Abstract: The hand is one of the most frequently injured parts of a child's body. Thorough knowledge of the pediatric hand anatomy is necessary to guide the evaluation and management of children presenting with hand injuries. Appropriate and timely management strategies have important functional and cosmetic outcomes and thus should be individualized to the patient's skeletal maturity, injury type, and severity, avoiding complications such as physeal damage and/or growth arrest. Ultimate outcome depends upon initial care. All pediatric hand fractures require close follow-up with the proper specialists for long-term monitoring. After emergency department evaluation, patients and families should be provided with complete and clear instructions including when to return to care, anticipatory guidance, and cast or splint care.

Keywords: pediatric hand injury; fracture; boutonniere deformity; boxer's fracture; scaphoid fracture; mallet finger; skier's thumb; gamekeeper thumb; jersey finger

Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA. Reprint requests and correspondence: Susan K. Yaeger, MD, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, AOB 2nd Floor Suite 2400, Pittsburgh, PA 15224. [email protected] 1522-8401 © 2016 Elsevier Inc. All rights reserved.

Pediatric Hand Injuries Susan K. Yaeger, MD, Mananda S. Bhende, MD

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nowledge of the detailed anatomy of the hand will help clinicians successfully assess pediatric hand injuries. The bones of the hand include 8 carpals, 5 metacarpals, and 14 phalanges. Each finger has 3 joints: the metacarpophalangeal (MCP), the proximal interphalangeal (PIP), and the distal interphalangeal (DIP) joints. The thumb has one MCP and one interphalangeal joint. The extrinsic muscles of the hand originate in the forearm and their tendons pass through the wrist and insert in the hand. These extrinsic muscles are responsible for flexion and extension of the wrist and digits. The extrinsic extensor tendons join to form the extensor hood at the MCP. The central portion of the extensor hood forms the central slip, which inserts onto the middle phalanx and acts to extend the PIP joint. The intrinsic muscles of the hand have their origins and insertions in the hand. They make up the thenar and hypothenar eminences as well as the lumbricals and interosseous muscles. The lateral bands are formed from the deep head of the dorsal interossi combining with the volar interossi. The lateral bands insert into the dorsal surface of the distal phalanx, along with the extensor hood, to extend the DIP joint. The radial and ulnar arteries supply blood to the hand through a series of arches. Innervation of the hand is supplied by the radial, ulnar, and median nerves. Hand movements are complex. These include: supination and pronation of the forearm; extension, flexion, ulnar deviation, and radial deviation of the wrist and extension, flexion, abduction, and adduction of the fingers. The thumb's movements include flexion, extension, opposition, palmar abduction, and radial abduction. 1 Particular attention should be paid to the physes in the management of pediatric hand fractures and during reductions. Pediatric bones have a strong periosteum and adjacent joint capsule and ligaments. This periosteum gives children great remodeling potential. However, the growth plate is the weakest area of a child's bone and is therefore most vulnerable to fracture. 2 Although variation exists, typically physes exist on the proximal ends of the PEDIATRIC HAND INJURIES / YAEGER AND BHENDE • VOL. 17, NO. 1 29

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through the metaphysis and the physis. Salter-Harris type III fractures include those extending through the physis and the epiphysis. Salter-Harris type IV fractures involve the metaphysis, physis, and epiphysis, and finally, Salter-Harris type V is a crush injury involving the physis. Although any fracture involving the physis can risk future growth, those at the greatest risk are Salter-Harris type III, IV, and V fractures. 3

APPROACH AND EXAMINATION OF PEDIATRIC HAND INJURIES

Figure 1. Normal hand x-ray of a 3-year-old girl demonstrating typical physes locations.

phalanges, the proximal end of the thumb metacarpal, and the distal end of the finger metacarpals (Figures 1 and 2). Salter and Harris devised a classification scheme for fractures involving the physis. Salter-Harris type I is a fracture involving only the growth plate and may appear normal on imaging. A Salter-Harris type II fracture extends

Figure 2. Normal hand x-ray of a 12-year-old boy demonstrating typical locations of physes.

