O2107: It’s Just a Fingertip! yet Controversy Exists: Standardizing a Treatment Pathway for Pediatric Fingertip Injuries

Background: Pediatric fingertip injuries are very common; however, treatment varies greatly. A paucity of data exists on how emergency department physicians and hand surgeons should treat these injuries. We sought to determine the common standard of care practice and develop consensus around treatment guidelines for these injuries.

Methods: We conducted a Delphi survey of self-identified pediatric hand surgeons. We recruited a convenience sample of participants through POSNA, ASSH, and PSHG (Pediatric Hand Study Group). Participants answered questions about 11 scenarios of fingertip injuries. These included minor (eg: < 50% subungual hematomas without fractures) to severe injuries (eg: complete amputations). Each question was answered on a 3-point Likert scale and included antibiotic use, hand surgery consultation, treatment, and need for hand surgeon follow-up. A kappa statistic was utilized to evaluate agreement between participants. The second round of Delphi asked the participants to re-answer questions that had moderate kappa values (kappa=0.40-0.69) to attempt to reach consensus.

Results: 34 surgeons took the first round of Delphi survey. Questions in each scenario ranged from very high to very poor levels of agreement . All but one scenario contained at least one question with moderate agreement allowing for re-survey and consensus building. Thirty-three (97%) of the same surgeons completed the second round. In the 11 scenarios, there were 22 questions re-surveyed. Of those 22 questions, 17 (77%) changed to higher levels of consensus with kappas >=0.70, allowing consensus of expert opinion to be reached on 45 treatments (Table 1). There were four scenarios with less than half of the questions meeting consensus, such as clear nail plate disruption or dislodgement without a fracture which had only 1 out of 8 questions meeting consensus.

Conclusion: This exercise highlighted several areas of consensus on treatment recommendations for pediatric fingertip injuries (Table 1), such as formal irrigation and debridement and antibiotics for Seymour fractures and complete amputations. In addition, we found points of contention that deserve future research, such as the use of antibiotics after tuft fractures with subungual hematomas. This study will begin to build a protocol for recommended treatment of fingertip injuries in the emergency department. Future research should focus on the scenarios with the least amount of consensus to build a more rigorous standard.