Immediate Referral to Emergency Department for Suspected Nerve Injury
This child requires immediate referral to the emergency department for evaluation of potential median or digital nerve injury, as numbness in the fingers following a penetrating hand wound indicates possible nerve damage that demands urgent surgical consultation. 1
Critical Assessment Findings
The combination of:
- Penetrating palm wound from sharp object (pencil)
- Loss of sensation in fingers (numbness)
- Preserved perfusion (good capillary refill and warm fingers)
...strongly suggests nerve injury without vascular compromise. 1 The preserved circulation rules out arterial injury but does NOT exclude significant nerve or tendon damage that requires specialist evaluation. 2
Why This Cannot Be Managed in Clinic
Pain or sensory changes disproportionate to visible injury severity, especially near bones or joints in the hand, should raise immediate concern for deeper structure involvement. 2 Hand wounds are inherently more serious than wounds to fleshy body parts due to the concentration of critical neurovascular and tendon structures in a small space. 2
The numbness indicates the pencil penetrated deep enough to affect nerve function, which requires:
- Formal exploration to assess nerve integrity 1
- Evaluation for foreign body retention (graphite fragments) 1
- Assessment of tendon function once anesthesia wears off 2
Immediate Actions Before Transfer
Wound Care
- Irrigate thoroughly with sterile normal saline without additives 1
- Remove only superficial visible debris—do NOT attempt deep exploration in clinic 1
- Do NOT close or suture the wound 1
- Apply sterile dressing and immobilize the hand in position of function 2
Tetanus Prophylaxis
Administer 0.5 mL tetanus toxoid intramuscularly immediately if immunization status is outdated or unknown. 1 This is a tetanus-prone puncture wound and prophylaxis cannot be delayed. 2 For a 6-year-old with uncertain vaccination history, DTaP is the appropriate formulation. 2
Antibiotic Prophylaxis
Initiate amoxicillin-clavulanate immediately (age-appropriate dosing: 45 mg/kg/day divided three times daily) to prevent polymicrobial infection from skin flora and environmental contamination. 1 Pencil wounds carry risk of Staphylococcus, Streptococcus, and anaerobic contamination. 2
What the ED Will Provide
The emergency department will:
- Obtain hand surgery or orthopedic consultation for formal exploration 1
- Perform detailed sensory and motor examination 2
- Obtain radiographs to rule out foreign body and assess for periosteal penetration 2
- Provide operative debridement if indicated 1
- Repair nerve or tendon injuries if identified 2
Critical Pitfalls to Avoid
Never reassure parents that "good circulation means everything is fine"—nerve injuries can occur with completely intact vascular supply. 2 The numbness is a red flag that demands specialist evaluation regardless of perfusion status.
Do not delay referral for "observation" or follow-up appointment. 1 Nerve injuries require evaluation within hours, not days, and delayed diagnosis significantly worsens outcomes. 2
Do not attempt wound closure in clinic. 1 Infected or contaminated wounds should never be sutured, and this wound requires formal exploration before any closure decision. 2