The mechanism of injury can help determine forces that were applied to the patient and resultant injury patterns. On examination of the hand, the examiner must assess the skin's integrity as well as the motor and sensory function of the hand. Often, the best functional examinations can be done while young children play with parents and siblings. First, a clinician should observe the patient, taking note of the hand's position and spontaneous movement, before a hands-on examination. For instance, a rotational deformity can be found with observation. As fingers are flexed all should be pointed toward the scaphoid, without overlapping or scissoring (Figure 3). A rotational deformity must be corrected, frequently by surgical pinning, as this could lead to permanent functional disability. Motor function of the fingers can be assessed by testing both the muscle strength and tendon function. With a cooperative patient's palm facing upward on the examination table, the physician can apply 2 fingers to the involved finger just proximal to the DIP joint, holding the injured finger against the table. One can assess the distal muscle strength and the integrity of the flexor digitorum profundus tendon, by asking the patient to flex the tip of their affected finger. Similarly, a clinician can assess the proximal muscle strength and the flexor digitorum superficialis tendon by holding the adjacent noninjured fingers

Figure 3. Rotational deformity can be detected with observation. When flexed, all fingers should point toward the scaphoid (on right), without overlapping or scissoring (on left) indicating a rotational deformity (illustrated by Erika Pasciuta, MD).

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against the examination table and asking the child to flex the injured finger. Extensor tendons can be evaluated by asking the child to close and open their hand. Pain, weakness, or, inability to perform these movements, especially against resistance, may indicate a tendon injury. A full neurovascular examination is also important. See “Traumatic Orthopedic Injuries” elsewhere in this issue for a thorough description of this examination. Radiographs are almost always indicated when there is point tenderness, swelling, or deformity. Imaging of the contralateral hand may help with variations at the ossification centers. In pediatric patients, judicious use of analgesics and anesthetics will help achieve the highest quality examination. A transthecal digital nerve block (Figure 4) of a single injection at the midproximal phalanx can achieve successful anesthesia for wound exploration, washout, and repair as well as fracture reductions. 4 Ultrasound-guided forearm nerve blocks in pediatric hand injuries have also been described. 5 Although most pediatric injuries are accidental, the examiner must also consider the age and development of the patient to help determine if the trauma may have been inflicted. In the event of accidental injury, the approach to pediatric patients and families should include guidance on future injury prevention strategies.

Figure 4. Transthecal digital nerve block can be used to anesthetize pediatric finger injuries for completion of the physical examination as well as before wound repairs or fracture reductions. This digital block is achieved with a single injection of local anesthetic into the flexor tendon sheath at the midpoint between the proximal digital and the PIP joint creases (illustrated by Erika Pasciuta, MD).

SCAPHOID Scaphoid fractures represent less than 1% of upper extremity fractures in children; however, this is the most commonly fractured carpal bone in children. 6 The usual mechanism of injury is a fall on an outstretched hand. These fractures should be suspected with tenderness upon deep palpation of the snuff box area just distal to the radial styloid. If x-rays are normal—including an oblique view, which best shows the scaphoid fracture—the patient should be immobilized with thumb spica splinting or casting

Figure 5. A, Scaphoid view x-ray of a 13-year-old adolescent girl who fell on an outstretched hand during gymnastics with scaphoid waist fracture, managed with thumb spica. Repeat imaging 6 weeks after injury (B) and 12 weeks after injury (C).

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and follow-up in 10 to 14 days for repeat radiographs. For further imaging, magnetic resonance imaging maybe more revealing than x-ray, 7 and there are recent publications demonstrating the use of ultrasound to detect scaphoid fractures. 8 Traditionally, scaphoid fractures in children and adolescents were thought to be predominantly injuries of the distal pole requiring no operative management. This excellent remodeling was attributed to the scaphoid's ossification pattern progressing distally to proximally and the bone's blood supply entering at the distal pole. However, more recently, fracture patterns have shifted to those more similar to adults, suggesting

that scaphoid waist fractures (Figure 5), those with the greatest propensity for nonunion, are becoming more common. 9 Still, patients aged 13 years and younger, continue to sustain distal pole fractures, and more than 90% of nondisplaced fractures immobilized with casting will have an uncomplicated union. 10 The more proximal and more displaced fractures managed with casting take more time for union, sometimes up to 12 weeks. 9 Surgical intervention is typically indicated for patients with acute displaced injuries, failed cast immobilization, and late-presenting scaphoid nonunions. If a scaphoid fracture is suspected but initial x-rays are normal, the patient should be

Figure 6. A, 14-year-old adolescent boy involved in a fist fight with distal 4th and 5th metacarpal fractures (boxer's fractures) with radial and ventral angulation. B, He was treated with an ulnar gutter cast and demonstrated incremental healing after 4 weeks of casting.

