Approach to the Problem
Fingertip swelling in a child is usually a consequence of trauma or infection. Traumatic injuries with a crush mechanism (e.g., digit crushed between door and door frame) are common in toddlers. These injuries may damage the fingertip soft tissues (nail fold, pulp), distal phalanx, and nail bed. Infections of the distal digit may be precipitated by trauma (felon) or occur spontaneously (paronychia) and may be caused by bacteria, viruses, or fungi.
Key Points in the History
• Crush injury is the most common etiology of fingertip trauma.
• Penetrating injuries from splinters, shards of glass, or minor puncture wounds may lead to an abscess of the distal finger pulp (felon).
• Thumb sucking or nail biting habits may predispose to infections (paronychia).
• Herpetic whitlow may occur as a complication of oral lesions due to herpes simplex virus.
Key Points in the Physical Examination
• Severe pain and multiple clear vesicles on an erythematous base are suggestive of a herpetic whitlow.
• Pain, erythema, and globular swelling of the distal pulp are consistent with a felon.
• Angulation deformity of the distal phalanx because of a fracture may be best detected by examining the finger flexion cascade, or flexion of all the digits together.
PHOTOGRAPHS OF SELECTED DIAGNOSES |
Figure 44-1
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