Pediatric Hand Injuries, Part II: Lacerations, Amputations, Bites, and Nail-bed Injuries
Authors: Carl Menckhoff, MD, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Medical College of Georgia, and Chair, Education Committee, Georgia College of Emergency Physicians; Nicholas Kimpel, DO, Resident Physician (PGY3), Department of Emergency Medicine, Medical College of Georgia; and Daniel Kaminstein, MD, Resident Physician (PGY3), Department of Emergency Medicine, Medical College of Georgia.
Peer Reviewer: Steven M. Winograd, MD, FACEP, Attending, Emergency Medicine, St. Joseph Medical Center, Yonkers, NY.
Pediatric hand injuries are common in the emergency department (ED), and may be challenging to manage. Children may be frightened and uncooperative, making a thorough and careful evaluation difficult.
Of particular importance is a comprehensive understanding of the spectrum of injury and potential complications to maximize the child's outcome. The authors complete their review of pediatric hand injuries with this second part, which addresses lacerations, amputations, bites, and nail-bed injuries.
- The Editor
Fingertip Amputation
Epidemiology/Patterns of Injury. Finger injuries are a common occurrence in children and frequently result in visits to the ED. The majority are caused by fingers being caught in closing doors. The resulting associated fractures, lacerations, and partial avulsions due to this mechanism represent the majority of injuries. Complete finger and fingertip amputations are more likely to occur from injuries with sharp objects, are more common in older children, and are less likely to be associated with fractures. One prospective study found that the majority of childhood fingertip injuries were caused by fingers being trapped in closing doors, with about 6% of these injuries resulting in amputation.1
Evaluation. The initial evaluation of fingertip injuries includes assuring hemodynamic stability. Active bleeding should be controlled with direct pressure or, if needed, a brief application of a tourniquet proximal to the injury. The extent of amputation should be assessed, as it will play a central part in management decisions. Vascular, neurological, and musculoskeletal status should be evaluated and documented. Other important factors, including the age of the patient, hand dominance, and mechanism of injury, should also be considered during initial evaluation, as they will play a role in treatment options.
The fingertip is divided into three zones. (See Figure 1.) Zone I injuries are distal to the bony phalanx. Zone II injuries are distal to the lunula of the nail. Zone III injuries are proximal to the distal end of the lunula.2 In zone I injuries, no bone is exposed. In zone II injuries bone is exposed. In zone III injuries, the entire nail bed is lost. These zones have implications for specialty intervention, wound care, cosmetic outcome, and potential wound closure options.
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Imaging. Any amputation that results from crush injury or that has exposed bone should undergo plain radiography to evaluate for fractures. (See Figures 2a and 2b.)
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Management. In general, children with fingertip amputations tend to do well because of their increased capacity to regenerate soft tissues. The majority can be managed with a conservative approach and good wound care. Amputations with no exposed bone (zone I injuries) may be allowed to heal via secondary intention. They must be thoroughly cleaned, wrapped in a non-adherent dressing, splinted, and referred for follow-up with good wound care instructions. In amputations that involve greater than 1 cm of exposed tissue, a skin graft may be necessary to potentiate wound healing.3 In certain cases of zone I injuries, reapplication of the intact fingertip as a composite tip graft may be considered, and has shown good outcomes in children younger than 6 years of age.3,4
In zone II injuries where a small amount (< 0.5cm) of bone is exposed, the bone can be trimmed back with a rongeur below the skin level and the wound allowed to heal via secondary intention.
In zone II injuries where there is a significant amount of exposed bone, consultation with a hand surgeon should be considered.5 The majority of these injuries in the pediatric population will require local or distant pedicle flap reconstruction.6 In dorsal or transverse planes of amputation some experienced emergency physicians can perform a V-Y plasty advancement flap to close the wound and cover the exposed bone once it is smoothed down. (See Figure 3.) There are many additional local flaps used to reconstruct fingertips including the volar V-Y, bilateral V-Y flaps, cross-finger flap, thenar flap, and island flaps.7,8 Flap choice depends on orientation and configuration of the wound, and which finger is injured. In zone II injuries, the lunula and germinal matrix are preserved so the patient will eventually have some regrowth of their fingernail.
