revised it with the addition of management principles (Table 1). Pulp Nail Bone Classification (1) including management principles ED Emergency department; PCP Primary care physician Pulp Nail Bone Classification (1) including management principles ED Emergency department; PCP Primary care physician Digital block is performed using lidocaine with epinephrine (2), using either a traditional digital block or a ‘one poke’ technique on the palmar side in the midline (3). Only absorbable sutures (plain gut) are used for repair. Any significant subungual hematoma is drained. If there is disruption of the nail, the nail bed underneath is inspected for possible injury. Plain gut or tissue adhesive can be used for nail bed repair (4). Avulsed nails can be secured with a suture on each side. In the absence of a nail, a piece of the foil suture packet may be used to splint the nail fold (5); however, there is no evidence that this facilitates nail regrowth. If the bone is exposed, a hand specialist should be consulted to determine whether the bone can be shortened, or whether a flap/graft is indicated to maintain length for function and/or to prevent nail deformities (eg, parrot-beak nail). Amputations without bone exposure can be left to heal by secondary intention, or the amputated part can be replaced as a composite graft. The success of these grafts is variable and may act more as a biological dressing. Bulky dressings are used for these injuries, incorporating more than just the injured digit. The current review did not find a difference between silicone net and paraffin gauze. Our preference is for a fine weave petrolatum-impregnated gauze product, such as Adaptic (Systagenix, United Kingdom), to minimize adherence to the injured area. Dry gauze is folded over the nonadherent gauze, and the fingers and wrist are wrapped using rolled gauze and tape to support the injury. The current review suggests that more severe injuries may be prone to infection. Antibiotic prophylaxis should be used in patients with underlying immunosuppression, contaminated injuries or in true compound fractures of the phalanges (including a Seymour fracture). Tetanus status should be assessed as usual. Ideally, follow-up occurs at one week, at which time the dressing will be removed for the first time. If the tip has been reapplied as a composite graft, it may be dusky or black at this visit. Leaving the initial dressing intact for a full week allows reasonable healing, such that daily washing, simple adhesive bandages and some exposure to air are often possible from then onward. Further follow-up occurs at two weeks and then as needed if there is an issue with nail regrowth or function. These common injuries generally have good functional and cosmetic outcomes that are optimized through complete initial assessment, appropriate repair and close follow-up. Future research may provide further guidance regarding optimal approaches to repair, dressing and antibiotic prophylaxis.

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