Figure 7. 17-year-old adolescent boy fell while playing soccer with first metacarpal base fracture (A), managed with thumb spica cast, and had incremental healing at 3 weeks (B). His cast was removed at that time, and then, he was given commercial thumb brace for 3 to 4 more weeks.

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immobilized with thumb spica splinting/casting and follow-up in 10 to 14 days for repeat radiographs.

METACARPALS One of the most commonly fractured bones in the hand is the fifth metacarpal. 11 The most common site of metacarpal fractures is the fifth metacarpal neck, an injury associated with a clenched fist making a direct blow onto a hard surface, which is referred to as the boxer's fracture (Figure 6). These fractures are managed with closed reduction and ulnar gutter splinting or casting in an intrinsic plus position. This position ensures tension on the collateral ligaments of the wrist and the MCP and interphalangeal joints of the hand, thus avoiding contractures while the hand is immobilized. For intrinsic plus positioning, place the wrist in 30° of extension, the MCP joints in 70° of flexion, and the interphalangeal joints in full extension. Closed reduction is achieved with the Jahss maneuver; application of a dorsally directed force to the 90° flexed proximal phalanx and palmar directed counter pressure to the fracture site. 12 Rotational deformity must be evaluated and corrected. There may be a laceration over the MCP joint, which should be evaluated for tendon damage and repair. If the injury was sustained from striking another person, a laceration may represent a human bite and require not only tetanus prophylaxis but also antibiotics.

Figure 8. Salter-Harris type II fracture of third proximal phalanx with minimal medial angulation of the distal fragment, managed with immobilization.

Figure 9. A, 13-year-old adolescent girl with Salter-Harris type III fracture at the base of the thumb's proximal phalanx (skier's thumb or gamekeeper's thumb) after a collision during softball game. B, Injury managed with closed reduction, pinning, and thumb spica.

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Metacarpal base fractures (Figure 7) are the most common thumb fractures in children. 13 If adequate closed reduction can be obtained, closed reduction and thumb spica splinting/casting are appropriate. Orthopedic consultation is not always necessary in the acute setting if acceptable reduction can be obtained. However close follow up (7-10 days) is indicated.

PROXIMAL AND MIDDLE PHALANX Of all phalangeal fractures, most involve the proximal phalanx. 11,14 Most common are Salter-Harris type II fractures at the base of the proximal phalanx (Figure 8), and these are often minimally displaced or nondisplaced requiring only immobilization. However, displaced injuries often result in deformity and decreased hand function. 13 Therefore, displaced and unstable phalanx fractures are often treated with closed reduction and percutaneous pinning with good results in both function and appearance. 15 Middle phalanx fractures are less common than proximal but continue to occur. These are treated similarly to their counterparts in the proximal phalanx. Typically, middle phalanx fractures in children are nondisplaced and can be treated with buddy taping. In all phalanx fractures, one must assess for and correct rotational deformities. Hand specialist consultation is required for rotational deformity, neurovascular compromise, and displaced fractures. Salter-Harris type III and IV fractures at the base of the thumb's proximal phalanx can contribute to ulnar collateral ligament instability (Figure 9). These injuries are commonly called skier's thumb or gamekeeper's thumb, as they occur with a fall on an outstretched hand holding a ski pole or when a ball forcibly hyperextends the thumb. Operative management is often required for this ligamentous injury; however, minor injuries may be conservatively managed by the appropriate subspecialist. Phalangeal neck fractures are almost exclusively seen in children after crush injuries. These injuries are difficult to detect radiographically, and malalignment is often missed. Displacement results in mechanical block to interphalangeal joint flexion. Thus, closed reduction and percutaneous pin fixation are recommended for initial management. 16 Because the phalanges do not have distal physes, the remodeling potential of these fractures is limited. Neglected fractures can progress to nonunion, particularly in the thumb. 17 Phalangeal fractures and lacerations may be associated with extensor tendon injuries due to the tendons' superficial location. Distally, an injury at the DIP joint is called a mallet finger. It may be due to fracture, tendon disruption from its insertion, or laceration. 1 It is usually caused by forcible flexion

