Gottschalk Hilton P, McMahon Niamh D, Piper Karen, Lawson Karla, Bauer Andrea, Chaundhry Sonia, Samora Julie, Freese Krister, Ho Christine A
Dell Medical School, University of Texas at Austin, Austin, TX, USA.
Central Texas Pediatric Orthopedics and Scoliosis Surgery, Austin, TX, USA.
J Pediatr Soc North Am. 2025 Mar 11;11:100163. doi: 10.1016/j.jposna.2025.100163. eCollection 2025 May.
Pediatric fingertip injuries are very common; however, treatment varies greatly depending on geographic location and surgeon. A paucity of data exists on how emergency department practitioners and hand surgeons should treat these injuries. We sought to develop consensus around treatment guidelines for these injuries.
We conducted a Delphi survey of self-identified pediatric hand surgeons. Participants answered care delivery questions about 11 scenarios of fingertip injuries. These included minor (e.g., <50% subungual hematomas without fractures) to severe injuries (e.g., complete to near-complete partial tip amputations). Each question was answered on a 3-point Likert scale and included inquiry about antibiotic use, clinical consults, treatment methods, and need for hand surgeon follow-up. The second round of Delphi asked the participants to view round-one responses and reanswer questions that had moderate kappa values (kappa = 0.40-0.69) to attempt to reach consensus.
Thirty-four 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 resurvey and consensus building. Thirty-three (97%) of the same surgeons completed the second round. In the 11 scenarios, there were 22 questions resurveyed. Of those 22 questions, 17 (77%) changed to higher levels of consensus with a kappa ≥0.70, allowing consensus of expert opinion to be reached on 45 treatments.
The panel reached consensus on when to use intravenous (IV), oral (PO) or no antibiotics for various scenarios of pediatric fingertip injuries. Clarification was achieved on the standard treatment and follow-up practices for multiple clinical scenarios. Further work is required to achieve expert consensus for management of multiple clinical scenarios.
(1)Fingertip traumas are commonly seen in pediatric emergency rooms with treatments varying widely depending on the region of care.(2)Oral (PO) antibiotics are recommended for a tuft fracture with nailbed displacement, a Seymour fracture, or during partial amputation without loss of vascularity, whereas IV and PO antibiotics are indicated for complete and near-complete amputation.(3)Hand surgeon consultation was recommended for Seymour fracture, partial amputation of the distal phalanx, and complete or near-complete amputation with loss of vascularity.(4)Further research needs to be done to achieve consensus on treatment of some traumas.
V, Expert Opinion.
小儿指尖损伤非常常见；然而，治疗方法因地理位置和外科医生的不同而有很大差异。关于急诊科医生和手外科医生应如何治疗这些损伤的数据很少。我们试图就这些损伤的治疗指南达成共识。
我们对自我认定的小儿手外科医生进行了德尔菲调查。参与者回答了关于11种指尖损伤情况的护理问题。这些情况包括轻度损伤（例如，指甲下血肿小于50%且无骨折）到重度损伤（例如，完全或接近完全的指尖部分离断）。每个问题采用3分李克特量表回答，包括询问抗生素使用、临床会诊、治疗方法以及手外科医生随访的必要性。第二轮德尔菲调查要求参与者查看第一轮的回答，并重新回答kappa值为中等（kappa = 0.40 - 0.69）的问题，以试图达成共识。
34名外科医生参加了第一轮德尔菲调查。每种情况中的问题一致性水平从非常高到非常低不等。除一种情况外，所有情况至少有一个问题的一致性为中等，从而可以进行重新调查并建立共识。33名（97%）相同的外科医生完成了第二轮调查。在11种情况中，有22个问题进行了重新调查。在这22个问题中，17个（77%）的一致性提高到更高水平，kappa≥0.70，从而就45种治疗方法达成了专家意见的共识。
该小组就小儿指尖损伤的各种情况何时使用静脉注射（IV）、口服（PO）抗生素或不使用抗生素达成了共识。对多种临床情况的标准治疗和随访做法进行了明确。要就多种临床情况的管理达成专家共识，还需要进一步开展工作。
（1）指尖创伤在儿科急诊室很常见，治疗方法因护理区域不同而差异很大。（2）对于伴有甲床移位的指骨骨折、西摩骨折或无血管损伤的部分离断，建议使用口服（PO）抗生素，而对于完全离断和接近完全离断，则需要静脉注射和口服抗生素。（3）对于西摩骨折、远节指骨部分离断以及伴有血管损伤的完全或接近完全离断，建议咨询手外科医生。（4）需要进一步研究以就某些创伤的治疗达成共识。
V，专家意见。
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