Fingertip entrapment injuries commonly happen in children when their fingertip is caught between the door and the door surround as the door closes. This damages the finger nail, surrounding tissue and bone, all of which are important structures in the protection of the fingertip and for nail growth. These injuries are also called trapped finger injuries, crush fingertip injuries or door jamb injuries.
Sometimes these injuries are treated without surgery ('conservatively') by cleaning them and dressing the wound. Alternatively, the injuries are treated with surgery, which typically involves a general anaesthetic, cleaning of the wound and removal of damaged tissue, and stitches to repair any cuts on the fingertip or the nail.
We searched the medical literature until 30 April 2013 for studies comparing different methods of treating fingertip entrapment injuries. Our review includes evidence from two studies where participants were randomly allocated to one of two conditions. The studies included 191 children with results available for a total of 180 children. Both the studies had weaknesses that could undermine the reliability of the results. Since the studies compared different methods, we could not combine their results.
One study looked at the routine use of antibiotics in children with a surgically repaired fingertip injury to prevent infection. Due to the small number of children experiencing infection this study does not provide conclusive evidence of the effect of giving or withholding antibiotics. Only one child in each group had an infection after a week. Both children had had more severe injuries.
The other study compared two different dressing types for use in fingertip entrapment injuries. The low number of complications was comparable in the two treatment groups. Due to the low number of participants in the study we could not be certain that length of time the injuries took to heal and the number of dressing changes were the same in the treatment groups. However, it also found that the dressing made of silicone caused less distress for the child when being changed after the first week, probably because it stuck less to the wound than the paraffin dressing.
Overall, there is not enough evidence about how to best treat fingertip entrapment injuries in children. We recommend that further research is carried out, especially to see if surgery leads to better outcomes than simple wound cleaning and dressing. These studies should evaluate the effect of the treatment on fingertip function, nail growth and nail deformity for a minimum of three months after treatment.
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 is low from one trial, we do not have conclusive evidence that prophylactic use of antibiotics after surgical repair fails to reduce risk of infection. The two children who experienced infection had 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 post-surgery 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.
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 stabilisation of fractures); however, no consensus currently exists regarding the most appropriate treatment modality.
To assess the effects (benefits and harms) of surgical and conservative interventions for fingertip entrapment injuries in children. We aimed to compare: different methods of conservative treatment; surgical versus conservative treatment; different methods of surgical treatment; and different methods of management after initial conservative or surgical treatment.
We searched 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 30 April 2013. We did not apply any restrictions based on language or publication status.
Randomised controlled trials (RCTs) and quasi-RCTs comparing interventions for treating fingertip entrapment injuries in children. The primary outcomes were fingertip function, nail growth, nail deformity and adverse events such as infection.
Two authors independently screened studies for inclusion, assessed the risk of bias in each included trial and extracted data. We resolved disagreements through discussion.
We included two RCTs examining 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 of 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 GRADE approach (i.e. further research is very likely to have an important impact on our 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 had an infection at day seven (1/66 antibiotic group versus 1/69 no antibiotic group; RR 1.05, 95% CI 0.07 to 16.37). Both participants with infections had a more severe injury (partial fingertip amputation).
The other 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 had 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 had 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 but benefits of either silicone or paraffin dressings could not be excluded (silicone mean 4.1 weeks versus paraffin mean 4.0 weeks; MD 0.10 weeks, 95% CI -0.61 to 0.81); (silicone mean 4.3 dressing changes versus paraffin mean 4.2 dressing changes; 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.