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Zone III injuries involve the nail matrix and result in the loss of the entire nail; adults with these injuries are not candidates for elaborate reconstruction.6 In children, however, a hand surgeon may consider reimplantation if the distal tip is well preserved. If reimplantation is not an option, revision amputation is performed. This involves shortening and smoothing the remaining bone stump with a rongeur or file to allow a tension-free closure of the soft tissues, and adequate fingertip padding. Any residual germinal matrix must be removed to prevent nail horn formation.3 Articular cartilage should be preserved, allowing for a shock pad for the fingertip.
Further management considerations. More extensive amputation of digits proximal to the distal interphalangeal (DIP) joint and entire digit amputations will almost all require evaluation and treatment by a hand specialist. (See Table.) Some basic early management strategies for more complex amputations can be instituted. While the hand surgeon will make the final decision, almost every pediatric digit amputation should be considered for reimplantation. Some general contraindications include unstable patients with other life-threatening injuries or multi-level amputations.
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Initial evaluation is similar to that described previously. Assessment of the injured extremity should include mechanism of injury and evaluation of neurologic, vascular, and musculoskeletal function. Amputations can be complete or partial (some remaining tissue connection between proximal and distal portions).
With partial amputations, the wound should be cleaned thoroughly with irrigation, wrapped in a sterile moist dressing, and splinted. Cold packs can be applied to delay further ischemia, and the involved digit should be kept elevated to minimize swelling.
Management for complete amputations is comparable. The proximal stump and amputated part both need to be cleaned. The stump should be wrapped in a saline-moistened sterile dressing to prevent further trauma and desiccation. The amputated part is wrapped in a moistened dressing, placed in a dry plastic bag, and then kept in ice water.
The age of the patient has significant treatment implications. In pediatric patients, the maturity level will vary greatly, requiring some unique considerations. This is especially true when considering pain control and sedation. While a 17-year-old may be able to sit through a prolonged fingertip closure, the younger child likely will be unable to do so. Sedation in the operating room or by the emergency physician may become necessary in certain cases.
A common complication encountered in the treatment of fingertip injuries is hypersensitivity and cold intolerance. These are complications of the injury itself, not the treatment, with a rate of approximately 50% regardless of treatment. This hypersensitivity is often self-limited and resolves in 1-2 years; nevertheless, parents and patients should be counseled to expect this.3 Antibiotic use in fingertip amputations also should be mentioned. Most authors recommend that patients with fingertip injuries receive an initial intravenous (IV) dose, followed by an oral course of a cephalosporin.9
Key points. The initial evaluation of the injury and determination of the zone involved is key in determining the type of treatment for fingertip amputations. Children frequently do well with these injuries, even in cases where an amputated tip is reimplanted.
Fingertip and Nail Bed Injuries
Epidemiology. Fingers caught in doors account for the majority of childhood fingertip injuries.10,11 Fractures to the underlying distal phalanx and injuries to the fingernail and nail bed are the most common complication of these injuries. The emergency physician must be prepared to adequately evaluate these injuries, repair them, and seek referral as appropriate.
Patterns of Injury. Fractures of the distal phalanx are a common complication of crush injuries to the fingertip. (See Figure 4.) (See "Pediatric Hand Fracture-Part I," September 2009 Pediatric Emergency Medicine Reports, page 111, for specific management details.) Subungual hematomas and nail bed lacerations are other common complications of crush injuries and frequently occur together. Distal phalanx fractures with greater than 50% subungual hematoma have a greater than 95% incidence of an associated nail bed laceration.12
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Evaluation. Evaluate the fingertip for the possibility of a fracture. Evaluate the nail for presence and size of lacerations and subungual hematomas.
Imaging. Plain radiographs of the finger should be obtained if there is any suspicion of a fracture.
Management. Nail-bed injuries. The entire nail bed is important for growth and migration of the nail; therefore, it is important to consider the integrity of the nail bed when encountering fingertip injuries in children.13 Simple lacerations to the distal aspect of the nail bed represent the majority of nail-bed damage.14 One system of classification divides these injuries into subungual hematoma, simple laceration, stellate laceration, severe crush, and avulsion.15 However, the disadvantage of this system is that to categorize the injury the nail must be removed and the nail bed explored-a painful and time-consuming process. While there is still some difference of opinion, basic management of nail-bed injuries for the emergency physician is probably best broken down into three categories: subungual hematoma with an intact nail and nail margin, subungual hematoma associated with disruption or laceration to the nail or nail margin, and the more significant crush or avulsion injuries to the fingertip likely to result in deformity or functional impairment. The first two of these can be managed by an emergency physician with referral for outpatient follow-up. The third requires specialty consultation.
