# Drawering a finger.



## mycrofft (Mar 17, 2014)

A kid slams his finger in the drawer, there is swelling of the disatal phalanx and a blue line of bruise in the fingernail. Ice and elevation soon dispel the pain, but not the tenderness, especially to the fingernail. A reddish blush developed under a small section of the central proximal nail.  Bought finger shield at Walmartgreens Pharmacy and all's done.

Four day's later the finger is still swollen, actually it has gotten worse, the tenderness has greatly worsened and spread up to the wrist, and the finger is a dusky red. The pt resists palpation and ROM demonstration, but it is hot to the touch.

What's going on, why and what should have been done?

Day one, evening




If untreated, maybe day four.


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## Anjel (Mar 17, 2014)

I'll say compartment syndrome due to the crush injury. 

Surgery will most likely be in his future. Blood flow needs to be restored and the toxins that have built up need to be addressed before they are released back into the blood stream.


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## mycrofft (Mar 17, 2014)

*A "no" and a hint*



Anjel said:


> I'll say compartment syndrome due to the crush injury.
> 
> Surgery will most likely be in his future. Blood flow needs to be restored and the toxins that have built up need to be addressed before they are released back into the blood stream.



Good thought, but in an area as small as the finger compartmentalization might more likely develop in hours. It is a very vital consideration, though.

 As one of my medical mentors said, you never want to mess around with hands (nor with eyes, gonads, or babies/kids/pregnancies).

Increasingly red, hot and tender...


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## teedubbyaw (Mar 17, 2014)

Something that ends in 'itis'


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## Anjel (Mar 17, 2014)

mycrofft said:


> Good thought, but in an area as small as the finger compartmentalization might more likely develop in hours. It is a very vital consideration, though.
> 
> 
> 
> ...




Ah right I missed the whole 4 days later thing


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## mycrofft (Mar 17, 2014)

*OK here it is.*

1. Bone fractured, emerged under the nail, then re-entered the skin (subungual fracture).

2. Subungual bacteria etc were carried back with it.

3. Pt has developed an anaerobic infection of the finger's distal and medial phalanges. The pain is perceived in the hand before it actually gets that far…or maybe it IS that far!

As a prehospital EMS person (or the person the concerned neighbor collars), here are some tips (no pun intended):

1.*As a layperson/first aider* (see references), punching a hole in the nail to relieve a subungual haematoma can be ok IF the paperclip was heated red hot first and then promptly (not while it is still glowing!) and very lightly applied to a fingernail which has been thoroughly cleaned (since they won't tolerate a scrub, soak it in betadine and H2O2). Personally, I have *never* done this because, even then, it has the potential to introduce bugs through the channel thus created.

2. Caution yourself and others this happens to: if pain and swelling don't promptly resolve (day or two; it will still be bruised), or redness/heat or increased tenderness evolve, see a doc. Even a closed subungal fracture ought to be xrayed if the doc says to, to track eventual healing or its absence.

Not real common, but anything that threatens fingers is important. A MD will need to X-ray, maybe culture, and prescribe antibiotics. If it is bad enough, the finger may be "filleted" (various tissue layers opened up) to facilitate disinfection and usually requiring plastic surgeons to make hem as close to original as possible if and when the infection resolves.

"If and when": a somewhat related syndrome from hand wounds by rose thorns can develop into a necrotizing tenofasciitis which in some cases will not give up without surgical debridement and radical antibiotics.


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## 9D4 (Mar 18, 2014)

Well shoot. I was thinking compartment as well. 
Personally, it would've taken me quite awhile to figure that one out. 
I don't think I'd feel comfortable with that treatment option, either.


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## mycrofft (Mar 18, 2014)

The impact of this on prehospital EMS:
1. Don't be decompressing nails on the job.
2. If you treat someone, suggest they get it looked at by a doc.
3. A red hot swollen finger a day or three after apparent blunt trauma needs to be seen very soon by a doc.


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## Kevinf (Mar 18, 2014)

I would expect an extremity suffering from compartment syndrome to be somewhat cool to the touch, and probably pale/ashen.


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## mycrofft (Mar 19, 2014)

Kevinf said:


> I would expect an extremity suffering from compartment syndrome to be somewhat cool to the touch, and probably pale/ashen.



Yes. And or sloughing skin by day two or three.


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