of the DIP joint, as when a ball hits the finger tip causing forceful flexion and avulsion of the extensor tendon. A finger splint can be placed on those injuries caused by tendon disruption. This splint should immobilize the DIP joint in full extension for 8 weeks, while leaving the PIP joint free. For those mallet fingers caused by distal tendon laceration, surgical repair is required. A boutonniere deformity can result from a direct blow over the extensor surface of the PIP joint and disruption of the extensor tendon, with volar subluxation of the lateral bands. The lateral bands typically lie dorsally and extend the joint; however, in the volar position, they cause the extensor mechanism to shorten, act as flexors, and thus flex the PIP joint. The inability to actively extend the flexed PIP joint against resistance suggests disruption of the extensor tendon, which may lead to this deformity. If this injury is suspected, splint the PIP joint in full extension, leaving the DIP and MCP joints free. 1 Jersey finger is an injury to the flexor digitorum profundus tendon at its attachment point on the

Figure 10. A and B, 11-year-old boy with tuft fracture and subungual hematoma after his finger was caught in a door. The hematoma was trephinated, and the injured finger was splinted in a commercial digit splint.

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distal phalanx. This sports injury occurs when a player grabs a jersey of an opponent as he is running away, causing the DIP joint to hyperextend while the proximal portion of the finger is flexed. There may be an associated avulsion fracture. These injuries are characterized by the inability to flex the finger at the DIP joint with swelling and tenderness. Partial tears may be treated with splinting and physical therapy, whereas complete flexor tendon injuries will require surgical repair. 1

DISTAL PHALANX—AMPUTATIONS, SUBUNGUAL HEMATOMAS, AND NAIL BED INJURIES Distal phalanx fractures in childhood are very common and are typically related to inadvertently slamming a child's finger in a door. Tuft fractures are a common result (Figure 10). These are typically managed conservatively with splinting or buddy taping. In the setting of tuft fracture and subungual hematoma or nail bed laceration, antibiotics are often given to prevent osteomyelitis; however, this practice has little supporting evidence. 18 Most finger amputations occur to children younger than 2 years old, related to fingertip crush injuries in doors. Adolescents tend to have more significant amputations from injuries related to lawn mowers, household tools, and bicycles. 19 Timely replantation of finger amputations in children has a generally excellent prognosis with survival rates approaching 98% and functional recovery superior to that seen in adults. 20 Emergency department management of amputations should include wrapping the digit in saline moistened gauze, sealing the amputated digit in a plastic bag and placing the bag on ice. Direct application of ice may damage the digit. Generally, acceptable ischemic times before surgical repair are 12 hours of warm and 24 hours of cold time for digits. 21 Subungual hematomas result from direct injury to the nail creating bleeding beneath the nail plate and increasing pressure resulting in pain. The pressure is easily reduced by simple trephination, creating a hole in the nail plate. However, management strategies are somewhat controversial depending on the severity of the injury. Some authors recommend that, for hematomas greater than 50% in size or greater than 25% in the presence of a fracture, that the nail plate should be removed and the nail bed explored for any reparable laceration. 22,23 However, more recently, it has been suggested that removal of the nail plate is not necessary for cosmetic or functional outcomes and if the nail plate remains intact, partially adherent to

Figure 11. A 16-year-old adolescent boy presenting after a collision during gym class, with volar DIP joint dislocation (A,B) and successful emergency department reduction (C,D).

the nail bed, and a fracture is not significantly displaced, nail bed exploration is not indicated. 24 -26 Nail bed lacerations typically occur with crush injuries and are often associated with underlying distal phalanx tuft fractures. Laceration repair requires digital nerve block and sometimes procedural sedation in younger children. Both absorbable sutures and skin adhesive glues have been used to repair nail bed lacerations with similar cosmetic and functional outcomes. Repair times are significantly shorter with skin adhesive. 27,28 The patient's nail or a synthetic material is typically placed to splint the proximal nailfold and prevent adhesions between the germinal matrix and eponychial fold. Distal phalanx fractures, subungual hematomas, and nail bed lacerations need to be evaluated in 3 to 5

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days for possible complications including wound infections. Long-term follow-up should be done with pediatric hand surgery to ensure adequate growth and outcomes of the finger tip and nail.