This method of categorization is somewhat oversimplified as it does not account for the controversy regarding exactly when nail-bed lacerations require removal of the nail and repair of the damaged nail bed.13,16 Some authors have argued that an intact nail will act as a splint for the laceration, and therefore, removal of the nail, regardless of the size of a subungual hematoma, is not required. Others suggest that the nail must be removed and the nail bed explored if there is any suspicion for laceration or if the subungual hematoma covers greater than 25% of the nail surface.13,17 The two most recent studies that have compared these two approaches have found that in intact nails, trephination alone without nail removal does not carry a higher risk of infection, complications, or deformity.13,18 Therefore, in most cases, intact nails with subungual hematomas can be managed with trephination alone, while nails that are disrupted should be removed and explored.
Subungual hematomas. Subungual hematomas are usually caused by a blow to the nail, most commonly from a finger being caught in a closing door. The nail-bed matrix bleeds under the nail, causing a discoloration and a significant amount of pain. Drainage is accomplished by nail trephination. The nail plate has no nerve endings, so local anesthesia usually is not required. The nail should be cleaned with povidone-iodine swabs and then punctured with a hot metal wire. This can be accomplished by means of either an electrocautery device or a large paper clip that has been heated. Once the hematoma is relieved, the puncture site should be kept covered with sterile gauze while the wound continues to drain. The dressing should be changed daily.
Any fracture of the distal phalanx with a subungual hematoma is considered an open fracture. Open fractures usually require antibiotics. However, in the cases of isolated nail-bed damage there is no clear evidence supporting the benefit of antibiotics, as some studies have shown a benefit while others have not.19,20 The decision to use prophylactic antibiotics in these patients (first-generation cephalosporin) should be on a case-by-case basis.
Nail-bed laceration and repair. If there is significant damage or disruption to the nail, then primary nail-bed repair should be performed to prevent aesthetic deformity, and the entire nail must be removed to allow appropriate inspection and repair. Simple or stellate lacerations can be repaired with 5-0 or 6-0 absorbable suture. After the nail bed is approximated, a hole is burned through the nail to allow for drainage of any accumulation of blood. If the intact nail is available, it can be reinserted into the nail fold and secured using tape or suture to form a splint and to prevent deformity with new nail growth. If the nail is not available, non-adherent gauze can be used as a temporary splint. After repair, patients should be followed up by a hand specialist to ensure that the injury is not becoming infected and that proper healing is taking place.
Key Points. In intact nails with subungual hematomas, trephination alone is adequate in most cases, even if a nail-bed disruption exists. Nails that are disrupted should be removed and the nail bed explored.
Lacerations
Patterns of injury and epidemiology. Lacerations to the hand are the most common pediatric hand injury, the majority of which require some form of closure.21,22 Lacerations from sharp objects occur as frequently as those caused by blunt mechanisms such as being shut in a door.22 Most of these injuries in the pediatric population will present soon after injury for evaluation. The emergency physician should be prepared to repair simple lacerations and seek referral for more complex injury patterns. A common mistake is failure to identify the need for surgical exploration for injuries involving joints, nerves, or flexor tendons.23
Evaluation. The appropriate evaluation of a laceration is essential to determine the need for repair and consultation. Tendons, joints, nerves, and vascular structures are all located in close proximity in the hand and coinjuries may occur easily. Because of the critical structures in the hand, appropriate exploration of the wound is essential. This can present a challenge in the pediatric population and may require procedural sedation in the case of extensive injuries.
Neurovascular and motor function should be carefully tested, and this can be particularly challenging in a young child. Active flexion and extension should be assessed to evaluate for possible tendon injuries. Gross sensation and two-point discrimination should be tested distally to assess for possible nerve damage. The hand has a dual blood supply with collateral flow via the palmar arch, and in general, injury to a vascular structure does not cause problems with distal blood supply.24 Arterial injuries that have distal ischemia require urgent surgical repair. In the nonverbal or uncooperative pediatric population, comparing the resting position of the injured hand with the uninjured hand may help to localize a possible tendon involvement. Two-point discrimination is of little value in young children.
