Blunt Finger Injury with Swelling — Pediatric (3-Year-Old) Management

1. Initial Assessment

• Mechanism: door crush? direct blow? folding chair?
• Time of injury, dominant hand
• Ability to move the finger before/after

• Site and degree of swelling
• Point tenderness (distal phalanx vs. shaft vs. base)
• Nail bed integrity — look for nail avulsion, laceration, or subungual hematoma
• Rotational deformity (flex all fingers — do they point toward scaphoid?)
• Active flexion/extension at DIP and PIP joints
• Neurovascular status (capillary refill, sensation)

2. Imaging

• X-ray (AP, lateral, oblique) of the affected finger — mandatory if there is pain, swelling, tenderness, or loss of functional integrity
• Look for: fracture pattern, physeal involvement, displacement, angulation

3. Fracture Types and Specific Management

A. Distal Phalanx Tuft Fracture (Most Common)

• Usually crush injury from a door
• Stable due to nail plate and pulp support
• Management: Finger splint (dorsal or volar) for 2–4 weeks, analgesia
• If nail bed injury is present → fracture is classified as open:
  • Requires nail bed repair (under ring block/procedural sedation)
  • Orthopedic or plastic surgery follow-up within 1 week
  • Role of prophylactic antibiotics is controversial (no clear evidence of benefit)

— Tintinalli's Emergency Medicine, p. 958; Rosen's Emergency Medicine, p. 569

B. The Seymour Fracture ⚠️ (Pediatric-Specific — Do NOT Miss)

• Transverse physeal fracture of the distal phalanx (Salter-Harris I or II) associated with crush injury
• Classic mechanism: finger caught in a door — the exact mechanism in this child
• Signs: exquisite tenderness at distal phalanx + nail avulsion at the germinal matrix
• Classified as an open fracture (nail bed laceration communicates with fracture site)
• Management:
  • Urgent orthopedic/plastic surgery consultation
  • Formal nail bed repair + fracture irrigation under anesthesia
  • IV antibiotics (open fracture protocol)
  • Close follow-up to monitor physeal growth

— Rosen's Emergency Medicine, p. 569

C. Phalangeal Shaft Fractures

• Assess for displacement, rotational deformity, and tendon disruption
• Non-displaced, non-rotated: Buddy taping + splinting for 3–4 weeks; orthopedic follow-up
• Significantly displaced, rotated, or tendon disruption: Urgent orthopedic/plastic surgery consultation for closed or open reduction

D. Salter-Harris Fractures (Physeal Injuries — Common in 3-Year-Olds)

4. Subungual Hematoma (Associated Finding)

• If hematoma covers >50% of nail or there is severe pain:
  • Trephination (nail drainage) for pain relief
  • X-ray first to rule out underlying fracture — if fracture present, treat as open fracture

5. Pain Management

• Paracetamol (acetaminophen): 15 mg/kg every 4–6 hours (max 75 mg/kg/day)
• Ibuprofen: 10 mg/kg every 6–8 hours (if >3 months, no contraindication)
• Local nerve block (digital ring block) for procedures

6. Disposition Summary

Key Pitfalls in This Age Group

1. Missing the Seymour fracture — a nail avulsion in a child with a crush injury is an open fracture until proven otherwise
2. Underestimating physeal injuries — plain X-rays may appear normal in SH I fractures; clinical diagnosis
3. Growth arrest risk — physeal injuries require appropriate follow-up even when managed conservatively
4. Rotational deformity — missed on AP X-ray alone; always check clinically and on lateral view