DIGIT DISLOCATIONS Digit dislocations are common in children and are often a result of falls or sports. 11 For PIP dislocations, the middle phalanx determines the type of dislocation (Figure 11). Similarly, in DIP dislocations, which are less common, the distal phalanx determines the type. These are described as dorsal, volar or lateral. Pre-reduction and postreduction x-rays are necessary to evaluate for fracture. A thorough digit examination, including active and passive range of motion, must also be completed. For reduction of a dorsal dislocation, the affected joint is first hyperextended, and then longitudinal traction is applied to the distal phalanx. Finally, the dislocated phalanx is gently pushed back into its proper position. After reduction, the joint should be stabilized with a splint, such as a foam-padded malleable digit splint. Because volar dislocations are often difficult to reduce, specialist consultation may be necessary for possible open reduction. Similarly, in the setting of a fracture or open injury or a dislocation that is irreducible or unstable after reduction, referral to a hand subspecialist is suggested. Delayed reduction can lead to joint instability and decrease function and range of motion. An unsuccessful reduction attempt can occur in the setting of intra-articular entrapment of the volar plate, extensor hood ligaments, and fragments of an avulsion fracture. 29

EMERGENCY DEPARTMENT SPLINTING In the Textbook of Pediatric Emergency Procedures, edited by King and Henretig, 29 there is an excellent illustrated description of splinting procedures in the emergency department. Here, we summarize the important points for hand injuries. Most splints have 4 layers: a stockinette placed against the skin for protection, cotton padding (Webril) placed around the stockinette for padding; plaster, fiberglass, or commercial splinting material for immobilization; and then finally, elastic bandage or gauze wrap to secure the immobilizing material. Bony prominences can be further protected with extra layers of cotton padding. The splint is applied and shaped at the large joints, and the splint contours are molded to the extremity. When applying the splint, adequate pain control and proper positioning are

essential. A splint must be kept in place until it is completely hardened. Buddy taping or dynamic splinting can be applied to a digit with a joint sprain or nondisplaced phalanx fracture. The injured digit is attached to and splinted by an adjacent uninjured digit with tape and some cotton padding in between to prevent skin breakdown. Thumb spica splints are indicated for nondisplaced fractures of the first metacarpal bone, proximal phalanx of the thumb, or scaphoid bone. The width of the splint covers to the midline of the hand on the dorsal and volar sides. The length is measured from the nail base of the thumb to the proximal forearm. The patient is positioned with the forearm placed vertically, and this can be achieved by having the patient sit in a parent's lap with the parent holding the elbow and the uninjured fingers. The wrist should be kept in a neutral position, and the thumb should be abducted and in a slight flexion at the MCP and interphalangeal joints (“wine glass” position of the thumb). A sling can help keep the injury elevated. Ulnar gutter splints are indicated for metacarpal or proximal phalangeal fractures of the fourth and fifth digits, immobilizing the plane of the ulna to the fourth and fifth digits. The dimensions of the splint are similar to those for the thumb spica. The width of the splint should extend to the midline of the hand on the volar and dorsal surfaces. The length of the splint extends from the nail base to the proximal forearm. The patient is positioned as they are for the thumb spica, with the forearm placed vertically. The wrist should be in a neutral position, the MCP joint should be in 70° flexion, and the PIP joints should be in 20 to 30° flexion. This position of the hand ensures stretching of the MCP collateral ligaments, preventing contractures while the hand is immobilized. A thin layer of padding may be placed between the fourth and fifth digits. A radial gutter splint is placed similarly for injuries to the second and third metacarpals or proximal phalanges

EMERGENCY DEPARTMENT AFTERCARE Adequate subspecialist and pediatrician follow-up is one of the most important features of care for children presenting to the emergency department with hand injuries. If the patient is casted or splinted, patients and families should be given information to prevent and detect complications. Compartment syndrome in the pediatric hand is rare but a possible surgical emergency. 30 Patients may present with severe pain, parasthesias, pallor, paralysis, and or pulselessness (see “Traumatic