The wrinkle test or the sweat test are two alternative ways that innervation can be assessed. In the wrinkle test, the hand is immersed in warm water for 20 minutes; normally innervated digital pulps will wrinkle, while those with disrupted sympathetic flow will not.25 With the sweat test, the hand is painted with povidone-iodine and placed in a sterile glove; sweating in the normal innervated areas will turn the talc in the glove black.
Lacerations should be carefully cleaned and any debris removed. Exploration must be performed through the entire range of motion, as partial tendon lacerations that occurred in finger flexion will not be seen if the wound is only explored with the finger extended. Also, completely lacerated tendons can retract into the wound. Hemostatic control can be achieved by inflating a blood pressure cuff proximal to the injury or using the rolled-up finger of a glove as a tourniquet.
Anesthesia is important to allow for appropriate cleaning and exploration. In the pediatric population, this can be accomplished by topical anesthetic, local anesthetic, or regional nerve block. Nerve function should be carefully evaluated prior to the utilization of anesthesia.
Imaging. Plain radiographs of the hand should be obtained in cases where the mechanism of injury may have led to fracture, joint involvement, dislocation, or retained foreign body.
Management. Simple lacerations. Lacerations to the hand that do not involve underlying structures can be cleaned, irrigated, and repaired like any other laceration. Deep sutures should be avoided, in general, in the repair of simple lacerations to the hand, as they can be a nidus for infection. Lacerations that are repaired over areas of motion require splinting of the involved extremity until the wound edges have time to adhere. Prophylactic antibiotics are generally not required in simple hand lacerations that have been well cleaned.
Extensor tendon injuries. The most common site of tendon injuries is over the dorsum of the hand and involves an extensor tendon. Extensor tendon repair should be performed with tendon lacerations that involve greater than 50% of the tendon or with a 50% decrease in strength compared to the contralateral finger.26
The dorsum of the hand is divided into eight zones to help facilitate treatment of extensor tendon injuries.27 (See Figure 5.) The decision to repair an extensor tendon laceration in the ED depends on the complexity of the injury and the zone of the hand involved. Simple lacerations to zones I, II, IV, and VI can be repaired primarily by the experienced emergency physician.9,24,26 Zone I and II injuries can be repaired by a roll-type suture or a figure-eight suture using 5-0 non absorbable suture. (See Figure 6.) Zone IV injuries can be repaired with either a figure-8 suture with buried knots or a modified Kessler stitch with 5-0 non absorbable suture.26 (See Figure 7.) Zone VI injuries can be repaired with the same technique using 4-0 non-absorbable suture.
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Tendon lacerations in zone III may involve portions of lateral bands or the central slip of the extensor mechanism and should be referred to a hand surgeon for repair.28 Lacerations to zone V are most frequently caused by human bites and should be left open and referred to a hand surgeon for follow-up and possible delayed closure.26 Zones VII and VIII can involve lacerations to the extensor retinaculum and require operative repair.28 Any injuries extending into the joint with significant overlying skin loss or underlying fractures are best managed by a subspecialist in the operating room.26
Treatment after extensor tendon repair used to involve static splinting for six weeks. More recent studies have shown improvement in outcomes for patients that undergo early mobilization after extensor tendon repair.29,30 Therefore, early follow-up with a hand surgeon is important for patients undergoing extensor repair in the ED. Broad-spectrum antibiotic prophylaxis is recommended in all lacerations with tendon involvement.
Flexor tendon injuries. Flexor tendon injuries associated with laceration to the hand require consultation and repair by a hand surgeon.24 If a surgeon is not immediately available, the wound can be cleaned and splinted. A volar splint with the wrist in 20° of flexion, the MCP joint in 60° of flexion, and the IP joints in 15° of flexion is the preferred splint in this case. Lacerations to the digital crease can damage more than one of the tendons of the finger. In these injuries, differentiating between lacerations to the flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS) is an important distinction. FDP function is tested by having the patient flex at the DIP joint while the finger is held in extension. (See Figure 8a.) The FDS is tested by having the patient flex at the proximal interphalangeal joint (PIPJ) while holding the remaining fingers in extension. (See Figure 8b.) Because of the common flexor mechanism of the FDP, holding the remaining fingers in extension prohibits the flexor action of the FDP on the finger being tested, thus isolating its FDS function.
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Key Points. Simple lacerations and most extensor tendon injuries can be repaired by the emergency physician. More complex patterns of injury, neurovascular compromise, or flexor tendon involvement require immediate surgical consultation or close follow-up.
Bites
Epidemiology / Patterns of Injury. Attacks by animals, either provoked or unprovoked, occur frequently in children and are likely to cause parents to bring their children to the ED. The emergency physician needs to appreciate the unique aspects of these injuries when evaluating children with animal bites to the hand.
Statistically, younger children experience more bites to the head and trunk, while adults and older children are more commonly bitten on the hand. The hand contains tendons, joints, vessels, bones, and fascial compartments in a small cross-sectional area; therefore, it is prone to serious injury and significant infections, making attention to these injuries particularly important. Additionally, ED evaluation must take into consideration who, if anyone, needs antibiotic prophylaxis, who needs to be vaccinated for rabies, and what common complications to consider with specific bites.
Evaluation. Initial approach to hand bites is similar to any other injury: assess the wound, stop any active bleeding, and evaluate neurologic and musculoskeletal function. Good wound care is the key to preventing infections. Bite wounds need to be thoroughly cleaned with soap and water and a fine-pore sponge if rabies is a concern. Devitalized tissue or gross debris must be removed.31 Hands are particularly prone to infection, and most authors recommend avoiding primary closure.32-34 Joint involvement is also a concern and should be considered in all puncture wounds.
Imaging. Location of the bite wound dictates the need for radiographic evaluation. In most wounds, x-rays of the involved area should be taken to rule out fractures or retained teeth. This is particularly important with dog bites, where the crush aspect of the injury can be as severe as the puncture.
Management. Dog bites. A review of pediatric dog bites found that approximately 28% of wounds are to the upper extremity and hand.35 Cultures from infected dog bite wounds are frequently polymicrobial. Common organisms include Staphylococcus aureus, alpha and beta hemolytic strep, Bacillus, Pasteurella, and Pseudomonas. Although Pasteurella is often discussed in association with dog bites, it is rarely the sole pathogen. Dog bites are most likely to cause crush injuries with ripping or tearing of the skin. As a result, these should be carefully inspected and imaged for possible fractures and other musculoskeletal injuries. Fractures, tendon injuries, joint penetration, and evidence of neurovascular compromise mandate appropriate splinting and consultation with a hand surgeon. All bites to the hand should receive antibiotic prophylaxis. First-line treatment includes amoxicillin/clavulanate for oral therapy or ampicillin/sulbactam for IV therapy. In penicillin-allergic patients, extended spectrum cephalosporins or trimethoprim-sulfamethoxazole plus clindamycin is recommended. One meta-analysis of prophylactic antibiotics for dog-bite wounds found that a relative risk of infection was 0.56 in patients treated with antibiotics compared to controls, and that the number needed to treat is 14 patients to prevent one infection.36
Capnocytophaga canimorsus is a serious but uncommon complication of bite wounds. Approximately 100 cases have been reported since 1976, most often associated with dog bites in immunocompromised patients.37 The illness begins within two to three days of exposure and is characterized by hypotension, disseminated intravascular coagulation (DIC), and renal failure. Treatment for established infection is supportive care and IV second- or third-generation cephalo-sporin plus amoxicillin/sulbactam.
Cat bites. Cat bites are almost always puncture wounds, and when located on the hand they frequently enter into the joint space. Therefore, when treating cat bites to the hand, the potential for the delayed complication of joint infection should always be considered. Pasteurella multocida, S. aureus, and Streptococcus are the most common pathogens, with Pasteurella being the most significant. Cats frequently clean their claws, so even scratches to the hand carry the risk of infection. Puncture wounds should not be irrigated directly into the puncture site unless it is a through-and-through injury, and wounds should not be closed primarily. Due to the high rate of infection, most cat bites in general and all cat bites to the hand require prophylactic antibiotics. Recommendations are similar to that of dog bites, with coverage aimed towards Pasteurella - amoxicillin/clavulanate or a second-generation cephalosporin such as cefuroxime are appropriate options. P. multocida is resistant to cephalexin, clindamycin, and erythromycin. Penicillin-allergic patients can be given extended spectrum macrolides such as azithromycin, fluoroquinolones, or TMP-SMX.38 Because up to half of cat bites become infected, some authors recommend that patients receive one dose of IV antibiotics while in the ED.32,38
Cat-scratch disease is a potential but uncommon complication of cat bites. It is caused by the organism Bartonella henselae. The primary lesion is a crusted papule that develops at the injury site 3-10 days after the bite or scratch. Tender lymphadenopathy occurs two weeks later, with malaise and fevers in about 25% of cases. Rare occurrences of encephalopathy and atypical pneumonia have been seen in association with this condition. The course is usually self-limited and resolves in 2-3 months without treatment. Severe cases can be treated with tetracyclines.34,38
Human bites. Another common pediatric injury is human bites. In young children, bites to the hand from other children that do not penetrate the skin need nothing more than local wound care. As with all human-inflicted wounds, child abuse should always be a consideration. Wound care and evaluation is similar to that of all other bites, including imaging as necessary.