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Orthopedic Emergencies” elsewhere in this issue). Patients should be instructed to avoid any additional trauma to the area and to keep the hand elevated. They should return to care with worsening pain, blue or pale digits, and any change in sensation. If a splinted patient develops symptoms concerning for compartment syndrome, they should be advised to return to care. In those patients traveling a long distance, the patient could be advised to remove the outer layer of elastic bandage or gauze wrap, while maintaining the position of the splint material on the extremity. In addition, to prevent skin irritation under a cast or splint, patients should keep the material clean and dry and avoid putting any objects inside the cast. 31

SUMMARY In summary, a thorough history, physical examination, and x-rays are important for diagnosis and treatment of acute hand trauma in children. It is important to know how to manage the injured hand as well as when to consult subspecialists as the ultimate outcome is often related to the initial care in the emergency department.

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11. Bhende MS, Dandrea LA, Davis HW. Hand injuries in children presenting to a pediatric emergency department. Ann Emerg Med 1993;22:1519-23. 12. Zhang X, Huang X, Shoa X. Reduction of fifth metacarpal neck fractures with a Kirschner wire. J Hand Surg [Am] 2015;40:1225-30. 13. Hastings II H, Simmons BP. Hand fractures in children. A statistical analysis. Clin Orthop Relat Res 1984;188:120-3. 14. Chew EM, Chong AK. Hand fractures in children: epidemiology and misdiagnosis in tertiary referral hospital. J Hand Surg [Am] 2012;27:24-30. 15. Boyer JS, London DA, Stepan JG, et al. Pediatric proximal phalanx fractures: outcomes and complications after the surgical treatment of displaced fractures. J Pediatr Orthop 2015;35:219-23. 16. Al-Qattan MM. Phalangeal neck fractures in children: classification and outcome in 66 cases. J Hand Surg (Br) 2001;26:112-21. 17. Al-Qattan MM. Nonunion and avascular necrosis following phalangeal neck fractures in children. J Hand Surg [Am] 2010;35:1269-74. 18. Altergott C, Garcia FJ, Nager Al. Pediatric fingertip injuries: do prophylactic antibiotics alter infection rates? Pediatr Emerg Care 2008;24:148-52. 19. Hostetler SG, Schwartz L, Shields BJ, et al. Characteristics of pediatric traumatic amputations treated in hospital emergency departments: United States, 1990-2002. Pediatrics 2005;116:e667-74. 20. Cheng GL, Pan DD, Zhang NP, et al. Digital replantation in children: a long-term follow-up study. Microsurgery 1990;11: 261-4. 21. Wolfe VM, Wang AA. Replantation of the upper extremity: current concepts. J Am Acad Orthop Surg 2015;23:373-81. 22. Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med 1987;5: 302-4. 23. Russell RC, Casas LA. Management of fingertip injuries. Clin Plast Surg 1989;16:405-25. 24. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg [Am] 1999;24:1166-70. 25. Dean B, Becker G, Little C. The management of the acute traumatic subungual haematoma: a systematic review. Hand Surg 2012;17:151-4. 26. Patel L. Management of simple nail bed lacerations and subungual hematomas in the emergency department. Pediatr Emerg Care 2014;30:742-8. 27. Strauss EJ, Weil WM, Jordan C, et al. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg [Am] 2008;33: 250-3. 28. Langlois J, Thevenin-Lemoine C, Rogier A, et al. The use of 2-octylcyanoacrylate (Dermabond®) for the treatment of nail bed injuries in children: results of a prospective series of 30 patients. J Child Orthop 2010;4:61-5. 29. King C, Henretig F, editors. Textbook of pediatric emergency procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. 30. Kanj WW, Gunderson MA, Carrigan RB, et al. Acute compartment syndrome of the upper extremity in children: diagnosis, management, and outcomes. J Child Orthop 2013; 7:225-33. 31. Dudley N. Appendix C. parental instruction sheets. In: Fleisher GR, Ludwig, Henretig FM, editors. Textbook of pediatric emergency medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins2006. p. 1997-8.