The "fight bite" is the most recognized human bite wound to the hand and carries with it a multitude of complications. Fight bites are more common in older children and occur when a clenched fist strikes a tooth, resulting in a deep laceration at the MCP joint. Upon relaxation of the fist, oral flora is inoculated in the relatively avascular fascial layer.34 Fight bites need to be carefully irrigated and then explored in both flexion and extension to evaluate for tendon injury. The presence of an extensor tendon injury is highly predictive of joint penetration, requiring evaluation by a hand surgeon.32 Children with fight bites often present late, once infection is already established. These patients need to be placed on IV antibiotics and be considered for surgical debridement.
Human bites are usually polymicrobial, with Streptococcus and Staphylococcus being the most common. Eikenella corrodens is a facultative anaerobe found in 25% of closed-fist injuries.39 Prophylactic and inpatient antibiotics are the same as in dog bites. Infected wounds may also require anaerobic coverage, and consideration on a case-by-case basis for infectious disease transmission of pathogens such as Hepatitis B, Hepatitis C, HIV, herpes, and syphilis.
Monkey bites. While rare, monkey bites deserve mention as they are reported to carry some of the highest risk for bacterial infection.40 Treatment is similar to that of human bites. All bites to the hand should receive prophylactic antibiotics selection similar to that for human bites. B virus (Cercopithecine herpesvirus) can be transmitted by wounds from infected macaque monkeys, in particular rhesus and cynomolgus. Wounds from potentially infected animals need to be cleaned immediately with chlorhexidine or povidone-iodine solutions for 15 minutes. If the exposure is high-risk (actively infected animal or one with visible lesions), then prophylactic anti-virals should be considered.
Rabies. A detailed discussion of rabies treatment is beyond the scope of this article, although some basics can be outlined here. Post-exposure prophylaxis is indicated if the animal is known or suspected to be rabid. High-risk animals include bats and wild carnivores (bobcat, coyote, fox, raccoon, skunk, and wolf). Bites from healthy animals that can be observed for 10 days, or animals who can be examined for rabies, do not require prophylaxis. Rabbit or rodent bites usually do not require treatment, but consult local public health officials about the prevalence of rabies in these animals. If prophylaxis is indicated, previously unimmunized patients should receive 20 IU/kg of the immune globulin. As much immune globulin as possible should be given directly at the bite site, with the remainder given in the deltoid. Human diploid cell rabies vaccine (1 mL) is indicated on days 0, 3, 7, 14, and 28. In the pediatric population, the amount that can be infiltrated near a hand injury will be minimal. As with all wounds, thorough cleaning of the injured area is the most important step to prevent infection with rabies.
Tetanus. Tetanus prophylaxis should be considered in all patients with a vaccination status more than five years out of date. DPT is recommended for children younger than 7 years old. Tdap is recommended for adolescents age 11-18 years in place of Td.
Key Points. Dog, cat, and human bites are the three most common animal bites seen; they are also the most common hand injuries that present with delayed infection.32,33 All bites to the hand and virtually all cat bites should receive antibiotics.
Conclusion
Pediatric hand injuries are commonplace in the ED. While some may need operative intervention, after a careful assessment and an awareness of potential pitfalls, the skilled emergency physician should be able to successfully diagnose and optimally treat these frequent pediatric injuries.
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Pediatric hand injuries are common in the emergency department (ED), and may be challenging to manage. Children may be frightened and uncooperative, making a thorough and careful evaluation difficult.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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